Achilles paratendonitis: an evaluation of steroid injection

Enthesitis in Spondyloarthritis Including Psoriatic Arthritis-To Inject or Not To Inject?: A Narrative Review

PURPOSE

Enthesitis is a key manifestation of psoriatic arthritis (PsA) and spondyloarthritis (SpA) and is considered to be the tissue where the disease initiates. Enthesitis leads to pain and substantial limitations in patients with PsA. Treatment is key in achieving remission or minimal disease activity. Whether it is safe to apply injections to entheseal tissue is unknown. This narrative review aimed to summarize the literature on the efficacy and tolerability of entheseal corticosteroid (CS) injections.

METHODS

The published literature was searched through PubMed as well as identifying relevant articles from their citations,  for articles on the anatomic location of the injection, tissue characteristics (eg, whether there is a tendon sheath), blind versus imaging-guided and entheseal versus perientheseal injections, and related studies in animals. Given that articles on SpA are limited, those on mechanical enthesopathies were also included.

FINDINGS

The literature on the efficacy and tolerability of entheseal CS injection in SpA and PsA are limited. In most articles on entheseal injection, the entheseal tissue has not actually been targeted. The decision of entheseal injection should be made on an individual basis, with consideration of the use of CS injection as the last treatment option following more conservative measures such as NSAIDs, physiotherapy, rest, and lifestyle modifications. Entheseal injection should be avoided in high-risk patients, such as those who have rupture at the enthesis. Diagnostic ultrasound is advised to ensure the presence of inflammation that can potentially benefit from corticosteroid injection, as well as the absence of rupture. In the authors' perspective, perientheseal injections should be tried before intraentheseal injections. Finally, ultrasound guidance for needle placement is strongly encouraged.

IMPLICATIONS

The literature on the efficacy and tolerability of entheseal CS injection in SpA and PsA is limited. With the lack of quality data, recommendations on entheseal corticosteroid injection remain expert opinion.

ICON 2020-International Scientific Tendinopathy Symposium Consensus: A Systematic Review of Outcome Measures Reported in Clinical Trials of Achilles Tendinopathy

BACKGROUND

Nine core domains for tendinopathy have been identified. For Achilles tendinopathy there is large variation in outcome measures used, and how these fit into the core domains has not been investigated.

OBJECTIVE

To identify all available outcome measures outcome measures used to assess the clinical phenotype of Achilles tendinopathy in prospective studies and to map the outcomes measures into predefined health-related core domains.

DESIGN

Systematic review.

DATA SOURCES

Embase, MEDLINE (Ovid), Web of Science, CINAHL, The Cochrane Library, SPORTDiscus and Google Scholar.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Clinical diagnosis of Achilles tendinopathy, sample size ≥ ten participants, age ≥ 16 years, and the study design was a randomized or non-randomized clinical trial, observational cohort, single-arm intervention, or case series.

RESULTS

9376 studies were initially screened and 307 studies were finally included, totaling 13,248 participants. There were 233 (177 core domain) different outcome measures identified across all domains. For each core domain outcome measures were identified, with a range between 8 and 35 unique outcome measures utilized for each domain. The proportion of studies that included outcomes for predefined core domains ranged from 4% for the psychological factors domain to 72% for the disability domain.

CONCLUSION

233 unique outcome measures for Achilles tendinopathy were identified. Most frequently, outcome measures were used within the disability domain. Outcome measures assessing psychological factors were scarcely used. The next step in developing a core outcome set for Achilles tendinopathy is to engage patients, clinicians and researchers to reach consensus on key outcomes measures.

PROSPERO REGISTRATION

CRD42020156763.

Topical diclofenac vs placebo for the treatment of chronic Achilles tendinopathy: A randomized controlled clinical trial

INTRODUCTION

The application of topical diclofenac has been suggested as a possible treatment for Achilles tendinopathy. Our aim was to answer the question, is topical diclofenac more effective than placebo for the treatment of Achilles tendinopathy?.

METHODS

67 participants with persistent midportion or insertional Achilles tendinopathy were randomly assigned to receive a 4 week course of 10% topical diclofenac (n = 32) or placebo (n = 35). The a priori primary outcome measure was change in severity of Achilles tendinopathy (VISA-A score) at 4 and 12 weeks. Secondary outcome measures included numeric pain rating, and patient-reported change in symptoms using a 7 point scale, from substantially worse to substantially better. Pressure pain threshold (N) and transverse tendon stiffness (N/m) were measured over the site of maximum Achilles tendon pathology at baseline and 4 weeks.

RESULTS

There were no statistically or clinically significant differences between the diclofenac and placebo groups in any of the primary or secondary outcome measures at any timepoint. Average VISA-A score improved in both groups (p<0.0001), but the improvements were marginal: at 4 weeks, the improvements in VISA-A were 9 (SD 11) in the diclofenac group and 8 (SD 12) in the placebo group, and at 12 weeks the improvements were 9 (SD 16) and 11 (SD13) respectively-these average changes are smaller than the minimum clinically important difference of the VISA-A.

CONCLUSION

The regular application of topical diclofenac for Achilles tendinopathy over a 4 week period was not associated with superior clinical outcomes to that achieved with placebo.

Achilles tendinopathy

BACKGROUND

Achilles Tendinopathy (AT) is essentially a failed healing response with haphazard proliferation of tenocytes, abnormalities in tenocytes with disruption of collagen fibers, and subsequent increase in non-collagenous matrix.

METHODS

The diagnosis of Achilles tendinopathy is clinical, and MRI and utrasound imaging can be useful in differential diagnosis. Conservative manegement, open surgery or minimally invasive techniques are available. Injections and physical therapy are also vauable options.

RESULTS

Eccentric exercises are useful tools to manage the pathology. If the condition does not ameliorate, shock wave therapy, or nitric oxide patches might be considered. Peritendinous injections or injections at the interface between the Achilles tendon and Kager's triangle could be considered if physical therapy should fail. Surgery is indicated after 6 months of non-operative management.

CONCLUSIONS

The clinical diagnosis and management of AT are not straightforward. Hence, patients should understand that symptoms may recur with either conservative or surgical approaches.

[Midportion Achilles tendinopathy]

Although the incidence of midportion Achilles tendinopathy is under 1% in the general population, it is quite a common disease in runners that is characterized by the symptom triad of pain, swelling and impaired physical performance. Pain and swelling are located in the area 2 to 7 cm proximal the tendon insertion onto the calcaneus.Diagnosis is made by adequate clinical symptoms and corresponding findings in sonography and/or magnetic resonance imaging scans. Histopathologically, mostly degenerative changes in the tendon structure are found, sometimes accompanied by intra- and paratendinous inflammation.Treatment options are conservative or surgical, but conservative ones should be tried first. The best evidence is available for eccentric exercise protocols, which represent the gold standard in conservative treatment options, followed by extracorporal shockwave (ECSW) therapy and corticoid injections.In about 25% of all cases, because of unsatisfactory nonoperative treatment results, surgery is recommended. Open, minimally invasive as well as tenoscopic methods exist, which show patients' satisfactory rates of about 80%. The return to sport or full physical performance is variable and may take up to 18 months for both treatment regimens.

Noninsertional Tendinopathy of the Achilles

Noninsertional Achilles tendinosis is differentiated from insertional Achilles tendinosis based on anatomic location. Tendinosis, as opposed to tendonitis, is primarily a degenerative process and the role of inflammation is believed limited. The etiology of Achilles tendinopathy may include overuse leading to repetitive microtrauma, poor vascularity of the tissue, mechanical imbalances of the extremity, or combination of these elements. There is evidence to support eccentric exercise nonoperative management for patients with noninsertional Achilles tendinopathy. Operative treatment options include percutaneous longitudinal tenotomies, minimally invasive tendon scraping, open débridement and tubularization, and tendon augmentation with flexor hallucis longus.

Targeting Inflammation in Rotator Cuff Tendon Degeneration and Repair

Rotator cuff degeneration is a common affliction that results in pain and disability. Tendinopathy was historically classified with or without the involvement of the immune system. However, technological advancements in screening have shown that the immune system is both present and active in all forms of tendinopathy. During injury and healing, the coordinated effort of numerous immune cell populations work with the resident stromal cells to break down damaged tissues and stimulate remodeling. These cells deploy a wide array of tools, including phagocytosis, enzyme secretion, and chemotactic gradients to direct these processes. Yet, there remains a knowledge gap in our understanding of the sequence of critical events and regulatory factors that mediate this is process in injury and healing. Furthermore, current treatments do not specifically target inflammation at the molecular level. Typical regimens include non-steroidal anti-inflammatory drugs or corticosteroids; however, researchers have found irrevocable functional deficits following treatment, and have disputed their long-term efficacy. Therefore, developing therapeutics that specifically consider the nuances of the immune system are necessary to improve patient outcomes.

Nonsurgical Management of Midsubstance Achilles Tendinopathy

Midsubstance Achilles tendinopathy is one of the most common lower leg conditions. Most patients can recover with nonsurgical treatment that focuses on tendon loading exercises and, when necessary, symptom modulating treatments such as topical, oral, or injected medication, ice, shoe inserts, manual therapy, stretching, taping, or low-level laser. If unresponsive to initial management, a small percentage of patients may consider shockwave or sclerosing treatment and possibly surgery.

Ultrasound-Guided Injection Therapy of Achilles Tendinopathy With Platelet-Rich Plasma or Saline: A Randomized, Blinded, Placebo-Controlled Trial

BACKGROUND

Achilles tendinopathy (AT) is a common and difficult to treat musculoskeletal disorder.

PURPOSE

To examine whether 1 injection of platelet-rich plasma (PRP) would improve outcomes more effectively than placebo (saline) after 3 months in patients with AT.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 24 patients with chronic AT (median disease duration, 33 months) were randomized (1:1) to receive either a blinded injection of PRP (n = 12) or saline (n = 12). The primary endpoint was improvement in Victorian Institute of Sports Assessment-Achilles (VISA-A) score at 3 months. Secondary outcomes were pain at rest, pain while walking, pain when tendon was squeezed, ultrasonographic changes in tendon thickness, and color Doppler activity. Patients were informed that they could drop out after 3 months if they were dissatisfied with the treatment.

RESULTS

After 3 months, all 24 patients were reassessed (no dropouts). No difference between the PRP and the saline group could be observed with regard to the primary outcome (VISA-A score: mean difference [MD], -1.3; 95% CI, -17.8 to 15.2; P = .868). Secondary outcomes were pain at rest (MD, 1.6; 95% CI, -0.5 to 3.7; P = .137), pain while walking (MD, 0.8; 95% CI, -1.8 to 3.3; P = .544), pain when tendon was squeezed (MD, 0.3; 95% CI, -0.2 to 0.9; P = .208), color Doppler activity (MD, 0.3; 95% CI, -0.2 to 0.8; P = .260), and tendon thickness (MD, 0.8 mm; 95% CI, 0.1 to 1.6 mm; P = .030). After the 3-month follow-up, a large dropout was observed: 75% of patients in the PRP group and 33% in the saline group.

CONCLUSION

PRP injection did not result in an improved VISA-A score over a 3-month period in patients with chronic AT compared with placebo. The only secondary outcome demonstrating a statistically significant difference between the groups was change in tendon thickness; this difference indicates that a PRP injection could increase tendon thickness compared with saline injection. The conclusions are limited to the 3 months after treatment owing to the large dropout rate.

Treatment of midportion Achilles tendinopathy: an evidence-based overview

In Achilles tendinopathy, differentiation should be made between paratendinopathy, insertional- and midportion Achilles tendinopathy. Midportion Achilles tendinopathy is clinically characterized by a combination of pain and swelling at the affected site, with impaired performance as an important consequence. The treatment of midportion Achilles tendinopathy contains both non-surgical and surgical options. Eccentric exercise has shown to be an effective treatment modality. Promising results are demonstrated for extracorporeal shockwave therapy. In terms of the surgical treatment of midportion Achilles tendinopathy, no definite recommendations can be made.

LEVEL OF EVIDENCE

IV.

Extracorporeal shockwave therapy (ESWT) for refractory Achilles tendinopathy: A prospective audit with 2-year follow up

BACKGROUND

Achilles tendinopathy (AT) represents a triad of tendon pain, swelling and impaired performance. Extracorporeal shockwave therapy (ESWT) has been endorsed by the National Institute for Health and Care Excellence (NICE) for refractory AT. This audit investigates the long-term outcomes of patients treated with ESWT for refractory AT.

METHODS

Forty-six patients treated with ESWT for AT between October 2010 and August 2011 completed visual analogue, satisfaction scores and functional assessment questionnaires over two years. Patients were subdivided into two groups depending on whether their AT was insertional (IAT) or non-insertional (NAT).

RESULTS

Forty-six patients (mean age 58 years) completed all treatments and full 2 year follow up. There was significant improvement in pain at rest, on activity and of function within both NAT and IAT groups over the two-year period. Satisfaction scores were significant in the NAT group but not in the IAT group.

CONCLUSIONS

ESWT appears to be of benefit in the long term improvement of pain at rest, on activity and functional outcome in patients with refractory AT. However, subjective patient opinion may not match the perceived clinical outcome observed in this audit in all patients and individuals should be counselled regarding this prior to treatment.

Infectious Achilles Tendinitis After Local Injection of Human Placental Extracts: A Case Report

Local injections of corticosteroids or human placental extracts are sometimes used for the treatment of resistant tendinitis or fasciitis. We report a case of infectious Achilles tendinitis complicated by calcaneal osteomyelitis after injection of human placental extracts for the Achilles tendinitis. She was treated with excision of the infected bone and tendon, followed by V-Y lengthening of the proximal portion of the Achilles tendon in a single stage. At 2 years postoperative, she remained symptom free without any signs of recurrence, and the follow-up magnetic resonance imaging scan demonstrated a well-maintained Achilles tendon with normal signal intensity.

Injection therapies for Achilles tendinopathy

BACKGROUND

Achilles tendinopathy is a common condition, often with significant functional consequences. As a wide range of injection treatments are available, a review of randomised trials evaluating injection therapies to help inform treatment decisions is warranted.

OBJECTIVES

To assess the effects (benefits and harms) of injection therapies for people with Achilles tendinopathy.

SEARCH METHODS

We searched the following databases up to 20 April 2015: the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, AMED, CINAHL and SPORTDiscus. We also searched trial registers (29 May 2014) and reference lists of articles to identify additional studies.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials evaluating injection therapies in adults with an investigator-reported diagnosis of Achilles tendinopathy. We accepted comparison arms of placebo (sham) or no injection control, or other active treatment (such as physiotherapy, pharmaceuticals or surgery). Our primary outcomes were function, using measures such as the VISA-A (Victorian Institute of Sport Assessment-Achilles questionnaire), and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from the included studies. We assessed treatment effects using mean differences (MDs) and 95% confidence intervals (CIs) for continuous variables and risk ratios (RRs) and 95% CIs for dichotomous variables. For follow-up data, we defined short-term as up to six weeks, medium-term as up to three months and longer-term as data beyond three months. We performed meta-analysis where appropriate.

MAIN RESULTS

We included 18 studies (732 participants). Seven trials exclusively studied athletic populations. The mean ages of the participants in the individual trials ranged from 20 years to 50 years. Fifteen trials compared an injection therapy with a placebo injection or no injection control, four trials compared an injection therapy with active treatment, and one compared two different concentrations of the same injection. Thus no trials compared different injection therapies. Two studies had three trial arms and we included them twice in two different categories. Within these categories, we further subdivided injection therapies by mode of action (injury-causing versus direct repair agents).The risk of bias was unclear (due to poor reporting) or high in six trials published between 1987 and 1994. Improved methodology and reporting for the subsequent trials published between 2004 and 2013 meant that these were at less risk of bias.Given the very low quality evidence available from each of four small trials comparing different combinations of injection therapy versus active treatment and the single trial comparing two doses of one injection therapy, only the results of the first comparison (injection therapy versus control) are presented.There is low quality evidence of a lack of significant or clinically important differences in VISA-A scores (0 to 100: best function) between injection therapy and control groups at six weeks (MD 0.79, 95% CI -4.56 to 6.14; 200 participants, five trials), three months (MD -0.94, 95% CI -6.34 to 4.46; 189 participants, five trials) or between six and 12 months (MD 0.14, 95% CI -6.54 to 6.82; 132 participants, three trials). Very low quality evidence from 13 trials showed little difference between the two groups in adverse events (14/243 versus 12/206; RR 0.97, 95% CI 0.50 to 1.89), most of which were minor and short-lasting. The only major adverse event in the injection therapy group was an Achilles tendon rupture, which happened in a trial testing corticosteroid injections. There was very low quality evidence in favour of the injection therapy group in short-term (under three months) pain (219 participants, seven trials) and in the return to sports (335 participants, seven trials). There was very low quality evidence indicating little difference between groups in patient satisfaction with treatment (152 participants, four trials). There was insufficient evidence to conclude on subgroup differences based on mode of action given that only two trials tested injury-causing agents and the clear heterogeneity of the other 13 trials, which tested seven different therapies that act directly on the repair pathway.

AUTHORS' CONCLUSIONS

There is insufficient evidence from randomised controlled trials to draw conclusions on the use, or to support the routine use, of injection therapies for treating Achilles tendinopathy. This review has highlighted a need for definitive research in the area of injection therapies for Achilles tendinopathy, including in older non-athletic populations. This review has shown that there is a consensus in the literature that placebo-controlled trials are considered the most appropriate trial design.

Pharmacological interventions for the treatment of Achilles tendinopathy: a systematic review of randomized controlled trials

INTRODUCTION

Several pharmacological interventions have been proposed for the management of Achilles tendinopathy, with no agreement on which is the overall best option available. This systematic review investigates the efficacy and safety of different local pharmacological treatments for Achilles tendinopathy.

SOURCES OF DATA

We included only randomized controlled studies (RCTs) focusing on clinical and functional outcomes of therapies consisting in injection of a substance or local application. Assessment of the methodological quality was performed using a modified version of the Coleman methodology score (CMS) to determine possible risks of bias.

AREAS OF AGREEMENT

Thirteen RCTs were included with a total of 528 studied patients. Eleven studies reported the outcomes of injection therapies. Two studies examined the outcomes of patients who applied glyceryl trinitrate patch. The mean modified CMS was 70.6 out of 90.

AREAS OF CONTROVERSY

There was no significant evidence of remarkable benefits provided by any of the therapies studied.

GROWING POINTS

There is not univocal evidence to advise any particular pharmacological treatment as the best advisable non-operative option for Achilles tendinopathy as equivalent alternative to the most commonly used eccentric loading rehabilitation program. However, potential was shown by the combination of different substances administered with physical therapy.

RESEARCH

There is a need for more long-term investigations, studying large enough cohort with standardized scores and evaluations shared by all the investigations to confirm the healing potential, and provide a stronger statistical comparison of the available treatments.

Achilles tendinosis: treatment options

Athletes usually complain of an ongoing or chronic pain over the Achilles tendon, but recently even non-athletes are experiencing the same kind of pain which affects their daily activities. Achilles tendinosis refers to a degenerative process of the tendon without histologic or clinical signs of intratendinous inflammation. Treatment is based on whether to stimulate or prevent neovascularization. Thus, until now, there is no consensus as to the best treatment for this condition. This paper aims to review the common ways of treating this condition from the conservative to the surgical options.

Evaluation of digital and skinfold caliper measurements of the Achilles tendon width

Background: A critical review of the literature shows that very few objective methods for clinically evaluating Achilles tendinopathy have been described.

Aim: To evaluate the validity and reliability of common digital and skinfold calipers in measuring the Achilles tendon width.

Methods: Reliability study of ten healthy adult volunteers (five males and five females) was performed at the Rheumatology Unit of Barzilai Medical Center, Ashkelon, Israel. Achilles tendon width was measured by ultrasound at two points of both legs (the tendon attachment and 5 cm proximally). Using regular and skinfold calipers, two further measurements were made, three hours apart, at the same sites.

Results: Test-retest reliability was high for the skinfold caliper at both the upper (intraclass correlation coefficient (ICC)=0.863, p<0.001) and lower (ICC=0.931, p<0.001) points, and moderate for the regular caliper at upper (ICC=0.730, p<0.001) and lower (ICC=0.641, p<0.001) points. Moderate association was found between ultrasound and caliper measurements at the lower point (Spearman's rank correlation coefficient (rho)=0.721, p=0.019 for regular calipers; rho=0.646, p=0.043 for skinfold calipers). At the upper point, the associations were high (rho=0.778, p=0.008 for regular calipers; rho=0.960, p<0.001 for skinfold calipers).

Conclusions: The skinfold caliper showed a higher correlation with ultrasound measurements and higher intraobserver reliability than the regular caliper. Therefore, the skinfold caliper can be recommended in clinics and trials when repeated measurements need to be performed.

How to perform local soft-tissue glucocorticoid injections?

Inflammation of periarticular soft-tissue structures such as tendons, tendon sheaths, entheses, bursae, ligaments and fasciae is the hallmark of many inflammatory rheumatic diseases, but inflammation or rather irritation of these structures also occurs in the absence of an underlying rheumatic disease. In both these primary and secondary soft-tissue lesions, local glucocorticoid injection often is beneficial, although evidence in the literature is limited. This chapter reviews local injection therapy for these lesions and for nerve compression syndromes.

Injectable treatments for noninsertional achilles tendinosis: a systematic review

BACKGROUND

Although there has been a recent increase in interest regarding injectable therapy for noninsertional Achilles tendinosis, there are currently no clear treatment guidelines for managing patients with this condition. The objective of this study was (1) to conduct a systematic review of clinical outcomes following injectable therapy of noninsertional Achilles tendinosis, (2) to identify patient-specific factors that are prognostic of treatment outcomes, (3) to provide treatment recommendations based on the best available literature, and (4) to identify knowledge deficits that require further investigation.

METHODS

We searched MEDLINE (1948 to March week 1 2012) and EMBASE (1980 to 2012 week 9) for clinical studies evaluating the efficacy of injectable therapies for noninsertional Achilles tendinosis. Specifically, we included randomized controlled trials and cohort studies with a comparative control group. Data abstraction was performed by 2 independent reviewers. The Oxford Level of Evidence Guidelines and GRADE recommendations were used to rate the quality of evidence and to make treatment recommendations.

RESULTS

Nine studies fit the inclusion criteria for our review, constituting 312 Achilles tendons at final follow-up. The interventions of interest included platelet-rich plasma (n = 54), autologous blood injection (n = 40), sclerosing agents (n = 72), protease inhibitors (n = 26), hemodialysate (n = 60), corticosteroids (n = 52), and prolotherapy (n = 20). Only 1 study met the criteria for a high-quality randomized controlled trial. All of the studies were designated as having a low quality of evidence. While some studies showed statistically significant effects of the treatment modalities, often studies revealed that certain injectables were no better than a placebo.

CONCLUSIONS

The literature surrounding injectable treatments for noninsertional Achilles tendinosis has variable results with conflicting methodologies and inconclusive evidence concerning indications for treatment and the mechanism of their effects on chronically degenerated tendons. Prospective, randomized studies are necessary in the future to guide Achilles tendinosis treatment recommendations using injectable therapies.

LEVEL OF EVIDENCE

Level II, systematic review.

Tendons--time to revisit inflammation

It is currently widely accepted among clinicians that chronic tendinopathy is caused by a degenerative process devoid of inflammation. Current treatment strategies are focused on physical treatments, peritendinous or intratendinous injections of blood or blood products and interruption of painful stimuli. Results have been at best, moderately good and at worst a failure. The evidence for non-infammatory degenerative processes alone as the cause of tendinopathy is surprisingly weak. There is convincing evidence that the inflammatory response is a key component of chronic tendinopathy. Newer anti-inflammatory modalities may provide alternative potential opportunities in treating chronic tendinopathies and should be explored further.

Conservative management of tendinopathy: an evidence-based approach

Tendinopathy is one of the most frequent overuse injuries associated with sport. It is a failure of a chronic healing response associated with both chronic overloaded and unloaded states. Although several conservative therapeutic options have been proposed, very few of them are supported by randomized controlled trials. Eccentric exercises provide excellent clinical results both in athletic and sedentary patients, with no reported adverse effects. Combining eccentric loading and low-energy shock wave therapy produces higher success rates compared with eccentric training alone or shock wave therapy alone. High-volume injection of normal saline solution, corticosteroids, or anesthetics can reduce pain and improve long-term function in patients with Achilles or patellar tendinopathy. The use of injectable substances such as platelet-rich plasma, autologous blood, polidocanol, and corticosteroids in and around tendons is not support by strong clinical evidence. Further randomized controlled trials are necessary to define the best conservative management of tendinopathy.

WITHDRAWN: Interventions for treating acute and chronic Achilles tendinitis

BACKGROUND

Achilles tendinitis is one of the most common of all sports injuries. There is no consensus on treatment.

OBJECTIVES

To assess the effectiveness of various treatment interventions for acute and chronic Achilles tendinitis in adults.

SEARCH STRATEGY

The Cochrane Bone, Joint and Muscle Trauma Group specialised register (December 2000), Cochrane Controlled Trials Register (The Cochrane Library Issue 4, 2000), MEDLINE (1966 to December 2000), EMBASE (1980 to 2001 wk 04), CINAHL (1982 to December 2000), and reference lists of identified trials were searched.

SELECTION CRITERIA

Randomised or quasi-randomised trials of treatment interventions for acute and chronic Achilles tendinitis in adults. Studies focusing on pathological tendinitis were excluded. Excluded were those trials that compared different dosages of the same drug or drugs within the same class of drugs, for example different non-steroidal anti-inflammatory drugs (NSAIDs).

DATA COLLECTION AND ANALYSIS

Three reviewers independently assessed trial quality, by use of a ten item check list, and extracted data. Requests were sent for separate data for Achilles tendinitis patients in studies within trials of mixed patient populations. Where possible, quantitative analysis and limited pooling of data were undertaken.

MAIN RESULTS

Nine trials, involving 697 patients, met the inclusion criteria of the review. Methodological quality was adequate in most of the trials with regards to blinding but the assessment of outcome was incomplete and short-term.There was weak but not robust evidence from three trials of a modest benefit of NSAIDs for the alleviation of acute symptoms. There was some weak evidence of no difference compared with no treatment of low dose heparin, heel pads, topical laser therapy and peritendonous steroid injection, but this could not be fully evaluated from the reports of four trials. The results of an experimental preparation of a calf-derived deproteinized haemodialysate, Actovegin, were promising but the severity of patient symptoms was questionable in the single small trial testing this comparison. The results of a comparison of glycosaminoglycan sulfate with a NSAID were inconclusive.

AUTHORS' CONCLUSIONS

There is insufficient evidence from randomised controlled trials to determine which method of treatment is the most appropriate for the treatment of acute or chronic Achilles tendinitis. Further research is warranted.

Injection techniques of platelet-rich plasma into and around the Achilles tendon: a cadaveric study

BACKGROUND

Platelet-rich plasma (PRP) injections are used to treat (Achilles) tendinopathies. Platelet-rich plasma has been injected at different locations, but the feasibility of PRP injections and the distribution after injection have not been studied.

PURPOSE

To evaluate (1) the feasibility of ultrasound-guided PRP injections into the Achilles tendon (AT) and in the area between the paratenon and the AT and (2) the distribution of PRP after injection into the AT and in the area between the paratenon and AT.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Fifteen cadaveric lower limbs were injected under ultrasound guidance with Indian blue-dyed PRP. Five injections were placed into the AT at the midportion level; 5 injections were located anterior between the paratenon and AT and 5 posterior between the paratenon and AT. The limbs were anatomically dissected and evaluated for the presence and distribution of PRP.

RESULTS

All injections into the AT showed PRP infiltration in the AT as well as in the area between the paratenon and AT (median craniocaudal spread, 100 mm; range, 75-110 mm); 1 of 5 limbs showed PRP leakage into the Kager fat pad after AT injection. Allanterior and posterior injections showed PRP infiltration in the area between the paratenon and AT (median, 100 mm; range, 75-150 mm). The AT was infiltrated with PRP after 3 of 10 paratenon injections.

CONCLUSION

The "AT" and "paratenon" injections under ultrasound guidance proved to be accurate. Injections into the AT showed distribution of PRP into the AT as well as in the area between the paratenon and AT. All injections between the paratenon and AT showed PRP distribution in that area, as well as in the Kager fat pad.

CLINICAL RELEVANCE

Different PRP injection techniques were evaluated. This aids in the optimization of PRP injections in the treatment of midportion Achilles tendinopathy.

Current treatment options for tendinopathy

IMPORTANCE OF THE FIELD

Tendon disorders are frequent and are responsible for much morbidity, both in sport and the workplace. Although several therapeutic options are routinely used, very few well-conducted randomised prospective, placebo, controlled trials have been performed to assist in choosing the best evidence-based management.

AREAS COVERED IN THIS REVIEW

We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL, and Embase databases over the years 1966 - 2010 to review the best evidence-based options for the management of patients with tendinopathy.

WHAT THE READER WILL GAIN

The reader will obtain information on the available medical and surgical therapies used to manage tendinopathy-related symptoms. The effectiveness of therapies, the length of management and the adverse effects are examined.

TAKE-HOME MESSAGE

Management of tendinopathy is often anecdotic and lacking well-researched scientific evidence. Teaching patients to control the symptoms may be more beneficial than leading them to believe that tendinopathy is fully curable.

The effectiveness of therapeutic ultrasound for musculoskeletal conditions of the lower limb: A literature review

BACKGROUND

Ultrasound is suggested as one of the treatment options available for soft tissue musculoskeletal conditions of the lower limb and to this end, the objective was to review the literature and evaluate the effectiveness of therapeutic ultrasound for musculoskeletal conditions of the lower limb.

METHODS

A search of the literature published between 1975 and February 2009 was carried out. All studies that fulfilled the inclusion criteria were quality assessed and scored using the Critical Appraisal Skills Programme (CASP) appraisal tool [1] for randomised controlled trials.

RESULTS

Ten studies out of a possible fifteen were included in the review. Only one trial was considered to be high quality (score 16+), three medium quality trials (score 11-15) were identified and six trials were considered to be low or poor quality (score≤10). None of the six placebo-controlled trials found any statistically significant differences between true and sham ultrasound therapy.

CONCLUSION

This literature review found that there is currently no high quality evidence available to suggest that therapeutic ultrasound is effective for musculoskeletal conditions of the lower limb.

Less promising results with sclerosing ethoxysclerol injections for midportion achilles tendinopathy: a retrospective study

BACKGROUND

Local injections of the sclerosing substance polidocanol (Ethoxysclerol) have shown good clinical results in patients with chronic midportion Achilles tendinopathy. After training by the inventors of the technique, sclerosing Ethoxysclerol injections were applied on a group of patients in our center.

HYPOTHESIS

Sclerosing Ethoxysclerol injections will yield good results in the majority of patients.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

In 113 patients (140 tendons) with Achilles tendinopathy, we identified 62 patients (70 tendons) showing neovascularization on color Doppler ultrasound. Fifty-three Achilles tendons (48 patients) were treated with sclerosing Ethoxysclerol injections, with intervals of 6 weeks and a maximum of 5 sessions. Treatment was completed when neovascularization or pain had disappeared, or when there was no positive treatment effect after 3 to 4 sessions.

RESULTS

Forty-eight patients (20 women and 28 men) with a median age of 45 years, (range, 33-68 years) were treated. Median symptom duration was 23 months (range, 3-300 months). Fifty-three tendons were treated with a median of 3 sessions of Ethoxysclerol injections. Six weeks after the last injection, 35% of patients had no complaints, 9% had minimal symptoms, 42% were the same, and 14% had more complaints. Women were 3.8 times (95% confidence interval: 1.1-13.8) more likely to have unsatisfactory outcome than men. Pain correlated positively with neovessels on ultrasound (P < .01). At 2.7 to 5.1 year follow-up, 53% had received additional (surgical/conservative) treatment; 3 of these patients (7.5%) still had complaints of Achilles tendinopathy. In 6 patients, complaints that were still present 6 weeks after treatment had resolved spontaneously by final follow-up.

CONCLUSION

Our study did not confirm the high beneficial value of sclerosing neovascularization in patients with midportion Achilles tendinopathy. Despite the retrospective design of our study, we consider it important to stress that injection of Ethoxysclerol may not be as promising as was thought.

New options in the management of tendinopathy

Tendon injuries can be acute or chronic, and caused by intrinsic or extrinsic factors, either alone or in combination. Tendinopathies are a common cause of disability in occupational medicine and account for a substantial proportion of overuse injuries in sports. Tendinopathy is essentially a failed healing response, with haphazard proliferation of tenocytes, abnormalities in tenocytes, with disruption of collagen fibres and subsequent increase in noncollagenous matrix. The scientific evidence base for managing tendinopathies is limited. What may appear clinically as an "acute tendinopathy" is actually a well advanced failure of a chronic healing response in which there is neither histologic nor biochemical evidence of inflammation. In this review we report the new options for the management of tendinopathy, including eccentric exercises, extracorporeal shockwave therapy, injections (intratendinous injections of corticosteroids, aprotinin, polidocanol platelet-rich plasma, autologous blood injection, high-volume injections) and surgery. Open surgery aims to excise fibrotic adhesions, remove areas of failed healing and make multiple longitudinal incisions in the tendon to detect intratendinous lesions, and to restore vascularity and possibly stimulate the remaining viable cells to initiate cell matrix response and healing. New surgical techniques aim to disrupt the abnormal neoinnervation to interfere with the pain sensation caused by tendinopathy. These procedures are intrinsically different from the classical ones in present use, because they do not attempt to address directly the pathologic lesion, but act only to denervate them. They include endoscopy, electrocoagulation, and minimally invasive stripping. Further randomized controlled trials are necessary to clarify better the best therapeutic options for the management of tendinopathy.

Conservative treatment of Achilles tendinopathy: emerging techniques

Achilles tendinopathy is a painful condition that occurs commonly in both active and inactive individuals. It seems that this condition is painful as a result of ingrowth of neural structures and neovessels leading to poor healing, rather than from inflammatory mediators. Traditional conservative measures are often successful. There is a subset of patients who fail to respond to these measures, however, and this has led to the investigation of newer conservative techniques. This article provides a review of many of the emerging techniques in the treatment of Achilles tendinopathy.

Soft tissue injections in the athlete

BACKGROUND

Injections into or adjacent to soft tissue structures, including muscle, tendon, bursa, and fascia, for pain relief and an earlier return to play have become common in the field of sports medicine.

STUDY DESIGN

Clinical review.

RESULTS

Corticosteroids, local anesthetics, and ketorolac tromethamine (Toradol) are the most commonly used injectable agents in athletes. The use of these injectable agents have proven efficacy in some disorders, whereas the clinical benefit for others remain questionable. All soft tissue injections performed for pain control and/or an anti-inflammatory effect have potentially serious side effects, which must be considered, especially in the pregame setting.

CONCLUSIONS

The primary concern regarding corticosteroid and local anesthetic injections is an increased risk of tendon rupture associated with the direct injection into the tendon. Intramuscular Toradol injections provide significant analgesia, as well as an anti-inflammatory effect via its inhibitory effect on the cyclooxygenase pathway. The risk of bleeding associated with Toradol use is recognized but not accurately quantified.

Intratendinous septic abscess of the Achilles tendon after local steroid injection

In the treatment of pathological processes of the skeletal system, local injection of corticosteroid has become a common form of treatment. Although rare, pyogenic abscess can develop secondary to local corticosteroid injection. In this article, we describe the case of a patient who presented with pain, swelling, and hyperemia following local infiltration of corticosteroid about the Achilles tendon. Magnetic resonance image scanning of the Achilles tendon revealed a smoothly shaped intratendinous mass 3 x 1 cm in diameter, extending to the posterosuperior aspect of the calcaneus. A needle aspiration of the suspected abscess revealed S aureus, and subsequent surgical drainage and debridement revealed chronic inflammation secondary to infection at the site of previous local corticosteroid injection. Antibiotic therapy was used following incision and drainage, and recurrence of infection was not detected throughout the duration of follow-up.

LEVEL OF CLINICAL EVIDENCE

4.

Glucocorticoid injections in lesions of the achilles tendon

BACKGROUND

A number of non-operative interventions are used to manage Achilles tendinopathy. In particular, local glucocorticoid injections have generated controversy. Although a number of case reports indicate symptomatic relief following glucocorticoid injection, one systematic review found little evidence to support their efficacy. Furthermore, local glucocorticoid injections may be associated with rupture of the Achilles tendon. This systematic review considered all available clinical trials measuring the effect of local glucocorticoid injections on symptom relief in patients with Achilles tendinopathy.

MATERIALS AND METHODS

The search strategy encompassed five databases: Medline, EMBASE, CINAHL, AMED and the Cochrane Library. Only studies reporting the outcome of glucocorticoid injection for Achilles tendinopathy were included.

RESULTS

A total of 72 articles were identified, five of which met the inclusion criteria. These included one randomized controlled trial, three retrospective studies, and one prospective case series.

CONCLUSION

There is no consensus as to whether local glucocorticoid injections have a therapeutic role in the treatment of Achilles tendinopathy However, they may incur a risk of tendon damage and therefore further research is required before glucocorticoid injections can be recommended for use in Achilles tendinopathy.

Role of biomechanics in the understanding of normal, injured, and healing ligaments and tendons

Ligaments and tendons are soft connective tissues which serve essential roles for biomechanical function of the musculoskeletal system by stabilizing and guiding the motion of diarthrodial joints. Nevertheless, these tissues are frequently injured due to repetition and overuse as well as quick cutting motions that involve acceleration and deceleration. These injuries often upset this balance between mobility and stability of the joint which causes damage to other soft tissues manifested as pain and other morbidity, such as osteoarthritis.

The healing of ligament and tendon injuries varies from tissue to tissue. Tendinopathies are ubiquitous and can take up to 12 months for the pain to subside before one could return to normal activity. A ruptured medial collateral ligament (MCL) can generally heal spontaneously; however, its remodeling process takes years and its biomechanical properties remain inferior when compared to the normal MCL. It is also known that a midsubstance anterior cruciate ligament (ACL) tear has limited healing capability, and reconstruction by soft tissue grafts has been regularly performed to regain knee function. However, long term follow-up studies have revealed that 20–25% of patients experience unsatisfactory results. Thus, a better understanding of the function of ligaments and tendons, together with knowledge on their healing potential, may help investigators to develop novel strategies to accelerate and improve the healing process of ligaments and tendons.

With thousands of new papers published in the last ten years that involve biomechanics of ligaments and tendons, there is an increasing appreciation of this subject area. Such attention has positively impacted clinical practice. On the other hand, biomechanical data are complex in nature, and there is a danger of misinterpreting them. Thus, in these review, we will provide the readers with a brief overview of ligaments and tendons and refer them to appropriate methodologies used to obtain their biomechanical properties. Specifically, we hope the reader will pay attention to how the properties of these tissues can be altered due to various experimental and biologic factors. Following this background material, we will present how biomechanics can be applied to gain an understanding of the mechanisms as well as clinical management of various ligament and tendon ailments. To conclude, new technology, including imaging and robotics as well as functional tissue engineering, that could form novel treatment strategies to enhance healing of ligament and tendon are presented.

Achilles and patellar tendinopathy: current understanding of pathophysiology and management

PURPOSE

Achilles and patellar tendinopathy cause significant morbidity in professional and recreational athletes. Both the Achilles and patellar tendons are weight-bearing tendons that lack a true tendon sheath but are surrounded by paratenon.

METHOD

A review of the literature to outline the characteristics of tendinopathy in these two tendons, and to discuss current concepts of pathophysiology, use of imaging in the diagnosis and aid to clinical management strategies in tendinopathy.

RESULTS

Achilles and patellar tendinopathy share common histopathology such as intratendinous failed healing response and neoangiogenesis.

CONCLUSION

Achilles and patellar tendinopathy cause much morbidity in the athletic and non athletic population attending sports medicine and rheumatology clinics. Tendinopathy is essentially an 'overuse', degenerative condition. Neovascularisation evident on Doppler ultrasound correlates well with pain and poor function. Peritendinous injections and eccentric training decrease neovascularity, relieve pain and improve outcome. Although surgery is the last resort in those patients failing conservative management, it is still unclear how the removal of adhesions and excision of affected tendinopathic areas affects healing and vascularity, or resolves pain.

Surgery for chronic Achilles tendinopathy produces worse results in women

PURPOSE

To report the middle term outcome in male and female patients who underwent surgery for chronic recalcitrant Achilles tendinopathy.

METHODS

We tried to match each of the 58 female patients with a diagnosis of tendinopathy of the main body of the Achilles tendon with a male patient with tendinopathy of the main body of the Achilles tendon who was within two years of age at the time of operation. A match accordingly was possible for 41 female subjects.

RESULTS

Female patients were shorter and lighter than male patients. They had similar BMI, lower calf circumference, similar side-to-side calf circumference differences, and greater subcutaneous body fat than men. Of the 41 sedentary patients, only 25 reported an excellent or good result. Of these, three had undergone a further exploration of the Achilles tendon. The remaining patients could not return to their normal levels of activity despite prolonged supervised post-operative physiotherapy, with cryotherapy, massage, ultrasound, pulsed magnetic, and laser therapy.

CONCLUSION

Females experience more prolonged recovery, more complications, and a greater risk of further surgery than males with recalcitrant Achilles tendinopathy.

Nonoperative treatment of midportion Achilles tendinopathy: a systematic review

OBJECTIVE

The aim of this systematic review is to provide an easily accessible, clear summary of the best available evidence for nonoperative treatment of midportion Achilles tendinopathy.

DATA SOURCES

MEDLINE, CINAHL, and Embase through April 2007. Search terms: achilles tendon or tendo achilles or triceps surae or tendoachilles or tendo-achilles or achilles AND tendinopathy or tendinosis or tendonitis or tenosynovitis.

STUDY SELECTION

Of 707 abstracts reviewed, 16 randomized trials met our inclusion criteria.

DATA EXTRACTION

Data extracted from each paper included: patient demographics (age and sex), duration of symptoms, method of diagnosis, treatments, cohort size, length of follow-up, pain-related outcome data, and secondary outcome data.

DATA SYNTHESIS

The primary outcome measurement was change in numeric pain score. Focal tenderness, tendon thickness, and validated outcome scores were used secondarily. Eccentric exercises were noted to be equivalent to extracorporeal shockwave therapy (1 study) and superior to wait-and-see treatment (2 trials), traditional concentric exercise (2 of 3 trials), and night splints (1 study). Extracorporeal shockwave therapy was shown to be superior to a wait-and-see method in 1 study but not superior to placebo in another. Sclerosing injections were shown to be superior to placebo in 1 study, but local steroid treatment was beneficial in 2 of 3 studies. Injection of deproteinized hemodialysate and topical glyceryl nitrate application were beneficial in 1 trial each.

CONCLUSIONS

Eccentric exercises have the most evidence of effectiveness in treatment of midportion Achilles tendinopathy. More investigation is needed into the utility of extracorporeal shockwave therapy, local corticosteroid treatments, injections of sclerosing agents or deproteinized hemodialysate, and topical glyceryl nitrate application.

Treatment of tendinopathy: what works, what does not, and what is on the horizon

Tendinopathy is a broad term encompassing painful conditions occurring in and around tendons in response to overuse. Recent basic science research suggests little or no inflammation is present in these conditions. Thus, traditional treatment modalities aimed at controlling inflammation such as corticosteroid injections and nonsteroidal antiinflammatory medications (NSAIDS) may not be the most effective options. We performed a systematic review of the literature to determine the best treatment options for tendinopathy. We evaluated the effectiveness of NSAIDS, corticosteroid injections, exercise-based physical therapy, physical therapy modalities, shock wave therapy, sclerotherapy, nitric oxide patches, surgery, growth factors, and stem cell treatment. NSAIDS and corticosteroids appear to provide pain relief in the short term, but their effectiveness in the long term has not been demonstrated. We identified inconsistent results with shock wave therapy and physical therapy modalities such as ultrasound, iontophoresis and low-level laser therapy. Current data support the use of eccentric strengthening protocols, sclerotherapy, and nitric oxide patches, but larger, multicenter trials are needed to confirm the early results with these treatments. Preliminary work with growth factors and stem cells is promising, but further study is required in these fields. Surgery remains the last option due to the morbidity and inconsistent outcomes. The ideal treatment for tendinopathy remains unclear.

LEVEL OF EVIDENCE

Level II, systematic review.

Successful management of tendinopathy with injections of the MMP-inhibitor aprotinin

Aprotinin is a broad spectrum proteinase inhibitor (including matrix metalloproteinase [MMP] inhibitor) used for treating patellar and Achilles tendinopathies. One previous randomized control trial demonstrated aprotinin injections superior to both corticosteroid and saline injections in patellar tendinopathy (Level II), whereas results reported for aprotinin treatment in Achilles tendinopathy have been mixed. We performed a case review and followup questionnaire for 430 consecutive patients with tendinopathy treated by 997 aprotinin injections (30,000 KIU). A response rate of 72% was achieved with a minimum followup of 3 months (average, 12.2 months; range, 3-54 months). Seventy-six percent of patients had improved, 22% of patients reported no change, and 2% were worse. Sixty-four percent of patients thought aprotinin injections were helpful, while 36% believed they had neither a positive nor negative effect. Mid-Achilles tendinopathy patients (84% improvement) were more successfully treated than patellar tendinopathy patients (69% improvement). Despite stronger published evidence of benefit in patellar tendinopathy, clinical outcomes appeared better with aprotinin use in Achilles tendinopathies.

LEVEL OF EVIDENCE

Level IV, case series.

Injection therapies for soft-tissue lesions

Local injection therapies, used in the management of a variety of musculoskeletal pain syndromes, include the local infiltration of substances such as corticosteroid, anaesthetic, sclerosants and botulinum toxin, as well as dry needling alone and neural blockade. In this chapter, a number of injection therapies for soft-tissue-mediated pain are described. The reasoning for their use, potential mechanisms of action and unwanted effects are discussed. The literature relating to their effects is critically reviewed. Practical suggestions for their utilisation in the management of soft-tissue conditions are given and proposals are made for future research in this important area.

Chondral metaplasia in calcific insertional tendinopathy of the Achilles tendon

OBJECTIVE

To ascertain whether tendon samples harvested from patients with calcific insertional Achilles tendinopathy showed features of failed healing response, and whether abnormal quantities of type II collagen had been produced in that area by these tenocytes.

DESIGN

Comparative laboratory study.

DESIGN

University teaching hospitals.

PATIENTS

Tendon samples were harvested from eight otherwise healthy male individuals (average age 47.5+/-8.4 years, range 38 to 60) who were operated for calcific insertional Achilles tendinopathy and from nine male patients who died of cardiovascular events (mean age 63.1+/-10.9 years) while in hospital.

INTERVENTIONS

Open surgery for calcific insertional Achilles tendinopathy.

MAIN OUTCOME MEASURE

Semi-quantitative histochemical, immunohistochemical, and immunocytochemical methods to ascertain whether tendinopathic tendons were morphologically different from control tendons, and whether abnormal types of collagen were produced.

RESULTS

Tenocytes from tendons from patients with calcific insertional Achilles tendinopathy exhibit chondral metaplasia, and produce abnormally high quantities of collagen type II and III.

CONCLUSIONS

The altered production of collagen may be one reason for the histopathological alterations described in the present study. Areas of calcific insertional Achilles tendinopathy have been subjected to abnormal loads. These tendons may be less resistant to tensile forces. Further studies should investigate why some tendons undergo these changes.

Surgery for chronic Achilles tendinopathy yields worse results in nonathletic patients

OBJECTIVE

To report the outcome of surgery for chronic recalcitrant Achilles tendinopathy in nonathletic and athletic subjects.

DESIGN

Case-control study.

SETTING

University teaching hospitals.

PATIENTS

We matched each of the 61 nonathletic patients with a diagnosis of tendinopathy of the Achilles tendon with an athletic patient with tendinopathy of the main body of the Achilles tendon of the same sex and age (+/-2 years). A match was possible for 56 patients (23 males and 33 females). Forty-eight nonathletic subjects and 45 athletic subjects agreed to participate.

INTERVENTIONS

Open surgery for Achilles tendinopathy.

MAIN OUTCOME MEASURE

Outcome of surgery, return to sport, complication rate.

RESULTS

Nonathletic patients were shorter and heavier than athletic patients. They had greater body mass index, calf circumference, side-to-side calf circumference differences, and subcutaneous body fat than athletic patients. Of the 48 nonathletic patients, 9 underwent further surgery during the study period, and only 25 reported an excellent or good result. Of the 45 athletic subjects, 4 underwent further surgery during the study period, and 36 reported an excellent or good result. The remaining patients could not return to their normal levels of activity. In all of them, pain significantly interfered with daily activities.

CONCLUSIONS

Nonathletic subjects experience more prolonged recovery, more complications, and a greater risk of further surgery than athletic subjects with recalcitrant Achilles tendinopathy.

Soft tissue injections

Soft tissue rheumatism includes a wide spectrum of common lesions of the tendons, enthesis, tendon sheaths, bursae, ligaments and fasciae as well as nerve compression syndromes. Studies on the pathogenesis of these lesions do not support a major role for inflammation, thus questioning the rationale for glucocorticoid injections. This chapter reviews current indications for local glucocorticoid injections and available evidence on its efficacy, as well as contraindications and potential risks. Randomised controlled studies of good methodological quality are rare and there is limited scientific evidence to support the superiority of glucocorticoid injections over alternative treatments. The basic principles of the glucocorticoid injection method are outlined, together with a description of the practical procedure for the more common conditions.

Evidence-based treatment of foot and ankle injuries in runners

Foot and ankle injuries are common in runners. Treatment is becoming more evidence-based for the most common of these conditions; however, further research is needed to determine the best treatments for injuries that are encountered less commonly.

Complications associated with the use of corticosteroids in the treatment of athletic injuries

BACKGROUND

The potent anti-inflammatory pharmacologic effects of the corticosteroids (cortisone and synthetic derivatives) has led to their extensive usage in the management of rheumatologic diseases and athletic musculoskeletal injuries. The efficacy and risks of locally injected or systemically administered corticosteroids in the treatment of athletic injuries are unclear.

OBJECTIVE

To review critically the medical literature and determine complications and risks associated with corticosteroid treatment of athletic injuries.

DATA SOURCES

A search of 3 databases-MEDLINE, CINAHL, and Cochrane Clinical Trial Register-was performed using the OVID interface for all years between 1966 and 2003. The search first combined all references under the medical subject headings adrenal cortex hormones, glucocorticoids, and glucocorticoids, synthetic. A second search combined all references under the medical subject headings athletic injuries, sprains and strains, tendon injuries, shoulder injuries, rotator cuff disease, tennis elbow, and lateral epicondylitis. The references identified by these 2 searches were intersected and limited to human only to produce 130 articles. Relevant review articles were scanned, references reviewed, and additional articles retrieved for consideration of inclusion.

STUDY SELECTION

For inclusion in this critical review, articles must meet the following criteria: (1) subjects were human, (2) subjects had athletic-related injuries, and (3) subjects received corticosteroid treatment. Ultimately, 43 studies met inclusion criteria.

DATA EXTRACTION AND SYNTHESIS

Selected articles were then categorized as to whether the primary focus was usage/efficacy of corticosteroid injection therapy, occurrence of complications of corticosteroid injection therapy, or usage or complications of systemic corticosteroid therapy.

MAIN RESULTS

Twenty-five selected studies primarily examined the usage/efficacy of corticosteroid injections in the treatment of various athletic injuries. Of the 983 total subjects who received corticosteroid injections among these studies, only minor complications of treatment were reported. Eighteen selected studies primarily described complications of corticosteroid injections in the treatment of athletic injuries. Of these, tendon and fascial ruptures were the predominant complications reported. The search identified no articles that addressed the usage of or complications of systemic corticosteroids in the treatment of athletic injuries, although tibial stress fracture and multifocal osteonecrosis occurred in individuals being treated for nonathletic injury conditions.

CONCLUSIONS

This critical review reveals that the existing medical literature does not provide precise estimates for complication rates following the therapeutic use of injected or systemic corticosteroids in the treatment of athletic injuries. Tendon and fascial ruptures are often reported complications of injected corticosteroids, whereas tibial stress fractures and multifocal osteonecrosis were described with systemic corticosteroids.

Achilles tendonopathy and tendon rupture: conservative versus surgical management

Injuries to the Achilles tendon are common in primary care. Insertional tendonitis, retrocalcaneal bursitis, and paratenonitis are acute injuries usually treated conservatively with rest, ice, anti-inflammatory measures, and physical rehabilitation. Causative factors such as improper training or biomechanical abnormalities must be corrected to prevent reoccurrence. Achilles tendinosis is a chronic condition that does not always cause clinical symptoms. When symptoms occur, they are thought to be due to microtrauma or progressive failure resulting in inflammation. Again, conservative treatment usually relieves symptoms, but treatment may be prolonged. Surgical treatment may occasionally be recommended. With rupture of the Achilles, there exists some controversy regarding the advantage of conservative versus surgical management. Treatment should be based on individual patient considerations and expectations.