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Ultrasound Guided Dextrose Injections as a New Treatment for Chronic Overuse Tendon Injuries
RS2006-DG05
Final Report Date: November 2007
| Principal Investigator: | Jack Taunton (UBC) |
| Co-Investigator: | Anthony Wong (St. Paul's Hospital) |
For more information about this project, please contact Dr. Jack Taunton.
Issue
Chronic tendon injuries can be debilitating for workers, and there are limited options for treatment. One treatment method that has shown promise is the injection of a solution (hypersmolar dextrose) into the tendon to stimulate healing. This study evaluated this treatment method when used in combination with an ultrasound examination to allow injections to be given directly into the areas of the tendons that show signs of degeneration.
Key findings
- Pain levels and signs of tendon damage were significantly reduced by the end of treatment for patients in all four groups — Achilles, heel (plantar fascia), knee and elbow.
- Long term pain reduction outcomes were excellent for the Achilles and heel groups. There was not enough information to assess long term outcomes for the other two groups.
Objectives
- To assess the effectiveness of a treatment for chronic tendon injuries (Achilles, heel, knee and elbow) in which a dextrose solution is injected into areas of the tendon that show signs of damage, as detected through an ultrasound examination
- To evaluate changes in pain and physical ability by the end of treatment and at a longer term follow-up
- To examine physical changes occurring in the tendon over the course of treatment, and the relationship of these changes to pain and physical ability outcomes
Method
Eligible patients referred to the radiology department at St. Paul’s hospital in Vancouver were invited to participate in the study. A total of 99 patients agreed to participate.
A radiologist used ultrasound to examine tendons and assess thickness, tears, collagen degeneration, new blood vessel growth, and bone irregularities. The dextrose solution was then injected into the tendon in locations that were found to have tears and/or collagen degeneration.
Patients received further injections approximately every six weeks. The treatments continued until patients were satisfied or it was determined that additional injections were unlikely to reduce pain further.
Before the first treatment, patients completed a questionnaire about previous treatments, symptom duration, activity history, and level of pain at rest, during normal daily activity, and during or after physical activity/sports. Pain levels were recorded again after the final treatment and at a later follow up by telephone, on average approximately one to one and a half years after treatment.
Results
A total of 99 patients were treated with ultrasound guided dextrose injections, involving 33 Achilles, 28 knee, 24 heel and 13 elbow tendons.
There were an average of four treatments for Achilles and knee tendons, and three for heel and elbow tendons. The average number of injection sites was 1.3 for elbow tendons, 1.4 for heel and knee tendons, and 2.6 for Achilles tendons.
Average pain levels were significantly reduced for all tendon groups (Achilles, knee, heel, elbow) from before treatment to the time of the final injection. The average reductions in pain for each group are shown below (numbers rounded).
|
|
During |
During |
Achilles |
88% |
84% |
78% |
Knee |
51% |
53% |
49% |
Heel |
72% |
67% |
58% |
Elbow |
77% |
63% |
63% |
There was a significant reduction in the number of tendons with signs of physical damage, specifically, the number of tendons with signs of:
- tendon tearing (in the Achilles, knee and heel groups)
- collagen degeneration (in the knee, heel and elbow groups)
- bone irregularities (in the knee, heel and elbow groups)
- new blood vessel in-growth (in the Achilles, knee and elbow groups)
Long term follow up results for each group were as follows:
| Achilles: |
|
Knee: |
|
Heel: |
|
Elbow: |
|
Conclusions
Short term results showed that treatment effectively reduced chronic tendon pain in the Achilles, knee, heel and elbow area. Long-term follow-up results confirmed excellent outcomes in the Achilles and heel patients.
It should be noted that this was a pilot study, without a control group and other procedures used in larger studies, and that this limits the strength of the evidence.
Future directions
Further research will explore the impact of timing the treatments closer together, and decreasing the space between injection sites for Achilles tendons. A double-blind, placebo controlled, prospective randomized clinical trial is being planned to provide stronger evidence on the efficacy of this treatment, and to improve understanding of the physical changes that makes this treatment effective.
Publications and Presentations
Maxwell N, Ryan M, Taunton J, Gillies J, Wong A. Sonographic Guided Intratendinous Injection of Hyperosmolar Dextrose to Treat Chronic Tendinosis of the Achilles Tendon: A Pilot Study. American Journal of Roentgenology, 2007;189:W215-220. http://www.ajronline.org/cgi/reprint/189/4/W215
Michael B Ryan, Anthony Wong, Jean Gillies, Julia Wong, and Jack Taunton. Sonographically Guided Intratendinous Injections of Hyperosmolar Dextrose/Lidocaine: A Pilot Study for the Treatment of Chronic Plantar Fasciitis. British Journal of Sports Medicine. Nov 2008; doi:10.1136/bjsm.2008.050021
Presentation. Annual meeting of the Canadian Academy of Sports Medicine. Quebec City, March 28, 2007. Abstract published in Clinical Journal of Sports Medicine. M. Ryan, A. Wong, J. Taunton, and J. Wong. A Pilot Investigation on a New Treatment for Chronic Plantar Fasciitis: Ultrasound Guided Hyperosmolar Dextrose Injections. Clin J Sport Med 2007 17(2):166.
Presentation: Two seminars at Frontrunners store in Victoria, B.C. to audiences primarily of sport medicine physicians, chiropractors, physiotherapists, orthopedists, and massage therapists. August 2007.
Presentation: Discussion of the rationale and theoretical mechanisms behind the positive clinical outcomes of dextrose injection therapy. The Anatomy, Diagnosis, and Treatment of Chronic Myofascial Pain with Prolotherapy conference. Madison, Wisconsin, October 2007.