Disclosures: David Oh, MD: No financial relationships or conflicts of interest

Case Description: A marathon runner previously treated with eccentric based therapy protocols, activity modification, NSAIDs, and AirHeel orthoses presented with left worse than right posterior ankle pain. Notably, he was prescribed levofloxacin for a sinus infection 1-2 weeks prior to symptom onset. There was left greater than right swelling of the Achilles tendon with tenderness to palpation on the left. Ankle ROM was full and without crepitus, but painful with plantarflexion bilaterally. A diagnostic ultrasound was consistent with left worse than right Achilles tendinosis with midportion hypertrophy and echogenic changes, a small retrocalcaneal bursopathy on the left, and neovessel invagination from Kager’s fat pad into the Achilles tendon bilaterally on Doppler visualization. After discussion of treatment options, he underwent US-guided percutaneous tendon scraping and neovessel ablation of the left Achilles tendon with peritendinous cortisone injection.

Setting: Outpatient

Patient: 30-year-old man with six-week history of bilateral ankle pain Assessment/

Results: Patient had immediate post-procedural pain relief with maintained strength. At 10-day follow-up, he reported 100% pain relief on the left following resumption of all ADL’s, demonstrated progress with re-initiation of eccentric based therapy program, and gradually increased symptom-free running to a 7-mile distance. Repeat diagnostic US showed interval healing of left Achilles tendon with improvement in tendon hypertrophy and intrasubstance fiber echogenicity, along with ablation of neovascularity and nascent vessel fat pad-tendon cross bridging.

Discussion: Interventional approaches for disruption of neovascularization in Achilles tendinopathy vary by injectate and arthroscopic or ultrasound guidance. The procedure attempts to decrease chronic irritation and promote tendinous healing by destroying aberrant vessels crossing from Kager’s fat pad into the Achilles tendon. This inhibits anchoring and limits avenues for proinflammatory effector recruitment.

Conclusion: Ultrasound-guided percutaneous neovessel ablation with cortisone infusion is a viable minimally invasive treatment option for chronic Achilles tendinopathy with sonographic evidence of neovascularization.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/acute-on-chronic-posterior-ankle-pain-refractory-to-eccentrics-in-a-marathon-runner-a-case-report/