No Good Evidence That Pharmacological Interventions Relieve Achilles Tendinopathy

There is no convincing evidence that any of the pharmacological interventions for Achilles tendinopathy work, according to a systematic review.

Current treatments include injectable corticosteroids, high-volume saline solution, prolotherapy, autologous blood, platelet-rich plasma and a variety of other substances, as well as transdermal topical application of glyceryl trinitrate and other drugs.

There are few studies, however, to establish which of these interventions are safe and effective.The recent study found 13 randomized controlled trials (with 528 patients) of pharmacological interventions for the treatment of Achilles tendinopathy.

There were three studies of platelet-rich plasma (PRP), two studies of autologous blood injection, two studies of polidocanol, and one study each of corticosteroids, skin-derived fibroblasts, prolotherapy and aprotinin injections. Two studies investigated the application of glyceryl trinitrate (GTN) patches on the tender site.

The follow-up times averaged 7.3 months (range, three to 14 months). Although some of the studies showed promising results, none of the interventions showed unequivocal evidence of remarkable benefits in terms of pain, disability, quality of life or histological changes.

Promising potentials were shown by different substances administered in combination with physical therapy, but there are not enough data to confirm their real additional benefit.

"There is a need for more long-term investigations, studying large enough cohort(s) with standardized scores and evaluations shared by all the investigations to confirm the healing potential, and provide a stronger statistical comparison of the available treatments," they write.

Maffulli N, Papalia R, D'Adamio S, Diaz Balzani L, Denaro V: Pharmacological interventions for the treatment of Achilles tendinopathy: a systematic review of randomized controlled trials. Br Med Bull. 2015 Jan 12

Brace Not Essential for Spinal Compression Fractures

Among patients with compression fractures, outcomes of disability, back pain, and progression of anterior body compression were similar among those treated without a brace or with soft or rigid braces, according to findings of a randomized clinical trial published in the December 3 issue of the Journal of Bone & Joint Surgery.

"In addition to the cost and discomfort associated with braces, the findings in this study suggest that brace treatment for osteoporotic compression fractures may not provide any additional improvement in fracture healing, mobility and pain," lead author Ho-Joong Kim, MD, PhD, orthopaedic surgeon and assistant professor, Seoul National University College of Medicine, said in a news release.

"Moreover, the gradual deterioration in life quality, including mental and social wellbeing, associated with this condition reemphasizes the need for prevention of osteoporotic compression and other fractures."

Within 3 days of injury, the researchers randomly assigned 60 patients (aged 65 years and older) with acute, one-level osteoporotic compression fractures to the no-brace, soft-brace, or rigid-brace groups. The baseline adjusted Oswestry Disability Index score at 12 weeks after fracture was the main study endpoint, with a noninferiority margin set at an average of 10 points.

At 12 weeks after fracture, this main study endpoint in the no-brace group was not inferior to that in the soft-brace or rigid-brace groups.

During follow-up, the groups did not differ significantly in terms of overall Oswestry Disability Index scores, visual analog pain scale scores for back pain, anterior body compression ratios, general health status, or patient satisfaction rates.

In all three groups, the Oswestry Disability Index scores and the visual analog pain scale scores for back pain improved with time after fracture (P < .001), and the body compression ratios significantly decreased with time (P < .001). Short Form 36 health survey scores decreased at 12 weeks after compression fractures in all groups, confirming earlier evidence of reduced quality of life after a compression fracture.

The researchers point out that annual incidence of spinal compression fracture is nearly 700,000, making them nearly twice as common as other osteoporosis fractures. More than 30% of women aged 70 or more years have had one or more osteoporosis-related spinal fractures, according to the news release.

Although soft or rigid bracing is often recommended to stabilize the spine, reduce pain, and prevent further fracture site deterioration and collapse, compliance is often poor because of discomfort. Prolonged bracing may also cause muscular atrophy, deconditioning, skin irritation, higher healthcare costs, and rehabilitation delays.

The authors concluded that the disability outcomes of treatment without a brace for osteoporotic compression fractures are not inferior compared with those associated with treatment with soft or rigid braces. The progression of the anterior body compression ratio at the fractured vertebral body does not seem to be different with orthosis use compared with treatment without braces.

J Bone Joint Surg Am. 2014;96:1959-1966