Review Cite as: Kakkos GA, Klontzas ME, Koltsakis E, Apostolos H.

Karantanas AH: US-guided high-volume

US-guided high-volume injectionJfor Achilles tendinopathy
injection for Achilles tendinopathy. Ultrason 2021; 21: e127–e133. doi: 10.15557/JoU.2021.0021.

Submitted: US-guided high-volume injection for Achilles tendinopathy

11.02.2021
Accepted:
16.03.2021 George A. Kakkos1, Michail E. Klontzas1,2,3, Emmanouil Koltsakis1,
Published: Apostolos H. Karantanas1,2,3
07.06.2021

1
 epartment of Medical Imaging, University Hospital of Heraklion, Crete, Greece
D
2
Advanced Hybrid Imaging Systems, Institute of Computer Science, FORTH, Crete, Greece
3
Department of Radiology, School of Medicine, University of Crete, Greece
Correspondence: Michail E. Klontzas, e-mail: [email protected]

DOI: 10.15557/JoU.2021.0021

Keywords Abstract
Achilles tendinopathy, Achilles tendinopathy is a common overuse condition affecting the adult population. The
neovascularity, incidence is on the rise because of greater participation of people in recreational or competi-
ultrasound, tive sporting activities. Chronic Achilles tendinopathy occurs most commonly in the tendon’s
high-volume mid-portion, and it is challenging to manage, leading to significant patient morbidity. Despite
image-guided conservative management many patients still require surgical intervention. The mechanism
injection underlying pain is not entirely understood; however, high-resolution color Doppler ultra-
sound has shown that neovascularisation could be involved. Minimally-invasive treatments
for chronic Achilles tendinopathy may prevent the need for surgery when conservative meth-
ods have failed. Ultrasound provides an option to guide therapeutic interventions accurately,
so that treatment is delivered to the desired site of pathology. High-volume image-guided
injection is a relatively new technique where a high volume of liquid is injected between the
anterior aspect of the Achilles tendon and the Kager’s fat pad, used to strip away the neovas-
cularity and disrupt the nerve ingrowth seen in chronic cases of Achilles tendinopathy. High-
volume image-guided injection has shown promising results in terms of reducing pain and
improving function in patients where conservative measures have failed. This review aims
to describe the fundamental technical factors, and investigate the efficacy of high-volume
image-guided injection with reference to the available literature.

Introduction Runners are most at risk of developing symptoms, with

a lifetime risk of 52%(4). However, patients with this con-
The Achilles tendon is the strongest and thickest weight- dition do not always participate in vigorous physical
bearing tendon in the human body. Its origin is near the activity(5).
middle of the calf and is the conjoint tendon of the gastroc-
nemius and soleus muscles(1). The tendon does not have Achilles tendinopathy as a clinical syndrome is charac-
a true synovial sheath; instead, it is enveloped on its dorsal, terized by a combination of pain, swelling, and impaired
lateral, and medial aspects by a paratenon composed of performance(6). Conservative or physical therapies are
connective tissue that allows for approximately 1.5 cm of established as first-line management, with eccentric load-
tendon gliding with activity(2). ing exercises considered as the gold standard in the initial
treatment(7). Despite the initiation of therapy, a significant
Along with the patellar tendon, the Achilles is the com- proportion of patients continue to have symptoms even
monest lower limb tendon to rupture, but also it is most after ten years(8). About one-third of these non-responders
frequently impaired as a result of overuse leading to ten- eventually require surgery(9). Therefore, effective minimally
dinopathy(3). Chronic midportion Achilles tendinopathy invasive treatment options are necessary to improve the
is a common overuse injury that is often long-standing. outcome of patients with chronic Achilles tendinopathy
Over the past three decades, the incidence has been ris- who fail to respond to the initial exercise treatment. The
ing because of greater participation in sports activities. use of injectable substances such as platelet-rich plasma,

© Polish Ultrasound Society. Published by Medical Communications Sp. z o.o. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-
NoDerivatives License (CC BY-NC-ND). Reproduction is permitted for personal, educational, non-commercial use, provided that the original article is in whole, unmodified, and properly cited. e127
 George A. Kakkos, Michail E. Klontzas, Emmanouil Koltsakis, Apostolos H. Karantanas

Fig. 1. L
 ongitudinal B-mode image of the Achilles tendon in a pa- Fig. 2. L
 ongitudinal color Doppler image of the Achilles tendon in
tient with chronic mid-portion Achilles tendinopathy. Fusiform the same patient as in Fig. 1, demonstrating florid neovascula-
swelling with increased anterior-posterior diameter and redu- rity with intratendinous neovessels inserting from the ventral
ced echogenicity of the superficial part of the tendon are shown side of the tendon

autologous blood, polidocanol, corticosteroids, and apro- in color and power Doppler ultrasound, small vessel
tinin in and around tendons is a widespread therapeutic detection in musculoskeletal structures is possible with
modality; however, there is minimal clinical evidence to great accuracy(19). In 2001, Öhberg et al.(20) first described
support its efficacy(10). High-volume image-guided injection the presence of blood flow on ultrasound in the areas of
(HVIGI) is a relatively new procedure that has shown good degenerative tendon changes (localized thickening with
short- to medium-term relief of symptoms in the manage- focal hypoechoic areas) in patients with chronic Achilles
ment of chronic mid-substance Achilles tendinopathy(11). tendinopathy, but not in any of the normal pain-free ten-
dons. The formation of new blood vessels, termed neovas-
cularization, has been linked to pain(21), reduced function,
Ultrasound imaging and chronicity of tendinopathy(22). When present, these
neovessels predominate on the ventral side of the Achilles
High-resolution ultrasound (US) is the imaging examina- tendon (Fig. 2). There is evidence that nerve structures of
tion of choice for assessing the Achilles tendon. The super- the ventral paratendinous tissue related to the neovessels
ficial location and orientation of the tendon allow excellent may be the source of pain in tendinopathy(23,24). Alfredson
evaluation results(12), and the current advances in probe et al.(23) injected a local anesthetic ventral to the tendon
and scanner design enable superior visualization even of in a cohort of affected individuals, achieving temporary
the finest anatomical details(13). On US, the normal Achilles pain relief in all patients. This finding led to the hypothesis
tendon is a bright echogenic structure that typically demon- that obliterating the neovasculature may diminish refrac-
strates a compact fibrillar pattern of parallel hyperechoic tory Achilles tendon pain. Öhberg and Alfredson(25,26) con-
lines corresponding to the collagen fiber bundles in the ducted a series of studies targeting neovessels in chronic
tendon(14). The paratenon surrounding the tendon appears tendinopathies, using polidocanol as a sclerosing agent.
as a thin echogenic line marking the edge of the tendon(15). Polidocanol injections showed good clinical results and an
In the current practice, there are several sonographic find- absence of or a decrease in neovascularity in the treated
ings that may suggest a diagnosis of Achilles tendinopathy, tendons. A potential disadvantage of sclerosing therapy
including an increase in tendon caliber (particularly of is that multiple treatment sessions are necessary, and the
the mid- and distal portions of the tendon), a disruption of long-term effects of the method still remain unclear(27).
the fibrillar pattern, and an increase in tendon vascularity
(Fig. 1). Additional signs include increased Kager’s fat pad
echogenicity and associated peritendinous adhesions, seen High-volume image-guided injection (HVIGI)
as thickening of the paratenon(16). Promising results for the
diagnosis of Achilles tendinopathy have been demonstrated The assumption behind HVIGI is that with the disruption of
with US elastography (both compression and shear wave), neovessels seen in degenerated Achilles tendons, the accom-
with comparable or even superior accuracy to standard panying nerve supply is also damaged, resulting in pain
B mode ultrasound. However large well-designed studies reduction. Chan et al. first(28) hypothesized that high-volume
are still needed to establish the suitability of this promising injections of normal saline would produce local mechani-
technique in the diagnosis of Achilles tendinopathy(17). cal effects, causing neovessels to stretch, break or occlude,
with the destruction of companion sensory nerves either by
trauma or ischemia. Using ultrasound guidance to place the
Neovascularity needle between the anterior aspect of the Achilles tendon
and the Kager’s fat pad, a mixture of 10 ml of 0.5% bupiva-
It has been shown that microcirculatory blood flow is sig- caine hydrochloride and 25 mg of hydrocortisone acetate was
nificantly elevated at the site of pain in insertional and mid- injected, followed by 40 ml of normal injectable saline. They
portion tendinopathy(18). With the technological advances found that high volume injections significantly reduced pain

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 US-guided high-volume injection for Achilles tendinopathy

Tab. 1. S
 ummary of published evidence for the application of HIVIGI in Achilles tendinopathy
Author Study Change in VAS Change
Intervention N Conclusion
(year) type score in VISA-A score
10 ml 0.5% Bupivacaine N = 21 HVIGI significantly reduces pain and improves
Chan et al. Case
25 mg Hydrocortisone 30 2 weeks – 50 mm 30 weeks + 31.4 function in patients with resistant Achilles
(2008)(28) series
40 ml N Saline 30 weeks – 47 mm tendinopathy in the short- and long-term
HVIGI for resistant tendinopathy of the main
10 ml 0.5% Bupivacaine body of the Achilles tendon is effective to
Humphrey et al. Case
25 mg Hydrocortisone 11 – 3 weeks + 38 improve symptoms, reduce neovascularisa-
(2010)(29) series
40 ml N Saline tion, and decrease maximal tendon thickness
at short-term follow-up
HVIGI is safe and clinically cost-effective in the
5 ml 1% Lidocaine
Restighini and Case 4 weeks – 34 mm 4 weeks + 26 3 treatment of Achilles tendinopathy. Results
25 mg Hydrocortisone 32
Yeoh (2012)(30) series 3 months – 37 mm months + 28.7 suggest that baseline neovascularity is rel-
up to 40 ml N Saline
evant to outcome following injection
HVIGI with aprotinin significantly reduces
10 ml 0.5% Bupivacaine
Maffuli et al. Case pain and improves function in patients with
25 mg Aprotinin up to 94 – 12 months + 32.9
(2013)(31) series chronic Achilles tendinopathy in the short-
40 ml N saline
and long-term follow-up
HVIGI without a corticosteroid appears to be
an effective procedure for patients with re-
10 ml 1% Lidocaine
Wheeler et al. Case calcitrant Achilles tendon symptoms. Further
40 ml N Saline 16 347 days − 6.1/10 347 days + 41
(2014)(32) series work is needed to formally establish benefits
No corticosteroid
from HVIGI for patients with Achilles tendi-
nopathy and to identify optimal injectate
Group 1:
10 ml 1% Lidocaine HVIGI reduces VISA-A scores in both groups.
Case Group 1: Group 1:
40 ml Saline A higher volume without dry needling
Wheeler et al. series 281 days − 4.6/10 281 days + 33.4
Group 2: 34 compared with a lower volume with dry
(2016)(33) –2 Group 2: Group 2:
10 ml 1% Lidocaine needling resulted in greater improvement in
Groups No data 271 days + 6.94
20 ml Saline + dry noninsertional Achilles tendinopathy
needling
All subjects performed
eccentric training Group 1: Group 1:
6 weeks – 48.5 mm 6 weeks + 27.1
Group 1: 12 weeks –44.9 mm 12 weeks + 28.8 Treatment with HVIGI or PRP in combination
10 ml 0.5% Bupivacaine 24 weeks -34.1 mm 24 weeks + 22.2 with eccentric training in chronic AT seems
Case 20 mg Depo-Medrol Group 2: Group 2: more effective in reducing pain, improving
Boesen et al. series 40 ml N saline 6 weeks – 37.3 mm 6 weeks + 13.8 activity level, and reducing tendon thickness
60
(2017)(34) –3 Group 2: 12 weeks –40.9 mm 12 weeks + 14.8 and intratendinous vascularity than eccentric
Groups 4 PRP injections each 24 weeks –37.1 mm 24 weeks + 19.6 training alone. HVIGI may be more effective in
14 days apart Group 3: Group 3: improving outcomes of chronic AT than PRP
6 weeks – 22.5 mm 6 weeks + 9.9 in the short term
Group 3:
12 weeks –29.5 mm 12 weeks + 10.6
Placebo (a few drops 24 weeks –18.1 mm 24 weeks + 8.8
of saline under the skin)
All subjects performed
eccentric training Group 1: Group 1:
High-volume injection with or without
Group 1: 6 weeks – 55.4 mm 6 weeks + 30.6
corticosteroid in combination with eccentric
Case 12 weeks –52.6 mm 12 weeks + 31.9
10 ml 0.5% Bupivacaine training seems effective in AT. HVIGI with
Boesen et al. series 24 weeks –40.1 mm 24 weeks + 26.4
20 mg Depo-Medrol 28 corticosteroid showed a better short-term im-
(2019)(35) –2 Group 2: Group 2:
40 ml N saline provement than HVIGI without corticosteroid,
Groups 6 weeks –16.1 mm 6 weeks + 13.8 indicating a short-term effect of corticoste-
Group 2: 12 weeks – 25 mm 12 weeks + 14.8 roid in HVIGI treatment of AT
10 ml 0.5% Bupivacaine 24 weeks –33.9 mm 24 weeks + 23.7
40 ml N saline
In this retrospective case-study, only 10
10 ml 0.5% Marcaine
patients (33%) benefitted from a single HVIGI
Nielsen et al. Case 0.5 mL Triamcinolonac- 12 months
30 – treatment at 12 months and an 11-point
(2020)(36) series etonid (40 mg/mL) 10 patients + 11
significant improvement was seen on the
40 ml N saline
VISA-A score
Significant reduction in pain, tendon thickness
2 ml 0.25% Bupivacaine Numeric rating and neovascularity were observed in 78% of
Edwards and Sivan Case
0.5 ml (20 mg) Kenalog 18 scale of pain (NRS) – patients. The recurrence rate was 39%. HVIGI
(2020)(37) series
37.5 ml N saline 8 weeks – 5.3 with eccentric training is a safe and effective
intervention in an outpatient clinic setting

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 George A. Kakkos, Michail E. Klontzas, Emmanouil Koltsakis, Apostolos H. Karantanas

A B
Fig. 3. T
 he Achilles tendon is best scanned with the patient prone. The foot overhangs the end of the examination bed to allow tendon movement (A).
Medial approach using a freehand in-plane technique. The ultrasound probe is held transversely relative to the Achilles tendon (B)

and improved function in 30 patients with chronic Achilles edge of the table (Fig. 3A). Gentle dorsiflexion of the ankle
tendinopathy who had failed to improve after a three-month and the use of sterile transmission gel help optimize imag-
program of eccentric loading of the gastro-soleus complex ing(43). A preliminary diagnostic scan using a linear high fre-
both in the short- and long-term. No complications were quency (7–12 MHz) ultrasound probe should be performed
reported. No patient experienced a rupture or tear of the before the procedure to document the baseline appearance
Achilles tendon at follow-up, and no patient progressed to of the abnormality, detect areas of increased neovascularity
surgery. Since then, several other studies have emerged using as target areas, locate any adjacent neurovascular structures
therapeutic HVIGI to treat chronic mid-substance Achilles to be avoided, and plan the optimal needle entry point and
tendinopathy. Table 1 outlines the HVIGI studies to date(29–37). route to the target site(44). The ideal injection site is at the
Most of them showed significant changes in Visual Analog level of the thickest portion of the tendon with the most sig-
Scale (VAS) and the Victorian Institute of Sports Assessment- nificant degree of neovascularity. Using a skin marker, a dot
Achilles questionnaire (VISA-A) scores. The VAS for pain and for the ideal needle entry point may be drawn.
the VISA-A are validated and reliable tools for measuring
Achilles tendinopathy pain and function, allowing a com-
parison of treatment results(38,39). At present, HVIGI is only Skin and transducer preparation
used in patients with insertional and non-insertional Achilles
tendinopathy, and avoided in patients with large tears. The The injection area is sterilized using an iodine-based solu-
application of HVIGI has not been established in other types tion. The transducer is also immersed in an iodine-based
of Achilles pathology. solution and surrounded by a sterile cover. A sterile gel
must be used, if necessary.

HVIGI procedure
Injectable substances, syringes and needles
Informed consent The following injectables and dosages are the author’s
preferred choice, based on published evidence and experi-
Through the consent process, it is a standard procedure to ence. A 10 ml syringe is typically used with a 25 G needle
discuss with the patient the (low) likelihood of bleeding, (blue), filled with 1% lidocaine for regional anesthesia,
infection and injury to adjacent neurovascular structures in a 10 ml syringe with a 21 G needle (green) filled with 1 mL
addition to the possible adverse effects associated with cor- of 40 mg/mL methylprednisolone or an equivalent cortico-
ticosteroid use: post-injection flare, local tissue atrophy, ten- steroid and 9 ml of a long-acting anesthetic, typically 0.5%
don rupture, flushing, and transient increased blood glucose bupivacaine, and two 20 ml syringes with an extension tube
level(40,41). Coagulation laboratory tests are not usually neces- filled with normal saline 0.9%.
sary prior to the injection due to the low risk of bleeding(42).

Injection procedure
Patient positioning and preprocedural scan
At our institution, the injection is routinely performed
To ensure patient comfort and optimal visualization of the using a freehand in-plane technique (45). The ultrasound
anatomy, the patient is prone, with the foot hanging over the probe is held transversely relative to the Achilles tendon.

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 US-guided high-volume injection for Achilles tendinopathy

A B
Fig. 4. T
 ransverse image during a high-volume image-guided injection showing needle placement ventral to the tendon between the tendon
and the Kager’s fat pad (A). Drawing demonstrating the target area between the tendon and the Kager’s fat pad, aiming at stripping the
tendon from neovessels originating from its ventral side (created with biorender.com) (B)

A medial approach is used to minimize the risk of injur- An eccentric loading exercise program is recommended
ing the sural nerve(46) (Fig. 3B). First, lidocaine is injected after three days following the procedure with gradually
into the skin, and subcutaneous and deep tissues. After increasing intensity as pain allows(48).
local anesthesia is achieved, the 21 G needle with the
syringe containing the mixture of methylprednisolone
and bupivacaine is inserted parallel to the long axis of Discussion
the ultrasound probe and – under continuous observa-
tion – is guided deep to the tendon between the tendon The management of Achilles tendinopathy remains
and the Kager’s fat pad (Fig. 4), targeting the area of a major challenge. Based on the relative limited pub-
maximal neovascularization. Once the first syringe is lished data in conjunction with our department’s experi-
injected and removed, the extension tube is connected to ence, HVIGI seems to be a safe, fast, relatively inexpen-
the needle, and the syringes containing 40 ml of normal sive, minimally invasive technique with a great potential
saline are injected at the same location. Constant visu- for the treatment of chronic mid-substance Achilles ten-
alization of needle position confirms proper placement, dinopathy. This treatment approach has been shown to
providing continuous monitoring of the distribution of significantly reduce pain and improve short- and long-
the administered agents, and ensuring that no unwanted term function in patients regardless of the severity of
structures are injured or injected(47). their symptoms(28,34). It works well in combination with
conservative treatments, especially eccentric loading exer-
cises(48). It has a very low complication rate and any seri-
Postprocedural care and rehabilitation ous complication has yet to be reported. HVIGI should
be considered as an option before surgery when other
After the needle is removed, a post-injection scan is per- conservative or minimally invasive methods have failed.
formed (Fig. 5). Pressure is applied at the puncture site, Surgery, in addition to an increased rate of complica-
and the area is covered with a small bandage. The patient tions, is more expensive and requires an extended period
is advised to rest and avoid movements for two days. of rehabilitation prior to the patient being able to return
Paracetamol and ice packs are recommended, if necessary. to sports or routine physical activities. With HVIGI, we
can document the abnormality and perform the procedure
within one patient visit.

The majority of published studies report positive results,

but almost all lack control groups and are limited by the
small number of included patients. There are also differ-
ences in the duration of follow-up between studies, dis-
crepancies in outcome measurements, and variations in
the injectable drugs and doses, making the results of this
group of studies challenging to interpret (a detailed presen-
tation of the available literature and the outcomes of exist-
ing studies is presented in Tab. 1). Discrepances in study
design have led to a great variability in reported treatment
Fig. 5. L
 ongitudinal color Doppler image of the Achilles tendon in efficacy, ranging from 18.1 mm to 61 mm of VAS score
the same patient as in Fig. 2 after the HVIGI procedure, sho- reduction(32,34). Nonetheless, irrespective of quantitative
wing no remaining intratendinous neovessels

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 George A. Kakkos, Michail E. Klontzas, Emmanouil Koltsakis, Apostolos H. Karantanas

data, the majority of published studies report a significant Conclusion

benefit in treated patients.
In conclusion, HVIGI presents an effective treatment
Work is still needed to optimize the technique and system- option for patients with Achilles tendinopathy, poten-
atically compare to outcomes of conservative and surgical tially offering a significant pain improvement when tra-
treatments over a long follow-up course. There is still no ditional conservative measures have failed. Work is still
consensus as to the optimal content and volume of the solu- required to further optimize the technique and acquire
tion used to achieve desired effects. Therefore, more good- long-term follow-up treatment outcome data. However,
quality randomized controlled trials including a larger num- existing data already indicate that HVIGI might be the
ber of patients with a non-injected control group matched treatment of choice in patients with persistent Achilles
for age, sex and physical activity with longer-term follow-up tendinopathy as a safe and effective way of delaying or
are still required to further determine the value of HVIGI even avoiding surgery.
in the treatment of Achilles tendinopathy. Other US-guided
treatment options for Achilles tendinopathy include sclero-
therapy for obliterating the neovessels, corticosteroid injec- Conflict of interest
tions, and intratendinous hyperosmolar dextrose injections
(prolotherapy). However, the need for multiple treatment The authors do not report any financial or personal connections
repeats with sclerotherapy and corticosteroids, the associa- with other persons or organizations which might negatively affect the
tion of corticosteroid intratendinous injections with Achilles contents of this publication and/or claim authorship rights to this
ruptures, and the lack of evidence for the efficacy of prolo- publication.
therapy have significantly limited their clinical use(49,50).

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