Hi guys! In this video, I'm going to discuss high-volume injections for Achilles tendinopathy
and whether they’re useful to have or not. What we're going to look at is, how high-volume
injections are meant to work and what they do when they actually do the injection for you,
and then also have a look at the latest research and see if the evidence is there that it's a
useful procedure to have, and when to have it. My name is Maryke. I'm one of the physiotherapists
from treatmyachilles.com, where you can get online physiotherapy assessment as well as
treatment for your Achilles injuries. Have a look at the description of this video if you
want to know more. So, I also have to apologise if you're hearing a lot of banging in the background;
we've got builders next door, and I can't do anything about it today. So,
let's move right on. How do high-volume injections work? So, they are mostly used to decrease pain so
that patients can get on with rehab. Now, often patients feel that they shouldn't decrease pain,
because it's a warning signal, and they're worried they'll injure themselves more. But
we know from the research that pain does not equal severity of injury, and sometimes pain
can be totally disproportionate to the injury you have. So, it's okay to decrease pain to allow you
to get on with a progressive rehab programme; it's not okay to decrease pain and then you go
do high-impact activities if you've not built up to it. So, it's all about how you use that. So,
it's always … These injections are always used in conjunction with a strength training programme,
because the injection is not a magic fix. What it does is, it just brings your pain levels down,
that you can actually get on with the rehab that will strengthen your tendon back up and get you
back to running or whatever sport you prefer. Now, what do they do during the injection? They
inject a large volume – usually about 50 mils, if I'm correct – of sterile fluid, saline,
normal saline. So, there's no magic in that; it's just the volume of fluid. They combine it with a
little bit of an anaesthetic to help with pain after the injection, so you don't feel it much
when they do it. And they also sometimes put some … a little bit of corticosteroid in there,
and other times they don't. How is it meant to work? There are three theories around it. One is
that it's the local effect of the high volume of fluid. So, they usually aim the injection … And
this I should also say is, these injections should be done under ultrasound guidance,
because you have to see where you inject, because you've gotta inject it towards the area with the
most tendinopathy and where you can see the little blood vessels growing. Healthy tendons don't have
blood vessels growing into them; that's a sign of a tendinopathy. Now, these blood vessels have
little nerves growing along them, and one school of thought is that the pain you feel when you have
Achilles tendinopathy is partly due to that little nerve that's growing into the tendon. So, this
high volume of fluid is thought to then squash the little blood vessels, which makes them disappear,
and then that also gets rid of that little nerve, and that's why your pain decreases. Second school
of thought is that it's actually just a local effect of the steroid that's being injected,
because we know steroids are very good at killing pain in the short term. But there are recent
studies where they looked at what happens if you leave the steroid component out. So,
they looked at high-volume injections with a little bit of steroid, without a bit of steroid,
and they found that actually both conditions improved at the same level. So, it's likely
not the effect of the steroid. But then, a third reason why it may be getting better,
which nobody has investigated so far, is the effect of that anaesthetic that they include
in the injection. So, we know with injuries that's been going on for more than three months
or longer, that the body's pain system can become oversensitive and overactive, and it can create
a lot more pain than what you should have. So, it may be that this anaesthetic just calms down that
pain system and resets it so that you actually feel the level of pain you should be feeling. So,
that is definitely something that they need to be investigating, because if that's the case,
they can do an injection that's much less disruptive still. What does the research show?
Does it actually work? Well, there's really not a lot of studies out there yet that's
investigated this properly, but the research that is out there does seem promising, that it
does have a good effect on pain, and it can be an adjunct to rehab. So, let me just quickly ... Yes,
so the important thing here is to remember that these injections are mainly used to allow people
to get on with their function, so, to decrease pain. So, you have to combine it with a structured
rehab programme, because the injection itself is not going to make the tendon strong; you have to
use the rehab to get the tendon strong. But it's definitely an injection that I would consider in
patients where pain is preventing them from getting on with their rehab. So, let me know
if you've got any questions. If you need more help with your injury, you're always welcome to
consult us via video call – link to the website is in the description of the video. Take care!