Achilles tendinoscopy and plantaris tendon release and division in the treatment of non-insertional Achilles tendinopathy

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Abstract

Background

The mainstay of treatment for non-insertional Achilles tendinopathy is non-operative, however a proportion of patients will fail conservative measures. We describe the results of Achilles tendinoscopy with plantaris tendon release in patients who have failed first line conservative treatment for at least 6 months.

Methods

A consecutive series of 11 patients with a minimum of 2 years follow up.

Results

The mean AOFAS scores significantly improved from 68 pre-op to 92 post op (p = 0.0002) as did the AOS scores for both pain (28% pre-op to 8% post op (p = 0.0004)) and disability (38% pre-op to 10% post op (p = 0.0005). The mean SF-36 scores also improved but were not statistically significant (pre-op 76, post op 87 (p = 0.059). There were no complications. 8 of the 11 patients were satisfied, the other 3 somewhat satisfied.

Conclusions

The results of Achilles tendinoscopy and division of the plantaris tendon are encouraging but further studies are required to compare it to other treatments. It is minimally invasive and low risk so should not affect the ability to perform a formal open procedure if unsuccessful.

Introduction

Non-insertional Achilles tendinopathy is a degenerative condition that affects athletes and the general population. Extrinsic factors such as a sudden increase in training intensity or duration and intrinsic factors such as abnormalities in lower limb biomechanics and tendon vascularity may contribute to the development of this condition. The area of degeneration usually occurs between 2 and 6 cm from the insertion of the Achilles tendon into the calcaneus and this coincides with the area of the tendon which has the poorest blood supply [1]. It is probably most accurate to describe the degenerative process as a failed healing response.

The major symptom in non-insertional Achilles tendinopathy is pain, which can significantly interfere with function and especially athletic activity. The exact source of this pain has been the subject of several research papers and much discussion but it seems to be related to areas of neovascularisation [2], [3], [4]. It has been shown that new nerve endings grow with the new vessels and those treatment modalities which reduce the amount of neovascularisation can lead to a reduction in symptoms [5], [6], [7], [8], [9]. Equally, treatments that have proven to be clinically effective have subsequently been shown to reduce neovascularisation within the tendon [10]. The new nerves and vessels which grow into the tendinopathic region appear to originate mainly from the paratenon, especially from the ventral aspect [2], [3]. The tendinoscopic technique described aims to denervate the painful area by releasing the paratenon from the Achilles tendon.

It has also been noted that patients most often present with symptoms and swelling on the medial side of the tendon which lead to the postulation that the plantaris insertion or its association with the TA plays a role in the symptomatology and/or development of the condition and that releasing it may be an important part of the treatment [11].

Section snippets

Method

We report a consecutive series of 11 patients who underwent Achilles tendinoscopy with stripping of the paratenon and division of the plantaris tendon. All patients had a clinical diagnosis of non-insertional Achilles tendinopathy with either MRI or ultrasound conformation of intra-tendinous disease as well as paratendinopathy. All had failed conservative treatment including a physiotherapist supervised eccentric exercise programme for at least 6 month and had opted for surgical intervention.

Results

The mean age of the patients was 36.5 years (range 24–55) at the time of surgery. The patients had been symptomatic for between 6 and 36 months pre-operatively with an average duration of symptoms of 13 months. The mean length of follow up was 30 months with a minimum follow up of 2 years (range 24–39).

The mean AOFAS hindfoot score pre-operatively was 68 (range 51–82) and these significantly improved to a mean of 92 (range 74–100) at final follow up (p = 0.0002). The AOS scores for pain (28%

Discussion

The mainstay of treatment in Achilles tendinopathy is conservative with an eccentric exercise programme having the most evidence for effectiveness at present [20]. Between a quarter and a third of patients will, however fail conservative treatment and require or request surgical intervention [21]. Open surgery for non-insertional Achilles tendinopathy has shown varying success rates of between 50 and 96% [13], [22], [23], [24] with surgery for intratendinous lesions and late presenting lesions

References (32)

  • F. Steenstra et al.

    Achilles tendoscopy

    Foot Ankle Clin

    (2006)
  • P.S. Myles et al.

    Patient satisfaction after anaesthesia and surgery: results of a prospective survey of 10,811 patients

    Br J Anaesth

    (2000)
  • J. Maquirriain et al.

    Endoscopic surgery in chronic Achilles tendinopathies: a preliminary report

    Arthroscopy

    (2002)
  • J. Vega et al.

    Endoscopic treatment for chronic Achilles tendinopathy

    Foot Ankle Surg

    (2008)
  • U.G. Longo et al.

    Achilles tendinopathy

    Sports Med Arthrosc Rev

    (2009)
  • H. Alfredson et al.

    Is vasculo-neural ingrowth the cause of pain in chronic Achilles tendinosis? An investigation using ultrasonography and colour Doppler, immunohistochemistry, and diagnostic injections

    Knee Surg Sports Traumatol Arthrosc

    (2003)
  • G. Andersson et al.

    Nerve-related characteristics of ventral paratendinous tissue in chronic Achilles tendinosis

    Knee Surg Sports Traumatol Arthrosc

    (2007)
  • L. Ohberg et al.

    Neovascularisation in Achilles tendons with painful tendinosis but not in normal tendons: an ultrasonographic investigation

    Knee Surg Sports Traumatol Arthrosc

    (2001)
  • H. Alfredson et al.

    Sclerosing injections to areas of neo-vascularisation reduce pain in chronic Achilles tendinopathy: a double-blind randomised controlled trial

    Knee Surg Sports Traumatol Arthrosc

    (2005)
  • H. Alfredson et al.

    Treatment of midportion Achilles tendinosis: similar clinical results with US and CD-guided surgery outside the tendon and sclerosing polidocanol injections

    Knee Surg Sports Traumatol Arthrosc

    (2007)
  • M.I. Boesen et al.

    Ultrasound guided electrocoagulation in patients with chronic non-insertional Achilles tendinopathy: a pilot study

    Br J Sports Med

    (2006)
  • B. Lind et al.

    Sclerosing polidocanol injections in mid-portion Achilles tendinosis: remaining good clinical results and decreased tendon thickness at 2-year follow-up

    Knee Surg Sports Traumatol Arthrosc

    (2006)
  • L. Willberg et al.

    Sclerosing injections to treat midportion Achilles tendinosis: a randomised controlled study evaluating two different concentrations of Polidocanol

    Knee Surg Sports Traumatol Arthrosc

    (2008)
  • L. Ohberg et al.

    Effects on neovascularisation behind the good results with eccentric training in chronic mid-portion Achilles tendinosis?

    Knee Surg Sports Traumatol Arthrosc

    (2004)
  • B.D. Den Hartog

    Flexor hallucis longus transfer for chronic Achilles tendonosis

    Foot Ankle Int

    (2003)
  • A.A. Schepsis et al.

    Surgical management of Achilles tendinitis

    Am J Sports Med

    (1987)
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      At follow-up of 25 months, there was a 93.3% satisfaction rate. Pearce and colleagues44 performed a retrospective study on 11 patients (mean age 36.5 years) who underwent endoscopic paratenon stripping and plantaris division for recalcitrant noninsertional Achilles tendinopathy. At a mean follow-up of 30 months, 8 out of 11 patients (72.7%) were satisfied with their treatment.

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