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    Chronic Tendinosis of the Achilles Tendon (2007)

    Achilles Tendonopathy DEX: Maxwell et al 2007 Dextrose 25% injection in chronic Achilles strain resulted in ultrasound documented healing. Maxwell NJ, Ryan MB, Taunton JE, Gillies JH, Wong AD. Sonographically guided intratendinous injection of hyperosmolar dextrose to treat chronic tendinosis of the Achilles tendon: a pilot study. JR Am J Roentgenol. 2007 Oct;189(4):W215-20. 

    In 2007 the Department of Radiology in Vancouver, BC, Canada published study in which 25% dextrose was injected in chronic Achilles strain. Their results showed pain with sport decreased 78% and by X-Ray the tendons became more healthy, as seen by less holes in the tendon, and better organization of tendon fibers. There is some evidence that abnormal blood vessels (neovessels) develop in chronic strain and these themselves can be sources of pain. The X-Ray findings also showed that these blood vessels shrank.

    Helpful information from the primary author indicates that 36 patients began the study, 1 was not completed due to obvious high grade partial tear noticeable during ultrasound observation of injection, 3 were not included as they had obvious calcific tendinopathy that correlated with their lack of improvement after 4 treatments., and 2 were non contactable. This raises the question about calcific tendinopathy and how to address it differently or to screen it out so that an intention to treat approach to data gathering can be used. The phone interviews were performed a mean of 12 months post injection (4.5 -28 months). If the patient was making progressive improvement in symptoms the injection were continued until complete symptom elimination or until the patient was happy with the pain level or until plateau. It is important to note that abnormal areas in the tendon and intrasubstance partial tears were targeted rather than neovessels. It is also important to note that neovascularity decreased in many of these patients even without directly targeting the neovessels, but neovascularity was present in 88% of the tendons.

    An abstract is available below.

    OBJECTIVE: Chronic tendinosis of the Achilles tendon is a common overuse injury that is difficult to manage. We report on a new injection treatment for this condition.

    SUBJECTS AND METHODS: Thirty-six consecutive patients (25 men, 11 women; mean age, 52.6 years) with symptoms for more than 3 months (mean, 28.6 months) underwent sonography-guided intratendinous injection of 25% hyperosmolar dextrose every 6 weeks until symptoms resolved or no improvement was shown. At baseline and before each injection, clinical assessment was performed using a visual analogue scale (VAS) for pain at rest (VAS1), pain during normal daily activity (VAS2), and pain during or after sporting or other physical activity (VAS3). Sonographic parameters including tendon thickness, echogenicity, and neovascularity were also recorded. Posttreatment clinical follow-up was performed via telephone interview.

    RESULTS: Thirty-three tendons in 32 patients were successfully treated. The mean number of treatment sessions was 4.0 (range, 2-11). There was a mean percentage reduction for VAS1 of 88.2% (p < 0.0001), for VAS2 of 84.0% (p < 0.0001), and for VAS3 of 78.1% (p < 0.0001). The mean tendon thickness decreased from 11.7 to 11.1 mm (p < 0.007). The number of tendons with anechoic clefts or foci was reduced by 78%. Echogenicity improved in six tendons (18%) but was unchanged in 27 tendons (82%). Neovascularity was unchanged in 11 tendons (33%) but decreased in 18 tendons (55%); no neovascularity was present before or after treatment in the four remaining tendons. Follow-up telephone interviews of the 30 available patients a mean of 12 months after treatment revealed that 20 patients were still asymptomatic, nine patients had only mild symptoms, and one patient had moderate symptoms.

    CONCLUSION: Intratendinous injections of hyperosmolar dextrose yielded a good clinical response--that is, a significant reduction in pain at rest and during tendon-loading activities--in patients with chronic tendinosis of the Achilles tendon