Exercise therapy combined with corticosteroid injections associated with clinical improvement of Achilles tendinopathy

1. This randomized controlled trial demonstrated that among 100 patients, exercise therapy combined with corticosteroid injections for the treatment of Achilles tendinopathy was associated with a significant improvement in Victorian Institute of Sports Assessment-Achilles score, tendon thickness, and morning pain compared with placebo.

2. The effects were observed at both short- and long-term follow-up and was not associated with increased risk of adverse events compared with placebo injections.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Achilles tendinopathy (AT) is a common, often sports-related injury, characterized by tenderness and swelling at the Achilles tendon. AT has a prevalence rate of 2.16 cases per 1000 person-years, with a lifetime incidence of 50% among elite athletes, and 6% among those with a sedentary lifestyle. While corticosteroid injections and exercise therapy are commonly used independently to treat AT, evidence on their effect in combination is limited. Hence, this randomized clinical trial investigated the effect of corticosteroid injections and exercise therapy compared with placebo injection and exercise therapy for patients living with Achilles tendinopathy. The main outcome of this study was the Victorian Institute of Sports Assessment-Achilles (VISA-A) score at 6 months. Secondary outcomes included pain measured in the morning and during exercise, tendon thickness, and global assessment. A total of 100 patients were included, 52 of which were randomized to placebo and 48 were randomized to corticosteroid injection. Patients receiving corticosteroid injections combined with exercise therapy had a 17.7-point greater improvement in VISA-A score from baseline to 6 months follow-up compared to patients receiving placebo. No severe adverse events were observed in either the intervention or placebo group and both groups improved over time. A limitation to this study was the relatively small sample size, however, this study adds valuable insight to the current knowledge base surrounding the management of AT.

Click to read the study in JAMA

Relevant Reading: Which treatment is most effective for patients with Achilles tendinopathy? A living systematic review with network meta-analysis of 29 randomised controlled trials

In-Depth [randomized controlled trial]: This study was a 2-group, 2-site, placebo-controlled randomized superiority trial, blinded at the patient, investigator and assessor level. Patients were included from both a clinic at the Institute of Sports Medicine at University of Copenhagen, and from a local private rheumatology clinic between 2016 to 2018. A total of 100 patients were included in this study, 52 randomized to placebo (mean age, 46 years [95% CI, 44-48 years]; 32 men [62%]) and 48 randomized to receive corticosteroid injection (mean age, 47 years [95% CI, 45-49 years]; 28 men [58%]. Patients in the corticosteroid injection and exercise therapy combination group had a 17.7-point (95% CI, 8.4-27.0 points; P < .001) greater improvement in VISA-A score from baseline to 6-month follow-up compared to the placebo group. For morning pain, there was a significantly larger improvement of 15.6mm on the Visual Analog Scale (VAS) after 2 months in the corticosteroid injection with exercise therapy group (95% CI, 2.6-28.6mm; P=.01). Achilles tendon thickness, measured using ultrasonography, significantly improved in the corticosteroid group compared to placebo at 1 month (mean difference, 1.9mm; 95%CI, 1.1-2.6mm; P<.001), at 2 months (mean difference, 2.2mm; 95%CI, 1.4-3.0mm; P <.001), at 3 months (mean difference, 2.2mm; 95% CI, 1.5-3.0mm; P <.001) and at 6 months (mean difference, 1.0mm; 95% CI, 0.1-1.9mm; P=.02).

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