Dr. Peter Resteghini

Consultant Physiotherapist

Homerton University Hospital

High Volume

Injection for

Achilles

Tendinopathy

Pathology

Chronic tendinopathy

consistently shows either absent

or minimal inflammation

(Ollivierre, 1996)

Predominant lesion is

degenerative: Achilles (Astrom,

1995; Movin, 1997), Rotator

Cuff (Hashimoto, 2003),

Patellar tendon (Khan, 1998),

CEO (Potter, 1995)

Importantly tendinopathy may

not be symptomatic (Maffulli,

2003)

Macroscpically soft disorganised

tissue of yellow/brown

appearance (Mucoid

degeneration) and loss of tightly

bundled collagen (Khan, 1999)

Microscopically there is

degeneration and

disorganisation of collagen with

fibrosis (Maffulli, 2000)

Neovascularisation

demonstrated (Khan ,1999;

Maffulli, 2000)

Findings

Tendinopathy

Histopathological changes seen in tendinopathy

demonstrating a lack of an inflammatory response

Normal tendon with scattered elongated cells

Slightly pathological tendinous tissue with islands

of high cellularity and initial disorganization

Highly degenerated tendon with some chondroid

cells; distinct lack of inflammatory infiltrate

Abnormal

Neovascularization in the distal

third of tendon

Thickened – ‘Spindle Shape’

Diagnosed by 1 or more of the

following findings

1. Tendon thickening with

heterogeneous echogenicity

2. Hypoechoic foci representing

intrasubstance tears (defined

as linear hypoechoic foci

associated with discontinuity

of tendon fibres)

3. Calcifications and

enthesiophytes at the tendon

attachment

4. Neovascularization

(Levin, 2005; Zanetti, 2003)

Evidence

Poor

‘The short-term effects of high volume image

guided injections in resistant non-insertional

Achilles tendinopathy’ (Humphrey, Chan et al 2010)

Equipment

The Procedure

Post Injection 1 week eccentrics

1 week low impact

Return to normal sport

Eccentric Exercise

10 Subjects

Average duration of symptoms 21 months (12-

60 months)

Ultrasound confirmed tendinopathy

Failed conservative treatment

Outcome

Pre and 3 month post injection:

VISA scores

VAS scores

0

1

2

3

4

5

6

7

8

9

1 2 3 4 5 6 7 8 9 10

VA

S S

co

re

Subject Number

Pre and 3 month post Injection VAS Scores

Pre VAS

3/12 Post VAS

P<0.001

0

10

20

30

40

50

60

70

80

90

1 2 3 4 5 6 7 8 9 10

VIS

A S

co

re

Subject Number

Pre and 3 month post Injection VISA Scores

Pre VISA

3/12 Post VISA

P<0.001

References

1. Astrom M, Rausing A (1995). Chronic Achilles tendinopathy. A survey of surgical and

histopathologic findings. Clin Orthop Rel Research. 316. 151-164

2. Hashimoto T, Nobuhara K, Hamada T (2003). Pathologic evidence of degeneration as a

primary cause of rotator cuff tear. Clin Orthop Relat Res. 415. 111-120

3. Khan KM, Maffulli N, Coleman BD, Cook JL, Taunton JE (1998). Patella tendinopathy: some

aspects of basic science and clinical management . Br J Sports Med. 32. 346-355

4. Khan KM, Cook JL, Bonar F, Harcourt P, Astrom M (1999). Histopathology of common

tendinopathies. Update and impilcations for clinical management. Sports Med. 27. 393-408

5. Levin D, Nazarian LN, Miller TT, et al. (2005). Sonographic detection of lateral epicondylitis

of the elbow. Radiology; 237:230–234

6. Maffulli N, Barrass V, Ewen SW (2000). Light microsopic histology of Achilles tendon

ruptures. A comparison with unruptured tendons. Am J Sports Med. 28. 857-863

7. Maffulli N, Wong J, Almekinders LC (2003). Types and epidemiology of tendinopathy. Clin

Sports Med. 22. 675-692

8. Movin T, Gad A, Reinholt FP, Rolf C (1997). Tendon pathology in long standing achillodynia.

Biopsy findings in 40 patients. Acta Orthop Scand. 68. 170-175

9. Ollivierre CO, Nirschl RP (1996). Tennis elbow: current concepts of treatment and

rehabilitation. Sports Med. 2. 133–139

10. Potter HG, Hannafin JA, Morwessel RM, DiCarlo EF, O’Brien SJ, Altcheck DW (1995).

Lateral epicondylitis: correlation of MR imaging, surgical, and histopathologic findings.

Radiology. 1961. 43-46

11. Zanetti M , Metzdorf A, Kunderf H P (2003). Achilles Tendons: Clinical Relevance of

Neovascularisation Diagnosed with Power Doppler. Musculoskeletal Imaging. 227. 2 556-560