To the Editor:

The concern raised by Dr. Hulse is that an injection of fluid anterior to the Achilles tendon may in fact be instilled in the anterior fat pad. And, he may be correct but the question remains unresolved. The citation (Maffulli, JBJS-B, 84:1-9) is a review article that mentions adhesions of the peritenon to the tendon and there is no citation that corroborates that statement.

There is extensive surgical experience reporting changes in the peritenon and adhesion of the membrane to the tendon, but the location of the adhesive condition is not uniformly in the region anterior to the tendon. One large series (Astrom, CORR 316, 1995) stated that 40% of the time, the peritenon was thickened at surgery and not all were adherent to the tendon. Dr. Maffulli is very experienced in the treatment of Achilles tendon surgery and perhaps he has some unpublished data he would like to share concerning the prevalence and location of peritendinous adhesions.

If the injection technique described in our article does deliver contrast, anesthetic and corticosteroid in the fat pad we cannot conclusively say yes or no based on the two dimensional imaging that we utilized (planar fluoroscopy).

This raises the intriguing possibility that the technique of passing the needle from posterior to anterior through the Achilles tendon may have an incidence of injection directly into the fat pad and not the peritendinous space. The photo of an injection labeled figure 2 in the article demonstrates a layering of the contrast along the anterior edge of the tendon suggesting that at least some of the fluid is along the anterior surface of the tendon. Whether this is true for some or all of the procedures, we will have to visually examine each of the pictures taken during the procedure. The premise of Achilles tendon safety with corticosteroid injection remains intact because of the documentation that the drug is not injected into the tendon.

What needs to be answered is the actual location of the fluid injected anterior to the tendon and this, perhaps, may be discovered in a future study to determine efficacy. We thank Dr. Hulse for bringing this possibility to our attention.

To The Editor:

In the article ‘‘Fluoroscopically guided low-volume peritendinous corticosteroid injection for Achilles tendinopathy-a safety study’’(1), the authors have concluded that it is safe to inject corticosteroids under direct fluoroscopic visualization into the peritendinous space for the treatment of Achilles tendinopathy. In figure-1 of the article, the authors have demonstrated a potential peritendinous space between paratenon and Achilles tendon and have tried to inject steroid in to this space using tenography.

However, from the available literature, we know that the paratenon can be affected in the early phase of tendinopathy and adhesions can be formed between the tendon and paratenon[2]obliterating this potential space. Obviously in such cases, the technique described by the authors, will deliver steroid in to pre- Achilles fat rather than in to peritendinous space.

References

1.Gill SS, Gelbke MK, Mattson SL, Anderson MW, Hurwitz SR. Fluoroscopically guided low-volume peritendinous corticosteroid injection for Achilles tendinopathy. A safety study. J Bone Joint Surg Am. 2004 Apr;86-A(4):802-6.

2.Maffulli N, Kader D. Tendinopathy of tendo achillis. J Bone Joint Surg Br. 2002 Jan;84(1):1-8.