night pain and tenderness together with improved functional measures at 6 months. Some 78% of patients using GTN patches were asymptomatic in activities of daily living compared with 49% patients using eccentric exercises alone. The key limitation of this initial study

was the lack of a validated outcome measure, however the same authors followed it up with one in which they employed the VISA-A questionnaire (16). This gave promising results, with 88% of patients completely asymptomatic at 3 years, compared to 67% of those on placebo (16).

These results are very encouraging

and offer an important alternative conservative treatment for Achilles tendinopathy. However, GTN patches do cause side effects, such as headaches, and in one study 10% of patients discontinued the treatment (17).

Extracorporeal shockwave therapy (ESWT) ESWT has had encouraging results in patients with Achilles tendinopathy. Lakshmanan (18) found significant improvements in VISA-A scores in 14 out of 16 affected tendons, with 11 patients reporting at least satisfactory results and returning to near normal activities. However, there was a significant gender bias towards males, and the limited sample size in this study limits our ability to draw any definitive conclusions. Nonetheless, several later studies also found positive effects of this treatment (19,20). In one prospective study on 23 patients, there was a reduction in VAS scores in 91% of patients after ESWT (19). The patients wore athletic shoes for 2 weeks after the procedure and then continued with normal activity thereafter. However, follow-up of this study was conducted at an average of 20 months after the treatment so it is difficult to conclude whether the results are simply due to the treatment itself (19).

Furia (20) demonstrated significant 8

reductions in VAS scores in patients with Achilles tendinopathy within 4 weeks of treatment compared with controls. Outcome measures were assessed at intervals of 1, 3 and 12 months; however at 12 months, both the ESWT and the control groups had similar significant reductions in symptoms. The Roles–Maudsley (Box 3) score was used to assess patient satisfaction with treatment, and patients receiving ESWT seemed more content with their treatment than the control group. It is important to note, however, that these patients were given a choice as to which treatment they received, therefore the results may be explained by the placebo effect. Furthermore, not clarifying the specific treatment that the controls received makes it difficult to draw firm conclusions (20). On the contrary, no difference in symptoms was demonstrated with ESWT in a randomised controlled trial of 48 patients with Achilles tendinopathy (21). In this study, furthermore, two ruptures were reported within 2 weeks of the treatment in two patients over the age of 60 years. However, this particular treatment regimen consisted of a lower total dose per session and only 1500 shocks at each visit, in comparison to the usual protocol of 3000 shocks. These less than encouraging results might relate to the inclusion of a large proportion of patients who had had several previous interventions on the tendon and may have had underlying joint disease (21). The use of ESWT in the treatment of Achilles tendinopathy, although looking optimistic, has generated some conflicting results. Therefore further evidence to support the treatment is necessary.

High-volume image-guided injections (HVIGI) HVIGI has displayed promising results in patients failing with eccentric exercises. The treatment consists of administering 40–50 ml of saline along with a low concentration (25 mg) of the steroid hydrocortisone and

sportEX medicine 2010;46(Oct):6-10

BOX 3: ROLES–MAUDSLEY SUBJECTIVE PAIN SCORE

1 = Excellent (no pain, full movement, full activity) 2 = Good (occasional discomfort, full movement, full activity)

3 = Fair (some discomfort after prolonged activity) 4 = Poor (pain-limiting activities)

0.5% of the anaesthetic bupivacaine hydrochloride. Injecting a high volume of saline (Figure 1) aims to strip the neoneural vascularisation around the Achilles tendon, in turn reducing pain and improving function (22). Figure 2 shows before and after images of the tendon.

A retrospective study of HVIGI

used VAS scores to assess short-term change in addition to VISA-A scores to evaluate the change in symptoms at a later stage. The results displayed a 70% significant clinical improvement in VAS scores at 2 weeks post- HVIGI and a sustained recovery was noted in the long-term follow-up (at an average of 30 months), whereby VISA-A scores significantly increased from 44.8 prior to the treatment to 76.2 at follow-up. The benefits of HVIGI were found to be similar among all patients regardless of the severity of their symptoms prior to the injection (22). A strict eccentric loading programme post-HVIGI was advocated and this treatment allowed subjects to return to their sporting activity within 2 weeks. Only 7% of them were

Figure 1: High- volume injection under ultrasound imaging.