Injection treatment for chronic midportion Achille

Authors: M N van Sterkenburg C N van Dijk

Publish Date: 2011/02/03

Volume: 19, Issue: 4, Pages: 513-515

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Abstract

An abundant amount of different treatment modalities has been developed for treatment of chronic midportion Achilles tendinopathy Amongst them are injection treatments with as corticosteroids Polidocanol autologous blood plateletrich plasma highvolume injections hyperosmolar dextrose brisement aprotinin and lowdose heparin The rationale behind these treatments is not always clear The goal of treatment in general is to relieve symptoms The main symptom is pain Up to date the cause of pain in chronic midportion Achilles tendinopathy has not been elucidated however So what is the rationale behind these treatmentsCorticosteroid injection has become obsolete in the treatment of midportion Achilles tendinopathy as tendon rupture has been reported in various cases 1 2 The role of chemical inflammation in this pathology is also a matter of debate and therefore there is no rationale for antiinflammatory treatment 3 4 Ultrasoundguided treatment with Polidocanol Ethoxysclerol was first described in 2002 5 as an effective and promising method to obliterate neovessels in and around the tendon which were hypothesized to be a possible cause of pain Studies on patellar tendinopathy lateral epicondylitis supraspinatus tendinitis and the effectiveness of larger doses in Achilles tendons followed 6 7 8 9 However not all authors have been able to reproduce a good outcome 10 The blood vessels are unlikely to be the cause of pain So what is the rationale behind this treatmentPlateletrich plasma PRP is possibly the current most controversial in the lineup of minimally invasive treatment options PRP is defined as ‘any elevated level of platelets’ A PubMed search with ‘plateletrich plasma’ generates 5565 results A search term such as ‘autologous blood’ or typographic changes would add many more references Medical companies legitimately take business advantage of this hype It is currently used in tendon muscle and ligament repair osteoarthritis surgical wounds and chronic ulcers However application has been confusing as each method leads to a different product with different biological characteristics and possible applications There are at least four different products pure PRP leucocyte and PRP pure plateletrich fibrin and leucocyte and plateletrich fibrin Some of these products can be activated or nonactivated 11 Many types of platelet collectors have been developed and platelet concentration varies from 16–44 fold between suppliers compared to whole blood 12 One of the goals seems to be to develop a technique that collects the highest concentration of platelets Autologous whole blood and PRP have been used in midportion Achilles tendinopathy with the aim of providing growth factors to promote healing in areas of degeneration However if effective the questions arise what concentration would suffice how long do platelets stay where injected and what is their halflife Supporting the hypothesis that tendinopathy develops due to a failed chemical healing response would then inducing a new chemical reaction suffice Or are we trying to induce a chemical response in a neurogenic area Moreover in case of chronic midportion Achilles tendinopathy the exact location of injection is not always clearly described Is it possible to inject a substance inside the opaque but degenerative tendon proper And if so is this degenerative area really the cause of complaints Several studies have reported intratendinous changes in up to 34 of cadaver specimens ultrasound and MRI images of patients without complaints 13 14 15 16 17 18 A longterm followup study published by Alfredson and coworkers revealed persistent structural abnormalities and thickening of the tendon 13 years after intratendinous surgery for Achilles tendinopathy whereas all patients were satisfied with the results and went back to Achilles tendon loading activities without restrictions 13 If the pain does not come from the tendon proper where does it originate Recently various studies have shown ingrowth of sensory and sympathetic nerves accompanying neovessels from the paratenon with release of nociceptive substances Denervating the Achilles tendon by release of the peritendineum would hereby hypothetically suffice to relieve pain Since pain is the predominant symptom in these patients and it has never been demonstrated that patients with tendinopathy are more prone to rupture this approach should be sufficient for obtaining a good clinical outcomeA minimally invasive technique such as highvolume injection has been successfully performed to produce local mechanical effects in order to release the adhesions formed between peritendineum and tendon proper thereby obliterating neovascularisation and accompanying neonerves Brisement first described in 1997 19 was initially meant to interrupt the degenerative cycle of the tendon proper by initiating a healing cascade but in essence seems equivalent to current highvolume injections Now could not a combination of these two theories old and new be the result of all injections Meaning that no matter what we introduce an inflammatory response will be generated This can be illustrated by a randomized study by De Vos et al where injection of PRP was compared with saline producing an equivalent outcome 20 Corticosteroid injections for lateral epicondylitis did not provide any longterm benefit compared with placebo 21 Brown et al performed a doubleblind placebocontrolled trial in patients with Achilles tendinopathy where aprotinin was compared with placebo showing no statistically significant benefit 22Until now an evidence based algorithm for the conservative management of midportion Achilles tendinopathy is unknown Research on Achilles tendonrelated problems is ongoing Further research should focus on the cause of pain in patients with chronic midportion Achilles tendinopathy Recognising the cause of pain will help to further define therapeutic strategiesThis article is published under an open access license Please check the Copyright Information section for details of this license and what reuse is permitted If your intended use exceeds what is permitted by the license or if you are unable to locate the licence and reuse information please contact the Rights and Permissions team

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