Achilles tendinopathy is the most common overuse injury in sport, and it is common in non-athletes as well. High volume image guided injection and structured rehabilitation (HVIGI+SR) has been shown in repeated studies to provide significant improvement in pain and function, and reductions in neovascularization and tendon thickness. Traditionally, these injections have included 25 mg of hydrocortisone acetate. Given the steroid’s potential to degrade the tendon, researchers from the United Kingdom and Spain conducted a pilot study to determine if the steroid was indeed necessary to maintain the clinical benefit of the HVIGI+SR regimen.
The researchers recruited 23 patients with 26 tendinopathies who were allowed to choose between injections of 10 mL of 0.5% Marcaine combined with either 40 mL of normal saline with 25 mg of hydrocortisone (n = 12) or 40 mL of saline alone (n=14). Injections were given with patients in supine position, hip externally rotated, knees flexed to 45o, ankle plantar grade. Using aseptic technique, a 21-guage needle was inserted between the Achilles tendon anterior aspect and Kager’s fat pad, using ultrasound to identify neovascularization.
Assessments, including the Victorian Institute of Sports Assessment – Achilles (VISA-A) and a 100-mm visual analogue scale (VAS) designed to assess pain and symptoms both pre- and post-injection, were given pre-injection, at 2, 6, and 10 weeks post-injection, and at 12 months follow-up.
Both groups showed significant improvement in the VISA-A across all follow-ups. There was no significant difference in the VAS scores between the 2 groups: For those who chose steroid, VAS pain scores improved by 40.8 mm (P=.01) and symptom scores improved 31.7 mm (P=0.05). For those who chose no steroid, VAS pain scores improved 49.7 mm (P<.01) and symptom scores improved 46.3 (P<.01).
The authors concluded that their short-term results show that HVIGI+SR without steroid may be a viable treatment for this common but difficult-to-treat condition, particularly for patients who want a conservative option, and they called for full-scale clinical trials to confirm their pilot findings.
Abdulhussein H, Chan O, Morton S, et al. High volume image guided injections with or without steroid for mid-portion Achilles tendinopathy: A pilot study. Clin Res Foot Ankle. 2018:5:249.