Working Diagnosis:
Acute on chronic bilateral midportion Achilles tendinopathy likely exacerbated by fluoroquinolone therapy, with concomitant left retrocalcaneal bursopathy

Treatment:
Patient underwent US-guided left Achilles tendon neovessel scraping with peritendinous cortisone injection performed via a lateral to medial approach underneath the tendon with hydrodissection of Kager's fat pad. Patient had immediate post-procedural pain relief with maintained strength.

Outcome:
At 10 day follow up, patient 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 ablation of neovascularity and nascent vessel fat pad-tendon cross bridging along with interval healing of left Achilles tendon, with mild improvement in tendon hypertrophy and intrasubstance fiber echogenicity.

Author's Comments:
Achilles tendinopathy is a prevalent cause of disability; however, its pathogenesis and mechanism remains unclear. Ultrasonography and color doppler techniques have shown a potential relationship between neurovascularization and chronic tendon pain. This hypothesis has led to investigation of minimally invasive techniques aimed towards neovessel disruption, via sclerosis or scraping. Interventional approaches vary by injectate and arthroscopic or ultrasound guidance.
For this patient, the physical appearance of the Achilles tendon, although trending towards healing, did not change significantly at 10 days post-op. However, the complete resolution of symptoms, successful outcomes/return to play, and disappearance of nascent neovasculature suggest that pain and limitation in chronic tendinosis stem more from vascular crossbridging/tethering rather than pathological hypertrophy of the Achilles tendon itself. The procedure destroys aberrant vessels crossing from Kager's fat pad into the Achilles tendon, to inhibit anchoring and limit avenues for proinflammatory effector recruitment. This may also decrease chronic irritation and promote tendinous healing.

Editor's Comments:
Fluoroquinolones have been linked to achilles tendon disorders including achilles tendon tears and tendonitis. The mechanism of tendon injury is not well understood but may be multifactorial including direct toxicity and degenerative changes in collagen fibers.
Risk factors for achilles disorders with fluoroquinolones include concomitant steroid use and age >60 years.
Mainstay of treatment is physical therapy with an emphasis on eccentrics. If there is continued pain biologics, PRP, hydrodissection have shown some promise with a need for more randomized controlled studies.

References:
Fluoroquinolones and the Risk of Tenon Injury: A Systematic Review and Meta-analysis. Alves C, Mendes D, Marques FB. Our J Clin Pharmacol. 2019 Oct;75(10):1431-1443. doin:10.1007/s00228-019-02713-1. Pub 2019 Jul4.

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