CME OnDemand: Novel Imaging and MIS Techniques in Foot and Ankle Care (2026)-US-guided high-volume injection for Achilles tendinopathy

US-guided high-volume injection for Achilles tendinopathy

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This review discusses ultrasound (US)-guided high-volume image-guided injection (HVIGI) as a minimally invasive treatment for chronic mid-portion Achilles tendinopathy, a common overuse condition whose incidence is increasing with greater sports participation. Achilles tendinopathy typically presents with pain, swelling, and impaired performance. Eccentric loading exercises are the first-line (gold standard) therapy, yet many patients have persistent long-term symptoms and about one-third of non-responders eventually undergo surgery, creating a need for effective non-surgical alternatives.<br /><br />High-resolution US is emphasized as the imaging modality of choice because the Achilles tendon’s superficial location allows excellent assessment. Typical sonographic features of tendinopathy include tendon thickening, disrupted fibrillar architecture, increased vascularity on Doppler, paratenon thickening/adhesions, and changes in Kager’s fat pad. Doppler studies have shown that neovascularization—often arising from the ventral side of the tendon—is associated with pain and dysfunction, likely due to accompanying nerve ingrowth in ventral paratendinous tissues. This supports treatments aimed at disrupting neovessels.<br /><br />HVIGI involves injecting a large volume of fluid into the plane between the anterior Achilles tendon and Kager’s fat pad under continuous US visualization. The proposed mechanism is mechanical “stripping” or disruption of neovessels and associated sensory nerves, reducing pain. Published case series and limited comparative evidence generally report improvements in pain (VAS/NRS) and function (VISA-A), though results vary widely and most studies lack robust control groups. Some protocols include corticosteroid plus local anesthetic followed by ~40 mL saline; others omit corticosteroid or use different agents.<br /><br />The article details practical technique: prone positioning with the foot overhanging, pre-procedure Doppler mapping, sterile preparation, medial in-plane approach (to reduce sural nerve risk), injectate options, and post-procedure rest followed by resumption of eccentric rehabilitation. Overall, HVIGI is presented as a safe, quick, low-cost option that may delay or avoid surgery, but higher-quality randomized trials are needed to define optimal injectate/volume and long-term efficacy.

Keywords

ultrasound-guided HVIGI

high-volume image-guided injection

chronic mid-portion Achilles tendinopathy

neovascularization disruption

Doppler ultrasound vascularity

Kager's fat pad injection plane

eccentric loading rehabilitation

VISA-A functional outcome

minimally invasive non-surgical treatment

paratenon adhesions thickening