Ryan M; Wong A; Rabago D; Lee K; Taunton J. Ultrasound-guided injections of hyperosmolar dextrose for overuse patellar tendinopathy: a pilot study [In Process Citation] Br J Sports Med 2011; 45(12):972-7.
DR. REEVES’ NOTES:
Chronic infrapatellar tendinopathy presents a challenge to the physician, especially after failing conservative exercise-based treatments. No single therapy has been identified. Dextrose injection treatments show promise for helping reduce pain at the plantar fascia, Achilles and adductor tendon injury sites. Ryan et al conducted a consecutive patient study of 47 subjects with a mean of four injection sessions and showed a reduction in pain and a correlated improvement in the ultrasound appearance. This suggests that dextrose affects patellar tendinopathy at a tissue level.
The abstract is available below.
To evaluate whether ultrasound-guided injection of hyperosmolar dextrose for treatment of patellar tendinopathy decreases pain scores and normalises the appearance of the patellar tendon on ultrasound.
Subjects were referred from primary care clinics and failed conservative treatment. Subjects received a diagnostic ultrasound examination, then ultrasound-guided injection of 25% dextrose with lidocaine into the area of tendinopathy until they were satisfied with treatment. The primary outcome measure was a three-part visual analogue scale (VAS; baseline and mean of 45 weeks after start of treatment) for pain at rest, activities of daily living (ADL) and during sport. Secondary outcomes included segmental ultrasound examinations assessing tendon hypoechogenicity (area and severity score), neovascularity (severity score) and the presence or absence of intratendinous tearing and calcification, irregularities of cortical bone and thickness.
47 consecutive referrals were included. Subjects received a mean of four (3) injection sessions. At mean 45 weeks post-enrollment, subjects reported a reduction in pain across the three VAS items (rest 38.425-18.718.4; ADL 51.122.9-25.820.1; sport 78.115.7-38.826.1; p <0.01). There was improvement in neovascularity following the dextrose injection. A significant correlation between hypoechogenicity severity scores and pain at follow-up is reported.
There was a reduction in pain and an improvement in ultrasound appearance following ultrasound-guided dextrose injections for refractory patellar tendinopathy. An improved hypoechoic appearance of the tendon was associated with decreased pain scores, suggesting that dextrose injections may modify patellar tendinopathy at the tissue level and that fibrillar changes may play a role in tendon nociception.
Orchard J; Massey A; Brown R; Cardon-Dunbar A; Hofmann J. Successful management of tendinopathy with injections of the MMP-inhibitor aprotinin. Clin Orthop Relat Res (United States), Jul 2008, 466(7) p1625-32
DR. REEVES’ NOTES:
Injection of solutions that block breakdown of tissue may also help healing. Metalloproteinase (collagenase is an example) breaks down issue and an inhibitor of metalloprotinease has been found to help some cases of tendon damage.
A copy of the study on Aprotinin Injection in PDF format is available here.
An abstract of the study on Aprotinin Injection is available here, with a copy of the content below.
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.
Volpi P, Marinoni L, Bait C, De Girolamo L, Schoenhuber H. Treatment of chronic patellar tendinosis with buffered platelet rich plasma: a preliminary study. Medicina DelloSport. 2007;60(4):595-603.
DR. REEVES’ NOTES:
8 athletes considering surgery with chronic patellar tendinosis recalcitrant to physical therapy were given a single injection of PRP with MRI imaging Pre and Post and VISA (Victorian Institute Sports Assessment) score (1 to 100 with 100 best for ability to play sports ) Pre and Post. At 120 day follow-up 1 had breeched protocol by early (40 day) return to full sport with flare and election for surgery. VISA score improved from 39 to 75 for the remaining 7 patients and MRI showed an improvement in irregularity of tendon for 80%. 1 year or more of symptoms. Non responsive to traditional PT, shock wave therapy, and TECAR therapy. PRP infiltration was under ultrasound guidance after 0.5 ml lidocaine infiltration. 3 ml volume with 7-8 repositionings and then supine for 30 minutes without movement. Progressive activity to full sport at 12 weeks.
This pilot study needs to be followed with a larger and preferably blinded study but objective measures will add significant weight to conclusions in a large size consecutive patient trial. The return to sport was prolonged in this group and perhaps more frequent treatment will enable quicker return to improve compliance. Mention was not made of how many of the 7 went back to full sport and how many received additional treatment to enable that.
Alfredson H; Ohberg L Neovascularisation in chronic painful patellar tendinosis–promising results after sclerosing neovessels outside the tendon challenge the need for surgery. Knee Surg Sports Traumatol Arthrosc (Germany), Mar 2005, 13(2) p74-80
DR. REEVES’ NOTES:
Fifteen elite or recreational athletes with patellar tendinosis/jumpers knee were injected with Polidocanol, targeting areas of neovascularization. At 6 month followup there was a good clinical result in 12/15 tendons. With previous sport level reached in 12/15 and pain decrease (VAS) from 81 to 10 on a 100 point scale.
An abstract of the study is available below.
Sclerosing injections targeting neovascularisation have been demonstrated to give promising clinical results in patients with chronic painful Achilles tendinosis. In this study, fifteen elite or recreational athletes (12 men and three women) with the diagnosis patellar tendinosis/Jumper’s knee in 15 patellar tendons were included. All the patients had a long duration of pain symptoms (mean = 23 months) from the patellar tendon, and ultra-sonography + colour doppler examination showed structural tendon changes with hypo-echoic areas and a neovascularisation, corresponding to the painful area. The patients were treated with ultrasound and colour doppler-guided injections of the sclerosing substance Polidocanol, targeting the area with neovascularisation.
At follow-up (mean = 6 months) after a mean amount of three treatments, there was a good clinical result in 12/15 tendons. The patients were back to their previous (before injury) sport activity level, and the amount of pain recorded on a VAS-scale had decreased significantly (VAS from 81 to 10). Our findings indicate that treatment with sclerosing injections, targeting the area with neovessels in patellar tendinosis, has the potential to cure the pain in the tendons and also allow the patients to go back to full patellar-tendon loading activity.