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Ankle / Foot

    

TOPICS 
Achilles tendinopathy 
Plantar fasciosis

Dextrose: Ryan et al 2009   Dextrose injection for chronic pain of Plantar fasciosis
Ryan MB, Wong AD, Gillies JH, Wong J, Traunton JE Sonographically guided intratendinous injections of hyperosmolar dextrose/lidocaine: a pilot study for the treatment of chronic plantar fasciitis. Br J Sports Med 2009;43 :303–306.

The is an article  about  injection of 25% dextrose in 20 consecutive patients with pain in the feet imitated by prssure over the plantar fascia.  Injections were given under ultrasound guidance. These were chronic cases with pain from 7 to 228 months (mean 21 months). Follow-up was for 6-20 months (mean 11.8) months from the final treatment. Three to 12 sessions (mean 3) were given at 2 week intervals. 16 out of 20 had good to excellent results.

My impression is that there were apparently no dropouts which is somewhat unusual in a study with foot injection every 2 weeks. This speaks well of the technique of the authors. However, the every 2 week frequency may have not allowed enough time in between to really determine the number of treatments needed with full healing intervals. There is always that balance between desire to move treatment along in an athlete and the desire to keep the number of treatments minimal. It is notable that, although ultrasound was used for injection there were no post treatment ultrasound results reported. Therefore there were no objective post treatment measures.  There also was not a group comparing blind injections to ultrasound guided.

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Here is the abstract:

bjective: To report on the effectiveness of sonographically guided injections of hyperosmolar dextrose at reducing the pain associated with chronic plantar fasciitis.  Design: Case series.  Setting: Ultrasound division of St Paul’s Hospital.  Patients: 20 referrals (3 men, 17 women; age 51 (SD 13) years) from local sports medicine primary care practitioners who had failed previous conservative  treatments.  

nterventions: A 27-gauge needle administered a 25% dextrose/lidocaine solution under sonographic guidance at 6 week intervals returning for a median of three  consultations.  Main outcome measures: Visual analogue scale (VAS) items for pain levels at rest (VAS1), activities of daily living (VAS2), and during or after physical activity (VAS3)  were recorded at baseline and at the final treatment consultation (post-test). A telephone interview conducted an average of 11.8 months after the post-test consultation provided a measure of long-term follow-up.  Results: 16 patients reported a good to excellent outcome, while the symptoms in 4 patients were unchanged. There was a significant decrease (p,0.001) in all mean VAS items from pre-test to post-test: VAS1 (36.8 (SD 25.6) to 10.3 (10.9)), VAS2 (74.7 (20.8) to 25.0 (27.7)) and VAS3 (91.6 (9.2) to 38.7 (35.1)) and there were no apparent changes after the follow-up interview.

Conclusions: Sonographically guided dextrose injections showed a good clinical response in patients with chronic plantar fasciitis insofar as pain was reduced during rest and activity. Further studies including a control group are needed to validate these outcomes.

Achilles and Patellar Tendon: Aprotinin injection Orchard et al 2008  
Injection of Solutions that block breakdown of tissue may also help healing. Metalloproteinase  (Collagenase is an example) breaks down issue and an inhibitor of metalloprotinease  has been found to help some  cases of tendon damage. 

Orchard J; Massey A; Brown R; Cardon-Dunbar A; Hofmann J. Successful management of tendinopathy with injections of the MMP-inhibitor aprotinin.

Clin Orthop Relat Res (United States), Jul 2008, 466(7) p1625-32 ABSTRACT: Aprotinin is a broad spectrum proteinase inhibitor (including matrix metalloproteinase [MMP] inhibitor) used for treating patellar and Achilles tendinopathies. One previous randomized control trial demonstrated aprotinin injections superior to both corticosteroid and saline injections in patellar tendinopathy (Level II), whereas results reported for aprotinin treatment in Achilles tendinopathy have been mixed. We performed a case review and followup questionnaire for 430 consecutive patients with tendinopathy treated by 997 aprotinin injections (30,000 KIU). A response rate of 72% was achieved with a minimum followup of 3 months (average, 12.2 months; range, 3-54 months). Seventy-six percent of patients had improved, 22% of patients reported no change, and 2% were worse. Sixty-four percent of patients thought aprotinin injections were helpful, while 36% believed they had neither a positive nor negative effect. Mid-Achilles tendinopathy patients (84% improvement) were more successfully treated than patellar tendinopathy patients (69% improvement). Despite stronger published evidence of benefit in patellar tendinopathy, clinical outcomes appeared better with aprotinin use in Achilles tendinopathies. LEVEL OF EVIDENCE: Level IV, case series.

Achilles Tendonopathy DEX: Maxwell et al 2007 

Dextrose 25% injection in chronic Achilles strain resulted in ultrasound documented healing. Maxwell NJ, Ryan MB, Taunton JE, Gillies JH, Wong AD. Sonographically guided intratendinous injection of hyperosmolar dextrose to treat chronic tendinosis of the Achilles tendon: a pilot study. JR Am J Roentgenol. 2007 Oct;189(4):W215-20.

In 2007 the Department of Radiology in Vancouver, BC, Canada published study in which 25% dextrose was injected in chronic Achilles strain. Their results showed pain with sport decreased 78% and by X-Ray the tendons became more healthy, as seen by less holes in the tendon, and better organization of tendon fibers. There is some evidence that abnormal blood vessels (neovessels) develop in chronic strain and these themselves can be sources of pain. The X-Ray findings also showed that these blood vessels shrank.  maxwellnj@upmc.edu

Helpful information from the primary author indicates that 36 patients began the study, 1 was not completed due to obvious high grade partial tear noticeable during ultrasound observation of injection, 3 were not included as they  had obvious calcific tendinopathy that correlated with their lack of improvement after 4 treatments., and 2 were non contactable.  This raises the question about calcific tendinopathy and how to address it differently or to screen it out so that an intention to treat approach to data gathering can be used.  The phone interviews were performed a mean of 12 months post injection (4.5 -28 months).  If the patient was making progressive improvement in symptoms the injection were continued until complete symptom elimination or until the patient was happy with the pain level  or until plateau.  It is important to note that abnormal areas in the tendon and intrasubstance partial tears were targeted rather than neovessels.  It is also important to note that neovascularity decreased in many of these patients even without directly targeting the neovessels, but neovascularity was present in 88% of the tendons.

Here is the abstract.

OBJECTIVE: Chronic tendinosis of the Achilles tendon is a common overuse injury that is difficult to manage. We report on a new injection treatment for this condition. SUBJECTS AND METHODS: Thirty-six consecutive patients (25 men, 11 women; mean age, 52.6 years) with symptoms for more than 3 months (mean, 28.6 months) underwent sonography-guided intratendinous injection of 25% hyperosmolar dextrose every 6 weeks until symptoms resolved or no improvement was shown. At baseline and before each injection, clinical assessment was performed using a visual analogue scale (VAS) for pain at rest (VAS1), pain during normal daily activity (VAS2), and pain during or after sporting or other physical activity (VAS3). Sonographic parameters including tendon thickness, echogenicity, and neovascularity were also recorded. Posttreatment clinical follow-up was performed via telephone interview. RESULTS: Thirty-three tendons in 32 patients were successfully treated.

The mean number of treatment sessions was 4.0 (range, 2-11). There was a mean percentage reduction for VAS1 of 88.2% (p < 0.0001), for VAS2 of 84.0% (p < 0.0001), and for VAS3 of 78.1% (p < 0.0001). The mean tendon thickness decreased from 11.7 to 11.1 mm (p < 0.007). The number of tendons with anechoic clefts or foci was reduced by 78%. Echogenicity improved in six tendons (18%) but was unchanged in 27 tendons (82%). Neovascularity was unchanged in 11 tendons (33%) but decreased in 18 tendons (55%); no neovascularity was present before or after treatment in the four remaining tendons. Follow-up telephone interviews of the 30 available patients a mean of 12 months after treatment revealed that 20 patients were still asymptomatic, nine patients had only mild symptoms, and one patient had moderate symptoms. CONCLUSION: Intratendinous injections of hyperosmolar dextrose yielded a good clinical response--that is, a significant reduction in pain at rest and during tendon-loading activities--in patients with chronic tendinosis of the Achilles tendon

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PRP: Volpi et al 2007.  Treatment of chronic patellar tendinosis with ultrasound followup

Volpi P,   Marinoni L, Bait C, De Girolamo L, Schoenhuber H.   Treatment of chronic patellar tendinosis with buffered platelet rich plasma: a preliminary study.    Medicina DelloSport.  1007;60(4):595-603.

SUMMMARY:  (MINE) 8 athletes considering surgery with chronic patellar tendinosis recalcitrant to physical therapy were given a single injection of PRP with MRI imaging Pre and Post and VISA (Victorian Institute Sports Assessment) score (1 to 100 with 100 best for ability to play sports ) Pre and Post.  At  120 day follow-up 1 had breched protocol by early (40 day) return to full sport with flare and election for surgery.  VISA score improved from 39 to 75 for the remaining 7 patients and MRI showed an improvement in irregularity of tendon for 80%.  1 year or more of symptoms. Non responsive to tradtional PT, shock wave therapy, and TECAR therapy.  PRP infiltration was under ultrasound guidance after 0.5 ml lidocaine infiltration. 3 ml volume with 7-8 repositionings and then supine for 30 minutes without movement.  Progressive activity to full sport at 12 weeks. This pilot study needs to be followed with a larger and preferably blinded study but objective measures  will add significant weight to conclusions  in a large size consecutive patient trial.  The return to sport was prolonged in this group and perhaps more frequent treatment will enable quicker return to improve compliance.   Mention was not made of how many of the 7 went back to full sport and how many received additional treatment to enable that.  

Achilles Tendonopathy Polidocanol: Alfredson et al 2007
2 year followup report by Dr. Alfredson showing sonographic remodeling with a thinner tendon and more normal structure.

By using ultrasound (US) + colour Doppler (CD), immunohistochemical analyses of tendon biopsies, and diagnostic injections of local anaesthesia, sensory nerves (Substance-P-SP and Calcitonin Gene Related Peptide-CGRP) were found inside and outside the vascular wall. In following clinical studies we have demonstrated good short-and mid-term clinical results using treatment with US+CD-guided sclerosing polidocanol injections, targeting the area with neovessels outside the tendon. Two-year follow ups have showed remaining good clinical results, and sonographically signs of remodelling with a significantly thinner tendon with a more normal structure. Whether the effects of polidocanol are mediated through destruction of neovessels, activity on nerves or a combination, is under evaluation. Alfredson H; Lorentzon R: Sclerosing polidocanol injections of small vessels to treat the chronic painful tendon.: Cardiovasc Hematol Agents Med Chem (Netherlands), Apr 2007, 5(2) p97-100

Achilles and Patellar Tendon: Aprotinin injection Orchard et al 2008  
Injection of Solutions that block breakdown of tissue may also help healing. Metalloproteinase  (Collagenase is an example) breaks down issue and an inhibitor of metalloprotinease  has been found to help some  cases of tendon damage.

Orchard J; Massey A; Brown R; Cardon-Dunbar A; Hofmann J. Successful management of tendinopathy with injections of the MMP-inhibitor aprotinin.

Clin Orthop Relat Res (United States), Jul 2008, 466(7) p1625-32 ABSTRACT: Aprotinin is a broad spectrum proteinase inhibitor (including matrix metalloproteinase [MMP] inhibitor) used for treating patellar and Achilles tendinopathies. One previous randomized control trial demonstrated aprotinin injections superior to both corticosteroid and saline injections in patellar tendinopathy (Level II), whereas results reported for aprotinin treatment in Achilles tendinopathy have been mixed. We performed a case review and followup questionnaire for 430 consecutive patients with tendinopathy treated by 997 aprotinin injections (30,000 KIU). A response rate of 72% was achieved with a minimum followup of 3 months (average, 12.2 months; range, 3-54 months). Seventy-six percent of patients had improved, 22% of patients reported no change, and 2% were worse. Sixty-four percent of patients thought aprotinin injections were helpful, while 36% believed they had neither a positive nor negative effect. Mid-Achilles tendinopathy patients (84% improvement) were more successfully treated than patellar tendinopathy patients (69% improvement). Despite stronger published evidence of benefit in patellar tendinopathy, clinical outcomes appeared better with aprotinin use in Achilles tendinopathies. LEVEL OF EVIDENCE: Level IV, case series.

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Achilles Tendon Polidocanol: Alfredson et al 2005

Injection of small amount of polidocanol were targeted using, ultrasound and color doppler guidance, to areas of abnormal small blood vessels found just outside the tendon on the anterior (deeper) side. The control group received anesthetic injection to the same areas. 5/10 patients in the polidocanol group responded to treatment within 2 treatments and the additional 5 responded to additional treatment. 0/10 of the anethetic patients responded to 2 treatments, but this group then received polidocanol injection and  9/10 responded. Alfredson H; Ohberg L Sclerosing injections to areas of neo-vascularisation reduce pain in chronic Achilles tendinopathy: a double-blind randomised controlled trial.  Knee Surg Sports Traumatol Arthrosc May 2005, 13(4) p338-44.

ABSTRACT:  Local injections of the sclerosing substance Polidocanol has been demonstrated to give good clinical results in a pilot study on patients with chronic Achilles tendinopathy. In this study, 20 consecutive patients (9 men and 11 women, mean age 50 years) with chronic painful mid-portion Achilles tendinopathy were randomised to injection treatment with either Polidocanol (5 mg/ml) (group A) or Lidocaine hydro-chloride (5 mg/ml) + Adrenaline (5 microg/ml) (group B). Both substances have a local anaesthetic effect, but Polidocanol also has a sclerosing effect. The patients and the treating physician were blinded to the substance injected.

The short-term effects were evaluated after a maximum of two treatments, 3-6 weeks apart. Before treatment, all patients had structural tendon changes and neo-vascularisation demonstrated with US and color doppler. Under US and color doppler-guidance, the injections targeted the area of neo-vascularisation just outside the ventral part of the tendon. For evaluation, the patients recorded the severity of Achilles tendon pain during tendon loading activity, before and after treatment, on a VAS. Patient's satisfaction with treatment was also assessed. At follow-up (mean 3 months) after a maximum of two treatments, 5/10 patients in group A were satisfied with the treatment and had a significantly reduced level of tendon pain (p < 0.005). In group B, no patient was satisfied with treatment. In the pain-free tendons, but not in the painful tendons, neo-vascularisation was absent after treatment. After completion of the study, treatment with Polidocanol injections (Cross-over in group B and additional treatments in group A) resulted in 10/10 and 9/10 satisfied patients in group A and B, respectively. In summary, injections with the sclerosing substance Polidocanol have the potential to reduce tendon pain during activity in patients with chronic painful mid-portion Achilles tendinopathy.

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