Achilles tendinopathy—do plantaris tendon removal and Achilles tendon scraping improve tendon structure? A prospective study using ultrasound tissue characterisation

ObjectivesChronic painful insertional Achilles tendinopathy is known to be difficult to manage. The diagnosis is not always easy because multiple different tissues can be involved. The plantaris tendon has recently been described to frequently be involved in chronic painful mid-portion Achilles tendinopathy. This study aimed to evaluate possible plantaris tendon involvement in patients with chronic painful insertional Achilles tendinopathy.MethodsNinety-nine consecutive patients (74 males, 25 females) with a mean age of 40 years (range 24–64) who were surgically treated for insertional Achilles tendinopathy, were included. Clinical examination, ultrasound (US)+Doppler examination, and surgical findings were used to evaluate plantaris tendon involvement.ResultsIn 48/99 patients, there were clinical symptoms of plantaris tendon involvement with pain and tenderness located medially at the Achilles tendon insertion. In all these cases, surgical findings showed a thick and wide plantaris tendon together with a richly vascularised fatty infiltration between the plantaris and Achilles tendon. US examination suspected plantaris involvement in 32/48 patients.ConclusionPlantaris tendon involvement can potentially be part of the pathology in chronic painful insertional Achilles tendinopathy and should be considered for diagnosis and treatment when there is distinct and focal medial pain and tenderness.Level of evidenceIV case series.

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Prevalence of Coexistent Plantaris Tendon Pathology in Patients with Mid-Portion Achilles Pathology: A Retrospective MRI Study

Sports ◽

10.3390/sports7050124 ◽

2019 ◽

Vol 7 (5) ◽

pp. 124

Author(s):

Sachin Khullar ◽

Prasanna Gamage ◽

Peter Malliaras ◽

Leesa Huguenin ◽

Ashutosh Prakash ◽

...

Keyword(s):

Achilles Tendon ◽

Correlation Coefficient ◽

Coefficient Of Variation ◽

Achilles Tendinopathy ◽

Careful Consideration ◽

Pathological Characteristics ◽

Plantaris Tendon ◽

Mri Study ◽

Tendon Pathology ◽

Musculoskeletal Radiologist

Co-existence of Plantaris tendinopathy (PT) in patients with mid-Achilles tendinopathy (Mid-AT) is of clinical significance. This study aims to describe the MRI-based pathological characteristics of co-existing PT and Mid-AT. One-hundred MRI studies of patients diagnosed with Mid-AT were retrospectively analysed by an experienced musculoskeletal radiologist. Presence or absence of a Plantaris tendon, co-existing PT with Mid-AT, insertional characteristics of Plantaris tendon, and maximum anteroposterior thickness of the tendon in Mid-AT (axial images) were evaluated. When PT co-existed with Mid-AT, the location of the tendon pathologies in relation to calcaneal insertion was assessed (sagittal images) and their association was analysed using the coefficient of variation (CV) and Pearson’s correlation coefficient. Plantaris was present in 84 cases (84%), and Mid-AT and PT co-existed in 10 cases (10%). A greater variability in the location of Plantaris pathology (CV = 42%) than Achilles tendinopathy (CV = 42%) was observed. The correlation coefficient also revealed a low and non-significant association between the location of two pathologies when they exist together (r = +0.06; p = 0.88). Clinical evaluation of Achilles tendon pain needs careful consideration into the possible co-existence of Plantaris pathology. The considerable difference observed in the location of PT and Mid-AT suggest possible isolated pathologies and differentials for Achilles tendon pain.

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Surgical plantaris tendon removal for patients with plantaris tendon-related pain only and a normal Achilles tendon: a case series

BMJ Open Sport & Exercise Medicine ◽

10.1136/bmjsem-2018-000462 ◽

2018 ◽

Vol 4 (1) ◽

pp. e000462 ◽

Cited By ~ 1

Author(s):

Håkan Alfredson ◽

Lorenzo Masci ◽

Christoph Spang

Keyword(s):

Achilles Tendon ◽

Case Series ◽

Achilles Tendinopathy ◽

Activity Level ◽

Secondary Outcome ◽

Surgical Removal ◽

Return To Sports ◽

Medial Side ◽

Plantaris Tendon ◽

Case Series Study

ObjectivesSurgical removal of the plantaris tendon can cure plantaris-associated Achilles tendinopathy, a condition in which Achilles and plantaris tendinopathy coexist. However, rare cases with plantaris tendinopathy alone are often misdiagnosed due to a normal Achilles tendon.Design and settingProspective case series study at one centre.ParticipantsTen consecutive patients (9 men and one woman, mean age 35 years, range 19–67) with plantaris tendon-related pain alone in altogether 13 tendons were included. All had had a long duration (median 10 months, range 3 months to 10 years) of pain symptoms on the medial side of the Achilles tendon mid-portion. Preoperative ultrasound showed thickened plantaris tendon but a normal Achilles tendon.InterventionsOperative treatment consisting of ultrasound-guided excision of the plantaris tendon.Primary and secondary outcome measuresScores from Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A)were taken preoperatively and postoperatively (median duration 10 months). Patient satisfaction and time until full return to sports activity level was asked by a questionnaire.ResultsThe VISA-A scores increased from 61 (range 45–81) preoperatively to 97 (range 94–100) postoperatively (p<0.01). Follow-up results at 10 months (range 7–72 months) on 9/10 patients showed full satisfaction and return to their preinjury sports or recreational activityConclusionThe plantaris tendon should be kept in mind when evaluating painful conditions in the Achilles tendon region, especially when no Achilles tendinopathy is present. Excision of the plantaris tendon via a minor surgical procedure in local anaesthesia results in a good outcome.

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High incidence of deep venous thrombosis after Achilles tendon rupture: a prospective study

Knee Surgery Sports Traumatology Arthroscopy ◽

10.1007/s00167-009-0727-y ◽

2009 ◽

Vol 17 (10) ◽

pp. 1234-1238 ◽

Cited By ~ 77

Author(s):

Katarina Nilsson-Helander ◽

Anders Thurin ◽

Jon Karlsson ◽

Bengt I. Eriksson

Keyword(s):

Prospective Study ◽

Venous Thrombosis ◽

Deep Venous Thrombosis ◽

Achilles Tendon ◽

Tendon Rupture ◽

Achilles Tendon Rupture ◽

High Incidence ◽

A Prospective Study

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Achilles Scraping and Plantaris Tendon Removal Improves Pain and Tendon Structure in Patients with Mid-Portion Achilles Tendinopathy—A 24 Month Follow-Up Case Series

Journal of Clinical Medicine ◽

10.3390/jcm10122695 ◽

2021 ◽

Vol 10 (12) ◽

pp. 2695

Author(s):

Lorenzo Masci ◽

Bradley Stephen Neal ◽

William Wynter Bee ◽

Christoph Spang ◽

Håkan Alfredson

Keyword(s):

Achilles Tendon ◽

Case Series ◽

Achilles Tendinopathy ◽

Mean Difference ◽

Symptom Duration ◽

Type I ◽

Program Outcomes ◽

Medial Side ◽

Plantaris Tendon

Background: Studies have demonstrated that a sub-group of patients with medial Achilles pain exhibit Achilles tendinopathy with plantaris tendon involvement. This clinical condition is characterised by structural relationships and functional interference between the two tendons, resulting in compressive or shearing forces. Surgical plantaris tendon removal together with an Achilles scraping procedure has demonstrated positive short-term clinical results. The aim of this case series was to determine the long-term outcomes on pain and Achilles tendon structure. Methods: 18 consecutive patients (13 males; 5 females; mean age 39 years; mean symptom duration 28 months), of which three were elites, were included. Clinical examination, b-mode ultrasound (US) and Ultrasound Tissue Characterisation (UTC) confirmed medial Achilles tendon pain and tenderness, medial Achilles tendinopathy plus a plantaris tendon located close to the medial side of the Achilles tendon. Patients underwent US-guided local Achilles scraping and plantaris tendon removal followed by a structured rehabilitation program. Outcomes were VISA-A score for pain and function and UTC for Achilles structure. Results: 16 of 18 patients completed the 24 months follow-up. Mean VISA-A scores increased from 58.2 (±15.9) to 92.0 (±9.2) (mean difference = 33.8, 95% CI 25.2, 42.8, p < 0.01). There was an improvement in Achilles structure with mean organised echo pixels (UTC type I+II, in %) increasing from 79.9 (±11.5) to 86.4 (±10.0) (mean difference = 6.5%, 95% CI 0.80, 13.80, p =0.01), exceeding the 3.4% minimum detectable change. All 16 patients reported satisfaction with the procedure and 14 returned to pre-injury activity levels. There were no reported complications. Conclusions: Improved pain, function and tendon structure were observed 24 months after treatment with Achilles scraping and plantaris excision. The improvement in structure on the medial side of the Achilles after plantaris removal indicates that compression from the plantaris tendon might be an important presenting factor in this sub-group.

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Combined ESWT and RSW Therapy for Achilles Tendinopathy: A Prospective Study

Muscles Ligaments and Tendons Journal ◽

10.32098/mltj.04.2019.10 ◽

2019 ◽

Vol 09 (04) ◽

pp. 552

Author(s):

A. Saxena ◽

L. Shou

Keyword(s):

Prospective Study ◽

Achilles Tendinopathy ◽

A Prospective Study

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Results of minimally invasive Achilles tendon scraping and plantaris tendon removal in patients with chronic midportion Achilles tendinopathy: A longer-term follow-up study

SAGE Open Medicine ◽

10.1177/2050312118822642 ◽

2019 ◽

Vol 7 ◽

pp. 205031211882264 ◽

Cited By ~ 2

Author(s):

Anna Ruergård ◽

Christoph Spang ◽

Håkan Alfredson

Keyword(s):

Minimally Invasive ◽

Achilles Tendon ◽

Treatment Time ◽

Achilles Tendinopathy ◽

Colour Doppler ◽

Follow Up Study ◽

Plantaris Tendon ◽

High Satisfaction ◽

Satisfaction Rates

Background: Treatment with ultrasound and colour Doppler–guided minimally invasive Achilles tendon scraping and plantaris tendon removal has shown promising short-term results in patients with chronic painful midportion Achilles tendinopathy. Methods: In a follow-up study, 182 consecutive patients (241 tendons) who had undergone Achilles tendon scraping and plantaris tendon removal were contacted on telephone by an independent investigator. The patients who answered the telephone call were included, and they answered a questionnaire on telephone and then also sent their written answers. The questionnaire included information about patient satisfaction with the result of the treatment, time to return to full Achilles tendon loading activity, and a pain score (Visual Analogue Scale-VAS). Results: The follow-up period was 5.8 years (mean) (range of 2–13 years) after surgery. Altogether, 110 patients (136 Achilles tendons), 52 years (mean)(range 18-73) old at surgery could be reached and were included. In total, 81 tendons were operated with the Achilles scraping procedure alone, and for 55 Achilles operations also a plantaris tendon removal was performed. For 93% of the operated tendons, the patients were satisfied with the surgical outcome and the VAS had decreased from 74 preoperatively to 8 postoperatively. Nine male patients (9 tendons), five operated with scraping + plantaris removal, had remaining tendon pain during loading and were not satisfied. Their VAS score ranged from 22 to 91. For 21% of the operated tendons, some occasional mild discomfort not preventing from full tendon loading, was reported. There were no differences in pain reduction and satisfaction rates between men and women, and between Achilles scraping alone and scraping plus plantaris removal. Conclusion: Ultrasound and colour Doppler–guided surgical Achilles tendon scraping and plantaris tendon removal in patients with chronic painful midportion Achilles tendinopathy show remaining good clinical outcomes and high satisfaction rates in this longer-term follow-up.

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The Role of the Vascular and Structural Response to Activity in the Development of Achilles Tendinopathy: A Prospective Study

The American Journal of Sports Medicine ◽

10.1177/0363546517750854 ◽

2018 ◽

Vol 46 (4) ◽

pp. 947-954 ◽

Cited By ~ 9

Author(s):

Evi Wezenbeek ◽

Tine Willems ◽

Nele Mahieu ◽

Martine De Muynck ◽

Luc Vanden Bossche ◽

...

Keyword(s):

Risk Factors ◽

Blood Flow ◽

Prospective Study ◽

Achilles Tendon ◽

Achilles Tendinopathy ◽

Foot Posture Index ◽

Flow Response ◽

Foot Posture ◽

Tendon Thickness

Background: Several risk factors have been suggested in the development of Achilles tendinopathy, but large-scale prospective studies are limited. Purpose: To investigate the role of the vascular response to activity of the Achilles tendon, tendon thickness, ultrasound tissue characterization (UTC) of tendon structure, and foot posture as possible risk factors in the development of Achilles tendinopathy. Study Design: Cohort study; Level of evidence, 2. Methods: The study began with 351 first-year students at Ghent University. After 51 students were excluded, 300 were tested in the academic years 2013-2014 and 2014-2015 and were followed prospectively for 2 consecutive years by use of a multilevel registration method. Of those, 250 students were included in the statistical analysis. At baseline, foot posture index and UTC were investigated bilaterally. Blood flow and tendon thickness were measured before and after a running activity. Cox regression analyses were performed to identify significant contributors to the development of Achilles tendinopathy. Results: During the 2-year follow-up, 27 of the included 250 participants developed Achilles tendinopathy (11%). Significant predictive effects were found for female sex and blood flow response after running ( P = .022 and P = .019, respectively). The risk of developing Achilles tendinopathy increased if the blood flow increase after running was reduced, regardless of sex, foot pronation, and timing of flow measurements. The model had a predictive accuracy of 81.5% regarding the development of Achilles tendinopathy, with a specificity of 85.0% and a sensitivity of 50.0%. Conclusion: This prospective study identified both female sex and the diminished blood flow response after running as significant risk factors for the development of Achilles tendinopathy. UTC of tendon structure, Achilles tendon thickness, and foot posture did not significantly contribute to the prediction of Achilles tendinopathy. A general evaluation of tendon structure by UTC, measurement of tendon thickness, or determination of the foot posture index will not allow clinicians to identify patients at risk for developing Achilles tendinopathy. Furthermore, it may be possible to improve blood flow after activity by using noninvasive techniques (such as prostaglandins, compression stockings, heat, massage, and vibration techniques). These techniques may be useful in the prevention and management of Achilles tendinopathy, but further research is needed.

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