There are a range of therapies that have been suggested as possible treatments for the treatment of Achilles tendinopathy. This edition of the FastFact highlights a paper, published in the BMJ, that evaluates the effectiveness of high volume injections.1
High volume injections involve injecting a large amount of fluid into the area surrounding a painful tendon. The aim of this type of procedure is to obliterate peri-tendinous and intra-tendinous neovascularisation (using mechanical pressure) and in doing so improve a patient’s symptoms. There is some limited evidence that these injection can be effective. These papers have small sample sizes, involve the injection of corticosteroids (along with saline) and a range of other methodological concerns. The effectiveness has not been tested in large well designed studies.
In this patient- and assessor-blinded, placebo controlled, randomised clinical trial a total of 80 adults (aged 18-70 years) who had been diagnosed with mid-portion Achilles tendinopathy and who had neovascularisation on ultrasound were recruited. A total of 39 were randomised to a high volume injection (without corticosteroids) and 41 to the placebo arm. All of the study participants underwent an exercise programme for 24 weeks. Those in the intervention group had a single 50 mL high volume injection of saline and lidocaine while those in the control group had a single 2 mL injection of saline and lidocaine. The primary outcome measure was the validated Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire. There were a range of secondary outcome measures including patient satisfaction, ability to return to sport, ultrasound appearance and a range of functional measures. Participants were evaluated at baseline and at 2, 6, 12, and 24 weeks.
Over the course of the study there was a clinically significant improvement in the VISA-A scores in both groups. There was no statistically significant difference between the groups in either the VISA-A scale or the other outcomes measures. It should be noted that patient satisfaction was relatively poor with approximately 50% of participants in each group reporting a good or excellent outcome (57% in the intervention group and 49% in the control group). Less than 20% of the patients in each group were able to return to their pre-injury level of sport.
This is a well designed and implemented clinical trial. Based on the results of this study it would appear that high volume injections are not an effective treatment for Achilles tendinopathy. It is important to highlight that the results may not be generalisable to younger, elite football players. The relatively short follow-up period is also worth highlighting.
1. van der Vlist Arco C, van Oosterom Robert F, van Veldhoven Peter L J, Bierma-Zeinstra Sita M A, Waarsing Jan H, Verhaar Jan A N et al. Effectiveness of a high volume injection as treatment for chronic Achilles tendinopathy: randomised controlled trial BMJ 2020; 370 :m3027