Treatments for Achilles Tendinopathy — CJSM Blog Post Journal Club

We’re celebrating our 30th Anniversary!!! Take a look what’s beneath the new, sleek cover.

We are celebrating our 30th year of publication in 2020 and we could not be happier to ring this new year in than with the publication of our January 2020 issue, full of the sorts of offerings that make CJSM a special part of the sports medicine universe. From original research to systematic reviews to case reports, we have several new offerings that help clinicians bring the latest in evidence-based medicine to their patients on the pitch, in the training rooms, and in the clinics.

One of those studies reports research results reported by authors practicing in the UK and deals with a very common problem among athletes: Novel Inerventions for Recalcitrant Achilles Tendinopathy.

Dr. Zaremski & assistant take a break from their writing.

This prospective cohort study is the focus of our first blog post journal club of the year, with CJSM Associate Editor Jason Zaremski M.D. guiding us through the ins and outs of the study.  Take it away Dr. Zaremski!

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Introduction:  As we begin a new decade and say goodbye to 2019, the winter CJSM journal club will be focusing on an issue that is extremely common in all individuals, chronic Achilles tendon injury. As many individuals make New Year’s resolutions to exercise more and live healthier lifestyles, we as sports medicine and musculoskeletal experts must be prepared for an increase in overuse injuries such as tendinopathies.  These conditions can be difficult to treat, and new, novel approaches to these common conditions are always of interest. A new study by Wheeler and Tattersall is a timely publication to review in this new year: Novel Interventions for Recalcitrant Achilles Tendinopathy. Benefits Seen Following High-Volume Image-Guided Injection or Extracorporeal Shockwave Therapy—A Prospective Cohort Study.

Purpose: The authors of this study set out to compare the outcomes for patients with chronic non-insertional Achilles tendinopathy (CNIAT) following extracorporeal shockwave therapy (ESWT) versus high-volume image-guided injection (HVIGI). The results may provide practitioners greater information for patients and to improve patient care.

Methods/Design:  This is a Prospective cohort study performed at a single Sports Medicine department.

63 patients with CNIAT with no signs of a partial thickness tear on ultrasonography prior to any procedure were confirmed. 41% of participants were male, 59% female, with a mean duration of symptoms of 27.7 months (range of three months to ten years). Mean age was 51.2 years (range 34-75, and mean length of symptoms was 27.8 months. 22 patients were treated with ESWT and 41 with HVIGI with a minimum of a three months follow-up. For ESWT patients average age was 48.9 (7.28 years), 24 % male, and average duration of symptoms 32.7 (25.6 months); For HVIGI participants average age was 52.7 (10.0 years), 33% male, and 18.2 (10.5 months) average duration of symptoms.

All patients were treated and failed a structured rehabilitation program. All patients were able to choose which modality they wanted performed. Written consent was obtained prior to any procedure. In addition, all procedures were registered with the hospital’s Procedure Group and the hospital audit team.

Interventions:  Patients received either three sessions of ESWT (1 session per week) or a single ultrasound-guided HVIGI (10 mL of 1% lidocaine and 40 mLs of sterile saline).  After either procedure, patient education included information about the aforementioned home exercise program, relative rest/light activities for 24 hours, re-initiating static stretches for 48 hours, and progression into an eccentric strengthening–based rehabilitation exercises depending on symptoms. Patient were normally evaluated again in clinic at approximately six weeks and three months and then as needed.

HVIGI Procedure: A single Sport and Exercise Medicine physician (not an author) with more than 10 years of experience performed the musculoskeletal ultrasound HVIGI procedure. The patient was positioned supine in a semi-recumbent, with their hip externally rotated, their knee flexed to approximately 45 degrees and their ankle in a relaxed neutral position. The Achilles tendon was scanned using a portable ultrasound machine with either a linear or “hockey-stick” probe, in both transverse and longitudinal views. Following cleaning of the skin with a clinical disinfectant wipe, under direct ultrasound visualization, using a short-axis view of the Achilles tendon, a 21-gauge needle was inserted deep to the tendon, on the deep/anterior surface, between the Achilles tendon and Kager’s fat pad. This needle had a connecting tube, a three- way tap attached to this, and a total of 10 mL of 1% lidocaine was injected, followed by 40-mL sterile saline to give a total of 50 mL of total fluid volume injected. The injection was performed under constant ultrasonographic visualization, ensuring optimal needle placement abutting, but not entering, the Achilles tendon. The technique was performed under sterile, no-touch technique with sterile ultrasound gel.

ESWT Procedure: Either one of the two authors of this study performed this procedure. The patients were positioned prone with their ankle over the end of the couch. Slight dorsiflexion was applied, and the site of maximal tenderness to palpation was identified. The ESWT was conducted using a portable ESWT machine with the manufacturer specified settings (frequency of 10.0 Hz and 2000 shocks per treatment). The energy level was set at the patient’s maximal comfortably tolerated dose. The mean (SD) bar pressures for each treatment sessions were as follows: ESWT-1: 52.1(0.3), ESWT-2: 52.6(0.3), ESWT-3: 52.9(0.4). Patients were advised to avoid NSAIDs for a few days before and after each ESWT session.

Data Acquisition:

Outcome Measures: The visual analog scale (VAS) (0-10 scoring) for self-reported “average pain” and “average stiffness” values was used.  Additionally, the Victoria Institute of Sport—Achilles questionnaire, (VISA-A), and Manchester-Oxford Foot Questionnaire (MOXFQ) were used. The primary outcome measure was a change in self-reported average pain at three months.

Statistical Measures/Analysis:  As the authors noted in their study, data were recorded at baseline and at clinic follow-up and analyzed in SPSS. Statistical significance was set at P<0.05.  Analysis was performed with parametric tests such as paired samples t tests within groups, independent samples T-tests between groups, and Pearson correlation testing. Comparisons were made between the baseline data and data at six weeks, three months, and six month follow-up appointments for all participants for each intervention and between groups.

Results/Outcomes:

Neither age nor gender varied significantly between the two groups. However, there was a statistically longer mean duration of symptoms in the HVIGI group than in the ESWT group. There were statistically significant improvements in self-reported measures of pain and stiffness following both procedures. Data were available for 29 of 41 patients (71%) in the HVIGI group at 3 months and 17 of 22 (77%) in the ESWT group. At six months, data were only available for 14 of 41 in the HVIGI group (34%) and 12 of 22 (55%) in the ESWT group.

At three months: VAS (pain) was improved from 6.7 to 3.6 (P=0.001) following HVIGI and from 6.6 to 4.4 (P=0.002) following ESWT.  VISA-A improved from 35% to 51% (P<0.001) following HVIGI and from 34% to 49% (P<0.001) following ESWT.

At six months: VAS (pain) was improved from 6.7 to 3.5 (P<0.001) following HVIGI and from 6.6 to 4.6 (P=0.002) following ESWT.  (P=0.007). VISA-A improved from 35% to 52% (P=0.002) following HVIGI and from 34% to 48% (P=0.066) following ESWT.

There was no statistical significance for changes in average stiffness at any time point and with either procedure as well as utilizing the MOXFQ questionnaire.

Strengths:

• As the authors state, this is the first comparison study of these two treatment modalities for CNIAT
• In the hands of experienced clinicians, both of these procedures may be performed safely in a clinic setting and may provide improvement with respect to pain and function

Weaknesses:

• Small sample size in both groups
• Lack of randomization, participants were not blinded, and the participants were able to choose which procedure they preferred (selection bias).
• There was no consistency with which physicians performed each procedure
• The authors state a graded eccentric loading program was performed for a minimum of two months. The details of this program were omitted from the discussion. How many times per day and per week was this performed? Were the patients actually compliant? And if so how was this confirmed? There needs to be greater detail and uniformity when using rehabilitation in a research study as a pre-treatment modality.
• There was no exact specification of how long to avoid NSAIDS with ESWT procedure
• There were different time frames for the improvements with each procedure (six weeks for ESWT and at three months for HVIGI.) However, the authors state this can, in part, be explained due to several patients in the HVIGI group having symptoms recorded of 10 years in duration before the procedure.
• It should be noted that two of the outcome measure tools (VAS, and MOXFQ) were not functional tools; they are primarily pain related tools (VAS) and a patient reported outcome (PRO) tool following foot and/or ankle surgical intervention.
• While not a weakness, it would be important for the authors to state when they performed the ultrasonographic examination of the achilles tendon whether they saw any evidence of neovascularization. Using this as a data point, it would be important to compare those participants that had neovascularization versus those that did not and analyze their response to the respective treatments.

Conclusion:

Based upon the data, patients with CNIAT improved following either a HVIGI or ESWT procedure. However, we cannot state with confidence the superiority of one modality over the other.

Clinical Relevance:

The usage of either HVIGI or ESWT may be a suitable modality for treatment in patients with for CNIAT. In the future it would be very interesting to compare CNIAT to insertional achilles tendinopathy with both of these procedures.

Jason Zaremski, M.D.