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*Results of a randomised clinical trial*:
Effectiveness of a high volume injection as treatment for chronic Achilles tendinopathy
@bmj_latest @BJSM_BMJ @rj_devos @janverhaar @BiermaS @MCHSport @ErasmusMC @ReumaNederland
#Open Access https://www.bmj.com/content/370/bmj.m3027
Thread*
Effectiveness of a high volume injection as treatment for chronic Achilles tendinopathy
@bmj_latest @BJSM_BMJ @rj_devos @janverhaar @BiermaS @MCHSport @ErasmusMC @ReumaNederland
#Open Access https://www.bmj.com/content/370/bmj.m3027
Thread*
1/
Achilles tendinopathy is a common disorder that is often difficult to treat, Effective treatment options are necessary to improve outcome of patients who fail to respond to usual care.
Achilles tendinopathy is a common disorder that is often difficult to treat, Effective treatment options are necessary to improve outcome of patients who fail to respond to usual care.
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Neovascularisation and adjacent nerve infiltration in/around the Achilles tendon is of increasing interest, as this is usually seen in patients with tendinopathy and mostly absent in healthy tendons. Neovessels are suggested to play a role in the chronicity of symptoms.
Neovascularisation and adjacent nerve infiltration in/around the Achilles tendon is of increasing interest, as this is usually seen in patients with tendinopathy and mostly absent in healthy tendons. Neovessels are suggested to play a role in the chronicity of symptoms.
3/
So how could neovessels be used for therapeutic interventions? A novel conservative treatment option is a high volume injection (HVI), which aims to destruct this neovascularisation and adjacent nervesthrough high mechanical pressure.
So how could neovessels be used for therapeutic interventions? A novel conservative treatment option is a high volume injection (HVI), which aims to destruct this neovascularisation and adjacent nervesthrough high mechanical pressure.
4/
Previous results are very promising, however it has not been tested in a large well-designed RCT. The aim of this study was to compare effectiveness of a HVI to a placebo injection in addition to usual care (education and exercise therapy).
Previous results are very promising, however it has not been tested in a large well-designed RCT. The aim of this study was to compare effectiveness of a HVI to a placebo injection in addition to usual care (education and exercise therapy).
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So what did we do? 80 adult patients with chronic midportion Achilles tendinopathy were randomized to receive 1) a 50cc HVI or 2) a 2cc placebo injection. Injections mixtures were similar, consisting of saline and lidocaine. No corticosteroids were added.
So what did we do? 80 adult patients with chronic midportion Achilles tendinopathy were randomized to receive 1) a 50cc HVI or 2) a 2cc placebo injection. Injections mixtures were similar, consisting of saline and lidocaine. No corticosteroids were added.
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Subsequently, all patients were instructed to perform an exercise programme (gradually progressing from isometric to isotonic, eccentric and plyometric exercises) and gradual return to sport.
Subsequently, all patients were instructed to perform an exercise programme (gradually progressing from isometric to isotonic, eccentric and plyometric exercises) and gradual return to sport.
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To evaluate outcome, we assessed the validated VISA-A score at 24 weeks as primary outcome.
Secondary outcomes included patient satisfaction and return to sport at 2, 6, 12, and 24 weeks (more outcomes in full manuscript)
To evaluate outcome, we assessed the validated VISA-A score at 24 weeks as primary outcome.
Secondary outcomes included patient satisfaction and return to sport at 2, 6, 12, and 24 weeks (more outcomes in full manuscript)
8/
Our lost to follow-up rate was only 1%. The course over time for the VISA-A score is presented for both groups. Both groups improved over time, however there are no significant or clinically relevant between group-differences at any time point.
Our lost to follow-up rate was only 1%. The course over time for the VISA-A score is presented for both groups. Both groups improved over time, however there are no significant or clinically relevant between group-differences at any time point.
9/
Also, no between-group difference was present at 24 weeks for patient satisfaction (57% vs 49%) and for return to sport (52 vs 61%), nor for any of the other secondary outcomes.
Also, no between-group difference was present at 24 weeks for patient satisfaction (57% vs 49%) and for return to sport (52 vs 61%), nor for any of the other secondary outcomes.
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But was the procedure performed successful? Doppler flow to visualise neovascularisation disappeared in 79% of the patients after the injection procedure in the HVI group, compared to 30% in the placebo group.
But was the procedure performed successful? Doppler flow to visualise neovascularisation disappeared in 79% of the patients after the injection procedure in the HVI group, compared to 30% in the placebo group.
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We tested whether the blinding procedure was successful by asking patients directly after the injection procedure: which type of injection do you think you have received? Approximately half of the patients guessed it correctly, which supports an adequate blinding.
We tested whether the blinding procedure was successful by asking patients directly after the injection procedure: which type of injection do you think you have received? Approximately half of the patients guessed it correctly, which supports an adequate blinding.
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Consequently, previously observed short-term improvement after HVIs is not a result of mechanical pressure on the neovessels, but is probably related to the corticosteroids in the mixture. We excluded corticosteroids as these are known to have detrimental long term effects.
Consequently, previously observed short-term improvement after HVIs is not a result of mechanical pressure on the neovessels, but is probably related to the corticosteroids in the mixture. We excluded corticosteroids as these are known to have detrimental long term effects.
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In conclusion, a high volume injection without corticosteroids has no added value to usual care in patients with chronic midportion Achilles tendinopathy.
In conclusion, a high volume injection without corticosteroids has no added value to usual care in patients with chronic midportion Achilles tendinopathy.
14/
Importantly, exercise therapy, patient education, and load management demonstrated to still be beneficial in patients with no previous improvement after calf muscle exercise training. So stimulate your patients to continue these interventions and improve them where possible!
Importantly, exercise therapy, patient education, and load management demonstrated to still be beneficial in patients with no previous improvement after calf muscle exercise training. So stimulate your patients to continue these interventions and improve them where possible!
