Page 9 of 897
Previous Page     Next Page        Smaller fonts | Larger fonts     Go back to the flash version

INJURY MANAGEMENT TENDINOPATHY

between patients using the splint and those who did not, and actually found reduced clinical improvement in those using the night splint compared with those using exercises alone at 6 and 12 weeks. This contradicts the notion that stretching the calf muscle reduces muscle soreness resulting from exercise (7).

repetitions with the knee straight, and a further three sets of fifteen repetitions with the knee slightly flexed (Box 2). Nevertheless, various factors have yet to be clarified, such as the correct rate, load and frequency of the exercises. Most studies assessing eccentric

exercises have been performed on physically active individuals, particularly athletes, and have demonstrated similar encouraging results. Results obtained from non-athletic populations are not as encouraging, with 44% of subjects failing to improve 12 weeks after treatment (6). One important factor that may explain this difference is the degree of motivation – and thus compliance – with the exercise regimen. It is time-consuming and it causes significant discomfort to the tendon, which might discourage patients from performing the exercises. Furthermore, for the patients in the study the treatment regimen was implemented gradually, over 12 weeks, rather than being an intensive regimen (6). However it is noteworthy that pain and muscle soreness is only to be expected at the beginning of the exercise programme (5). The use of a night-time splint

during the eccentric exercise regimen has been investigated by two randomised trials. The theory was that the night splint might afford further clinical improvement and reduce the muscle soreness resulting from the eccentric exercises (7,8). Both studies displayed no significant difference

www.sportEX.net

Sclerosing injections The use of sclerosant injections is based on the association between neovascularisation and pain experienced by the Achilles tendon. The sclerosant used, polidocanol, is an aliphatic non-ionised nitrogen- free substance that is widely used in the treatment of varicose veins and telangiectases. Polidocanol acts both intra- and extravascularly, causing the thrombosis of the blood vessel as well as other new smaller vessels that have formed nearby. It has also been suggested that polidocanol may damage nerves near the neovessels (9,10).

A double-blind, randomised pilot study involving 10 patients with mid-portion Achilles tendinopathy demonstrated a reduction in symptoms in 80% of patients when polidocanol (5 mg/mL) was injected (9). The treatment was administered against the vessels entering the Achilles tendon under colour Doppler ultrasound guidance. However, some of the patients did require an average of two injections before they were satisfactorily symptom free. Follow- up with ultrasound after 6 months supported the association between neovascularisation (see Part 1 in previous issue) and symptoms, as no asymptomatic patient displayed signs of neovascularisation. Two remaining symptomatic patients had persisting neovascularisation at 6 months post- injection (9). A further study performed by the same authors followed up a larger sample size 2 years after polidocanol injections, and showed 90% satisfaction with the treatment and a mean reduction in VAS (visual analogue scale) scores from 75 to 7 (p<0.05) (10). A significant reduction in tendon thickness from 10 mm to 8 mm (p<0.05) was also noted. Furthermore, although neovascularisation was eliminated in 30 tendons, a few vessels were still present in 8 asymptomatic tendons.

AND RESTORING THE TENDON PHYSIOLOGY

BOX 2: ALFREDSON PROTOCOL FOR ECCENTRIC EXERCISES

n 3 x 15 repetitions with knee straight n 3 x 15 repetitions with knee slightly flexed

Willberg et al.(11) wanted to determine whether the number of treatments required can be decreased by increasing the dose of polidocanol. They conducted a randomised control trial on the effects of a higher concentration of polidocanol (10 mg/mL) compared to the original dose of 5 g/ mL . However, no significant difference in the number of patients treated satisfactorily was found with the two dosages.

Polidocanol also has a local anaesthetic effect. To verify that the therapeutic effect of polidocanol relates to its sclerosant properties, two non- sclerosing substances (lignocaine and epinephrine) were also injected in a double-blind randomised control trial (12). No patients receiving the non- sclerosing drugs showed improvement in symptoms, compared with over 90% of patients who received polidocanol. These results clearly demonstrate that polidocanol is more successful in treatment of Achilles tendinopathy.

Topical glyceryl trinitrate (GTN) GTN has been trialled in the treatment of supraspinatus and common extensor tendinopathy and has been shown to provide some degree of symptomatic relief (13,14). Its mechanism of action is not yet confirmed, but it has been suggested that it modifies the local activity of nitric oxide and impacts on collagen synthesis and fibroblast activity (15). A few randomised controlled trials have been conducted using GTN patches along with eccentric exercises. Paoloni et al. (15) conducted a double- blind randomised controlled trial of GTN patches in addition to an eccentric exercise regimen. The patches were applied to the most tender area of the Achilles tendon daily for a 6-month period. There was an improvement in symptoms at 12 and 24 weeks in comparison to placebo, and decreased

7

ECCENTRIC EXERCISE IS THE KEY TO IMPROVING

Previous arrowPrevious Page     Next PageNext arrow        Smaller fonts | Larger fonts     Go back to the flash version
1  |  2  |  3  |  4  |  5  |  6  |  7  |  8  |  9  |  10  |  11  |  12  |  13  |  14  |  15  |  16  |  17  |  18  |  19  |  20  |  21  |  22  |  23  |  24  |  25  |  26  |  27  |  28  |  29  |  30  |  31  |  32  |  33  |  34  |  35  |  36  |  37  |  38  |  39  |  40  |  41  |  42  |  43  |  44  |  45  |  46  |  47  |  48  |  49  |  50  |  51  |  52  |  53  |  54  |  55  |  56  |  57  |  58  |  59  |  60  |  61  |  62  |  63  |  64  |  65  |  66  |  67  |  68  |  69  |  70  |  71  |  72  |  73  |  74  |  75  |  76  |  77  |  78  |  79  |  80  |  81  |  82  |  83  |  84  |  85  |  86  |  87  |  88  |  89  |  90  |  91  |  92  |  93  |  94  |  95  |  96  |  97  |  98  |  99  |  100  |  101  |  102  |  103  |  104  |  105  |  106  |  107  |  108  |  109  |  110  |  111  |  112  |  113  |  114  |  115  |  116  |  117  |  118  |  119  |  120  |  121  |  122  |  123  |  124  |  125  |  126  |  127  |  128  |  129  |  130  |  131  |  132  |  133  |  134  |  135  |  136  |  137  |  138  |  139  |  140  |  141  |  142  |  143  |  144  |  145  |  146  |  147  |  148  |  149  |  150  |  151  |  152  |  153  |  154  |  155  |  156  |  157  |  158  |  159  |  160  |  161  |  162  |  163  |  164  |  165  |  166  |  167  |  168  |  169  |  170  |  171  |  172  |  173  |  174  |  175  |  176  |  177  |  178  |  179  |  180  |  181  |  182  |  183  |  184  |  185  |  186  |  187  |  188  |  189  |  190  |  191  |  192  |  193  |  194  |  195  |  196  |  197  |  198  |  199  |  200  |  201  |  202  |  203  |  204  |  205  |  206  |  207  |  208  |  209  |  210  |  211  |  212  |  213  |  214  |  215  |  216  |  217  |  218  |  219  |  220  |  221  |  222  |  223  |  224  |  225  |  226  |  227  |  228  |  229  |  230  |  231  |  232  |  233  |  234  |  235  |  236  |  237  |  238  |  239  |  240  |  241  |  242  |  243  |  244  |  245  |  246  |  247  |  248  |  249  |  250  |  251  |  252  |  253  |  254  |  255  |  256  |  257  |  258  |  259  |  260  |  261  |  262  |  263  |  264  |  265  |  266  |  267  |  268  |  269  |  270  |  271  |  272  |  273  |  274  |  275  |  276  |  277  |  278  |  279  |  280  |  281  |  282  |  283  |  284  |  285  |  286  |  287  |  288  |  289  |  290  |  291  |  292  |  293  |  294  |  295  |  296  |  297  |  298  |  299  |  300  |  301  |  302  |  303  |  304  |  305  |  306  |  307  |  308  |  309  |  310  |  311  |  312  |  313  |  314  |  315  |  316  |  317  |  318  |  319  |  320  |  321  |  322  |  323  |  324  |  325  |  326  |  327  |  328  |  329  |  330  |  331  |  332  |  333  |  334  |  335  |  336  |  337  |  338  |  339  |  340  |  341  |  342  |  343  |  344  |  345  |  346  |  347  |  348  |  349  |  350  |  351  |  352  |  353  |  354  |  355  |  356  |  357  |  358  |  359  |  360  |  361  |  362  |  363  |  364  |  365  |  366  |  367  |  368  |  369  |  370  |  371  |  372  |  373  |  374  |  375  |  376  |  377  |  378  |  379  |  380  |  381  |  382  |  383  |  384  |  385  |  386  |  387  |  388  |  389  |  390  |  391  |  392  |  393  |  394  |  395  |  396  |  397  |  398  |  399  |  400  |  401  |  402  |  403  |  404  |  405  |  406  |  407  |  408  |  409  |  410  |  411  |  412  |  413  |  414  |  415  |  416  |  417  |  418  |  419  |  420  |  421  |  422  |  423  |  424  |  425  |  426  |  427  |  428  |  429  |  430  |  431  |  432  |  433  |  434  |  435  |  436  |  437  |  438  |  439  |  440  |  441  |  442  |  443  |  444  |  445  |  446  |  447  |  448  |  449  |  450  |  451  |  452  |  453  |  454  |  455  |  456  |  457  |  458  |  459  |  460  |  461  |  462  |  463  |  464  |  465  |  466  |  467  |  468  |  469  |  470  |  471  |  472  |  473  |  474  |  475  |  476  |  477  |  478  |  479  |  480  |  481  |  482  |  483  |  484  |  485  |  486  |  487  |  488  |  489  |  490  |  491  |  492  |  493  |  494  |  495  |  496  |  497  |  498  |  499  |  500  |  501  |  502  |  503  |  504  |  505  |  506  |  507  |  508  |  509  |  510  |  511  |  512  |  513  |  514  |  515  |  516  |  517  |  518  |  519  |  520  |  521  |  522  |  523  |  524  |  525  |  526  |  527  |  528  |  529  |  530  |  531  |  532  |  533  |  534  |  535  |  536  |  537  |  538  |  539  |  540  |  541  |  542  |  543  |  544  |  545  |  546  |  547  |  548  |  549  |  550  |  551  |  552  |  553  |  554  |  555  |  556  |  557  |  558  |  559  |  560  |  561  |  562  |  563  |  564  |  565  |  566  |  567  |  568  |  569  |  570  |  571  |  572  |  573  |  574  |  575  |  576  |  577  |  578  |  579  |  580  |  581  |  582  |  583  |  584  |  585  |  586  |  587  |  588  |  589  |  590  |  591  |  592  |  593  |  594  |  595  |  596  |  597  |  598  |  599  |  600  |  601  |  602  |  603  |  604  |  605  |  606  |  607  |  608  |  609  |  610  |  611  |  612  |  613  |  614  |  615  |  616  |  617  |  618  |  619  |  620  |  621  |  622  |  623  |  624  |  625  |  626  |  627  |  628  |  629  |  630  |  631  |  632  |  633  |  634  |  635  |  636  |  637  |  638  |  639  |  640  |  641  |  642  |  643  |  644  |  645  |  646  |  647  |  648  |  649  |  650  |  651  |  652  |  653  |  654  |  655  |  656  |  657  |  658  |  659  |  660  |  661  |  662  |  663  |  664  |  665  |  666  |  667  |  668  |  669  |  670  |  671  |  672  |  673  |  674  |  675  |  676  |  677  |  678  |  679  |  680  |  681  |  682  |  683  |  684  |  685  |  686  |  687  |  688  |  689  |  690  |  691  |  692  |  693  |  694  |  695  |  696  |  697  |  698  |  699  |  700  |  701  |  702  |  703  |  704  |  705  |  706  |  707  |  708  |  709  |  710  |  711  |  712  |  713  |  714  |  715  |  716  |  717  |  718  |  719  |  720  |  721  |  722  |  723  |  724  |  725  |  726  |  727  |  728  |  729  |  730  |  731  |  732  |  733  |  734  |  735  |  736  |  737  |  738  |  739  |  740  |  741  |  742  |  743  |  744  |  745  |  746  |  747  |  748  |  749  |  750  |  751  |  752  |  753  |  754  |  755  |  756  |  757  |  758  |  759  |  760  |  761  |  762  |  763  |  764  |  765  |  766  |  767  |  768  |  769  |  770  |  771  |  772  |  773  |  774  |  775  |  776  |  777  |  778  |  779  |  780  |  781  |  782  |  783  |  784  |  785  |  786  |  787  |  788  |  789  |  790  |  791  |  792  |  793  |  794  |  795  |  796  |  797  |  798  |  799  |  800  |  801  |  802  |  803  |  804  |  805  |  806  |  807  |  808  |  809  |  810  |  811  |  812  |  813  |  814  |  815  |  816  |  817  |  818  |  819  |  820  |  821  |  822  |  823  |  824  |  825  |  826  |  827  |  828  |  829  |  830  |  831  |  832  |  833  |  834  |  835  |  836  |  837  |  838  |  839  |  840  |  841  |  842  |  843  |  844  |  845  |  846  |  847  |  848  |  849  |  850  |  851  |  852  |  853  |  854  |  855  |  856  |  857  |  858  |  859  |  860  |  861  |  862  |  863  |  864  |  865  |  866  |  867  |  868  |  869  |  870  |  871  |  872  |  873  |  874  |  875  |  876  |  877  |  878  |  879  |  880  |  881  |  882  |  883  |  884  |  885  |  886  |  887  |  888  |  889  |  890  |  891  |  892  |  893  |  894  |  895  |  896  |  897