title: Injectable treatments for noninsertional achilles tendinosis: a systematic review.
abstract: BACKGROUND
  Although there has been a recent increase in interest regarding injectable therapy for noninsertional Achilles tendinosis, there are currently no clear treatment guidelines for managing patients with this condition. The objective of this study was (1) to conduct a systematic review of clinical outcomes following injectable therapy of noninsertional Achilles tendinosis, (2) to identify patient-specific factors that are prognostic of treatment outcomes, (3) to provide treatment recommendations based on the best available literature, and (4) to identify knowledge deficits that require further investigation.
  
  
  METHODS
  We searched MEDLINE (1948 to March week 1 2012) and EMBASE (1980 to 2012 week 9) for clinical studies evaluating the efficacy of injectable therapies for noninsertional Achilles tendinosis. Specifically, we included randomized controlled trials and cohort studies with a comparative control group. Data abstraction was performed by 2 independent reviewers. The Oxford Level of Evidence Guidelines and GRADE recommendations were used to rate the quality of evidence and to make treatment recommendations.
  
  
  RESULTS
  Nine studies fit the inclusion criteria for our review, constituting 312 Achilles tendons at final follow-up. The interventions of interest included platelet-rich plasma (n = 54), autologous blood injection (n = 40), sclerosing agents (n = 72), protease inhibitors (n = 26), hemodialysate (n = 60), corticosteroids (n = 52), and prolotherapy (n = 20). Only 1 study met the criteria for a high-quality randomized controlled trial. All of the studies were designated as having a low quality of evidence. While some studies showed statistically significant effects of the treatment modalities, often studies revealed that certain injectables were no better than a placebo.
  
  
  CONCLUSIONS
  The literature surrounding injectable treatments for noninsertional Achilles tendinosis has variable results with conflicting methodologies and inconclusive evidence concerning indications for treatment and the mechanism of their effects on chronically degenerated tendons. Prospective, randomized studies are necessary in the future to guide Achilles tendinosis treatment recommendations using injectable therapies.
  
  
  METHODS
  Level II, systematic review.
authors: Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL 60612, USA.
authors: Christopher E
authors: CE
authors: Gross
authors: Andrew R
authors: AR
authors: Hsu
authors: Jaskarndip
authors: J
authors: Chahal
authors: George B
authors: GB
authors: Holmes
mesh_terms: D000125:Achilles Tendon; D000305:Adrenal Cortex Hormones / Q000008:administration & dosage; D015312:Hemodialysis Solutions / Q000008:administration & dosage; D006801:Humans; D007267:Injections; D053657:Platelet-Rich Plasma; D011480:Protease Inhibitors / Q000008:administration & dosage; D012597:Sclerosing Solutions / Q000008:administration & dosage; D052256:Tendinopathy / Q000628:therapy*; D016896:Treatment Outcome
chemical_list: D000305:Adrenal Cortex Hormones; D015312:Hemodialysis Solutions; D011480:Protease Inhibitors; D012597:Sclerosing Solutions
keywords: Achilles tendon; injections; midsubstance; tendinopathy; tendinosis