Many treatment options exist for recalcitrant Achilles tendinopathy, as detailed in Clinical Sports Medicine, including sclerosing, autologous blood and corticosteroid injections. What is lacking in most research reports is a clinical decision-making algorithm –when, and in whom, should I use these various interventions?
As interventions are investigated in isolation the literature does not enlighten us at all; so we are left to clinical guidance. This does not necessarily help us either, as many clinicians become advocates for certain treatments, convinced of its efficacy, and are not thoughtful about selecting interventions for different clinical presentations.
So what to do? Aside from being well informed on the pathology and presentation of Achilles tendinopathy, clinicians should consider the answers to at least some of the following questions before recommending invasive Achilles tendon treatments:
- Is the premise underlying the treatment defensible??
- Are there comprehensive pre-clinical data?
- Are there comprehensive supportive clinical data?
- What is the quality of the clinical data?
- Is it economically reasonable and are there any practitioner competing interests?
- Does the treatment have a clinical reasoning process?
- Are the risks reasonable compared to the projected benefits?
So many of the uni-modal treatments for Achilles tendinopathy fail first at Point 1, where the pathology of tendinopathy and the proposed treatment effect cannot be reconciled. They then fail at many of the subsequent points as well: this is when the thoughtful clinician will look for other more logical alternatives.
Few of the current injections offered for tendinopathy can be justified if we ask the hard questions about the treatment. So the answer to the original question “when should an Achilles tendon be injected?” is “rarely.” Or at least that is the answer until there is more clinical research that improves the background understanding of these treatments.
Jill Cook is a Professor in musculoskeletal health in the School of Primary Health Care, Monash University in Australia. Cook’s research areas include sports medicine and tendon injury. Cook currently supplements her research by conducting a specialist tendon practice and by lecturing and presenting workshops both in Australia and overseas.