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Effectiveness of a high volume injection as a treatment for chronic Achilles tendinopathy: randomised controlled trial

Review written by Dr Ebonie Rio info

Key Points

  1. No statistically significant difference was reported between groups at any time point in this study.
  2. Restoring the functional capacity of the tendon through load modification and progressive exercise remains central to the rehabilitation of mid-portion Achilles tendinopathy.

BACKGROUND & OBJECTIVE

Characterized by localized pain, morning stiffness and functional impairment - mid-portion Achilles tendinopathy (AT) affects both sedentary and athletic populations (1,2). Exercise and load management are the most efficacious treatment for this condition (3).

However, novel adjunct therapies are frequently being trialled. Recently, high-volume injection with corticosteroid was found to have a superior (short-term) effect on pain and function when compared to injection without corticosteroid (4).

The aim of this study was to compare the effect of a high volume injection without corticosteroid with a placebo injection (both combined with an exercise program) on pain and functional outcomes at 24 weeks in patients with chronic mid-portion AT.

Mid-portion Achilles tendinopathy is characterized by localized pain, morning stiffness and functional impairment.
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Patients with mid-portion Achilles tendinopathy can expect to see improvements in pain and function within 4 weeks of beginning an exercise rehab programme.

METHODS

Participants were eligible if they were aged 18-70 years, presented with painful swelling of the AT 2-7cm proximal to the insertion on the calcaneus, had symptoms for a period > 2 months, reported unsatisfactory outcome following 6-weeks of exercise, and had detectable Doppler flow.

Patients were excluded if they had a history of Achilles tendon rupture/surgery, were unable to perform the exercise programme, were engaged in concurrent treatment programmes, were diagnosed with sural nerve disease or were suspected of having other musculoskeletal disorders.

Participants in the study were first stratified by pre-injury activity level. Once stratified, participants were randomized into one of two groups (high volume or placebo injection). An un-blinded sports medicine physician who was not involved in the study carried out the injection. Participants were also blind to the injection they received.

Interventions

  • High volume injection of saline and lidocaine mixture (50ml total)
  • Placebo (low volume) injection of same mixture (2ml total)

Exercise Programme

Both groups completed a 3-phase exercise programme that consisted of isometric, concentric and eccentric exercises. If participants were able to maintain a VAS score of ≤3/10 during their exercises (as well during activities of daily living) for a period of 1 week, they were instructed to progress to the next phase. Following the 3-phase exercise programme, participants were asked to complete a 4-phase return to sport program.

Outcome Measures

VISA-A (Dutch) was used as the primary outcome. Secondary outcome measures included patient satisfaction, return to sport, Doppler flow, VAS on 10 hop-test, power and flexibility of the gastrocnemius and soleus, the pain detect questionnaire and the pain coping inventory.

RESULTS

80 participants were included in this study. The mean age of the participants included was 47.9 years. At 6, 12 and 24-week follow up, VISA-A scores in both groups improved significantly. When time was accounted for, no statistically significant difference between groups was reported (see Figure 1).

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Of those who received the high volume injection, 57% reported good or excellent outcomes. 49% of participants who received the placebo injection group reported similar outcomes; this finding was not statistically significant.

When compared, return to sport following high volume and the placebo injection were 52% and 61% respectively; these differences were also not statistically significant.

LIMITATIONS

Pain location and response to loading is key to differentially diagnosing mid-portion AT from other disorders of the posterior heel, e.g. posterior heel pain that increases during double leg heel raise, single leg heel raise, double leg jump, single leg hop, etc. Eligibility and exclusion criteria in the present study were exhaustive, however, pain location during load testing was not considered – this is a limitation.

The progressive exercise program completed by participants in this study required the completion of daily exercise for a period of 24-weeks. When reading this paper, clinicians must consider that part of the improvement seen in VISA-A scores may have been as a result of the significant and consistent period of progressive loading. If clinicians wish to see similar outcomes to those reported in this study, they too must provide a substantial and progressive loading program.

Now, we aren’t suggesting that this would have changed the results, we are simply suggesting that these are both important considerations in tendon research.

CLINICAL IMPLICATIONS

This study compared the effect of a high volume injection without corticosteroid with a placebo injection (both combined with an exercise program) on pain and functional outcomes at 24 weeks, in patients with chronic mid-portion AT. This is important as previous results from high volume injection (HVI) studies may be influenced by the inclusion of corticosteroid. This study would support that suggestion.

At 6, 12 and 24-week follow up, VISA-A scores in both groups improved significantly. The difference between the groups over the duration of the study however, was not significant (P=0.42).

In addition to load modification and a 24-week progressive exercise programme, high volume injection without corticosteroid was no more effective at improving pain and functional outcomes in those with chronic mid-portion AT than a placebo injection.

It can be difficult to manage the expectations of patients who experience mid-portion AT. This study does not support the use of HVI for symptom reduction in people with AT. Given the costs and potential risks associated with injections, more research is required to determine whether or not they are efficacious.

A recent systematic review published in Sports Medicine suggests that patients with mid-portion AT can expect to see improvements in pain and function within 4 weeks of beginning an exercise rehab programme. Although it is unlikely that this is due to a change in muscle capacity or muscle size, this information can provide patients with the encouragement to begin exercise-based rehab. In addition to the benefits experienced after 4-weeks, patients and clinicians can expect to see continued improvement up to 12 weeks.

As attractive as novel adjunct therapies can be, education, load modification and progressive exercise that aims to restore the functional capacity of the tendon remains central to the rehabilitation of mid-portion Achilles tendinopathy.

+STUDY REFERENCE

van der Vlist A, van Oosterom R, van Veldhoven P, Bierma-Zeinstra S, Waarsing J, Verhaar J and de Vos R (2020) Effectiveness of a high volume injection as treatment for chronic Achilles tendinopathy: randomised controlled trial. BMJ, 370, 1-8.

SUPPORTING REFERENCE

  1. Cook, J. and Purdam, C., 2008. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine, 43(6), pp.409-416.
  2. Lopes, A., Hespanhol, L., Yeung, S. and Costa, L., 2012. What are the Main Running-Related Musculoskeletal Injuries?. Sports Medicine, 42(10), pp.891-905.
  3. Couppé, C., Svensson, R., Silbernagel, K., Langberg, H. and Magnusson, S., 2015. Eccentric or Concentric Exercises for the Treatment of Tendinopathies?. Journal of Orthopaedic & Sports Physical Therapy, 45(11), pp.853-863.
  4. Boesen, A., Langberg, H., Hansen, R., Malliaras, P. and Boesen, M., 2019. High volume injection with and without corticosteroid in chronic midportion achilles tendinopathy. Scandinavian Journal of Medicine & Science in Sports,.
  5. Murphy, M., Travers, M., Gibson, W., Chivers, P., Debenham, J., Docking, S. and Rio, E., 2018. Rate of Improvement of Pain and Function in Mid-Portion Achilles Tendinopathy with Loading Protocols: A Systematic Review and Longitudinal Meta-Analysis. Sports Medicine, 48(8), pp.1875-1891.