high-volume injection in the management of recalcitrant ... · peter resteghini, justin yeoh ......

Audit/Musculoskeletal Medicine in Practice

High-volume injection in the management ofrecalcitrant mid-body Achilles tendinopathy:a prospective case series assessing theinfluence of neovascularity and outcomePeter Resteghini, Justin Yeoh

Sports and Musculoskeletal Medicine Department, Homerton University Hospital NHS Foundation Trust,1 Homerton Row, London E9 6SR

Objectives: To determine the effectiveness of ultrasound-guided high-volume injection (HVI) and relevance ofneovascularity on outcome in Achilles tendinopathy.Methods: This prospective clinical study at the Homerton University Hospital included 32 patients withrecalcitrant unilateral mid-substance Achilles tendinopathy. Outcome measures used were VictorianInstitute of Sport Assessment-Achilles tendon (VISA-A), Visual Analogue Score (VAS), modified Öhbergscore and mean maximum tendon thickness.Results: Significant improvements in both VAS and VISA-A scores at 1 month (95% confidence interval (CI),6.6–3.2, P< 0.001 and 37.2–63.7, P< 0.001). This improvement was maintained at 3 months (95% CI,6.6–2.9, P< 0.001 and 37.2–65.9, P< 0.001). Symptomatic tendons were significantly thicker at baselinethan the asymptomatic side (95% CI, 8.3 mm compared to 5.9 mm, P< 0.001). There was a significantdecrease in maximum tendon thickness in the symptomatic tendons at baseline and at 3 months (95% CI,8.3–7.6 mm, P< 0.001). Mean Öhberg neovascularity scores demonstrated a significant decreasebetween baseline and 3 month review (95% CI, 2.5–1.1, P< 0.001). There was a significant difference inneovascularity at baseline for the symptomatic and asymptomatic sides (95% CI, 2.5 compared to 0.2,P< 0.001). There was a positive correlation between baseline neovascularity and difference in VAS scoresat baseline and 3 months. Patients with higher baseline Öhberg scores demonstrated a more positiveoutcome (95% CI, correlation coefficient 0.696, P< 0.01).Discussion: Ultrasound-guided HVI is safe and clinically cost-effective in treating Achilles tendinopathy.Results suggest that baseline neovascularity is relevant to outcome following injection.

Keywords: Achilles tendinopathy, Chronic, High-volume injection, Neovascularity, Treatment

IntroductionChronic Achilles tendon pain is a common disorderamong both recreational and professional athleteswith an estimated 18% of all lower-limb injuries inrecreational runners involving the Achilles tendon.1,2

Although the prevalence of Achilles tendon painappears to be higher in recreational and professionalathletes than in those individuals who participate inlittle or no regular exercise, studies have demonstratedthat up to 33% of patients who complain of Achillestendon pain do not partake of any regular physicalactivity.3–6 Achilles tendon pain appears to occur inboth male and female populations of all ages, but

seems to be a particular problem in men agedbetween 35 and 45 years.7,8

Although the pathological changes associated withtendinopathy are poorly understood, it is generallyaccepted that in the chronically injured tendon therepair capacity of the tendon is exceeded.Histological examination of tendon tissue in sympto-matic individuals consistently shows either absent orminimal inflammation.9–12 Rather Achilles tendonpain seems degenerative in nature. These pathologicalchanges are not limited to the Achilles tendon,10,11 buthave also been identified in the rotator cuff of theshoulder,12 patellar tendon of the knee13 and thecommon extensor tendon of the elbow.14 When seenin the Achilles tendon the degenerative change hasbeen described as being a combination of both1 Correspondence to: Justin Yeoh. Email: [email protected]

© W.S. Maney & Son Ltd. and the British Institute of Musculoskeletal Medicine 2012DOI 10.1179/1753615412Y.0000000004 International Musculoskeletal Medicine 2012 VOL. 0 NO. 0 1

mailto:[email protected]



intratendinous lesions and thickening and adhesionaround the paratenon. This is demonstrated particu-larly between the paratenon and the cruralfascia.10,15 Intratendinous degeneration consists oftenocyte hyperplasia with prominent neovasculariza-tion, and endothelial hyperplasia.16 In light of thelack of inflammatory cells found, the term tendinitiswould seem to be inappropriate and misleading.Rather the term tendinopathy would seem the moreaccurate descriptor and is increasingly being used todescribe Achilles tendon pain.In terms of clinical relevance the degree of tendon

thickening and associated intratendinous degenerativechange have been shown to impact negatively onoutcome.17,18 However, increased neovascularity, asestablished in both patella19 and Achilles tendons20

seems to be of less clear clinical relevance withZanetti21 demonstrating that although neovascularityappeared to be a specific sign for tendon pain it didnot indicate an unfavourable outcome in the Achillestendon following conservative treatment consisting ofexercise and physiotherapy.There is no single, specific test for Achilles tendino-

pathy with clinical assessment remaining the mainstayof diagnosis. Ultrasonography (US) has increasinglybeen used to grade pathological changes with regardto tendon thickening with changes in tendon echogeni-city indicating the presence of tendinosis, partial andcomplete tearing.17,22 In addition to grey-scalechanges, Power Doppler assessment provides ameans to measure the degree of neovascularitywithin and around tendons.20

However, the relevance of this neovascularity in ten-dinopathy remains unclear as does subsequent changein the degree of neovascularity present in tendons fol-lowing intervention. Öhberg23,24 reported neovascular-ity to be present in all symptomatic Achilles tendonsthat subsequently decreased with a concurrentreduction in symptoms following conservative treat-ment. Alfredson25 noted that the degree of neovascular-ization of Achilles tendons increased within the first 3weeks following sclerosing injections although this sub-sequently decreased at further review. These findingswould suggest some possible short-term benefit of neo-vascularity in the early stages following treatment. Anumber of measurement scales have been suggested astools by which the degree of neovascularizationpresent may be recorded. Although all these measuresinclude a degree of subjectivity, one, the modifiedÖhberg score of a simple 5-point scale, has beenshown to have excellent interobserver reliability2 .26

The management of Achilles tendinopathy mostlyrelies on conservative therapeutic interventions,including therapeutic ultrasound, deep transversefriction massage, flexibility exercises, orthotics, andeccentric loading of the tendon.7 At present, eccentric

overload exercise is widely used in clinical practice:however, the exact mechanism of how eccentricloading of the Achilles tendon results in a direct histo-logical effect with concurrent decrease in pain andincrease in reported function remains unclear.Although the general consensus has until recentlybeen that eccentric exercises are able to generategreater forces within the tendon than concentric exer-cises,27 a recent study by Rees28 demonstrated that thiswas not the case and that peak tendon forces ineccentric exercise were of the same magnitude asseen in concentric exercise. Intriguingly Rees28 didnote a pattern of sinusoidal loading and unloadingin eccentric exercise that was not demonstrated in con-centric exercise and proposed that these fluctuations inforce may provide the stimulus for tendon regener-ation. In a systematic review of the literatureKingma29 examined nine clinical trials but foundthat only one was considered to be of a high methodo-logical rigour. Although this trial did demonstrate apositive outcome in favour of eccentric loading, theconclusion of the authors was that larger trials, withbetter methodology, were required.

Surgery is considered when conservative therapiesfail with techniques including debridement of patho-logical peritendinous tissue, decompression of centraltendon lesions and tendon augmentation with fascialstrips of the gastrocnemius soleus complex.30,31

Excision of the pathological peritendinous tissue andlongitudinal incisions of the tendon in isolation orwith excision of the intratendinous lesion are perhapsthe surgical procedures most commonly per-formed.15,32 Alternative procedures include excisionof intratendinous lesions either with augmentationusing tendon or fascia33 or without augmentation.34

Multiple longitudinal incisions of the tendon havealso been performed percutaneously.35,36

The aim of this prospective clinical study was to evalu-ate the efficacy of an ultrasound-guided high-volumeinjection (HVI) in the treatment of recalcitrant mid-substanceAchilles tendinopathyand to evaluate the clini-cal relevance of the degree of neovascularity present atbaseline with perceived outcome following treatment.

MethodsPatientsPatients were included in the study if they had beengiven a diagnosis of mid-substance Achilles tendino-pathy from those attending the Homerton UniversityHospital Sports and Musculoskeletal Clinic betweenSeptember 2010 and February 2011. This clinical diag-nosis had to be confirmed on ultrasound examination.All agreed to participate in the prospective follow-upafter full explanation of the study. Patients wereexcluded if they had a previous injection or surgeryor if they had bilateral symptoms.

Resteghini and Yeoh High-volume injection in the management of recalcitrant mid-body Achilles tendinopathy

International Musculoskeletal Medicine 2012 VOL. 0 NO. 02

All patients must have been prescribed a course ofeccentric exercise and continued with this programmefor at least 3 months prior to inclusion, but at thispoint had either failed to continue due to lack of per-ceived improvement or pain.

EthicsConsultation with the Local Ethics Committee deter-mined that ethical approval was not required as thestudy involved no additional treatment and no treat-ment was withheld from patients. Patient notes wereheld in accordance with current NHS guidelines.Results generated from the study were stored in strictconfidentiality and coded in such a way that patientscould not be identified from the final collated data.

InterventionFollowing explanation of the procedure HVI was thenperformed. Under ultrasound guidance the site ofmaximal tendon thickness was identified and using amedial approach the anterior edge of the tendon wasinjected (Figs. 1 and 2). In total injection consistedof 25 mg of hydrocortisone, 5 ml of 1% lignocaineand up to 40 ml of normal saline.Needle placement was directed by a first operator

under ultrasound guidance and the injection givenby a second operator using low-pressure tubing(Angiotech, connecting tube, Mana-Tech Ltd.3 ). Thisenabled the necessary pressure to be applied to thesyringe during injection without unnecessary needlemovement (Figs. 3 and 4).Post injection patients were advised to refrain from

exercise for 3 days but allowed to partake in normalactivities of daily living. For a further 3 days theywere advised to return to their eccentric programme

of exercise only. Then 3 days of eccentric exerciseand low-impact exercise were followed by a slowreturn to normal exercise as pain allowed. Theeccentric exercise programme was to be continuedfor 3 months.The eccentric programme prescribed consisted of

four sets of 20 repetitions of Achilles loading withthe knee straight and a further four sets of 20 rep-etitions with the knee bent. These exercises were tobe carried out at a level that was uncomfortable andfor one session per day.

Study protocolEach patient was examined pre-injection and at 1- and3-month follow-up. The study protocol was the same

Figure 1 Transverse needle placement under US guidancewith second operator delivering the injection. (Source:Photograph taken in Sports and Musculoskeletal MedicineDepartment at the Homerton University Hospital).

Figure 2 Transverse US image of Achilles tendon at maximalAP thickness 4. Needle positioned immediately anterior to thetendon (note reverberation artefact). (Source: Image fromSports and Musculoskeletal Medicine Department at theHomerton University Hospital).

Figure 3 Needle, syringe, and low-pressure tubing(Angiotech, connecting tube, Mana-Tech Ltd.). (Source:Photograph taken in Sports and Musculoskeletal MedicineDepartment at the Homerton University Hospital).


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at pre-injection and at 1- and 3-month follow-up. Itconsisted of the following assessments and outcomemeasures being utilized.

VAS and VISA-AThe visual analogue scale (VAS) consisted of a lineexactly 100 mm long. The patient was asked to placea mark on the scale that represented the severity oftheir pain at that time. The scale ran from no pain tosevere pain.37 The VAS is generally believed to workadequately for acute pain states.38

The Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire was developedspecifically for evaluation of Achilles tendon pathol-ogy and consists of eight questions includes elementsthat assess pain and function. It has been demon-strated to be a valid and reliable index of the clinicalseverity of Achilles tendinopathy.39

Achilles tendon diameterMeasurement of the maximum anterior to posteriortendon thickness took place in the transverse plane(Fig. 5).

Ultrasound and neovascularityAll US examinations were performed by one of theauthors, an experienced musculoskeletal sonographerwith several years experience using a Siemens AcusonX300 with a VF13-5 linear probe. US examinationswere performed bilaterally at initial assessment priorto injection and repeated at 1- and 3-month review.Patients were asked to lay prone on the examinationcouch with their feet freely hanging over the edge ofthe couch in a neutral position. The initial US assess-ment utilized Power Doppler imaging to assess for neo-vascularity. This was carried out prior to assessmentfor tendon homogeneity and tendon thickness toavoid occlusion of the neovessels that may haveoccurred if the foot was dorsiflexed. No pressure wasapplied to the foot while assessment of neovascularitytook place. The Doppler gain was set just below back-ground noise at 3 dB. Following assessment for neovas-cularity the foot was positioned at 90° and the tendonwas assessed for homogeneity and thickness.

The degree of observed neovascularity with PowerDoppler was measured using the 5-point modifiedÖhberg score.26This scoring system isoutlined inTable 1.

An example of a modified Öhberg score 4+ isdemonstrated below (Figs. 6 and 7).

Table 1 The modified Öhberg score for tendonneovascularity26

Score Descriptor

0 No vessels visible1+ One vessel visible mostly anterior to the tendon2+ One or two vessels throughout the tendon3+ Three vessels throughout the tendon4+ More than three vessels throughout the tendon

Figure 4 Left Achilles tendon immediately post-injectiondemonstrating significant swelling. (Source: Photographtaken in Sports and Musculoskeletal Medicine Department atthe Homerton University Hospital).

Figure 5 Transverse image of Achilles tendon demonstratinga significant anterior-to-posterior thickening. The twocrosses represent the measurement callipers and recorda distance of 8.2 mm. (Source: Image from Sports andMusculoskeletal Medicine Department at the HomertonUniversity Hospital).

Figure 6 Longitudinal image of an Achilles tendondemonstrating a florid neovascularity with significantthickening. The modified Öhberg score for this tendonwas 4+. (Source: Image from Sports and MusculoskeletalMedicine Department at the Homerton University Hospital).



Statistical analysisStatistical analysis was performed using SPSS version16 (SPSS Science, Chicago, USA) and significancewas assumed for all measures when P values were

less than 0.05. An initial Kolmogorov–Smirnov testwas carried out to assess for the degree of normalityof the distribution of the data.The difference between baseline, 1- and 3-month

review VAS and VISA-A scores was analysed. For stat-istical purposes, these data were considered to be non-parametric in nature and were analysed using theWilcoxon Signed Ranks Test. Baseline and 3-monthreview Öhberg scores for symptomatic and asympto-matic tendons were also considered non-parametricin nature and were analysed using the WilcoxonSigned Ranks Test. Tendon diameter at baseline and3-month review for both symptomatic and asympto-matic patients was considered parametric and ana-lysed using the paired sample t-test.The difference between the baseline and 3-month

review VAS scores was calculated for each patientand examined for correlation with that subject’s base-line Öhberg score to explore whether the degree ofneovascularity at baseline influenced outcome. Forthe purposes of statistical analysis, the data weretreated as non-parametric and were analysed usingSpearman’s rho test.

Figure 8 Patient progress through the study.

Figure 7 Transverse ultrasound image of a symptomaticAchilles tendon. Power Doppler imaging demonstratesneovascularity originating from the anterior region of thetendon. Note also the posterior enhancement suggestingpoor-quality tendon tissue at this level. (Source: Image fromSports and Musculoskeletal Medicine Department at theHomerton University Hospital).



ResultsPatientsThe flow diagram (Fig. 8) demonstrates the progressof patients through the study with details of thosewho were not included in the final analysis of results.During the study, no patients were lost to finalfollow-up. Two patients who described a pooroutcome to treatment opted for referral for a surgicalopinion. Baseline patient demographics are shown inTable 2.

Mean VAS and VISA-A scores pre-injection,1- and 3-month reviewMean VAS scores decreased significantly from baselineto 1-month review (95% confidence interval (CI),6.6–3.2, P< 0.001) a trend that was maintained at 3-month review (95% CI, 6.6–2.9, P< 0.001) (Graph 1).Concurrently the mean VISA-A scores increased

significantly from baseline to 1-month review (95%CI, 37.2–63.7, P< 0.001) a trend that was maintainedat 3-month review (95% CI, 37.2–65.9, P< 0.001)(Graph 2).

Mean maximum tendon diameterThere was a significant decrease in the meanmaximum tendon diameter from baseline to 3-monthreview (95% CI, 8.3–7.6 mm, P< 0.001). Likewise, asignificant difference was also seen between the meanmaximum tendon thickness at baseline for the

symptomatic and asymptomatic sides (95% CI,8.3 mm compared to 5.9 mm, P< 0.001) (Graph 3).

Mean Öhberg neovascularity scoresThere was a significant decrease in the mean Öhbergneovascularity scores between baseline and 3-monthreview (95% CI, 2.5–1.1, P< 0.001). There was alsoa significant difference between the mean scores atbaseline for the symptomatic and asymptomatic sides(95% CI, 2.5 compared to 0.2, P< 0.001) (Graph 4).

The relationship of tendon neovascularity atbaseline and outcomeThere was a significant correlation between the base-line Öhberg neovascularity scores and difference inbaseline and 3-month review VAS scores, such thatpatients with higher baseline Öhberg scores demon-strated a trend to a more positive outcome (95% CI,correlation coefficient 0.696, P< 0.01) (Graph 5).

There was no correlation between the Öhberg neo-vascularity scores at baseline and duration of reportedsymptoms (correlation coefficient −0.074, P< 0.686)or the self-reported baseline VAS and VISA scores

Table 2 Patient characteristics and outcome variables atbaseline (pre-HVI)

Mean age (years) (range) 40.3 (25–63)Gender 20 male/12

femaleMean duration of symptoms (months)

(range)17 (6–60)

Active in sports (%) 20 (62.5)Mean tendon thickness symptomatic side

(mm) (range)8.4 (5.7–10.5)

Mean tendon thickness asymptomatic side(mm) (range)

5.7 (4.7–7)

Mean Öhberg score symptomatic side 2.3Mean Öhberg score asymptomatic side 0.2Mean VAS score (range) 6.6 (4–9)Mean VISA-A score (range) 37.2 (10–60)

Graph 1 Mean VAS scores at baseline, 1 and 3 monthsreview.

Graph 2 Mean VISA-A scores at baseline, 1 and 3 monthsreview.

Graph 3 Mean Achilles diameter (mm) of the asymptomaticand baseline and 3-month review symptomatic Achillestendon.

Graph 4 Mean Öhberg score of the asymptomatic andbaseline and 3-month review symptomatic sides.



(correlation coefficient −0.047, P< 0.799 and 0.238,P< 0.189, respectively).

DiscussionThis prospective 3-month follow-up study demon-strated that the short-term results of an ultrasound-guided HVI for chronic mid-substance Achillestendinopathy were good. Significant improvement inself-reported functional activity as measured by theVISA-A was reported at both 1 and 3 months (P<0.001). In association with this functional improve-ment, a significant decrease in pain as measured bythe VAS was also reported at both 1 and 3 monthspost-injection (P< 0.001). In addition, there was ademonstrable and significant decrease in themaximum anterior–posterior tendon diameter 3months post-injection (P< 0.001). However, thisdiameter still remained significantly greater than theasymptomatic Achilles tendon. Finally, this studyalso demonstrated a significant decrease in the modi-fied Öhberg scores 3 months post-injection (P<0.001) and a significant correlation between baselineÖhberg scores and outcome such that higher baselinescores correlated with a more positive outcome at 3months (P< 0.01). The findings of this study are sup-ported by Chan40 who demonstrated in a cohort of 30patients with chronic mid-substance Achilles tendino-pathy (mean duration 35.8 months) a significantimprovement in self-reported function and painscores (P< 0.0001) at 1-month post-ultrasound-guided HVI.However, there are a number of clear limitations to

our study and conclusions that can be drawn. First,although demonstrating significant improvement inboth function and pain within a relatively short-timepost-intervention, a longer follow-up is needed todetermine whether this improvement is maintained.Secondly, this study is limited by the absence of atrue control group matched for age, sex, and physicalactivity. Patients were asked to continue with theireccentric exercise programme and the inclusion ofthis regime of exercise may well have overshadowedthe effects of the HVI resulting in the subsequentchanges in perceived outcome. In an attempt to

avoid this all patients included in this study hadalready been prescribed a programme of eccentricexercise at least 3 months previously and had been sub-sequently referred for HVI because of a perceived lackof progress with the programme. Finally, it should benoted that the injection given included two possibletreatment interventions namely the corticosteroidand high-volume effect. It may well be that either thecorticosteroid or high volume alone would have hada similar effect. Further work with separate matchedgroups undergoing only corticosteroid or highvolume together with a control group is planned.Chan40 observed no significant complication post-

HVI either immediately following or at longer-termfollow-up post-injection (mean 30.3 weeks).Similarly, our study noted no significant post-HVIcomplication other than some immediate post-injec-tion soreness. Paavola41 documented an overall com-plication rate of 11% in a series of 432 consecutivepatients who had undergone surgical treatment forchronic Achilles tendinopathy. In a further study,Paavola18 noted an overall complication rate of 19%with delayed wound healing being the most commonproblem. This complication appeared to be moreprevalent in patients who had a combination of bothperitendinous adhesions and intratendinous lesions(27%) than in those patients with peritendinous adhe-sions only (6%).In addition to the increased possibility of compli-

cation, surgery is also more expensive than HVI andresults in a longer period of rehabilitation prior tothe patient being able to return to sport. In ourstudy, patients recommenced their eccentric exercisesimmediately following the HVI and were advised toreturn to low-impact exercise within 3 days, graduallyincreasing this as pain allowed.Besides surgical intervention, other treatment inter-

ventions for recalcitrant Achilles tendinopathy thathave been proposed include injection of platelet-richplasma (PRP). This is defined as a concentrated injec-tion of platelets, which have the ability to releaseseveral growth factors that in theory enhances thetissue repair processes and subsequent tendon integ-rity. Although in vitro evidence suggests that PRPmay lead to an accelerated remodelling of damagedtendon with concurrent vascularization,42 this hasnot been demonstrated in the clinical setting. Indeed,de Vos43 concluded that PRP does not contribute toincreased tendon structure or alter the degree of neo-vascularization present when compared with placebo.The clinical relevance of this increased neovascular-

ization in tendons is uncertain. Movin11 found anincrease in the neovascularity present in 26 of the 40tendon samples obtained during semi-quantitative his-tological analysis of symptomatic Achilles tendons.This finding was supported by Zanetti21 who found

Graph 5 Correlation of baseline Öhberg scores and reportedimprovement noted with VAS.



that neovascularisation was present in 33 of 55 painfulAchilles tendons but in only 1 of 25 asymptomatictendons. Although this strongly suggests that neovas-cularity is a good indicator of pain the authorsfound no indication that this increase in tendon vascu-larization was associated with poor outcome. Indeed,our study would suggest that the greater the initialdegree of neovascularization present the more positivean outcome may be expected. Although this findingmay be specifically related to the use of HVI it couldalso reflect the fact that those patients with a higherinitial tendon neovascularity have a greater degree ofpathological change present and if this is associatedwith greater symptoms may also be a reflection ofthese patients having more to gain following HVI.The location of the neovessels appears more marked

within the anterior region of the tendon.20,21 Thisobservation is supported by the findings of our ownstudy. Although we did not specifically assesstendons for the location of neovascularity, Dopplerimaging confirmed that this was predominantlylocated within the anterior region (Figs. 6 and 7).The prevalence of anteriorly located neovascularity

has implications with regard to treatment and in termsof pathological process. The HVI outlined in our studyis given at the anterior edge of the Achilles tendon atits interface with the anterior peritendinous tissueand Kager’s fat. Immediately post–HVI and the neo-vessels are seen to have disappeared on Dopplerimaging. It could be argued that the pressure of theinjected fluid is sufficient to temporally compressand therefore occlude these neovessels. Indeed, firmpressure with the ultrasound transducer is often suffi-cient to reproduce this effect without injection.However, the decrease in neovascularity in our studywas still significantly reduced at 3 months (P<0.001) long after the injected fluid had been absorbed.Theoretically then HVI may result in the neovessels

being stripped from the anterior aspect of the tendonand that this leads to an alteration in the failingtendon repair process with subsequent regenerationof more normal, healthy tissue. Conversely, as theneo-vascular vessels are stripped from the anteriortendon then there is also a stripping of the associatedneo-neural tissue. This would result in denervation ofthe painful tendon that may also have a positiveeffect on tendon regeneration but would also allowpatients to perform a programme of eccentricloading more effectively and with greater compliance.The relatively rapid improvement in symptoms post-injection noted in our study and that of Chan40

would suggest that although HVI may have aprimary and direct effect on tendon pathogenesis,denervation of painful tendon tissue maybe theprimary treatment effect. The changes noted sub-sequently, such as a decrease in tendon diameter and

decrease in the neovascularity represent secondarychange.

In conclusion, this prospective follow-up studydemonstrated that US-guided HVI appears to be asafe and clinically cost-effective treatment optionin the management of recalcitrant mid-substanceAchilles tendinopathy when delivered in conjunctionwith an eccentric exercise programme. In addition,our study suggests that the degree of neovascularityas measured by the modified Öhberg score appearsto be related with regard to outcome such thatgreater initial neovascularity predisposes a more posi-tive outcome. This finding may help clinicians andpatients in deciding whether or not to proceed withinjection when discussing possible treatment options.

Given the limitations of our study randomized trialswith a non-injected control group, matched for age,sex and physical activity with longer-term follow-upare required to further determine the value of HVIin the treatment of recalcitrant Achilles tendinopathy.

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prospective case series assessing the influence of neovascularity and outcome

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