Ultrasound-guided high-volume Achilles tendon injection

Non insertional Achilles tendinopathy

Ultrasound guided high volume injection Achilles tendon

What is Achilles tendinopathy?

Achilles tendinopathy refers to inflammation of the Achilles tendon. Achilles tendon issues can be insertional (affecting the insertion or attachment of the tendon to the calcaneum) and non-insertional (affecting the mid-portion of the Achilles tendon). Both conditions can be very restrictive to movement and activities. Pain lasts more than a year in approximately 50% of patients; therefore, getting the correct diagnosis and starting the appropriate treatment early is essential. Ultrasound examination provides an excellent assessment of the Achilles tendon. Achilles tendinopathy is often seen in association with sports like running. It is reported in approx. 7% of marathon runners. However, Achilles tendinopathy can also be seen in people with sedentary lifestyles.

Relevant Achilles tendon anatomy

The Achilles tendon connects the large calf muscles to the heel bone, known as the calcaneum.
Non-insertional Achilles tendinopathy affects the mid-portion of the Achilles tendon.

Between the attachment of the Achilles tendon and the calcaneum, there is a small fluid sac called the retrocalcaneal bursa that helps reduce friction. Inflammation of this sac, known as retrocalcaneal bursitis, is often associated with issues in the lower part of the Achilles tendon (insertional tendinosis). This condition is discussed separately.

What are the causes of Achilles tendinopathy?

Achilles tendinopathy is usually caused by activities that put too much strain on the tendon, especially if they are repetitive and don't allow enough time for recovery. This will lead to tendon inflammation and swelling, termed “Achilles tendinitis”. Repeated episodes will interfere with the normal healing of the tendon, causing the tendon to thicken and weaken, resulting in Achilles tendinopathy.

What are the symptoms of Achilles tendinopathy?

The symptoms of Achilles tendinopathy include:

-Pain and swelling of the Achilles tendon.

-Activities, particularly running and jumping, usually exacerbate the pain, as these put significant extra stress on the tendon.

-The pain can be felt more after periods of rest and in the morning. Gentle movements usually ease the pain.

-The Achilles tendon will be tender to touch. This is usually felt 2-3 above the attachment to the heel bone.

How to tell if I have Achilles tendinopathy?

Achilles tendinopathy is characterised by pain often felt at the start and end of physical activities such as running, jumping, or walking. Many patients report that the pain diminishes during the activity but returns once completed. If Achilles tendinopathy progresses, the pain may persist even during exercise, making engaging in sports or other physical activities difficult. The pain may become continuous as the condition progresses, making everyday activities like walking or climbing stairs difficult and painful.

How to tell if I have an Achilles tendon tear or rupture?

If you feel sudden pain in your Achilles tendon area while participating in activities like running, tennis, football, or rugby, it could be a sign of an Achilles tendon tear.
The pain is usually severe, causing you to stop the activity.
There could be an audible snap, and often you will notice the area becoming swollen and bruised. If you experience such symptoms, you must urgently see a doctor or foot specialist. In most cases, an ultrasound examination will be done to assess the tear and decide about further management.

How to diagnose Achilles tendinopathy?

When the condition is suspected after assessment by your doctor or foot specialist, you will be referred for an ultrasound or MRI examination. Ultrasound assessment is very useful when Achilles tendinopathy is suspected.

How can ultrasound help with Achilles tendinopathy?

Ultrasound assessment will provide the following useful information:

-Confirm the presence of Achilles tendinopathy and rule out other causes, like Achilles tendon tear.

-Assess the degree of changes. The ultrasound examination will accurately assess the degree of thickening and inflammatory changes in the Achilles tendon.

-Assess the site of inflammation. Ultrasound will accurately differentiate insertional vs non-insertional Achilles tendinopathy, as the management is usually different. It will also assess for any thickening or inflammation of the sheath surrounding the tendon. This is known as the paratenon, and inflammation here is called paratenonitis. The management is different depending on the site of inflammation.

-Assess for the presence of Achilles tendon tear. Tendinopathy can be associated with small tears in the tendon. Ultrasound allows for an accurate assessment of the size and location of such tears.

-Check for any additional injuries, such as damage to the plantaris tendon located on the inner aspect of the Achilles tendon or the sural nerve located on the outside of the Achilles tendon. Ultrasound will also assess the retrocalcaneal bursa and the adjacent fat pad for any inflammation.

-Ultrasound allows for a special assessment of the tendon using the power Doppler technique. This will assess for the formation of new blood vessels within the Achilles tendon and the deep fat layer, a condition known as “neovascularity”. Such information is very important for diagnosis and allow us to decide about a specific treatment option, termed high volume Achilles tendon injection.

What other conditions can mimic Achilles tendinopathy?

Conditions that can be confused with Achilles tendinopathy include:

What is the treatment for Achilles tendinopathy?

Treatment starts with conservative management, including a specific exercise programme to strengthen the calf muscles. Helpful treatment measures include reducing physical activity for a few weeks, using ice, and anti-inflammatory creams (like Voltarol). Before start using any medicine, make sure to talk to your doctor or pharmacist.

What if conservative management is not helping my Achilles tendon pain?

If the above measures are not helping, other treatment options include:

Extra corporal Shockwave Therapy (ESWT)

Shockwave therapy can be used in the treatment of Achilles tendinopathy. It uses soundwave pulses to create precise micro-injuries in the Achilles tendon. This process aims to induce natural healing within the inflamed Achilles tendon. In addition, the surrounding nerve endings become desensitised to the pain, leading to enhanced pain relief. The treatment consists of a few sessions (usually 3-5) combined with other conservative treatment measures mentioned above and a specific physiotherapy program.

Ultrasound guided injections for Achilles tendinopathy

Ultrasound guided injections are another available treatment option if conservative management is not helping. Ultrasound guidance is very important as it ensures accurate delivery of the medicine to the targeted site and avoids injection into the Achilles tendon itself. Any injection into the substance of the Achilles tendon itself might weaken the tendon and should be avoided. The exception is platelet-rich plasma (PRP) injections which can be injected into the Achilles tendon at the tendinopathy site.

The available treatment options for Achilles tendinopathy include:

1. High volume Achilles tendon stripping

This is the most common injection treatment we perform for patients with Achilles tendinopathy. In this procedure, the consultant will inject a mixture of normal saline (sterile water) and local anaesthetic (numbing medicine) into the plane between the Achilles tendon and deep fatty tissue. The injection might include a small dose of steroids in the mixture. The procedure aims to strip the Achilles tendon from the underlying fat and disrupt any new vessels formed by inflammation (neovascularization).

Achilles tendinopathy results in the thickening and inflammation of the tendon, accompanied by a process of neovascularisation. This refers to the formation of small new blood vessels that usually start in the fatty tissue deep within the tendon and extend into the tendon itself, along with small nerves. Evidence shows that these are responsible for some of the pain and symptoms of Achilles tendinopathy.

High volume Achilles tendon injection abolishes these new vessels and nerves, reducing pain and enhancing tendon recovery. Studies have shown that this method, combined with controlled progressive Achilles tendon loading, can significantly reduce pain and improve overall function. To learn more about the procedure, please read our article about High volume Achilles tendon stripping.