Knee Surg Sports Traumatol Arthrosc DOI 10.1007/s00167-014-3458-7
ANKLE
Ultrasound‑guided dry needling with percutaneous paratenon decompression for chronic Achilles tendinopathy Andrea Yeo · Namita Kendall · Sunderarajan Jayaraman
Received: 19 May 2014 / Accepted: 20 November 2014 © European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2014
Abstract Purpose Chronic Achilles tendinopathy is a common overuse injury. There are several modalities of treatment, reflecting difficulties in management. In particular, due to the well-recognised surgical morbidity, treatment has steered towards less invasive routes. Previous studies have targeted pathology either inside or outside the tendon in isolation with varying results. This study aimed to target both pathological sites by combining dry needling with percutaneous hydrostatic decompression as a novel treatment. Methods Twenty-one patients with 26 chronic, non-insertional Achilles tendinopathy were prospectively enrolled. Ultrasound-guided dry needling of neovascular areas and small-volume hydrostatic paratenon decompression was performed 6-weekly. Sonographic assessment of tendon thickness and neovascularity was undertaken. Following treatment, a standardised physiotherapy regime was adopted. Visual analogue scores (VAS) were used as the primary outcome measure. Telephonic interviews were carried out 12 and 24 months post-treatment. Results Twenty-four tendons (in 19 patients) were successfully treated. The mean treatment session was 2. There was no significant change in neovascularity or tendon thickness. Therapeutic intervention led to a significant improvement in VAS at rest (42.4 ± 24.4 vs. 18.4 ± 26.0, p = 0.0005) and during activity (72.8 ± 16.0 vs. 33.7 ± 23.2, p 75 % A. Yeo (*) St George’s Hospital, Blackshaw Road, Tooting, London SW17 0QT, UK e-mail: [email protected] N. Kendall · S. Jayaraman St Richard’s Hospital, Spitalfield Lane, Chichester, West Sussex PO19 6SE, UK
of patients were highly satisfied with their outcome with nearly half reporting complete resolution of their symptoms. >85 % were also able to return to their sporting interests. Conclusion Combined therapy of dry needling with percutaneous hydrostatic paratenon decompression under ultrasound guidance is a well-tolerated procedure with good short- and long-term pain and functional outcomes. Level of evidence Prospective case series, Level IV. Keywords Non-insertional Achilles tendinopathy · Non-surgical treatment · Dry needling · Percutaneous decompression · Hydrostatic decompression
Introduction Painful disorders of the Achilles tendon are common. Often considered a condition afflicting athletes, approximately a third of cases affect the more sedentary population [1, 23, 34]. The incidence of Achilles tendinopathy (and other overuse injuries) is rising, especially in the developed world as more people regularly participate in recreational and competitive sport, and the duration and intensity of training regimes increases [34]. Achilles tendon injuries give rise to substantial morbidity and may be refractory to treatment. There are numerous treatment modalities available, with eccentric training, in particular, showing good efficacy [2] and considered to be the “gold standard” treatment. However, in recalcitrant cases, the condition remains a source of frustration. Surgery is often the end-point of treatment for such cases; however, due to the not insubstantial complication rate, especially of wound healing, recent treatments have steered towards a less invasive route.
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Current understanding of the mechanisms involved in tendon injury and pain generation is limited. Interventions have aimed at proposed pain generators either within the Achilles tendon itself [5, 10, 12, 14, 19, 22, 24, 25, 28] or its surrounding structure (i.e. paratenon) [7, 39], with varying success. To target the tendon itself, dry needling— which is the repeated lancing of an abnormal area within the tendon—in conjunction with adjuvant therapies like autologous blood injection has shown promise in the treatment of other tendinopathies of the patellar tendon [18], medial epicondyle [37] and lateral epicondyle [8, 16] of the elbow and of plantar fasciitis [21]. Only very recently have similar treatments been trialled in the Achilles tendon, with mixed results. Most involve injection of autologous blood [5] or platelet-rich plasma (PRP) [12, 14, 19, 25], but none used dry needling alone. To target the paratenon, interventions involving large volumes of injectant [7] or minimally invasive surgical techniques [39] have shown promise. This study therefore aimed to target the dual generators of pain by dry needling the Achilles tendon, using ultrasound guidance, and small-volume percutaneous hydrostatic paratenon decompression as a novel treatment for non-insertional chronic Achilles tendinopathy and to report on the long-term results.
Materials and methods The study has been prospectively approved by our institutional review board (St Richard’s Hospital clinical governance board) and has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments; and in line with guidance [IPG438] by the National Institute for Health and Care Excellence (NICE), UK [4]. All study participants gave their informed consent prior to inclusion in the study. Our tertiary unit received referrals from allied specialists (e.g. rheumatologists, sports physicians, physiotherapists) for consideration of surgical intervention in patients with chronic Achilles tendinopathy who have exhausted traditional medical therapy. All patients referred between February and November 2009 were assessed for eligibility. Inclusion criteria included patients over 18 years old, with non-insertional Achilles tendinopathy confirmed on ultrasound and were symptomatic for more than 3 months. Our exclusion criteria included patients with partial or complete tendon rupture as diagnosed on ultrasound, those who were not able to comply with our rehabilitation protocols (e.g. learning disability), those who have a phobia of needles and those who have coexisting causes of lower leg pain (e.g. sciatica). A total of 25 consecutive patients (30 tendons) were eligible for the study. Three patients (3 tendons) were
13
Knee Surg Sports Traumatol Arthrosc
excluded due to needle phobia (1) and coexisting sciatica (2); leaving 22 patients (27 tendons) for study. One patient (one tendon) was subsequently excluded due to spontaneous resolution of symptoms prior to commencement of any intervention. Of the remaining 21 patients (26 tendons), 15 tendons were on the left, 11 on the right. There were 9 men and 12 women, with a mean age of 55.3 (range, 39–76) years. All patients were symptomatic for more than 6 months with a mean of 24.9 (range, 6.5–108) months, and all had failed alternative conservative treatments like physiotherapy (21), therapeutic ultrasound (7), orthotics (4) and steroid injection (2). Of note, all 21 patients had undergone a physiotherapy programme involving eccentric (heel-drop) exercises for at least 12 weeks prior to commencement of the study. None of the patients were professional athletes, but all engaged in some form of regular activity—hiking (18), running (7), cycling (2), golf (2), football (1), tennis (1)— which their condition excluded them from participating satisfactorily.
Sonographic examination The diagnostic and therapeutic intervention was performed by a dedicated musculoskeletal radiologist. Sonographic assessment was performed in the prone position with the foot overhanging the end of the examination couch. The tendon in its entirety was examined in the longitudinal and transverse planes. The diagnosis of Achilles tendinopathy was based on the characteristic sonographic presence of increased tendon size, focal alteration in tendon echotexture and neovascularity. Tendon size was recorded as the maximum anteroposterior diameter as measured in the transverse plane—tendon thickness >6 mm was considered pathological [33]. Good reproducibility of tendon measurements has been shown, especially when performed by the same observer [26]. Colour flow Doppler imaging was used to grade neovascularity (“none”, “mild” with 1–2 vessels, “moderate” with 3–4 vessels or “severe” with more than four vessels) and target for dry needling.
Procedure The procedure was carried out under aseptic conditions. 5 ml of 1 % lidocaine was instilled subcutaneously around the Achilles tendon for anaesthesia. Under ultrasound guidance using a 7–12 MHz linear array high-resolution transducer, a 21G needle was placed in the space between the paratenon and tendon via a medial approach. 5 ml of 0.5 % Marcain was subsequently injected at high
Knee Surg Sports Traumatol Arthrosc
Fig. 1 Procedure. Ultrasound of the Achilles tendon was carried out with the patient in the prone position with the foot hanging off the edge of the bed. Under Colour Doppler USS (left), areas of neovascularisation can be visualised and targeted for dry needling (right)
pressure to strip off the paratenon from the underlying tendon. The same needle was then used to dry needle areas of neovascularity as visualised on Doppler ultrasound (Fig. 1). All patients then underwent a standardised physiotherapy regime (supervised by a physiotherapist) for 4 weeks concentrating on eccentric exercises as described by Alfredson et al. [2]. No restrictions were placed on patients with regard to return to sporting activities. After 6 weeks, each patient was reassessed with ultrasound and a second decompression via a lateral approach and further dry needling using the same described technique was performed if there was sonographic evidence of persistent paratenon adhesion and neovascularity. This procedure was repeated at 6-weekly intervals until symptomatic resolution or no improvement was evident.
Data collection All patients were asked to complete a questionnaire regarding their condition including length of symptomatic period, participation in sporting or recreational activity and previous treatments. Visual analogue scores (VAS) were recorded for the assessment of tendon pain at rest and during activity at baseline and 6 weeks post-final procedure. The scale consisted of two lines of varying lengths (one each for rest pain and activity pain) set orthogonally on the questionnaire with anchors at each end—representing “No pain” which corresponded to a VAS of 0 and “Severe pain” which corresponded to 100. Patients were asked to indicate with an “X” on each line the level of their tendon pain. Patients were asked to rate on a Likert scale how well they tolerated the procedure (“very well”, “well”, “fair” or “not at all”), and whether they would go through it again or recommend it to someone else. Telephonic interview with each study patient was performed at 12 and 24 months
to assess satisfaction level and ability to return to activity. Satisfaction level was graded as “90–100 %” (very high), “80–89 %” (high), “50–79 %” (fair) or “
ANKLE
Ultrasound‑guided dry needling with percutaneous paratenon decompression for chronic Achilles tendinopathy Andrea Yeo · Namita Kendall · Sunderarajan Jayaraman
Received: 19 May 2014 / Accepted: 20 November 2014 © European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2014
Abstract Purpose Chronic Achilles tendinopathy is a common overuse injury. There are several modalities of treatment, reflecting difficulties in management. In particular, due to the well-recognised surgical morbidity, treatment has steered towards less invasive routes. Previous studies have targeted pathology either inside or outside the tendon in isolation with varying results. This study aimed to target both pathological sites by combining dry needling with percutaneous hydrostatic decompression as a novel treatment. Methods Twenty-one patients with 26 chronic, non-insertional Achilles tendinopathy were prospectively enrolled. Ultrasound-guided dry needling of neovascular areas and small-volume hydrostatic paratenon decompression was performed 6-weekly. Sonographic assessment of tendon thickness and neovascularity was undertaken. Following treatment, a standardised physiotherapy regime was adopted. Visual analogue scores (VAS) were used as the primary outcome measure. Telephonic interviews were carried out 12 and 24 months post-treatment. Results Twenty-four tendons (in 19 patients) were successfully treated. The mean treatment session was 2. There was no significant change in neovascularity or tendon thickness. Therapeutic intervention led to a significant improvement in VAS at rest (42.4 ± 24.4 vs. 18.4 ± 26.0, p = 0.0005) and during activity (72.8 ± 16.0 vs. 33.7 ± 23.2, p 75 % A. Yeo (*) St George’s Hospital, Blackshaw Road, Tooting, London SW17 0QT, UK e-mail: [email protected] N. Kendall · S. Jayaraman St Richard’s Hospital, Spitalfield Lane, Chichester, West Sussex PO19 6SE, UK
of patients were highly satisfied with their outcome with nearly half reporting complete resolution of their symptoms. >85 % were also able to return to their sporting interests. Conclusion Combined therapy of dry needling with percutaneous hydrostatic paratenon decompression under ultrasound guidance is a well-tolerated procedure with good short- and long-term pain and functional outcomes. Level of evidence Prospective case series, Level IV. Keywords Non-insertional Achilles tendinopathy · Non-surgical treatment · Dry needling · Percutaneous decompression · Hydrostatic decompression
Introduction Painful disorders of the Achilles tendon are common. Often considered a condition afflicting athletes, approximately a third of cases affect the more sedentary population [1, 23, 34]. The incidence of Achilles tendinopathy (and other overuse injuries) is rising, especially in the developed world as more people regularly participate in recreational and competitive sport, and the duration and intensity of training regimes increases [34]. Achilles tendon injuries give rise to substantial morbidity and may be refractory to treatment. There are numerous treatment modalities available, with eccentric training, in particular, showing good efficacy [2] and considered to be the “gold standard” treatment. However, in recalcitrant cases, the condition remains a source of frustration. Surgery is often the end-point of treatment for such cases; however, due to the not insubstantial complication rate, especially of wound healing, recent treatments have steered towards a less invasive route.
13
Current understanding of the mechanisms involved in tendon injury and pain generation is limited. Interventions have aimed at proposed pain generators either within the Achilles tendon itself [5, 10, 12, 14, 19, 22, 24, 25, 28] or its surrounding structure (i.e. paratenon) [7, 39], with varying success. To target the tendon itself, dry needling— which is the repeated lancing of an abnormal area within the tendon—in conjunction with adjuvant therapies like autologous blood injection has shown promise in the treatment of other tendinopathies of the patellar tendon [18], medial epicondyle [37] and lateral epicondyle [8, 16] of the elbow and of plantar fasciitis [21]. Only very recently have similar treatments been trialled in the Achilles tendon, with mixed results. Most involve injection of autologous blood [5] or platelet-rich plasma (PRP) [12, 14, 19, 25], but none used dry needling alone. To target the paratenon, interventions involving large volumes of injectant [7] or minimally invasive surgical techniques [39] have shown promise. This study therefore aimed to target the dual generators of pain by dry needling the Achilles tendon, using ultrasound guidance, and small-volume percutaneous hydrostatic paratenon decompression as a novel treatment for non-insertional chronic Achilles tendinopathy and to report on the long-term results.
Materials and methods The study has been prospectively approved by our institutional review board (St Richard’s Hospital clinical governance board) and has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments; and in line with guidance [IPG438] by the National Institute for Health and Care Excellence (NICE), UK [4]. All study participants gave their informed consent prior to inclusion in the study. Our tertiary unit received referrals from allied specialists (e.g. rheumatologists, sports physicians, physiotherapists) for consideration of surgical intervention in patients with chronic Achilles tendinopathy who have exhausted traditional medical therapy. All patients referred between February and November 2009 were assessed for eligibility. Inclusion criteria included patients over 18 years old, with non-insertional Achilles tendinopathy confirmed on ultrasound and were symptomatic for more than 3 months. Our exclusion criteria included patients with partial or complete tendon rupture as diagnosed on ultrasound, those who were not able to comply with our rehabilitation protocols (e.g. learning disability), those who have a phobia of needles and those who have coexisting causes of lower leg pain (e.g. sciatica). A total of 25 consecutive patients (30 tendons) were eligible for the study. Three patients (3 tendons) were
13
Knee Surg Sports Traumatol Arthrosc
excluded due to needle phobia (1) and coexisting sciatica (2); leaving 22 patients (27 tendons) for study. One patient (one tendon) was subsequently excluded due to spontaneous resolution of symptoms prior to commencement of any intervention. Of the remaining 21 patients (26 tendons), 15 tendons were on the left, 11 on the right. There were 9 men and 12 women, with a mean age of 55.3 (range, 39–76) years. All patients were symptomatic for more than 6 months with a mean of 24.9 (range, 6.5–108) months, and all had failed alternative conservative treatments like physiotherapy (21), therapeutic ultrasound (7), orthotics (4) and steroid injection (2). Of note, all 21 patients had undergone a physiotherapy programme involving eccentric (heel-drop) exercises for at least 12 weeks prior to commencement of the study. None of the patients were professional athletes, but all engaged in some form of regular activity—hiking (18), running (7), cycling (2), golf (2), football (1), tennis (1)— which their condition excluded them from participating satisfactorily.
Sonographic examination The diagnostic and therapeutic intervention was performed by a dedicated musculoskeletal radiologist. Sonographic assessment was performed in the prone position with the foot overhanging the end of the examination couch. The tendon in its entirety was examined in the longitudinal and transverse planes. The diagnosis of Achilles tendinopathy was based on the characteristic sonographic presence of increased tendon size, focal alteration in tendon echotexture and neovascularity. Tendon size was recorded as the maximum anteroposterior diameter as measured in the transverse plane—tendon thickness >6 mm was considered pathological [33]. Good reproducibility of tendon measurements has been shown, especially when performed by the same observer [26]. Colour flow Doppler imaging was used to grade neovascularity (“none”, “mild” with 1–2 vessels, “moderate” with 3–4 vessels or “severe” with more than four vessels) and target for dry needling.
Procedure The procedure was carried out under aseptic conditions. 5 ml of 1 % lidocaine was instilled subcutaneously around the Achilles tendon for anaesthesia. Under ultrasound guidance using a 7–12 MHz linear array high-resolution transducer, a 21G needle was placed in the space between the paratenon and tendon via a medial approach. 5 ml of 0.5 % Marcain was subsequently injected at high
Knee Surg Sports Traumatol Arthrosc
Fig. 1 Procedure. Ultrasound of the Achilles tendon was carried out with the patient in the prone position with the foot hanging off the edge of the bed. Under Colour Doppler USS (left), areas of neovascularisation can be visualised and targeted for dry needling (right)
pressure to strip off the paratenon from the underlying tendon. The same needle was then used to dry needle areas of neovascularity as visualised on Doppler ultrasound (Fig. 1). All patients then underwent a standardised physiotherapy regime (supervised by a physiotherapist) for 4 weeks concentrating on eccentric exercises as described by Alfredson et al. [2]. No restrictions were placed on patients with regard to return to sporting activities. After 6 weeks, each patient was reassessed with ultrasound and a second decompression via a lateral approach and further dry needling using the same described technique was performed if there was sonographic evidence of persistent paratenon adhesion and neovascularity. This procedure was repeated at 6-weekly intervals until symptomatic resolution or no improvement was evident.
Data collection All patients were asked to complete a questionnaire regarding their condition including length of symptomatic period, participation in sporting or recreational activity and previous treatments. Visual analogue scores (VAS) were recorded for the assessment of tendon pain at rest and during activity at baseline and 6 weeks post-final procedure. The scale consisted of two lines of varying lengths (one each for rest pain and activity pain) set orthogonally on the questionnaire with anchors at each end—representing “No pain” which corresponded to a VAS of 0 and “Severe pain” which corresponded to 100. Patients were asked to indicate with an “X” on each line the level of their tendon pain. Patients were asked to rate on a Likert scale how well they tolerated the procedure (“very well”, “well”, “fair” or “not at all”), and whether they would go through it again or recommend it to someone else. Telephonic interview with each study patient was performed at 12 and 24 months
to assess satisfaction level and ability to return to activity. Satisfaction level was graded as “90–100 %” (very high), “80–89 %” (high), “50–79 %” (fair) or “
