The chronic painful Achilles tendon : sonographic findings and new methods for treatment

Abstract: The aim of the present thesis was to evaluate sonographic methods for investigation of the chronic painful Achilles tendon. In a prospective study on patients with chronic painful mid-portion Achilles tendinosis, grey-scale ultrasound (US) showed a decreased tendon thickness and a “normalized” structure in the majority of patients successfully treated with eccentric calf-muscle training. By combining US with colour Doppler examination (CDV), a neovascularisation was shown in the region with structural tendon changes in all painful tendons, but not in any of the pain-free normal tendons. In a small pilot study, the sclerosing agent Polidocanol was injected towards the neovessels under US and CDV guidance. The majority of the patients became painfree and had no remaining neovessels, while the patients with remaining pain had remaining neovessels. The combined findings from US, immuno-histochemical analyses of biopsies, and diagnostic injections, showed that the patients were temporarily pain-free after US and CDV guided injections of local anaesthesia towards the region with neovessels, and biopsies from the region with tendon changes and neovascularisation showed nerve structures in close relation to blood vessels. The presence of neovessels was shown also in patients with chronic pain in the Achilles tendon insertion, and it was found that treatment with sclerosing injections cured the pain in the majority of patients. A good result of treatment was associated with no remaining neovessels. In a prospective study on patients with chronic mid-portion Achilles tendinosis treated with eccentric training, CDV after treatment showed no remaining neovessels in the majority of the pain-free patients. In the patients with remaining tendon pain there were remaining neovessels. In conclusion, the findings in this thesis indicate that neovessels and accompanying nerves might be the source of chronic Achilles tendon pain. Sclerosing injections towards the neovessels, and eccentric training, seem to have a potential to cure the pain.