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St. Paul's Hospital Vancouver, BC, Canada
WEB—This is a Web exclusive article.
As I think they realize, the study was not designed to measure the increased collagen synthesis shown with eccentric training. Most of our patients had either failed in the heavy-load eccentric program or were unable to tolerate it. Instead, our study was a pilot investigation to evaluate whether the intratendinous injections of hyperosmolar dextrose could improve the disabling symptoms of chronic Achilles tendinosis and at the same time heal the interstitial clefts (some of which were up to 1.5 cm in length) that were often seen sonographically in our subjects. In fact, it was the presence of these sonographic changes that provided the initial impetus to perform intratendinous injections. It did not seem logical to sclerose neovessels that we thought may be part of the healing response to the chronically injured tendons and not address the often severe sonographically visible changes. Almost all of these clefts healed or became smaller over the course of the treatments along with the positive clinical responses.
In addition, during the initial stage of treatment, there was sonographically visible spread of the injected dextrose within the tendons in many of the patients. This was seen as a dispersal of tiny echoes within the substance of the tendon (often over a distance of up to 4 cm). In some of the more severely affected subjects, multiple small transient clefts (0. 1–0.3 cm) appeared during the injections that were not visible before the injection and disappeared after the injection. As the symptoms improved, these sonographic findings resolved. I assume that this was due to the deposition of collagen.
Regarding the neovascularity often associated with the condition, we did not notice a strong association between the de gree of neovascularity and the severity of the tendinosis. We also did not observe any consistent change in the degree of neovascularity associated with the symptomatic improvement.
We are aware that there are potential side effects to intratendinous injections. Our follow-up data on treated patients now extends up to 3 years with no side effects reported and no evidence of low-grade infections. In fact, almost all of the patients remain extremely grateful for their treatment. It is also worth mentioning that dextrose has been widely used as a sclerosing–proliferant agent in prolotherapy for many years and is Food and Drug Administration (FDA) approved. In contrast, polidocanol does not have FDA approval in North America.
At this stage, we cannot be certain whether it is the lidocaine (Xylocaine, AstraZeneca) or the dextrose that is the effective agent. In the Mishra and Pavelko study [3], bupivacaine was used in the control group, with poor therapeutic results in that group. We are planning a new study to answer this question. In addition, there have been recent studies [3–5], using autologous blood injections with a "peppering technique" for elbow epicondylar tendinosis and patellar tendinosis, with good results that focus attention on the possible therapeutic effects of needle-stick injury.
I hope that this reply answers at least some of the questions posed.
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