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Can Achilles tendinosis be treated effectively with lidocaine and glucose infiltrations, and if so, is the effect lasting? A longitudinal, observational on 27 consecutive patients
¿Puede tratarse la tendinosis aquílea de forma eficaz con lidocaína e infiltraciones de glucosa y, de ser así, es duradero su efecto? Estudio observacional longitudinal en 27 pacientes consecutivos
A. Bello Baeza,
Corresponding author
adanbellobaez@gmail.com

Corresponding author.
, M.L. Nieto Moralesa, P. Mora Guanchea, A. Cavada Lazaa, Lina Inmaculada Pérez Méndezb
a Servicio de Radiología Osteomuscular, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
b Departamento de Epidemiología Clínica y Bioestadística, Unidad de Investigación, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
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Pain in tendinopathy has been a matter of debate&#46; The latest studies point to neo-vascularisation and neo-innervation as the ultimate triggers<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#8211;8</span></a>&#46; There is a large correlation between areas with intratendinous hyperaemia&#44; as identified by Doppler ultrasound&#44; and the zones of maximum pain reported by the patients<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46; Achilles tendinosis can be classified according to the affected anatomical region&#44; ie&#44; mid-portion tendinosis &#40;2&#8211;6 cm from the bone insertion&#41; and insertional tendinosis&#46; The first is more prevalent and accounts for 66&#37; of all injuries<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46; Patients with Achilles tendinosis frequently report having gone through several relapses throughout life&#44; with increasing and increasingly difficult to control pain&#46; Precisely this mechanism of damage&#44; healing&#44; and new damage by returning to daily physical activity favours injury and thus contributes to extracellular matrix degradation and changes in the collagen composition of the tendon fibre&#44; which result in a biomechanically compromised tissue&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Although&#44; at present&#44; eccentric exercise is the first-line physiotherapeutic treatment for Achilles tendinosis<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#44; this option is not enough in a non-negligible number of cases&#46; Recently&#44; a variety of percutaneous and extracorporeal treatments have emerged&#44; such as shock wave therapy&#44; infiltration treatment with platelet growth factors or stem cells&#44; and Achilles intratendinous prolotherapy with hyperosmolar dextrose solution&#46; The latter has been validated<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a> but still requires&#44; according to the authors themselves&#44; a larger body of evidence to confirm the promising&#44; seemingly long-lasting results&#46; The aim of this study was to evaluate Achilles tendinosis treatment with 25&#37; dextrose intratendinous prolotherapy&#44; preceded by ultrasound-guided paratenon hydrodissection with 2&#37; lidocaine in patients with chronic Achilles tendinosis&#44; resistant to rehabilitative measures&#44; in order to add evidence to the long-term effectiveness of the technique and introduce a supportive and pain-relieving therapeutic step&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">This was a longitudinal&#44; observational study &#40;case series&#41; on 27 consecutive patients diagnosed with Achilles tendinosis at the University Hospital Nuestra Se&#241;ora de Candelaria &#40;HUNSC&#41;&#44; Tenerife&#44; in whom conservative treatment had failed&#46; The study was approved by the local Medical Ethics Committee for Research on Medicines &#40;ABB- LID 2019-01&#41; and conducted in accordance with the Declaration of Helsinki&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Participants</span><p id="par0020" class="elsevierStylePara elsevierViewall">The 27 enrolled patients &#40;15 men and 12 women&#41;&#44; aged 25&#8211;70 years&#44; had suffered from Achilles tendinosis for more than three months &#40;mean duration 28 months&#44; range 3&#8211;120 months&#41; with unsatisfactory treatment outcomes from one or more of the following rehabilitation techniques&#58; eccentric exercise &#40;<span class="elsevierStyleItalic">n</span> &#61; 17&#41;&#44; shock wave therapy &#40;<span class="elsevierStyleItalic">n</span> &#61; 9&#41;&#44; and intra- tissue percutaneous electrolysis &#40;<span class="elsevierStyleItalic">n</span> &#61; 2&#41;&#46; Exclusion criteria were insertional calcific tendinosis &#40;irreversible tendinosis&#41; and large intra-substance or tendon insertion ruptures&#46; Patients underwent anaesthesia and hydrodissection of the paratenon with 2&#37; lidocaine and subsequent ultrasound-guided injections with a 25&#37;&#44; i&#46;e&#46;&#44; hyperosmolar&#44; glucose solution into the tendinous foci every 5 weeks&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Ultrasonography&#58; technique and application</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Ultrasound study</span><p id="par0025" class="elsevierStylePara elsevierViewall">The diagnostic ultrasound studies as well as the percutaneous interventional procedure were performed by three experienced radiologists with a professional background of 9&#8211;20 years in musculoskeletal radiology&#46; The technique was performed on patients in prone position with their feet hanging at the end of a table equipped with a hydraulic lift for proper height adjustment&#46; A high-end Toshiba Aplio XG equipment &#40;Toshiba Medical Systems&#44; Japan&#41; and 7-14 MHz linear transducers&#44; 27-G needles&#44; 10-ml luer lock syringes&#44; sterile gloves&#44; a sterile sleeve for the ultrasound probe&#44; as well as material to form a sterile field were used&#46; First&#44; an axial and longitudinal exploration of the tendon was performed&#44; keeping the probe parallel to the fibres in the longitudinal axis and perpendicular to the transverse axis to avoid anisotropy artefacts&#46; Then&#44; neo-vascularisation&#44; calcifications&#44; tendinous foci&#44; and maximum thickness of each tendon were determined at baseline and after each of the interventions&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Maximum tendon thickness &#40;in mm&#41; was determined in the maximum anteroposterior &#40;AP&#41; axis&#46; Only 2 of the 27 treated Achilles tendons exhibited insertional tendinosis&#44; the other 25 were cases of mid-portion tendinosis&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Hydrodissection of the paratenon with 2&#37; lidocaine</span><p id="par0035" class="elsevierStylePara elsevierViewall">Tendinous foci were localised as hypoechoic areas of poorly defined margins&#44; with or without associated hyperaemia&#44; thus confirming the pain-producing zones upon palpation&#46; These areas were marked on the skin&#44; and a small bleb of 2&#37; lidocaine was created cutaneously&#44; subcutaneously without ultrasound guidance&#46; Then&#44; aseptic measures were taken&#44; i&#46;e&#46;&#44; providing a sterile probe sleeve and cable&#44; and a sterile field around the Achilles area and on the examination table&#46; Past disinfecting the skin with povidone iodine&#44; hydrodissection of the paratenon with 2&#37; lidocaine was initiated&#46; With the same luer lock 10-ml syringe used for bleb setting and under strict ultrasound control&#44; the paratenon was separated from the adjacent subcutaneous fat tissue in order to break adhesions&#44; mechanically destroy neo-vessels and neo-nerves that could have formed in the process of tendon degeneration&#44; and lastly provoke an anaesthetic block to avoid any pain during the whole procedure&#46; For an effective hydrodissection&#44; 10 ml of 2&#37; lidocaine were required&#46; <a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1&#8211;3</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Hyperosmolar glucose solution injection</span><p id="par0040" class="elsevierStylePara elsevierViewall">Next&#44; the hypoechoic foci of tendinosis or collagen degeneration were infiltrated with a 25&#37; glucose solution&#44; mixing 1 ml of 2&#37; lidocaine &#40;20 mg&#47;ml&#41; with 1 ml of 50&#37; glucose solution &#40;25 g&#47;50 ml&#41; in a 10-ml luer lock syringe&#46; Any air in the syringe was purged to avoid artefacts in the visual field&#46; Each treatment consisted of infiltrating all the identified hypoechoic foci by performing a puncture technique parallel to the transducer or a free-hand technique &#40;Figs&#46; <a class="elsevierStyleCrossRef" href="#fig0020">4</a>&#44; <a class="elsevierStyleCrossRef" href="#fig0025">5</a>&#41;&#46; The total amount of administered solution depended on the number of foci&#44; the resistance or intratendinous pressure&#44; and the distribution of the solution within the tendon and towards the peritendon&#46; Every patient was treated from 1 to 3 tendinous foci from avarage at each procedure&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">At the end of the procedure&#44; the tendon was checked for liquid distribution and leakage of the irritant solution to the peritendon&#46; When there was considerable leakage&#44; a discrete quantity of betamethasone &#40;0&#46;5 ml&#41; was injected into this area to avoid paratenonitis&#44; a potential complication of the procedure&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Patients were given the guidelines to adhere to during the following post-procedure weeks&#46; These comprised avoiding non-steroidal anti-inflammatory drugs &#40;NSAIDs&#41;&#44; especially during the first 72 h&#44; and recommended paracetamol 1 g every 8 h as the only permitted analgesic if pain occurred&#44; as the latter does not inhibit COX-2 unlike the other non-steroidal anti-inflammatory drugs&#46; Likewise&#44; patients were asked not to perform intense axial load exercise at least 72 h following the procedure&#46; Thereafter&#44; they were allowed to return to their habitual physical activity&#44; including their routine eccentric exercise supervised by a professional&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">A brief follow up by telephone or WhatsApp&#44; asking for the patient&#8217;s current level of pain&#44; was performed 24 months after the final treatment&#46; VAS Assessment was included on those interviews using WhatsAPP&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Pain assessment</span><p id="par0060" class="elsevierStylePara elsevierViewall">Visual analogue scale &#40;VAS&#41; grading from 0 to 100 was applied for pain assessment at baseline and the final treatment consultation&#46; Pain at rest &#40;VAS1&#41;&#44; with activities of daily living &#40;VAS2&#41;&#44; and during or immediately after moderate exercise &#40;VAS3&#41; was recorded at baseline and the final treatment<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>&#46; Variations were evaluated &#40;a&#41; as final scores of the VAS1&#44; VAS2&#44; and VAS3 and &#40;b&#41; as percentages of individual variations with respect to the baseline scores&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Vascularisation assessment</span><p id="par0065" class="elsevierStylePara elsevierViewall">To determine the progression of tendon neo-vascularisation&#44; a classification system was applied&#58; grade 0 &#40;i&#46;e&#46;&#44; no neo-vascularisation&#41;&#44; grade 1 &#40;i&#46;e&#46;&#44; mild neo-vascularisation with 1-2 vessels entering the tendon&#41;&#44; grade 2 &#40;i&#46;e&#46;&#44; moderate neo-vascularisation with 3-4 vessels&#41;&#44; and grade 3 &#40;i&#46;e&#46;&#44; severe neo-vascularisation with more than 4 vessels&#41;&#46; Thus&#44; initial grades were termed Gi0&#44; Gi1&#44; Gi2&#44; and Gi3 and the final grades Gf0&#44; Gf1&#44; Gf2&#44; and Gf3&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Statistical analyses</span><p id="par0070" class="elsevierStylePara elsevierViewall">Data for categorical variables were summarised as frequencies&#44; and as mean &#177; SD and median &#40;25th and 75th percentile&#44; P25&#44; P75&#41; for numerical variables&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Treatment effectiveness was estimated applying a 95&#37; CI&#44; taking into account scoring and the relative decrease with respect to initial pain&#46; Comparisons between baseline and final VAS scores and changes in tendon thickness and vascularisation were explored using the non-parametric Wilcoxon test for paired data and a general linear model &#40;GLIM&#41; for repeated measurements as appropriate&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Statistical significance was set at <span class="elsevierStyleItalic">p</span> &#60; 0&#46;05&#46; All analyses were performed with the SPSS&#47;PC software &#40;V&#46;24&#46;0 for Windows&#59; SPSS&#44; Inc&#46;&#44; Chicago&#44; IL&#44; USA&#41; and EPIDAT &#40;V&#46;3&#46;0&#44; Conseller&#237;a de Sanidade Xunta de Galicia and Panamerican Health 0rganization&#41;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Public and patient involvement</span><p id="par0085" class="elsevierStylePara elsevierViewall">No members of the public or patients were involved in the design&#44; conduct and interpretation of this study&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Results</span><p id="par0090" class="elsevierStylePara elsevierViewall">This prospective case series included 27 consecutive patients with a mean age of 25 years&#44; who suffered from Achilles tendinosis refractory to conventional treatment with eccentric exercise&#44; shock wave therapy&#44; or intra-tissue percutaneous electrolysis&#46; Their dominant condition &#40;91&#37;&#41; was a mid-portion tendinosis that contrasted with only 2 cases of insertional tendinosis&#46; Repeating the percutaneous treatment every 5&#8211;6 weeks&#44; a mean number of 5 treatment sessions &#40;1&#8211;11&#41; In other words&#44; 25&#8211;30 weeks of treatment from average was required to achieve satisfactory results&#44; i&#46;e&#46;&#44; VAS &#60; 3&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">At inclusion&#44; patients reported mean scores of 67&#44; 76&#44; and 86 in VAS1&#44; VAS2&#44; and VAS3 scale&#44; respectively&#46; After completing prolotherapy treatment&#44; a statistically significant decrease &#40;<span class="elsevierStyleItalic">p</span> &#60; 0&#46;0001&#41; was observed in all three pain scores&#46; The relative decrease compared to the initial resting score was 75&#37; in VAS1 &#40;95&#37; CI&#59; 61&#8211;93&#37;&#41;&#44; 69&#37; in VAS2 &#40;95&#37; CI&#59; 55-83&#37;&#41;&#44; and 70&#37; in VAS3 &#40;95&#37; CI&#59; 57&#8211;84&#37;&#41;&#46; Only two patients reported no change with respect to their initial pain scores&#46; The statistics that describe the decrease in pain &#40;mean&#44; median&#44; and p values&#41; in all three conditions are given in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> and <a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">In the course of therapy&#44; visible vessels in the hypoechoic foci diminished throughout the tendon layer&#59; tendon neo-vascularisation reflected a statistically significant &#40;<span class="elsevierStyleItalic">p</span> &#60; 0&#46;001&#41; decrease &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>&#41;&#46; Individual improvement was observed in each patient&#46; Initial vascularisation was classified as Gi1 in 1&#44; Gi2 in14&#44; and Gi3 in 13 patients&#46; Of note&#44; 78&#46;6&#37; of the treated tendons changed from a vascularisation degree Gi2 to Gf0&#44; and 100&#37; with Gi3 passed to Gf1&#46; Only the patient who started with Gi2 maintained the grade &#40;Gf2&#41;&#46; Thus&#44; by the end of the treatment&#44; 96&#37; of the tendons were classified as either grade 0 or grade 1 on the vascularisation scale &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#44; <a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>&#41;&#46;</p><elsevierMultimedia ident="fig0035"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">We did not observe significant changes in tendon thickness&#44; neither between initial and final means &#40;13&#46;82 mm&#44; 13&#46;68 mm&#59; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;083&#41; nor in medians &#40;percentiles P25&#44; P75&#59; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;083&#41; of the initial &#40;12&#44; 14&#44; 16&#41; and the final maximum AP &#40;13&#46;5&#44; 12&#44; 15&#46;25&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> and <a class="elsevierStyleCrossRef" href="#fig0040">Fig&#46; 8</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0040"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">No adverse effects or complication were observed during or after the procedure&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Discussion</span><p id="par0115" class="elsevierStylePara elsevierViewall">This study aimed to add evidence to the little data available on tendinosis and its possible treatment&#46; Our work supports data&#44; obtained by Maxwell et al and Ryan et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a>&#44; which represent the largest series on treatment and follow up of Achilles tendinosis published to date and provide an excellent reference with which tocompare our results&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Reducing the severe pain patients with Achilles tendinosis suffer&#44; not only in moderate exercise but also in their daily activity and even at rest&#44; is the goal of conventional therapies&#44; which as of yet have been applied with doubtful success&#46; Today&#44; eccentric &#40;heel-drop&#41; exercise is the gold standard physiotherapy for Achilles tendinosis&#44; included in various guides and internationally validated &#40;10&#41;&#46; When this option is not enough and fails to mitigate the patient&#39;s pain&#44; different recently published&#44; percutaneous and extracorporeal treatments come into play&#44; such as shock wave therapy&#44; dry needle puncture&#44; high volume injections&#44; treatment with platelet growth factors&#44; and prolotherapy with hyperosmolar glucose<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#8211;16</span></a>&#46; Our ultrasound-guided&#44; percutaneous treatment method encompassed paratenon hydrodissection with 2&#37; lidocaine and intratendinous prolotherapy with 25&#37; dextrose and led&#44; under these conditions&#44; to promising results&#46; In addition&#44; it combined two of the described percutaneous treatment methods in one procedure&#44; i&#46;e&#46;&#44; paratenon high volume hydrodissection and prolotherapy with a hyperosmolar glucose solution&#46; Notably&#44; our study describes for the first time paratenon hydrodissection with 2&#37; lidocaine&#44; fulfilling a dual purpose&#46; On the one hand&#44; the tendon is anaesthetised such that the patient does not experience any pain during the procedure&#46; Importantly&#44; pain is one of the principle handicaps attributed to prolotherapy and tendon treatments in general&#46; On the other hand&#44; neo-vessels that penetrate the paratenon are more likely destroyed using the highest possible volume&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Pain is known to be a subjective symptom&#46; By using the same visual analogue scale for pain evaluation as other authors&#44; we were able to compare results<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>&#46; All three baseline mean values&#44; VAS1&#44; VAS2&#44; and VAS3&#44; were somewhat higher in our patients than in the two previously published series<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a>&#46; After completing prolotherapy&#44; pain had decreased significantly and to similar final scores in all three conditions&#44; also reflected by the relative decrease&#46; Moreover&#44; the maximum relative reduction in pain at rest resembled the data found by Maxwell et al in his series of 36 cases<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The mean change in tendon thickness of 0&#46;1 mm by the end of treatment was not significant&#44; similar to the mean decrease of 0&#46;6 mm found by Maxwell et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> and of mm in the 108 treated tendons reported by Ryan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Current studies on tendinopathies and their appropriate treatment have focused on the concurrent neo-vascularisation as a probable source of pain<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#46; Tendons by definition are virtually avascular and therefore prone to hypoxaemia&#44; which may lead to inadequate repair in conditions of acute or chronic stress&#46; Micro-dialysis studies have demonstrated that lactate in tendinosis persists at rest&#44; suggesting hypoxia in tendinopathy even beyond physical stress<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#46; In a recent work&#44; J&#228;rvinen TAH explained the paradox of hypoxaemia despite extensive neo-vascularisation in tendinosis based on the theory of hyper-permeability<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#46; Basically&#44; this author discusses that hypoxia-stimulated tendon neo-vascularisation and its consequent secretion of vascular growth factors would lead to hyper-permeable vessels&#44; probably due to an altered lumenisation&#44; i&#46;e&#46;&#44; the structural integrity of endothelial cells and pericytes in the vessel wall&#46; This in turn&#44; would lead to poor tissue perfusion and clearing of fibrin-rich exudates from the extra-luminal tissue&#44; thus leading to fibrinoid degeneration of the tendon<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#46; Latest advances in genetics and vascular biology have identified genes responsible for adequate vascular stabilisation and lumenisation&#44; among them R-Ras<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46; A lack of R-Ras expression is responsible for hyper-permeable neo-vessels in distinct diseases like&#44; e&#46;g&#46;&#44; retinopathy&#44; cancer&#44; and evidently musculoskeletal ischaemia&#46; On the contrary&#44; restoration of R-Ras gene activity in mouse endothelial cells reverts the hypoxaemia phenomena<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#44; which opens up a completely new and unexplored field in the treatmentof this pathology&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">In our case series as well as in those published by Maxwell et al and Ryan et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a>&#44; initial vascularisation grade 2 was predominant &#40;59&#37;&#41;&#44; followed by grade 3 in 35&#37; of the tendons&#46; We would like to emphasise that by the end of treatment 100&#37; of the tendons were grade 0 or grade 1&#44; a significant decrease&#44; individually presented in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; The mean decrease in tendon vascularisation in the aforementioned studies was significant as well&#44; although individual changes were not given&#59; however&#44; most likely none of the tendons will have worsened&#46;</p><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Limitations and strengths</span><p id="par0145" class="elsevierStylePara elsevierViewall">A certain limitation of our study is the lack of a control group or groups with other therapies&#8212;as presented in the above mentioned works<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a>&#8212;that would allow comparison&#46; There are no clinical trials that assess the use of 25&#37; glucose vs placebo or that blind patients for pain evaluation before and after treatment&#44; taking into account the subjectivity of pain perception&#46; In this regard&#44; our study provides objective&#44; ultrasound-based evidence of a significant decrease in defective neo-vessels&#44; which would perpetuate inflammation and structurally affect tissues and which seem to correlate with pain<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#46; All our patients had undergone other therapies without success and exhibited a high degree of pain and a high level of neo-vascularisation&#46; As Maxwell et al mentioned in their conclusions<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#58; &#8220;&#8230; further clinical studies comparing hyperosmolar dextrose injections with other therapies and with no therapy are required&#8221;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Achilles tendinosis is a health problem that affects both athletes and sedentary persons&#46; Its actual incidence is unknown&#46; Standing for a long time supporting the body weight as well as sports based on running are recognised risk factors for this condition&#46; Achilles tendinosis is a challenge for health care professionals&#44; as there is still very little information available on its etiopathogenesis and adequate treatment&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Achilles intratendinous prolotherapy with a hyperosmolar dextrose solution is a cheap&#44; safe&#44; and long-lasting therapeutic method&#44; validated with the longest case series &#40;108 Achilles tendons&#41; in this field as of yet<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>&#46; The pain resulting from injecting the hypertonic&#44; irritant solution into the Achilles tendon during prolotherapy is perhaps the most limiting factor for its regular use&#46; Taking into account the latter and the high volume treatments with physiological saline described by Chang et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#44; we decided to incorporate a novel&#44; foregoing step of anaesthesia and hydrodissection of the paratenon with 2&#37; lidocaine into the originally described technique<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a>&#46; This allowed us to perform painless Achilles infiltration with hypertonic solution and&#44; in addition&#44; to break potential adhesions&#44; neo-vascularisation and neo-innervation that irrigate and innervate the hypoechoic&#44; tendinous foci&#44; thus contributing to the outcome of the prolotherapy itself&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The histopathological changes that accompany prolotherapy had been suggested by Banks AR in 1991<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a>&#46; The author had proposed four basic mechanisms to bring about repair and recovery of the damaged tissue&#58; &#40;1&#41; The injected solution would cause osmolarity-induced cell dehydration and in consequence a local inflammatory reaction&#46; &#40;2&#41; Cell debris would attract granulocytes&#44; which in turn would secrete humoral factors and thus lead to macrophage infiltration&#46; &#40;3&#41; The macrophages would phagocytise the cell debris and secrete growth factors that attract and activate fibroblasts&#46; &#40;4&#41; Finally&#44; the fibroblasts would produce collagen&#44; resulting in a re-organised&#44; stronger tendon connective tissue than before infiltration&#46; However we are aware of discordant findings in animal studies regarding density&#44; viability and recruitment of proteoblasts or tendon vascularisation after administration of prolotherapy so more Studies about histopathological mechanisms are needed&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">In our study&#44; we were able to confirm the increase in tendon resistance with each administration of hyperosmolar solution&#44; which seems to confirm the latter point proposed by Banks&#46; Functional MRI using T2 relaxation maps before&#44; during&#44; and after prolotherapy treatment could help confirm this hypothesis&#8212;a stimulus for future research&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Likewise&#44; we have observed a continuous decrease throughout the tendon layer in numbers of visible vessels in the hypoechoic foci&#46; This progressive decrease was reflected in reduced pain determined by VAS grading &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46; Our observation favours the hypothesis that the usually reported pain may be largely due to the neo-innervation that accompanies neo-vascularisation<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Ultrasound-guided dry puncture&#44; also known as percutaneous tenotomy&#44; is a technique that has been performed with satisfactory results in recent years<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;16</span></a>&#44; a fact that brings about a debate on the need of adding irritant or hypertonic solutions to percutaneous treatment&#46; Further studies are required to compare both methods to clarify the question&#46; We also believe that other percutaneous treatments like shock wave therapy and platelet-rich plasma infiltration should be included in such a study&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Alternatively&#44; stabilising the damaged&#44; malformed neo-vessels during stress-induced hypoxaemia and thus reverting hypoxia-derived phenomena could be the definitive treatment approach in this pathology&#46; Progress in vascular biology and related therapies in the near future may finally solve these questions&#46;</p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conclusion</span><p id="par0185" class="elsevierStylePara elsevierViewall">Percutaneous Achilles tendinosis treatment combining anaesthesia and paratenon hydrodissection with subsequent prolotherapy with hyperosmolar glucose solution is a safe&#44; cheap&#44; and virtually painless technique&#46; It results in a progressive reduction in neo- vessels throughout the tendon layer as well as a significant decrease in the perception of pain at rest&#44; with daily physical activity&#44; and during moderate exercise&#44; which is maintained over time&#46;<elsevierMultimedia ident="tb0005"></elsevierMultimedia></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Funding</span><p id="par0215" class="elsevierStylePara elsevierViewall">This research received no specific grant from any funding agency in the public&#44; commercial&#44; or not-for-profit sector&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Authorship</span><p id="par0280" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">1</span><p id="par0220" class="elsevierStylePara elsevierViewall">Responsible for study integrity&#58; ABB</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">2</span><p id="par0225" class="elsevierStylePara elsevierViewall">Study conception&#58; ABB</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">3</span><p id="par0230" class="elsevierStylePara elsevierViewall">Study design&#58; ABB</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">4</span><p id="par0235" class="elsevierStylePara elsevierViewall">Data acquisition&#58; ABB&#44; MLNM&#44; PMG y ACL</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">5</span><p id="par0240" class="elsevierStylePara elsevierViewall">Data analysis and interpretation&#58; LIPM</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">6</span><p id="par0245" class="elsevierStylePara elsevierViewall">Statistical processing&#58; LIPM</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">7</span><p id="par0250" class="elsevierStylePara elsevierViewall">Literature search&#58; ABB</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">8</span><p id="par0255" class="elsevierStylePara elsevierViewall">Drafting of the manuscript&#58; ABB</p></li></ul></p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Conflict of interests</span><p id="par0260" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interests&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Our aim was to add to the small but growing body of evidence on the effectiveness of ultrasound-guided Achilles intratendinous hyperosmolar dextrose prolotherapy and introduce a novel&#44; preceding step of paratenon hydrodissection with lidocaine in patients with chronic Achilles tendinosis resistant to rehabilitation therapy&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">We conducted a longitudinal&#44; observational study on 27 consecutive patients diagnosed with Achilles tendinosis&#44; in whom conservative treatment&#44; ie&#44; physiotherapy or shock wave therapy&#44; had failed&#46; A 2&#37; lidocaine paratenon anesthesia and hydrodissection was followed by ultrasound-guided&#44; intratendinous injections of 25&#37; glucose every 5 weeks&#46; Visual analogue scales &#40;VAS&#41; were used for pain assessment at rest&#44; for activities of daily living&#44; and after moderate exercise at the begining and at the end of the treatment&#46; Moreover&#44; tendon thickness and vascularisation were recorded at baseline and final treatment consultation&#46; Effectiveness was estimated from scoring and relative pain reduction using a 95&#37; CI&#46; The non-parametric Wilcoxon test and a general linear model for repeated measures were applied&#46; Statistical significance was established as <span class="elsevierStyleItalic">p</span> &#60; 0&#46;05&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">A median of 5 &#40;1&#8211;11&#41; injection consultations per patient were required&#46; Pain scores decreased significantly in all three conditions &#40;<span class="elsevierStyleItalic">p</span> &#60; 0&#46;001&#41;&#46; Relative reductions were 75&#37; in pain at rest &#40;95&#37; CI&#59;61&#8211;93&#37;&#41;&#44; 69&#37; in pain with daily living activities &#40;95&#37; CI&#59; 55&#8211;83&#37;&#41;&#44; and 70&#37; in pain after moderate exercise &#40;95&#37; CI&#59; 57&#8211;84&#37;&#41;&#46; Tendon neo-vascularisation was significantly reduced &#40;<span class="elsevierStyleItalic">p</span> &#60; 0&#46;001&#41;&#46; We did not observe significant changes in tendon thickness &#40;<span class="elsevierStyleItalic">p</span> &#61; 0&#46;083&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Achilles tendinosis treatment with paratenon lidocaine hydrodissection and subsequent prolotherapy with hyperosmolar glucose solution is safe&#44; effective&#44; inexpensive&#44; and virtually painless with results maintained over time&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Nuestro objetivo era contribuir al peque&#241;o pero creciente conjunto de datos sobre la eficacia de la proloterapia con glucosa hiperosmolar intratendinosa en el tend&#243;n de Aquiles guiada por ecograf&#237;a e introducir un paso previo nuevo de hidrodisecci&#243;n del paratend&#243;n con lidoca&#237;na en pacientes con tendinosis aqu&#237;lea cr&#243;nica resistente a la fisioterapia&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Llevamos a cabo un estudio observacional longitudinal en 27 pacientes consecutivos con diagn&#243;stico de tendinosis aqu&#237;lea en los que el tratamiento conservador&#44; es decir&#44; fisioterapia o terapia con ondas de choque&#44; hab&#237;a sido ineficaz&#46; A la anestesia e hidrodisecci&#243;n del paratend&#243;n con lidoca&#237;na al 2&#37; le siguieron inyecciones intratendinosas guiadas por ecograf&#237;a de glucosa al 25&#37; cada 5 semanas&#46; Se utiliz&#243; la escala visual anal&#243;gica &#40;EVA&#41; para evaluar el dolor en reposo&#44; en las actividades de la vida diaria y despu&#233;s de ejercicio moderado&#44; al inicio y al final del tratamiento&#46; Adem&#225;s&#44; el grosor y la vascularizaci&#243;n del tend&#243;n se registraron en la consulta de inicio y final del tratamiento&#46; La eficacia se estim&#243; a partir de la puntuaci&#243;n y de la reducci&#243;n del dolor relativo utilizando un intervalo de confianza &#40;IC&#41; del 95&#37;&#46; Se aplicaron la prueba de Wilcoxon no param&#233;trica y un modelo lineal general para medidas repetidas&#46; La significaci&#243;n estad&#237;stica se estableci&#243; en p &#60; 0&#44;05&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">Se necesit&#243; una media de 5 &#40;1-11&#41; consultas para administrar inyecciones&#46; Las puntuaciones del dolor disminuyeron significativamente en los 3 casos &#40;p &#60; 0&#44;001&#41;&#46; Las reducciones relativas fueron de un 75&#37; para el dolor en reposo &#40;IC del 95 &#37;&#44; 61-93&#37;&#41;&#44; un 69&#37; para el dolor con las actividades de la vida diaria &#40;IC del 95 &#37;&#41; y un 70 &#37; para el dolor despu&#233;s de ejercicio moderado &#40;IC del 95&#37;&#59; 57-84&#37;&#41;&#46; La neovascularizaci&#243;n del tend&#243;n se redujo significativamente &#40;p &#60; 0&#44;001&#41;&#46; No observamos cambios significativos en el grosor del tend&#243;n &#40;p &#61; 0&#44;083&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">El tratamiento de la tendinosis aqu&#237;lea con hidrodisecci&#243;n con lidoca&#237;na del paratend&#243;n y proloterapia posterior con soluci&#243;n glucosada hiperosmolar es seguro&#44; eficaz&#44; barato y pr&#225;cticamente indoloro&#44; manteni&#233;ndose los resultados a lo largo del tiempo&#46;</p></span>"
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                  \t\t\t\t">17&#46;41 &#177; 25&#46;36&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Median &#91;P25&#59; P75&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">80 &#91;60&#59; 90&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#91;0&#59; 30&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VAS 2</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mean &#177; SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">78&#46;15 &#177; 6&#46;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&#46;70 &#177; 28&#46;18&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Median &#91;P25&#59; P75&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">80 &#91;70&#59; 90&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#91;0&#59; 30&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VAS 3</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mean &#177; SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">87&#46;78 &#177; 10&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#46;55 &#177; 30&#46;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Median &#91;P25&#59; P75&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Total &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">27&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Vascularity grading at baseline and final treatment consultation Neo- vascularisation by the end of treatment&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">13&#46;82 &#177; 2&#46;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">13&#46;68 &#177; 2&#46;25&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Sonographic Evaluation of the Achilles Tendon Thickness&#46; Maximum anteroposterior diameter &#40;mm&#41; at baseline and at final session&#46;</p>"
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          "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">What are the findings&#63;</span><p id="par0270" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><p id="par0190" class="elsevierStylePara elsevierViewall">A decrease in tendinosis neo-vascularisation can be attained with percutaneous prolotherapy&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><p id="par0195" class="elsevierStylePara elsevierViewall">Paratenon lidocaine hydrodissection ensures an asymptomatic percutaneous procedure and releases any potential tissue adherence&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><p id="par0200" class="elsevierStylePara elsevierViewall">The achieved decrease in neo-vascularisation was proportional to the decrease in pain intensity assessed with visual analogue scales&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><p id="par0205" class="elsevierStylePara elsevierViewall">The effects of prolotherapy lasted over time within a 24-months follow up&#46;</p></li></ul></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">How might it impact on clinical practice in the future&#63;</span><p id="par0275" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><p id="par0210" class="elsevierStylePara elsevierViewall">Ultrasound-guided&#44; percutaneous tendinosis treatment with lidocaine paratenon hydrodissection followed by glucose infiltration into hypoechoic foci is an inexpensive and available method with seemingly excellent long-term results&#46;</p></li></ul></p></span></span>"
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                    0 => array:2 [
                      "titulo" => "Achilles tendinitis and peritendinitis&#58; etiology and treatment"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "D&#46;B&#46; Clement"
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                            2 => "G&#46;W&#46; Smart"
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                    0 => array:2 [
                      "doi" => "10.1177/036354658401200301"
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                        "tituloSerie" => "Am J Sports Med"
                        "fecha" => "1984"
                        "volumen" => "12"
                        "paginaInicial" => "179"
                        "paginaFinal" => "184"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6742297"
                            "web" => "Medline"
                          ]
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              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Cumulative incidence of Achilles tendon rupture and tendinopathy in male former elite athletes"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "U&#46;M&#46; Kujala"
                            1 => "S&#46; Sama"
                            2 => "J&#46; Kaprio"
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                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1097/01.jsm.0000165347.55638.23"
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                        "tituloSerie" => "Clin J Sport Med"
                        "fecha" => "2005"
                        "volumen" => "15"
                        "paginaInicial" => "133"
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                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15867554"
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                    0 => array:2 [
                      "titulo" => "Long-term prognosis of patients with achilles tendinopathy&#46; An observational 8-year follow-up study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "M&#46; Paavola"
                            1 => "P&#46; Kannus"
                            2 => "T&#46; Paakkala"
                            3 => "M&#46; Pasanen"
                            4 => "M&#46; J&#228;rvinen"
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                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1177/03635465000280050301"
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                        "fecha" => "2000"
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                        "paginaInicial" => "634"
                        "paginaFinal" => "642"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11032217"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Etiology&#44; histopathology&#44; and outcome of surgery in achillodynia"
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                          "autores" => array:2 [
                            0 => "C&#46; Rolf"
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                    0 => array:2 [
                      "doi" => "10.1177/107110079701800906"
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                        "tituloSerie" => "Foot Ankle Int"
                        "fecha" => "1997"
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                            2 => "A&#46; Lichtenberg"
                            3 => "M&#46; Jagodzinski"
                            4 => "T&#46; Gossling"
                            5 => "M&#46; Richter"
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                    0 => array:2 [
                      "doi" => "10.1177/0363546505278705"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16219947"
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                      "titulo" => "Is vasculo-neural ingrowth the cause of pain in chronic Achilles tendinosis&#63; An investigation using ultrasonography and colour Doppler&#44; immunohistochemistry&#44; and diagnostic injections"
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                          "etal" => false
                          "autores" => array:3 [
                            0 => "H&#46; Alfredson"
                            1 => "L&#46; Ohberg"
                            2 => "S&#46; Forsgren"
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                      "doi" => "10.1007/s00167-003-0391-6"
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                        "tituloSerie" => "Knee Surg Sports Traumatol Arthrosc"
                        "fecha" => "2003"
                        "volumen" => "11"
                        "paginaInicial" => "334"
                        "paginaFinal" => "338"
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                      "titulo" => "Neovascularisation in chronic tendon injuries detected with colour Doppler ultrasound in horse and man&#58; Implications for research and treatment"
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                          "etal" => false
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                            2 => "C&#46; Johnston"
                            3 => "H&#46; Alfredson"
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                      "titulo" => "Neovascularisation in Achilles tendons with painful tendinosis but not in normal tendons&#58; An ultrasonographic investigation"
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                          "etal" => false
                          "autores" => array:3 [
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Article information
ISSN: 21735107
Original language: English
DOI:10.1016/j.rxeng.2022.05.002
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