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US-guided high-volume injection for Achilles tendinopathy

George A. Kakkos
George A. Kakkos
, 
Michail E. Klontzas
Michail E. Klontzas
, 
Emmanouil Koltsakis
Emmanouil Koltsakis
 y 
Apostolos H. Karantanas
Apostolos H. Karantanas
   | 18 jun 2021
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Article Category: review-article
Publicado en línea: 18 jun 2021
Páginas: 127 - 133
Recibido: 11 feb 2021
Aceptado: 16 mar 2021
DOI: https://doi.org/10.15557/jou.2021.0021
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© 2021 Polish Ultrasound Society. Published by Medical Communications Sp. z o.o.
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.

Fig. 1.

Longitudinal B-mode image of the Achilles tendon in a patient with chronic mid-portion Achilles tendinopathy. Fusiform swelling with increased anterior-posterior diameter and reduced echogenicity of the superficial part of the tendon are shown
Longitudinal B-mode image of the Achilles tendon in a patient with chronic mid-portion Achilles tendinopathy. Fusiform swelling with increased anterior-posterior diameter and reduced echogenicity of the superficial part of the tendon are shown

Fig. 2.

Longitudinal color Doppler image of the Achilles tendon in the same patient as in Fig. 1, demonstrating florid neovascularity with intratendinous neovessels inserting from the ventral side of the tendon
Longitudinal color Doppler image of the Achilles tendon in the same patient as in Fig. 1, demonstrating florid neovascularity with intratendinous neovessels inserting from the ventral side of the tendon

Fig. 3.

The Achilles tendon is best scanned with the patient prone. The foot overhangs the end of the examination bed to allow tendon movement ( A ). Medial approach using a freehand in-plane technique. The ultrasound probe is held transversely relative to the Achilles tendon ( B )
The Achilles tendon is best scanned with the patient prone. The foot overhangs the end of the examination bed to allow tendon movement ( A ). Medial approach using a freehand in-plane technique. The ultrasound probe is held transversely relative to the Achilles tendon ( B )

Fig. 4.

Transverse image during a high-volume image-guided injection showing needle placement ventral to the tendon between the tendon and the Kager’s fat pad ( A ). Drawing demonstrating the target area between the tendon and the Kager’s fat pad, aiming at stripping the tendon from neovessels originating from its ventral side (created with biorender.com) ( B )
Transverse image during a high-volume image-guided injection showing needle placement ventral to the tendon between the tendon and the Kager’s fat pad ( A ). Drawing demonstrating the target area between the tendon and the Kager’s fat pad, aiming at stripping the tendon from neovessels originating from its ventral side (created with biorender.com) ( B )

Fig. 5.

Longitudinal color Doppler image of the Achilles tendon in the same patient as in Fig. 2 after the HVIGI procedure, showing no remaining intratendinous neovessels
Longitudinal color Doppler image of the Achilles tendon in the same patient as in Fig. 2 after the HVIGI procedure, showing no remaining intratendinous neovessels

Summary of published evidence for the application of HIVIGI in Achilles tendinopathy

Author (year) Study type Intervention N Change in VAS score Change in VISA-A score Conclusion
Chan et al. (2008)(28) Case series 10 ml 0.5% Bupivacaine25 mg Hydrocortisone40 ml N Saline 30 N = 212 weeks – 50 mm30 weeks – 47 mm 30 weeks + 31.4 HVIGI significantly reduces pain and improves function in patients with resistant Achilles tendinopathy in the short- and long-term
Humphrey et al. (2010)(29) Case series 10 ml 0.5% Bupivacaine25 mg Hydrocortisone40 ml N Saline 11 – 3 weeks + 38 HVIGI for resistant tendinopathy of the main body of the Achilles tendon is effective to improve symptoms, reduce neovascularisation, and decrease maximal tendon thickness at short-term follow-up
Restighini and Yeoh (2012)(30) Case series 5 ml 1% Lidocaine25 mg Hydrocortisone up to40 ml N Saline 32 4 weeks – 34 mm3 months – 37 mm 4 weeks + 263 months + 28.7 HVIGI is safe and clinically cost-effective in the treatment of Achilles tendinopathy. Results suggest that baseline neovascularity is relevant to outcome following injection
Maffuli et al. (2013)(31) Case series 10 ml 0.5% Bupivacaine25 mg Aprotinin up to40 ml N saline 94 – 12 months + 32.9 HVIGI with aprotinin significantly reduces pain and improves function in patients with chronic Achilles tendinopathy in the short-and long-term follow-up
Wheeler et al. (2014)(32) Case series 10 ml 1% Lidocaine40 ml N Saline No corticosteroid 16 347 days ‒ 6.1/10 347 days + 41 HVIGI without a corticosteroid appears to be an effective procedure for patients with recalcitrant Achilles tendon symptoms. Further work is needed to formally establish benefits from HVIGI for patients with Achilles tendinopathy and to identify optimal injectate
Wheeler et al. (2016)(33) Case series – 2 Groups Group 1:10 ml 1% Lidocaine40 ml Saline Group 2:10 ml 1% Lidocaine20 ml Saline + dry needling 34 Group 1:81 days ‒ 4.6/10 Group 2:No data Group 1:281 days + 33.4 Group 2: 271 days + 6.94 HVIGI reduces VISA-A scores in both groups. A higher volume without dry needling compared with a lower volume with dry needling resulted in greater improvement in noninsertional Achilles tendinopathy
Boesen et al. (2017)(34) Case series – 3 Groups All subjects performed eccentric training Group 1:10 ml 0.5% Bupivacaine20 mg Depo-Medrol40 ml N saline Group 2: PRP injections each 14 days apart Group 3:Placebo (a few drops of saline under the skin) 60 Group 1:6 weeks – 48.5 mm12 weeks –44.9 mm24 weeks -34.1 mm Group 2:6 weeks – 37.3 mm12 weeks –40.9 mm24 weeks –37.1 mm Group 3:6 weeks – 22.5 mm12 weeks –29.5 mm24 weeks –18.1 mm Group 1:6 weeks + 27.112 weeks + 28.824 weeks + 22.2 Group 2:6 weeks + 13.812 weeks + 14.824 weeks + 19.6 Group 3:6 weeks + 9.912 weeks + 10.624 weeks + 8.8 Treatment with HVIGI or PRP in combination with eccentric training in chronic AT seems more effective in reducing pain, improving activity level, and reducing tendon thickness and intratendinous vascularity than eccentric training alone. HVIGI may be more effective in improving outcomes of chronic AT than PRP in the short term
Boesen et al. (2019)(35) Case series –2 Groups All subjects performed eccentric training Group 1:10 ml 0.5% Bupivacaine20 mg Depo-Medrol40 ml N saline Group 2:10 ml 0.5% Bupivacaine40 ml N saline 28 Group 1:6 weeks – 55.4 mm12 weeks –52.6 mm24 weeks –40.1 mm Group 2:6 weeks –16.1 mm12 weeks –25 mm24 weeks –33.9 mm Group 1:6 weeks + 30.612 weeks + 31.924 weeks + 26.4 Group 2:6 weeks + 13.812 weeks + 14.824 weeks + 23.7 High-volume injection with or without corticosteroid in combination with eccentric training seems effective in AT. HVIGI with corticosteroid showed a better short-term improvement than HVIGI without corticosteroid, indicating a short-term effect of corticosteroid in HVIGI treatment of AT
Nielsen et al. (2020)(36) Case series 10 ml 0.5% Marcaine0.5 mL Triamcinolonacetonid (40 mg/mL)40 ml N saline 30 – 12 months10 patients + 11 In this retrospective case-study, only 10 patients (33%) benefitted from a single HVIGI treatment at 12 months and an 11-point significant improvement was seen on the VISA-A score
Edwards and Sivan (2020)(37) Case series 2 ml 0.25% Bupivacaine0.5 ml (20 mg) Kenalog37.5 ml N saline 18 Numeric rating scale of pain (NRS) 8 weeks – 5.3 – Significant reduction in pain, tendon thickness and neovascularity were observed in 78% of patients. The recurrence rate was 39%. HVIGI with eccentric training is a safe and effective intervention in an outpatient clinic setting
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