SLR - August 2017 - Matthew Tschudy
Ultrasound-Guided Dry Needling with Percutaneous Paratenon Decompression for Chronic Achilles Tendinopathy
Reference: Yeo A, Kendall N, Jayaraman S. Ultrasound-Guided Dry Needling with Percutaneous Decompression for Chronic Achilles Tendinopathy. Knee Surg Sports Traumatol Arthrosc. 2016 Jul;24(7):2112-8. doi: 10.1007/s00167-014-3458-7. Epub 2014 Dec 2
Scientific Literature Review
Reviewed By: Matthew Tschudy, DPM
Residency Program: Hennepin County Medical Center, Minneapolis, MN
Podiatric Relevance: Chronic Achilles tendinopathy is a common injury. Given the comorbidities with surgical open procedures, attempts have been made for less invasive procedures. The authors looked at both inside and outside the tendon pathologies and using dry needling with percutaneous hydrostatic decompression as a viable treatment option.
Methods: This was a prospective study involving 21 patients and a total of 26 tendons. Mean age of 55.3 with chronic noninsertional Achilles tendinopathy. Achilles tendinopathy was confirmed on ultrasound, and the patients were symptomatic for greater than three months. Exclusion criteria included partial or complete tendon rupture, those unable to comply with rehabilitation protocols, those who have a phobia of needles and those with coexisting causes of lower leg pain. All patients had failed previous conservative therapy. All patients underwent ultrasound-guided dry needling at six-week intervals until symptomatic resolution or no improvement was evident. Patients were followed for two years after surgery using Statistical Package for the Social Sciences (SPSS), Visual Analogue Scores (VAS) and tendon thickness as evaluation.
Results: Of the 26 tendons undergoing the procedure, there were two treatment failures. Ninety-five percent of the patients tolerated the procedure “well” or “very well.” Neovascularity was “mild” in five tendons, “moderate” in 18 and “severe” in five tendons pre procedure. This remained unchanged in 53 percent of cases and decreased in 47 percent. There was no significant change in the AP diameter of the tendon (9.7 mm pre procedure and 9.2 mm post procedure). The VAS pre procedure at rest and during activity was 42.4 (SD 24.3) and 72.8 (SD 16), respectively. This decreased significantly to 18.4 (SD 26.0) and 33.7 (SD23.2) six weeks post procedure. At 12 months, 77 percent of patients had very high or high satisfaction level with seven patients having complete resolution. At 24 months, 76 percent of patients had very high or high satisfaction level with eight patients having complete resolution.
Conclusion: Dry needling with percutaneous paratenon decompression in recalcitrant noninsertional Achilles tendinopathy resulted in rapid and sustained favorable response. Other noninvasive approaches to relieving Achilles tendinopathy include Platelet Rich Plasma (PRP), polidocanol, percutaneous tenotomy and high-volume injections. This article proposed a noninvasive technique with good short-term and long-term results. They combined both dry needling of the Achilles tendon with small-volume paratenon decompression. Overall, this article discusses a viable noninvasive option for treatment of chronic noninsertional achilles. However, this was a very small sample size, with no control group to compare results. Also, the authors combined multiple approaches of treatment of Achilles tendinopathy with small-volume hydrostatic paratenon decompression and dry needling along with ongoing physiotherapy. It is unclear, based on this, what part of the treatment helped the patient improve the most. Further analysis via randomized control trials would need to be examined before I would consider this in treatment of patients with chronic noninsertional Achilles tendinopathy.