Achilles Tendinopathy Toolkit: Section F - Medical and Surgical Interventions: Difference between revisions

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== Dry Needling  ==
== Dry Needling  ==


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The term ‘dry needling’ has been used to describe several techniques that involve insertion of a needle without injection of a substance. Needling of the tendon has been described by a number of practitioners using a hypodermic needle. Similar results using acupuncture needles have become more common. The technique is described below.
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| colspan="2" | '''Proposed Mechanism'''
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| rowspan="2" | '''Benefit: Pros/Cons'''<br>
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| '''Cons:'''
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| colspan="2" | '''Evidence'''
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'''Take Home Message '''''<br>''''''Implications for Physiotherapy'''
 
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=== Dry Needline using a Hypordermic Needle ("tendon fenestration") ===
=== Dry Needline using a Hypordermic Needle ("tendon fenestration")<ref>Housner J, Jacobsen J, Misko R. Sonographically guided percutaneous needle tenotomy for treatment of chronic tendinosis. Journal of Ultrasound Medicine. 2009;28(8):1187‐1192.</ref> ===


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| colspan="2" | '''Method'''  
| colspan="2" | '''Method'''  
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| Tissue trauma from the cutting edge of the needle/lumen.
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| colspan="2" | '''Proposed Mechanism'''  
| colspan="2" | '''Proposed Mechanism'''  
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| Repeated lancing of abnormal tendon tissue creates haemorrhage followed by an inflammatory response, granulation and healing. Some needling techniques employ US to guide the needle (percutaneous needle tenotomy).
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| rowspan="2" | '''Benefit: Pros/Cons'''<br>  
| rowspan="2" | '''Benefit: Pros/Cons'''<br>  
| '''Pros:'''  
| '''Pros:'''  
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*Invasive treatment that avoids full surgical exposure and risks.
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| '''Cons:'''  
| '''Cons:'''  
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*Requires sonography equipment.
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| colspan="2" | '''Evidence'''  
| colspan="2" | '''Evidence'''  
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| Needling alone without injection of a substance has shown a positive result for improving pain without complications.
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| colspan="2" |  
| colspan="2" |  
'''Take Home Message '''''<br>''''''Implications for Physiotherapy'''  
'''Take Home Message '''''<br>''''''Implications for Physiotherapy'''  


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| Provides another treatment option for clients that have failed to respond to other conservative treatment.
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=== <br> ===


== Surgical Approaches  ==
== Surgical Approaches  ==

Revision as of 18:23, 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:
  • Precautions and contraindications that accompany specific medications.
  • Inhibition of inflammation may delay soft tissue repair by impairing fibroblastic proliferation.
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
'Implications for Physiotherapy

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:
  • Easily accessible.
  • Careful administration outside the structure of the tendon is considered ‘safe’ i.e., in the paratendon sheath.
Cons:
  • Invasive, painful.
  • Risk of infection (1%) ‘universal precautions’ required.
  • Destructive; risk of tendon rupture; impairs tissue repair mechanism.
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
'Implications for Physiotherapy

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:
  • GTN improves outcomes compared to exercise alone.
  • Increased compliance because of ease of application. Selfapplied.
  • Non‐invasive.
Cons:
  • Labour‐ intensive; requires repeated applications over 12 weeks.
  • Potential headache as a side-effect of nitro patch.
Evidence Conflicting evidence limits conclusions.

Take Home Message
'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.

Injection Therapies[edit | edit source]

Chronic Achilles tendinopathy is associated with abnormal proliferation of neovessels in the ventral portion of the tendon, and along with accompanying neural tissue, is associated with pain in tendinopathy. The presence of neovessels can be visualized by use of ultrasound (US) (sonography). Grey‐scale US is a reliable method to assess tendon structure. Color Doppler or power Doppler has also been used to visualize blood flow.

Conservative treatment for Achilles tendinopathy is unsuccessful in 24‐45% of cases. US‐guided injections are becoming increasingly considered as part of ‘best practice’ for treatment of tendinopathies that have failed to respond to other conservative treatment.

Polidocanol[10][11][12][13][14][15][edit | edit source]

Method Originally developed as an anaesthetic, and widely used as a sclerosing agent in the treatment of varicose veins.
Proposed Mechanism There is a body of literature that supports the use of US-guided injections of polidocanol to disrupt neovessels and accompanying nerve structures associated with chronic tendinopathy.
Benefit: Pros/Cons
 Pros:
  • Increasingly used, registered drug with few side‐effects.
  • No need to use additional anaesthetic, as it has its own aesthetic properties.
Cons:
  • Expensive sonography equipment, requiring an experienced operator.
Evidence There is some evidence which supports the use of sclerosing agents to treat Achilles tendinopathy, although some studies present conflicting results.

Take Home Message
'Implications for Physiotherapy

PTs should have knowledge of more invasive techniques to help to facilitate referral of patients to other procedures when conventional treatment fails to result in a sufficient positive response.

Prolotherapy[16][17][edit | edit source]

Method Injection of hyperosmolar dextrose with small amount of anaesthetic to induce a ‘pro‐inflammatory’ proliferative cell response.
Proposed Mechanism

Fibroblast proliferation, collagen maturation and resolution of neovessels are observed, with near normal appearance of tendon tissue structure observed with US.

New viable tissue hypothesised to result from local release of cell growth factors.

Medical dextrose also has a weak sclerosing effect on vessels.

Benefit: Pros/Cons
 Pros:
  • Can be performed with or without US‐guided localisation. US‐guided technique permits localization to a specific target site. However, injections without US imaging may also be effective, even in a subcutaneous approach superficial to the target tissue.
Cons:
  • Not covered by medical plans (BC); usually requires a private fee that reflects the expertise of the practitioner.
  • Requires three or more repeated treatments, similar to other injection therapies.
  • Expensive sonography equipment requiring an experienced operator.
Evidence Prolotherapy combined with eccentric exercise for Achilles tendon loading provides more rapid improvement in symptoms than eccentrics alone, although long‐term VISA‐A scores are similar.

Take Home Message
'Implications for Physiotherapy

Prolotherapy may enhance outcomes compared to using eccentric exercise, alone.

Platelet Rich Plasma (PRP) and Autologous whole blood[18][19][20][21][edit | edit source]

Method Centrifuge of autologous blood to collect a concentrate of the platelets and plasma. This is then injected back into the patient’s tendon.
Proposed Mechanism Cellular and humoral (blood) mediators promote healing in areas of tendon degeneration.
Benefit: Pros/Cons
 Pros:
  • Growing interest in PRP (platelet rich plasma).
Cons:
  • Requires expensive blood processing equipment and centrifuge. Also, it is a US-guided technique requiring sonography and an experienced operator.
Evidence A single RCT demonstrated no benefit of PRP compared to saline injections in AT. A consensus panel from the International Olympic Committee (IOC) recommended that physicians should proceed with caution using PRP in sports medicine (including Achilles tendon injuries).

Take Home Message
'Implications for Physiotherapy

PTs are part of a treatment team when treating tendon injury. General knowledge of PRP, PRGF and PDGF is important to assist
patients in decision-making.

High volume injection (HVI) or Hydrostatic dissection[22][edit | edit source]

Method Small volume of anaesthetic/steroid and high volume of saline, delivered by US‐guided imaging.
Proposed Mechanism The pressure created by the volume of substance into the tendon sheath is proposed to disrupt the neovessel ingrowth in Achilles tendinopathy.
Benefit: Pros/Cons
 Pros:
  • Non‐surgical option.
Cons:
  • Requires sonography equipment.
Evidence Potential treatment option for Achilles tendinopathy that has failed to respond to a more conservative approach.

Take Home Message
'Implications for Physiotherapy

Provides another treatment option when conservative
treatment has been unsatisfactory.

Dry Needling[edit | edit source]

The term ‘dry needling’ has been used to describe several techniques that involve insertion of a needle without injection of a substance. Needling of the tendon has been described by a number of practitioners using a hypodermic needle. Similar results using acupuncture needles have become more common. The technique is described below.

Dry Needline using a Hypordermic Needle ("tendon fenestration")[23][edit | edit source]

Method Tissue trauma from the cutting edge of the needle/lumen.
Proposed Mechanism Repeated lancing of abnormal tendon tissue creates haemorrhage followed by an inflammatory response, granulation and healing. Some needling techniques employ US to guide the needle (percutaneous needle tenotomy).
Benefit: Pros/Cons
 Pros:
  • Invasive treatment that avoids full surgical exposure and risks.
Cons:
  • Requires sonography equipment.
Evidence Needling alone without injection of a substance has shown a positive result for improving pain without complications.

Take Home Message
'Implications for Physiotherapy

Provides another treatment option for clients that have failed to respond to other conservative treatment.


[edit | edit source]

Surgical Approaches[edit | edit source]

Percutaneous tenetomy[edit | edit source]

Method
Proposed Mechanism
Benefit: Pros/Cons
 Pros:
Cons:
Evidence

Take Home Message
'Implications for Physiotherapy

Surgical debridement[edit | edit source]

Method
Proposed Mechanism
Benefit: Pros/Cons
 Pros:
Cons:
Evidence

Take Home Message
'Implications for Physiotherapy

Minimally invasive stripping[edit | edit source]

Method
Proposed Mechanism
Benefit: Pros/Cons
 Pros:
Cons:
Evidence

Take Home Message
'Implications for Physiotherapy

Developed by Michael Yates, PT. BC Physiotherapy Tendinopathy Task Force. April 2012.

References[edit | edit source]

  1. ↑ McLauchlan , G, Handoll, H. Interventions for treating acute and chronic Achilles tendinitis. Cochrane Collaboration of Systemic Reviews. 2009;2:1‐36.
  2. ↑ DaCuz D, Geeson M, Allen M, Phair I. Achilles paratendonitis: an evaluation of steroid injection. Br J Sports Med. 1988;22(2):64‐65.
  3. ↑ Shrier I, Matheson G, Kohl G. Achilles tendinitis: are corticosteroid injections useful or harmful? Clin J Sports Med. 1996;6(4):245‐250.
  4. ↑ 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.
  5. ↑ Speed C. Corticosteroid injections in tendon lesions. Br Med J. 2001;323:382‐386.
  6. ↑ 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.
  7. ↑ Hunter G, Lloyd‐Smith R. Topical GTN for chronic Achilles tendinopathy. Clin J Sports Med. 2005;15(2):116‐117.
  8. ↑ 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.
  9. ↑ 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.
  10. ↑ Ohberg L, Alfredson H. US‐guided sclerosis of neovessels in painful chronic Achilles tendinosis: pilot study of new treatment (original article). Br Med Association. 2001;p 1‐7.
  11. ↑ Alfredson H, Ohberg L. Sclerosing injections to areas of neovascularization reduces pain in chronic Achilles tendinopathy: a double‐blinded randomized trial. Knee Surgery, Sports Traumatology, Arthroscopy. 2005;13:338‐344.
  12. ↑ Alfredson H, Ohberg L, Zeisig E, Lorentzan R. Treatment of mid‐portion Achilles tendinosis: similar clinical results with US and CD‐guided surgery outside the tendon and sclerosing polidocanol injections. Knee Surgery, Sports Traumatology, Arthroscopy. 2007;15:1504‐1509.
  13. ↑ Willberg L, Sunding K, Ohberg L, Forssblad M, Fahlstrom M, Alfredson H. Sclerosing injections to treat mid‐portion Achilles tendinosis: a randomized controlled study evaluating two different concentrations of polidocanol. Knee Surgery, Sports Traumatology, Arthroscopy. 2008;16:859‐864.
  14. ↑ Wijesekera N, Chew N, Lee J, Mitchell A, et al. US‐guided treatment for chronic Achilles tendinopathy: an update and current status. Skeletal Radiology. 2010;39:425‐434.
  15. ↑ van Sterkenburg M, Jonge M. Less promising results with sclerosing ethoxysclerol (polidocanol) injections for mid‐portion Achilles tendinopathy. Am J Sports Med. 2010;38(11):2226‐2232.
  16. ↑ Ryan M, Wong A, Taunton J. Favorable outcomes after US‐guided intertendinous injection of hyerosmolar dextrose for chronic insertional and mid‐portion Achilles tendinitis. (Original research). Am J Roengentoloty. 2010;194:1047‐1053.
  17. ↑ Wijesekera N, Chew N, Lee J, Mitchell A, et al. US‐guided treatment for chronic Achilles tendinopathy: an update and current status. Skeletal Radiology. 2010;39:425‐434.
  18. ↑ Wijesekera N, Chew N, Lee J, Mitchell A, et al. US‐guided treatment for chronic Achilles tendinopathy: an update and current status. Skeletal Radiology. 2010;39:425‐434.
  19. ↑ De Vos R, Weir A, et al. PRP injection for chronic Achilles tendinopathy. Journal of the American Medical Association. 2010;303(3):144‐149.
  20. ↑ Engebretsen L, Steffen K, et al. IOC consensus paper on use of PRP in sports medicine. British Journal of Sports Medicine. 2010;44(15):1072‐1081.
  21. ↑ De Jonge S, de Vos R, Weir A, et al. 1‐year follow‐up of PRP treatment in chronic Achilles tendinopathy: a double‐blind random placebo‐controlled trial. American Journal of Sports Medicine. 2011;39(8):1623‐1629.
  22. ↑ Chan O, O’Dowd D, Padhiar N, et al. High volume image guided injections in chronic Achilles tendinopathy. Disability and Rehabilitation. 2008;30:1697‐1708.
  23. ↑ Housner J, Jacobsen J, Misko R. Sonographically guided percutaneous needle tenotomy for treatment of chronic tendinosis. Journal of Ultrasound Medicine. 2009;28(8):1187‐1192.
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