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Fluoroscopically Guided Low-Volume Peritendinous Corticosteroid Injection for Achilles TendinopathyA Safety Study
Sanjitpal S. Gill, MD1; Martin K. Gelbke, MD2; Steve L. Mattson, MD3; Mark W. Anderson, MD4; Shepard R. Hurwitz, MD1
1 Department of Orthopaedic Surgery, University of Virginia, Box 800159, Charlottesville, VA 22908. E-mail address for S.R. Hurwitz: srh5u@virginia.edu
2 Department of Orthopaedic Surgery, University of Michigan Medical Center, 1500 East Medical Center Drive, UH Box 0328, Ann Arbor, MI 48109-0328
3 Department of Anesthesia, University of Washington, Box 356540, Seattle, WA 98195
4 Division of Musculoskeletal Radiology, Department of Radiology, University of Virginia, Charlottesville, VA 22908
View Disclosures and Other Information
The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at University of Virginia Health System, Charlottesville, Virginia

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2004 Apr 01;86(4):802-806
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Background: The safety and efficacy of corticosteroid injection for the treatment of Achilles tendinopathy is not known, with some reports indicating the hazard of tendon rupture and others extolling the efficacy of such injections. This study was undertaken to assess the safety of fluoroscopically guided corticosteroid injections into the peritendinous space for the treatment of Achilles tendinopathy.

Methods: A series of patients was treated with fluoroscopically guided corticosteroid injections into the space surrounding the Achilles tendon. Major and minor complications were recorded, as were the number of repeat injections, the duration of symptomatic relief attained with the injection, and a subjective rating of symptoms related to the Achilles tendon.

Results: Of eighty-three patients who had been treated, seventy-eight were available for follow-up and forty-three met our requirement for a minimum two-year follow-up (average duration of follow-up, 37.4 months). No major complications and one minor complication occurred in the forty-three patients. Seventeen (40%) of the patients reported improvement after the procedure, twenty-three (53%) thought that their condition was unchanged, and three (7%) felt that their condition was worse than it had been prior to the injection.

Conclusions: This retrospective cohort study establishes the safety of low-volume injections of corticosteroids for the treatment of Achilles tendinopathy when the needle is carefully inserted into the peritendinous space under direct fluoroscopic visualization.

Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    shepard r hurwitz
    Posted on June 12, 2004
    Dr. Hurwitz responds:
    University of Virginia

    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.

    Narayan Hulse
    Posted on May 24, 2004
    Obliteration of peritendinous space in Achilles tendinopathy
    Manchester Royal Infirmary (U.K)

    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.


    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.

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