Prolotherapy to Mid Tendon Achilles Tendonopathy – Only Mildly Better Results When Compared to Eccentric Loading Exercises – How Could That Be Better?

Article in Press found at 12 months, Relief scores were 73% for Eccentric Loading Exercises (ELE), 79% for prolotherapy and 86% for combined treatment in treatment of achilles tendonitis.

Prolotherapy injections and eccentric loading exercises for painful Achilles tendinosis: a randomised trial
Michael J Yelland, Kent R Sweeting, John A Lyftogt, Shu Kay Ng, Paul A Scuffham, Kerrie A Evans
Br J Sports Med in press 2010 abstract

• They start by mentioning just how scarry a disease this can be:
  “Mid-portion Achilles tendinosis has proven very difficult to treat[8] with reported success rates of zero to 36% for treatments including rest, anti-inflammatory medications, stretching and massage[5,9,10] and from 70 to 85% with surgery followed by four to six months rehabilitation.”

• The Eccentric Loading Exercises (ELE) which they count as 180 eccentric calf muscle contrations a day has an apparent success rate of 60 – 100%. I have given an account of a eccentric program based on this here but to get to 180/day you would have to over double the amounts done. – They did a 12 week program

• Prolotherapy intervention was:
  “Prolotherapy Injections: A doctor injected tender points in the subcutaneous
  tissues adjacent to the affected tendon with a solution consisting of 20% glucose/0.1% lignocaine/0.1% ropivacaine weekly for four to 12 treatments, using the technique described by Lyftogt.[19] The tender points were most commonly the anterolateral and anteromedial margins of the tendon and on the most posterior aspect of the tendon 2-7 centimetres from the calcaneus attachment. At each point 0.5 to 1 ml of solution was used to a maximum total of 5 mls. The number of treatments was determined by the time it took to reach a pain-free
  activity or until the participant requested to cease treatment.”

They did find that improvements were faster with the prolotherapy and combined group.

You would have thought the results should have been better – Why not? I think one has to consider the pathogenesis of the disease – something I call neurovascular fuzz- a growth of blood vesesl (?angiogenesis) and nerves that has been found to occur behind inflamed achilles tendonitis. I discussed it here

Does Pain “Grow” at Tendon injury sites? -and Treatment tennis elbowIt has been now demonstrated that arthritis has a neurogenic component and blocking the nerves gives some lasting relief. I suspect tendonitis is the same and the nerves in the area need attention. What are options? All articles read dismiss phenol as being too toxic. However, the sclerosant used in some tendonopathy studies is polidocanol – this article dismissed it because it required ultrasound use- I have used Ultrasound on a tennis elbow case and found you couldn’t miss the blood vessesl – they immediately blanched on injection without even trying.

It has been suspected that pilocarpine might have advantages because of neurolytic properties.

In: Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy
J L Cook1, C R Purdam2
British Journal of Sports Medicine 2009;43:409-416 abstract
they mention ” the positive effect on pain may be through chemical neurolysis”

I suspect a compromise might be the addition to the 20% glucose of 5% lidocaine (spinal strength) found to have neurolytic properties. This can have systemic effects so needs to be limited to 1.5 – 3.0 mls depending on the size and sensitivity of the individual (maybe start with less until sure fine). They should not drive after if lightheaded. Do not use on cardiac patients or if have a heart block.

On another issue, it looks like problems of this nature might have a genetic component – mentioned here

Any suggestions?

Any other suggestions?