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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