Achilles Tendinopathy Toolkit: Section F - Medical and Surgical Interventions: Difference between revisions
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=== Glycerol Trinitrate (GTN) === | === Glycerol Trinitrate (GTN)<ref>Paoloni J, Appleyard R, Nelson J, Murrell G. Topical GTN treatment of chronic non‐insertional Achilles tendinopathy. A randomized, double‐blind, placebo‐controlled trial. Journal of Bone and Joint Surgery ‐ America. 2004;86‐A(5):916‐922.</ref><ref>Hunter G, Lloyd‐Smith R. Topical GTN for chronic Achilles tendinopathy. Clin J Sports Med. 2005;15(2):116‐117.</ref><ref>Paolini J, Murrell G. Three year follow‐up study of topical GTN treatment of chronic non‐insertional Achilles tendinopathy. Foot and Ankle International. 2007;28(10):1064‐1068.</ref><ref>Gambit E, Gonzalez‐Suarez C, Oquinena T, Agbyani R. Evidence on the effectiveness of topical nitroglycerin in the treatment of tendinopathies: a systemic review and meta‐analysis. Arch Phys Med Rehabil. 2010;91(8):1291‐1305.</ref> === | ||
{| width="700" border="1" cellpadding="1" cellspacing="1" | {| width="700" border="1" cellpadding="1" cellspacing="1" | ||
|- | |- | ||
| colspan="2" | '''Method''' | | colspan="2" | '''Method''' | ||
| | | Nitro‐glycerine patches applied over tendon to enhance healing. | ||
|- | |- | ||
| colspan="2" | '''Proposed Mechanism''' | | colspan="2" | '''Proposed Mechanism''' | ||
| | | Nitric oxide may increase blood flow to the tendon and stimulate repair by enhancing fibroblast proliferation. | ||
|- | |- | ||
| rowspan="2" | '''Benefit: Pros/Cons'''<br> | | rowspan="2" | '''Benefit: Pros/Cons'''<br> | ||
| '''Pros:''' | | '''Pros:''' | ||
| | | | ||
*GTN improves outcomes compared to exercise alone. | |||
*Increased compliance because of ease of application. Selfapplied. | |||
*Non‐invasive. | |||
|- | |- | ||
| '''Cons:''' | | '''Cons:''' | ||
| | | | ||
*Labour‐ intensive; requires repeated applications over 12 weeks. | |||
*Potential headache as a side-effect of nitro patch. | |||
|- | |- | ||
| colspan="2" | '''Evidence''' | | colspan="2" | '''Evidence''' | ||
| | | Conflicting evidence limits conclusions. | ||
|- | |- | ||
| colspan="2" | | | colspan="2" | | ||
'''Take Home Message '''''<br>''''''Implications for Physiotherapy''' | '''Take Home Message '''''<br>''''''Implications for Physiotherapy''' | ||
| | | Use of GTN may enhance exercise outcomes. If prescribed by a physician may be applied by a physiotherapist and used in conjunction with an eccentric exercise program. | ||
|} | |} | ||
Revision as of 18:02, 31 July 2012
Achilles Tendinopathy: Medical and Surgical Interventions[edit | edit source]
The purpose of this document is to summarize common medical and surgical interventions which may be considered for the management of Achilles tendinopathy – particularly if it is not responding adequately to more strongly supported conservative management strategies (see “Achilles Tendinopathy: Summary of the Evidence for Physical Therapy Interventions”).
Pharmacological Approaches[edit | edit source]
NSAIDS[1][edit | edit source]
Method | Short term benefit in the acute stage of tendinopathy to minimise inflammatory process. | |
Proposed Mechanism | Interrupts the chemical pathway of inflammation. | |
Benefit: Pros/Cons |
Pros: | Inexpensive, easily accessible. |
Cons: |
| |
Evidence |
Weak evidence for a modest effect in acute stage in Achilles tendinopathy. Recommendation for a short course of NSAIDs for acute symptoms within 14 days. No difference between oral or topical application. | |
Take Home Message |
PTs are involved in the treatment of tendon pain at all stages of recovery. General knowledge of commonly used NSAIDS is important for treatment planning. |
Corticosteroid (injection)[2][3][4][5][edit | edit source]
Method | Short‐term benefit in acute stage. In chronic tendinopathy, the role of inflammation is unclear, and the rationale for the use of anti‐inflammatory injections is controversial. Many studies report an absence of cellular features of inflammation in chronic tendinopathy. | |
Proposed Mechanism | Injection into the paratendon to interrupt the inflammatory process. | |
Benefit: Pros/Cons |
Pros: |
|
Cons: |
| |
Evidence | There is a lack of high quality evidence to support the use of local corticosteroid injections in chronic Achilles tendon lesions. Generally, lack of well‐designed clinical trials. | |
Take Home Message |
PTs are involved in the treatment of tendon pain at all stages of recovery. The appropriate use of corticosteroid is important in treatment planning. There are animal studies that suggest risk of tendon rupture after corticosteroid injection. A greater risk of rupture in human tendons has not been demonstrated in comparison to the natural history of tendon rupture (case studies only). Caution is recommended in progressing the loading of the tendon within two weeks of injection (exercise precautions). |
Glycerol Trinitrate (GTN)[6][7][8][9][edit | edit source]
Method | Nitro‐glycerine patches applied over tendon to enhance healing. | |
Proposed Mechanism | Nitric oxide may increase blood flow to the tendon and stimulate repair by enhancing fibroblast proliferation. | |
Benefit: Pros/Cons |
Pros: |
|
Cons: |
| |
Evidence | Conflicting evidence limits conclusions. | |
Take Home Message |
Use of GTN may enhance exercise outcomes. If prescribed by a physician may be applied by a physiotherapist and used in conjunction with an eccentric exercise program. |
Injection Therapies[edit | edit source]
Method | ||
Proposed Mechanism | ||
Benefit: Pros/Cons |
Pros: | |
Cons: | ||
Evidence | ||
Take Home Message |
Polidocanol[edit | edit source]
Method | ||
Proposed Mechanism | ||
Benefit: Pros/Cons |
Pros: | |
Cons: | ||
Evidence | ||
Take Home Message |
Prolotherapy[edit | edit source]
Method | ||
Proposed Mechanism | ||
Benefit: Pros/Cons |
Pros: | |
Cons: | ||
Evidence | ||
Take Home Message |
Platelet Rich Plasma (PRP) and Autologous whole blood[edit | edit source]
Method | ||
Proposed Mechanism | ||
Benefit: Pros/Cons |
Pros: | |
Cons: | ||
Evidence | ||
Take Home Message |
High volume injection (HVI) or Hydrostatic dissection[edit | edit source]
Method | ||
Proposed Mechanism | ||
Benefit: Pros/Cons |
Pros: | |
Cons: | ||
Evidence | ||
Take Home Message |
Dry Needling[edit | edit source]
Method | ||
Proposed Mechanism | ||
Benefit: Pros/Cons |
Pros: | |
Cons: | ||
Evidence | ||
Take Home Message |
Dry Needline using a Hypordermic Needle ("tendon fenestration")[edit | edit source]
Method | ||
Proposed Mechanism | ||
Benefit: Pros/Cons |
Pros: | |
Cons: | ||
Evidence | ||
Take Home Message |
Surgical Approaches[edit | edit source]
Percutaneous tenetomy[edit | edit source]
Method | ||
Proposed Mechanism | ||
Benefit: Pros/Cons |
Pros: | |
Cons: | ||
Evidence | ||
Take Home Message |
Surgical debridement[edit | edit source]
Method | ||
Proposed Mechanism | ||
Benefit: Pros/Cons |
Pros: | |
Cons: | ||
Evidence | ||
Take Home Message |
Minimally invasive stripping[edit | edit source]
Method | ||
Proposed Mechanism | ||
Benefit: Pros/Cons |
Pros: | |
Cons: | ||
Evidence | ||
Take Home Message |
Developed by Michael Yates, PT. BC Physiotherapy Tendinopathy Task Force. April 2012.
References[edit | edit source]
- ↑ McLauchlan , G, Handoll, H. Interventions for treating acute and chronic Achilles tendinitis. Cochrane Collaboration of Systemic Reviews. 2009;2:1‐36.
- ↑ DaCuz D, Geeson M, Allen M, Phair I. Achilles paratendonitis: an evaluation of steroid injection. Br J Sports Med. 1988;22(2):64‐65.
- ↑ Shrier I, Matheson G, Kohl G. Achilles tendinitis: are corticosteroid injections useful or harmful? Clin J Sports Med. 1996;6(4):245‐250.
- ↑ Fredberg U. Local corticosteroid injection in sport: a review of literature and guidelines for treatment. Scand J Med Sci Sports. 1997;7(3):131‐139.
- ↑ Speed C. Corticosteroid injections in tendon lesions. Br Med J. 2001;323:382‐386.
- ↑ Paoloni J, Appleyard R, Nelson J, Murrell G. Topical GTN treatment of chronic non‐insertional Achilles tendinopathy. A randomized, double‐blind, placebo‐controlled trial. Journal of Bone and Joint Surgery ‐ America. 2004;86‐A(5):916‐922.
- ↑ Hunter G, Lloyd‐Smith R. Topical GTN for chronic Achilles tendinopathy. Clin J Sports Med. 2005;15(2):116‐117.
- ↑ Paolini J, Murrell G. Three year follow‐up study of topical GTN treatment of chronic non‐insertional Achilles tendinopathy. Foot and Ankle International. 2007;28(10):1064‐1068.
- ↑ Gambit E, Gonzalez‐Suarez C, Oquinena T, Agbyani R. Evidence on the effectiveness of topical nitroglycerin in the treatment of tendinopathies: a systemic review and meta‐analysis. Arch Phys Med Rehabil. 2010;91(8):1291‐1305.