Ep 209: REVISITED: Saying "hasta la vista" to injections for tendinopathy, with Dr Robert-Jan de Vos

[00:00:04] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality

[00:00:09] research to quality practice. I'm Clare Ardern, the Editor-in-Chief of the Journal of Orthopaedic

[00:00:15] and Sports Physical Therapy. It's great to have you listening today. As 2024 wraps up

[00:00:24] and the JOSPT Insights team are taking a few weeks break, we're taking the opportunity

[00:00:28] to revisit a few of the episodes that were definite fan favourites in 2024. The topics

[00:00:34] are just as relevant today as they were when the episodes first aired. Before today's episode

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[00:01:20] Until then, our very best holiday wishes to you and those you love. And here's today's episode.

[00:01:27] Welcome back for part two of our dive into diagnosing and managing tendinopathy with Dr. Robert Jan DeVos.

[00:01:34] Last week was all about getting your tendinopathy diagnosis right and getting going with the first

[00:01:39] line exercise therapy treatment. Today is all about the other types of interventions that you might

[00:01:45] think about or that patients might ask you about. You're going to hear about injection therapies,

[00:01:50] heel lifts, shockwave and orthopedic surgery, among other things. Dan's asking the questions.

[00:01:57] So let's jump back into Achilles tendinopathy.

[00:02:02] Another hot topic in the world of tendon care and something that I think has changed a fair amount.

[00:02:08] What if the patient in front of you says, hey, my friend got a corticosteroid injection and it seemed

[00:02:14] to really help their pain. Do you think I should get one of those? What do you say? What are the

[00:02:21] thoughts on that?

[00:02:22] Yeah, it does depend on the specific question the patient has in front of me, what the patient has

[00:02:28] in front of me. And corticosteroid has an immediate and short-term pain relieving effect. So

[00:02:34] somewhere up to eight weeks. If the patient has a very important short-term goal, you should consider

[00:02:43] it in careful consideration of the potential benefits and also the potential harms. This treatment also

[00:02:51] results in poorer long-term outcomes than wait and see in various tendinopathies. And also a large

[00:02:58] database study shows that the tendon rupture risk after corticosteroid injections increases

[00:03:04] two to fivefold when compared to controls, with also the risk increasing with the number of injections.

[00:03:12] So there are some serious harms. But on the other end, we have a recent placebo-controlled RCT

[00:03:19] that suggests that one to three period tendinous corticosteroid injections may have clinical benefits

[00:03:27] when combined with an exercise therapy for Achilles tendinopathy in the mid-portion.

[00:03:33] And I think this is a very interesting study. And I think we should also applaud the authors of that study

[00:03:39] for performing it because it's not easy to perform those studies. There are some limitations in this study.

[00:03:46] And we recently described these in a viewpoint of the GOSPT. And for this reason, because of these limitations,

[00:03:53] I would discourage implementation of corticosteroid injections on a very large scale.

[00:03:58] And I personally very rarely perform this type of injection. But on the other hand,

[00:04:06] this study also challenges our personal biases. And perhaps this treatment could still

[00:04:11] be considered if every other conservative treatment option fails. But also due to the uncertainties that

[00:04:18] remain after this new trial, I do not propose it as a standard treatment.

[00:04:22] That sounds like it makes sense. And it sounds like a pretty nuanced position of, you know,

[00:04:29] it's not our first line treatment. However, if we're exhausting all other options and you're not

[00:04:34] getting better, then maybe it's worth considering them given that we talk to the patient about

[00:04:40] the potential downstream effects and the negative outcomes that can come of them.

[00:04:45] But if we've really exhausted all other options, it can certainly be considered.

[00:04:50] You mentioned increased risk of ruptures. Is there a general timeline which those are expected if

[00:04:58] they're going to happen? From my clinical experience, the times I did see it happen, then normally it

[00:05:05] would be weeks to months after the injection. But I would say after six months, that chance will decrease.

[00:05:15] That's what my experience tells. But there's no exact data on this. There's one large American

[00:05:21] database study in which the risk of a tendon rupture in general in patients with achilles

[00:05:28] tendinopathy is 4%. They did not really specify a timeframe there. So it's uncertain in what time

[00:05:36] period that 4% is. It's not clear whether this risk is higher in the beginning stage of the disease or in the

[00:05:44] beginning stage of a specific intervention.

[00:05:48] What about if the patient in front of you says, okay, well, maybe we don't do corticosteroid injection

[00:05:52] or we wait on that decision, but I've heard about these really cool platelet-rich plasma injections.

[00:05:59] Do you think that's a good idea? What do you say to the patient in that case?

[00:06:03] PRP injections were considered to improve healing by release of growth factors from platelets in the

[00:06:08] blood and multiple case series showed promising results. But already in 2010, we performed the first placebo-controlled

[00:06:16] RCT in this field and showed that it is not more effective in improving pain of function than a placebo,

[00:06:23] nor in improving tendon structure. Recently, the study was repeated in 240 patients with mid-portion

[00:06:30] achilles tendinopathy and the results were the same. So I do not see a role for this injection treatment

[00:06:36] in achilles tendinopathy. There's been a lot of discussion about PRP lately. So that's really,

[00:06:43] really good data to help clinicians inform that conversation that I have a feeling is just

[00:06:48] happening more and more and more commonly. So what other interventions are recommended alongside

[00:06:54] exercise interventions? We already discussed the main treatment principles already, which is the

[00:07:01] trial of education, load management advice, and progressive strengthening exercises.

[00:07:07] For other adjunct treatments, we performed a living systematic review with a network meta-analysis,

[00:07:14] where we included all randomized trials on the effectiveness of interventions for achilles tendinopathy.

[00:07:20] The current findings indicate a range of treatment options available for achilles tendinopathy,

[00:07:27] and particularly the mid-portion achilles tendinopathy. And in many cases, exercise therapy was used as

[00:07:34] treatment alongside an adjunct treatment. So active treatment seems to be superior to wait and see policy,

[00:07:40] but the certainty of the evidence is low to very low. So that's a bit disappointing.

[00:07:48] I think the estimated treatment effects between different active conservative treatments was

[00:07:54] generally equal. So you could say, well, at least I would conclude that exercise therapy is an

[00:08:01] excellent basis for tendins and added interventions, well, add minimally to exercise therapy regarding

[00:08:09] effectiveness of treatment. And of course, it depends on the setting where you work. But I think exercise

[00:08:16] therapy is accessible everywhere. It's not expensive, and there are not a lot of harms. I think it also

[00:08:24] helps the people from, well, that more psychological perspective, and also the load management advices that

[00:08:31] we give. So there are a lot of advantages. Of course, the disadvantage is that people have to invest and

[00:08:38] also have to do a lot of work by themselves. But I still think that that is one of the cores of this treatment.

[00:08:46] So remaining active or becoming active, however, still using that pain monitoring model, progressive

[00:08:53] strengthening. It sounds like, you know, if a patient is saying, hey, it really helps when I do X, and that

[00:09:01] happens to be a passive modality, as long as they're doing all the other things, it might be worth putting

[00:09:07] that in for that patient. But it's not something that you should necessarily go to as an effective

[00:09:13] treatment method. Does that make sense?

[00:09:15] Yeah, I think that's really fair. And exactly when considering adjunct treatments, I think we

[00:09:22] should discuss certain topics and the treatment effectiveness or mainly the uncertainty of it,

[00:09:28] safety, the time costs, and also the clinical experience of the healthcare provider and the

[00:09:33] patient preference. We should all take that into account when considering it. And I think it's very

[00:09:39] crucial to make the right decision for that specific individual. And also in the guideline process,

[00:09:46] we also identified a number of adjunct treatments that have been assessed in randomized trials like

[00:09:52] shockwave therapy, the addition of heel lift. So there are really certain options that you could

[00:09:58] consider with low risk of harms and still perhaps something that has a preference for the patient and

[00:10:05] something you could consider together.

[00:10:08] Yeah. Could we touch on shockwave and heel lifts real quick? And kind of what was the takeaway from

[00:10:13] the guideline on those?

[00:10:14] Yeah. So also for these ones, there's a low level of evidence. And also when you compare to

[00:10:21] other active treatments, there seems to be not more benefits, clinically relevant improvement.

[00:10:28] Again, here it can be considered because of that low amount of harmful events that we see after these

[00:10:38] treatments. Of course, costs are involved here. So that's something you need to discuss with the

[00:10:44] patient. It could be an option. And I am aware of one recent randomized control trial where they also

[00:10:51] performed an arm with placebo shockwave therapy. And there we see that there was no difference between

[00:10:58] these two arms with the real focus shockwave and the placebo shockwave. So I think here we should also

[00:11:08] be careful to think it's not something we should implement for everyone, but still something you can

[00:11:15] consider, although there's a low level of evidence.

[00:11:20] Are there any things that we should not do as far as adjunct therapies or interventions?

[00:11:27] Yeah. Yeah. We just discussed the corticosteroid injections, which I would be really careful with,

[00:11:33] as well as the NSAIDs. And both of them can cause serious harms. And I think that's the reason also

[00:11:39] in our guideline why we discourage them. Based on this new study we just spoke about for the

[00:11:47] corticosteroid injections. I think, well, perhaps we can also change here a little bit that we shouldn't

[00:11:56] say that we should never do it, but at least have a reservation to do this.

[00:12:02] If the patient says, well, why not NSAIDs? I feel a lot better. My pain's a lot lower when I do them.

[00:12:07] Why don't you want me to use them? What is the thought process behind what's going on when these

[00:12:14] patients are taking NSAIDs? Yeah. So there are multiple RCTs showing that they don't have a benefit

[00:12:20] on the short or long term when compared to a placebo. And this is both for oral and topical

[00:12:26] administration. There's not already a lot of evidence stating that we should advise them.

[00:12:33] And on the other end, it can also cause serious harms like gastrointestinal bleedings,

[00:12:39] things like that, which we should be careful about, especially in patients with longstanding pain.

[00:12:44] If they use these medications for prolonged periods, that might also cause serious harms.

[00:12:50] So we don't see any evidence showing that they help short or long term,

[00:12:53] but we do know that they can have quite serious side effects, especially if you're taking them over

[00:12:58] a fair period of time. But there's also an opportunity cost of like, that's time spending

[00:13:03] doing that when we could be doing other things that we know work better. And then just kind of

[00:13:09] taking that into consideration with the patient preferences, like you mentioned, it's just,

[00:13:13] it's not a cut and dry, easy decision, but one to have, you know, with the patient and then kind

[00:13:19] of come to a mutual decision from there. That's a, that's really important.

[00:13:23] So for those like worst case scenarios, those cases that are just not getting better, we've

[00:13:29] done exercise therapy, we've considered all other, other options. Is there ever a place for surgical

[00:13:37] interventions? And if so, you know, when do those come in?

[00:13:41] Yeah. So the non-responders, so this is a hard group. It is a small group, luckily, but still

[00:13:48] in these cases, surgery might be considered as a last resort. And I think important here is to discuss

[00:13:55] the expected effectiveness of a surgical intervention when you compare it to a prolonged

[00:14:02] conservative treatment. And also here again, the potential surgical complications, such as wound

[00:14:08] healing problems, which is observed in approximately 10% of the cases after surgery. And there are many

[00:14:16] different surgical techniques that have been described. And yeah, these are often related to the expertise

[00:14:22] of a specific surgeon and also the tissue abnormalities that have been observed in the patient.

[00:14:29] And the effectiveness of most of these procedures is assessed in case series. So while the results seem

[00:14:37] promising in many of these cases, we cannot rule out a placebo effect, which is normally quite high in such

[00:14:44] invasive interventions. And this does not mean that you should never do surgery. There is also a trend

[00:14:51] towards surgical procedures outside the tendon, so such as a plantarous tendon excision and also

[00:14:57] peritendinous shaving. And these procedures are most commonly performed nowadays. And in a minority of

[00:15:03] cases, I do refer patients to an orthopedic surgeon to consider these procedures. And a recent placebo-controlled

[00:15:11] RCT suggested that peritendinous shaving might result in superior outcomes compared to placebo.

[00:15:18] So I think it's good to keep in mind that surgery could have a place in the management of this problem.

[00:15:24] Not off the table, but it's for those that, you know, it's certainly not a first-line intervention.

[00:15:29] It's for those that are really, really not responding to everything that we've tried.

[00:15:33] What's the timeframe, would you say, from beginning to treatment, before you say,

[00:15:36] hey, you know, it's really looking like we're not moving in the right direction? When does that

[00:15:41] first thought kind of come into your head?

[00:15:44] The timing of surgery, that's debatable. In that guideline process, the working group decided

[00:15:48] to consider this after six months of failure to conservative treatment. And internationally,

[00:15:54] a timeframe of 12 months has also been mentioned after a review of the research group of Neil Miller.

[00:16:00] And I think it mainly depends on the context of the patient here again. And if the achilles

[00:16:06] tendinopathy results in an absence from work, the choices will be different when compared to cases

[00:16:11] where the patient cannot perform their recreational sports activities. I think those contextual factors

[00:16:19] mainly influence the timing of surgery or other invasive treatments.

[00:16:24] I love how time and time again, you are coming back to what matters to the patient is really,

[00:16:31] really important. And there's not a cookie cutter approach. And you need to kind of take all of this

[00:16:36] evidence, all this hard work that y'all have put in to give us this really good information and then

[00:16:40] contextualize it with the person that's in front of you and have that conversation. What have we not

[00:16:45] touched on that you want listeners to know about Achilles tendon rehab?

[00:16:51] I think we touched on most things that are more at least the things that are most important.

[00:16:56] I can talk a day about this problem. And sometimes I do. But I think for this podcast,

[00:17:03] I think this is the most important things I have shared with you.

[00:17:07] Robert-Jean, thank you so much for sharing your time with me, with JOSPT, with all of our listeners.

[00:17:13] This has been a thorough and comprehensive kind of overlook at Achilles tendinopathy management. And

[00:17:21] I think that specifically, there's a lot of clinical takeaways here that our clinicians are going to

[00:17:26] benefit from and patients literally around the world are going to benefit from. So thank you.

[00:17:30] Thank you so much.

[00:17:31] Nice to hear you. And thank you for also this interview.

[00:17:35] So one big last thank you to Dr. Robert-Jean DeVos for sharing all of his insights,

[00:17:41] his expertise with all of us and all of you. And as always, we want to thank you for listening to

[00:17:46] JOSPT Insights.

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