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INJURY MANAGEMENT TENDINOPATHY
with eccentric exercise and therefore their true benefit – that is without eccentric exercise – has not been documented. Modalities such as such as electrocoagulation, laser therapy and dry needling, autologous blood injections and cryotherapy have been described.
Electrocoagulation has been
Figure 2: (a) Presence of neovascularisation before HVIGI and (b) absence of neovascularisation after HVIGI.
unable to return to their sport, and the professional athletes were more likely to return to their usual level of sport (23). The clinical improvement was very similar to that seen following sclerosant injection, and there was no need for multiple injections. This study used a validated questionnaire for measuring outcomes, so the results are more closely associated with the symptoms of Achilles tendinopathy, however the small sample size and the retrospective nature of the study imposes some limitations which means that further prospective studies will be required to further validate the treatment.
Other conservative treatments Other novel treatments are being proposed for patients who have failed with eccentric exercises. However, these modalities are often combined
reported as a possible treatment for Achilles tendinopathy (24). However, the procedure involves making an incision in the skin, which of course increases the risk of infection and other complications. But because the inclusion criteria specifically include patients who have failed other forms of treatment, this is a valuable option for patients who have shown no improvement after other forms of conservative management. Laser therapy is a very recent treatment. One study investigating its role in treatment of Achilles tendinopathy (25) employed methodology that was feasible and provided data that has been used to design a larger study in the future. However the sample size was small, and no subjects were included who had failed eccentric exercises, which makes it difficult to draw firm conclusions.
On the strength of some promising results from earlier studies, autologous blood injections have been looked at as a possible treatment for patella tendinopathy (26). However, evidence is lacking for their role in Achilles tendinopathy. The analgesic effect of cryotherapy has important advantages in treatment (27). It aims to reduce blood flow to the tendon and the combined effect of cryotherapy and compression reduces extravasations of blood and proteins from neovessels (27).
SURGERY
Approximately a quarter of patients are resistant to conservative measures and require more invasive surgical treatments (28). Many studies have been carried out on the surgical management of Achilles tendinopathy.
THE POTENTIAL TO BE THE INJECTION OF CHOICE IN THE FUTURE
HIGH-VOLUME IMAGE-GUIDED INJECTION PIONEERED BY LONDON SPORTSCARE HAS
BOX 4: KISS APPROACH (KEEP IT SIMPLE STUPID) TO ACHILLES TENDINOPATHY
n History n Examination n Ultrasound scan n Intervene early with eccentric exercise program (EEP)
n Consider HVIGI if there is failure with EEP, there is pain inhibition, and all other conservative management has failed.
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However, the surgical techniques vary widely depending on the diagnosis. The surgical procedure for chronic Achilles tendinopathy involves incision of the paratenon, the removal of adhesions and abnormal tissue and the repair of any partial tears (29). With the recent speculation about the relationship between neovascularisation and clinical symptoms of Achilles tendinopathy, the disruption of new vessels is a key focus (23,30). The incision of the tendon can be open or percutaneous; more recently the percutaneous approach has been performed under real-time ultrasound guidance, giving similar results to open tenotomy (23,31). Minimally invasive stripping is a novel percutaneous surgical technique in which Ethibond™ suture thread is used to break away the neovascularisation and the accompanying nerve supply to the tendon, with the aim of eliminating pain experienced by the patient (32). This technique is inexpensive and, in theory, there is a reduced risk of wound infection in comparison to open surgery. However, no formal studies have been conducted to compare the two procedures in Achilles tendinopathy (23). Most studies report surgical success in 85% of cases of chronic Achilles tendinopathy (33). Nevertheless surgical repair of the tendon in a clinical setting is not without complications. An analysis of a 432 patients who were treated surgically demonstrated complication rate of 11% within a 5-month study period. These complications included superficial wound infections, irritation and damage to the sural nerve and deep vein thrombosis (34). Furthermore, 14 of the 46 complications required further surgery.
A strict rehabilitation programme should be followed post-surgery with the aim of returning the patient to