Can Peritenolysis Facilitate A Quicker Return To Activity For Runners With Achilles Tendinosis?
Runners with Achilles tendinopathy can get back on their feet faster following peritenolysis, according to a new study.
The study, published in the Journal of Foot and Ankle Surgery, focused on 100 patients, 65 of whom were runners, with main body Achilles tendinopathy. The mean time necessary to return to activity for all patients was 10.9 weeks, according to the study. The authors note the average return to activity was 7.3 weeks after peritenolysis and 14.1 weeks after debridement, consisting of removing the watershed band and a portion of the Achilles itself.
Lead study author Amol Saxena, DPM, says peritenolysis with debridement directly treats the cause of the pain, namely the watershed band, and has been proven for over 30 years in athletes. He notes that with the surgery, more than 97 percent of athletes return to their desired sport and level. Peritenolysis does not weaken any other structures, according to Dr. Saxena, the Fellowship Director of the Department of Sports Medicine at Palo Alto Medical Foundation in Palo Alto, Calif. He cautions that untrained surgeons may not release a sufficient amount of the watershed band and that for any surgeon, a suture reaction/infection can occur.
Doug Richie Jr., DPM, FACFAS, notes peritenolysis with debridement has been around for over 25 years and has shown better results than closed or percutaneous procedures, especially in patients with paratendinosis. As he says, the main disadvantage of open surgery in and around the Achilles is the chance for wound healing complications. Peritenolysis offers direct visualization to determine the need for debridement versus simple paratenolysis, according to Dr. Richie, an Adjunct Associate Professor within the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University in Oakland, Calif.
However, Dr. Richie notes the study only considered return to activity as an endpoint.
“Just because the patient returned to activity, we really do not know the true functional outcome as there was no objective or subjective scoring of variables related to this particular technique for Achilles tendon surgery,” says Dr. Richie.
Dr. Richie says patients with pure Achilles paratendinosis have shown better outcomes than those with advanced Achilles tendinosis with peritenolysis. In general, he says the longer the condition has gone neglected, the more the prognosis for this surgical technique will be compromised.
As Dr. Saxena says, patients can benefit from peritenolysis if they have failed an eccentric exercise program, sound wave/extracorporeal shockwave (ESWT) and have had Achilles pain for more than six months and are unable to do their sport. However, in elite runners, Dr. Saxena may consider surgery after three months since most start running around six weeks “and if they can’t run, they don’t make money.”
“Athletes care about return to activity. Clinicians value scoring systems but they have not correlated with patient-reported outcomes,” says Dr. Saxena.
For midportion Achilles tendinopathy in athletes, Dr. Richie has always used open surgical procedures for direct visualization and debridement as necessary. However, he says the need for surgery on patients with both paratendinosis and tendinosis has “diminished significantly” in his own practice over the past 10 years due the success of newer non-operative treatments such as ESWT and platelet rich plasma injections.
How To Prevent Adverse Reactions When Patients Take Opioids And Benzodiazepines
By Brian McCurdy, Managing Editor
Given the high prevalence of concurrent use of opioids with benzodiazepines, a new study in the Journal of Addiction Medicine advises more effective clinician assessment and intervention to prevent overdoses.
Researchers analyzed 231,228 sets of test results from 144,535 patients who had been prescribed at least one drug and been tested for opioids and benzodiazepines. The study found more than 25 percent of study patients concurrently used opioids and benzodiazepines. Furthermore, 19 percent of those who tested positive for prescription opioids also tested positive for non-prescribed benzodiazepines and more than 15 percent of those who tested positive for prescribed benzodiazepines also used non-prescription opioids.
The authors note that more than 63 percent of the 52,000 drug overdoses in the United States in 2015 involved heroin and opioid pain medications, and benzodiazepines were a factor in 30 percent of opioid deaths. The study concurs with the Centers for Disease Control and Prevention (CDC) opioid prescription guidelines to conduct testing for prescription and illicit drugs before and periodically throughout opioid use. The study authors also suggest extending testing to patients taking prescription benzodiazepines.
Robert Smith, DPM, MSc, RPh, CPed, emphasizes that prescription painkillers are the second most prevalent type of abused drug. He warns that respiratory depression leading to opioid-related death is exacerbated by the presence of additional substances, including alcohol, illicit drugs and other prescription medications, particularly benzodiazepines. Benzodiazepine use can contribute to life-threatening sleep-disordered breathing, according to Dr. Smith, who is in private practice in Ormond Beach, Fla.
Dr. Smith points to several factors that drive the increase in opioid and benzodiazepine use. These factors include benzodiazepines being the go-to muscle relaxants; the lack of insurance coverage for non-pharmacologic management; reductions in physical therapy coverage prodding primary care physicians toward opioid medications for back pain; and reductions in mental health coverage prodding primary care physicians toward benzodiazepine medications.
Podiatrists should document the nature and intensity of the pain, current and past treatments for pain, underlying or coexisting diseases or conditions, the effect of the pain on physical and psychological function, a review of previous medical records, previous diagnostic studies, and whether there is history of alcohol and substance abuse, emphasizes Dr. Smith. He also says pain management providers develop a written plan for assessing each patient’s risk of aberrant drug-related behavior, which may include patient drug testing. Dr. Smith says DPMs may want to employ this standard if they are treating chronic pain with opioids.
“All providers should assess each patient’s risk for aberrant drug-related behavior and monitor that risk on an ongoing basis in accordance with the plan,” says Dr. Smith. “The podiatric physician should monitor patient (adherence) in medication usage, related treatment plans, controlled substance agreements and indications of substance abuse or diversion.”
Dr. Smith advises DPMs to use such resources as the prescription monitoring drug program in their state and employ the Five-Step Approach to Treating Patients with Chronic Complex Non-Cancer Pain. These steps include patient assessment, non-opioid treatment, patient reassessment and follow-up visits, according to Dr. Smith. He cites the importance of avoiding dose escalation when treating acute pain in a patient using opiates. If necessary, Dr. Smith says DPMs should prescribe a short-acting opioid for a short period of time for these patients.
Dr. Smith also cites use of the phrase “STOP BANG” to evaluate the risk of respiratory depression with opioids. The phrase stands for Snoring, Tiredness, Obstruction symptoms, high blood Pressure, BMI, Age, Neck circumference, and Gender.
Study: Topical Opioids Safe And Effective For Chronic Pain
By Brian McCurdy, Managing Editor
Topical analgesics can provide safe relief from chronic pain, according to recent research.
The study, published in the Journal of Pain Research, involved 631 patients who used topical opioids for chronic pain and authors measured pain relief via the Brief Pain Inventory survey. The study researchers noted “significantly greater decreases” in pain severity and interference scores in patients using topical analgesics in comparison to control patients at three- and six-month follow-up. Less than 1 percent of patients reported side effects from topical analgesics. The authors call for randomized controlled trials to verify the study findings.
Stephen Barrett, DPM, FACFAS, says the main advantage for topical analgesics is the fact that they usually pose no systemic complications so patients with gastrointestinal issues can use the topicals. Patients can also use topical analgesics in combination with enteric medical management, according to Dr. Barrett, the author of Practical Pain Management For The Lower Extremity Surgeon.
Dr. Barrett has used various topical analgesics for chronic pain. He has found the combination of topical analgesics with ketamine seems to have the most efficacy. A Diplomate of the American Board of Podiatric Medicine, Dr. Barrett adds that athletes also tend to appreciate topicals in lieu of oral medications for treating chronic pain.
