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

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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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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Ultrasound and surgical inspection of plantaris tendon involvement in chronic painful insertional Achilles tendinopathy: a case series

BMJ Open Sport & Exercise Medicine ◽

10.1136/bmjsem-2020-000979 ◽

2021 ◽

Vol 7 (1) ◽

pp. e000979

Author(s):

Håkan Alfredson ◽

Lorenzo Masci ◽

Christoph Spang

Keyword(s):

Achilles Tendon ◽

Clinical Symptoms ◽

Fatty Infiltration ◽

Case Series ◽

Achilles Tendinopathy ◽

Level Of Evidence ◽

Plantaris Tendon ◽

Medial Pain ◽

Tendon Insertion ◽

Insertional Achilles Tendinopathy

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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Endoscopy-Assisted Achilles Tendon Reconstruction With a Central Turndown Flap and Semitendinosus Augmentation

Foot & Ankle International ◽

10.1177/1071100716666365 ◽

2016 ◽

Vol 37 (12) ◽

pp. 1333-1342 ◽

Cited By ~ 4

Author(s):

Prashant N. Gedam ◽

Faizaan M. Rushnaiwala

Keyword(s):

Minimally Invasive ◽

Achilles Tendon ◽

Achilles Tendon Rupture ◽

Wound Complication ◽

Reconstruction Technique ◽

Level Of Evidence ◽

Invasive Approach ◽

Perioperative Morbidity ◽

The Mean

Background: The objective of this study was to report the results of a new minimally invasive Achilles reconstruction technique and to assess the perioperative morbidity, medium- to long-term outcomes, and functional results. Methods: Our series was comprised 14 patients (11 men and 3 women), with a mean age of 45.6 years at surgery. Each patient had a chronic Achilles tendon rupture. The mean interval from rupture to surgery was 5.5 months (range, 2-10). The mean total follow-up was 30.1 months (range, 12-78). All patients were operated with a central turndown flap augmented with free semitendinosus tendon graft and percutaneous sutures in a minimally invasive approach assisted by endoscopy. The patients underwent retrospective assessment by clinical examination, the American Orthopaedic Foot & Ankle Society (AOFAS) ankle and hindfoot score, and the Achilles Tendon Total Rupture Score (ATRS). Paired t tests were used to assess the preoperative and postoperative AOFAS scores, ATRS scores, and ankle range of motion. Results: The length of the defect ranged from 3 to 8 cm (mean, 5.1), while the length of the turndown flap ranged from 8 to 13 cm (mean, 10.1). The mean AOFAS score improved from 64.5 points preoperatively to 96.9 points at last follow-up. The mean ATRS score improved from 49.4 preoperatively to 91.4 points at last follow-up. None of the patients developed a wound complication. No patient had a rerupture or sural nerve damage. Conclusion: All patients in our study had a favorable outcome with no complications. We believe that with this triple-repair technique, one can achieve a strong and robust repair such as in open surgery while at the same time reducing the incidence of complications. Level of Evidence: Level III, retrospective comparative study.

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Conservative Treatment of Achilles Tendon Rupture:A Follow-Up Study of Li Cases

Acta Orthopaedica Scandinavica ◽

10.3109/17453677608988719 ◽

1976 ◽

Vol 47 (4) ◽

pp. 454-458 ◽

Cited By ~ 23

Author(s):

Torben Llldholdt ◽

T. Munch-jøhgensen

Keyword(s):

Conservative Treatment ◽

Achilles Tendon ◽

Follow Up Study

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Continued Sports Activity, Using a Pain-Monitoring Model, during Rehabilitation in Patients with Achilles Tendinopathy

The American Journal of Sports Medicine ◽

10.1177/0363546506298279 ◽

2007 ◽

Vol 35 (6) ◽

pp. 897-906 ◽

Cited By ~ 138

Author(s):

Karin Grävare Silbernagel ◽

Roland Thomeé ◽

Bengt I. Eriksson ◽

Jon Karlsson

Keyword(s):

Standard Deviation ◽

Exercise Training ◽

Achilles Tendon ◽

Primary Outcome ◽

Initial Period ◽

Treatment Protocol ◽

Training Group ◽

Achilles Tendinopathy ◽

Monitoring Model

Background Achilles tendinopathy is a common overuse injury, especially among athletes involved in activities that include running and jumping. Often an initial period of rest from the pain-provoking activity is recommended. Purpose To prospectively evaluate if continued running and jumping during treatment with an Achilles tendon-loading strengthening program has an effect on the outcome. Study Design Randomized clinical control trial; Level of evidence, 1. Methods Thirty-eight patients with Achilles tendinopathy were randomly allocated to 2 different treatment groups. The exercise training group (n = 19) was allowed, with the use of a pain-monitoring model, to continue Achilles tendon-loading activity, such as running and jumping, whereas the active rest group (n = 19) had to stop such activities during the first 6 weeks. All patients were rehabilitated according to an identical rehabilitation program. The primary outcome measures were the Swedish version of the Victorian Institute of Sports Assessment—Achilles questionnaire (VISA-A-S) and the pain level during tendon-loading activity. Results No significant differences in the rate of improvements were found between the groups. Both groups showed, however, significant (P < .01) improvements, compared with baseline, on the primary outcome measure at all the evaluations. The exercise training group had a mean (standard deviation) VISA-A-S score of 57 (15.8) at baseline and 85 (12.7) at the 12-month follow-up (P < .01). The active rest group had a mean (standard deviation) VISA-A-S score of 57 (15.7) at baseline and 91 (8.2) at the 12-month follow-up (P < .01). Conclusions No negative effects could be demonstrated from continuing Achilles tendon-loading activity, such as running and jumping, with the use of a pain-monitoring model, during treatment. Our treatment protocol for patients with Achilles tendinopathy, which gradually increases the load on the Achilles tendon and calf muscle, demonstrated significant improvements. A training regimen of continued, pain-monitored, tendon-loading physical activity might therefore represent a valuable option for patients with Achilles tendinopathy.

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Novel Physical Therapy Protocol Targeting Insertional Achilles Tendinopathy Improves Patient Reported Outcomes that Persist For 1 Year

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00284 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0028

Author(s):

Meghan Kelly ◽

Ashlee MacDonald ◽

Rachel Olson ◽

Grace Weyand ◽

Ruth Chimenti ◽

...

Keyword(s):

Physical Therapy ◽

Achilles Tendon ◽

Exercise Program ◽

Achilles Tendinopathy ◽

Home Exercise ◽

Sf 36 ◽

Patient Reported ◽

One Year ◽

Therapy Protocol

Category: Sports Introduction/Purpose: Insertional Achilles Tendinopathy (IAT) affects 5% of the general population and up to 20% of the athletic population. Despite trials of non-surgical management such as physical therapy and heels lifts, more than 50% of patients ultimately pursue surgery. One hypothesis regarding the development of IAT pain and stiffness is that ankle dorsiflexion and associated calcaneal impingement causes transverse compression of the tendon insertion, inducing metaplastic changes within the Achilles tendon, and bursa, contributing to inflammation. Thus the aim of the current study is to examine the effect of a home exercise program designed to minimize compression of insertional tissues for patients with IAT on patient reported outcomes (PRO) measures at 3 months and one year. Methods: Thirty-five patients with IAT were enrolled in the study from May 2014 until June 2015 as two separate cohorts (21 and 14 patients, respectively) of whom 26 completed the study (mean age: 56.7 + 10.1 years, BMI: 29.5 + 6.0 kg/m2, 58% women). One patient elected for surgery prior to completing the physical therapy protocol. Physical therapy exercises were progressive eccentric loading of the Achilles tendon and seated isometric plantar flexion that were performed 4 times a week for 3 months. The Victorian Institute of Sport Assessment – Achilles (VISA-A), the Foot and Ankle Ability Measure (FAAM) and the SF-36 questionnaires were completed at baseline and at the completion of the 3-month physical therapy protocol. Six of the 14 patients in the second cohort returned for a 1 year follow up visit; four patients were lost to follow up and 4 had undergone surgical intervention prior to 1-year follow up. Results: Completion of the 3 month protocol resulted in statistically significant improvements in VISA-A, FAAM ADL and sports scores as well as multiple subcategories of the SF-36 (physical function, role limiting physical function, energy/vitality, social functioning and general pain). Twenty-two of the 26 patients (~85%) that completed the study had clinically significant, greater than MCID, improvements in their VISA-A and/or FAAM scores. In the second cohort, all six patients that returned for a one year follow up assessment maintained their improved VISA-A and FAAM scores observed at the end of the initial physical therapy protocol. Of the four patients that underwent surgical intervention prior to follow up, two did not demonstrate improvement in any of their outcomes following the initial study period. Conclusion: The results of the present study suggest that a physical therapy home exercise program utilizing eccentric and isometric Achilles exercises may result in a greater improvement in functional outcomes compared to other exercise programs that do not progressively increase both ankle dorsiflexion and Achilles tendon loading. Furthermore, improvements in pain and function result in increased energy and social wellbeing. Finally, symptomatic improvement that occurs after 3 months is likely to persist for at least one year following initial treatment.

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Tendon Morphology and Mechanical Properties Are Associated With the Recovery of Symptoms and Function in Patients With Achilles Tendinopathy

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120917271 ◽

2020 ◽

Vol 8 (4) ◽

pp. 232596712091727

Author(s):

Patrick Corrigan ◽

Daniel H. Cortes ◽

Ryan T. Pohlig ◽

Karin Grävare Silbernagel

Keyword(s):

Mechanical Properties ◽

Shear Modulus ◽

Achilles Tendon ◽

Achilles Tendinopathy ◽

Calf Muscle ◽

Initial Assessment ◽

Muscle Endurance ◽

Patient Reported ◽

Morphology And Mechanical Properties

Background: Achilles tendinopathy is a debilitating overuse injury characterized by pain, altered Achilles tendon structure, and impaired functional performance. Evaluating tendon structure as part of the physical examination may help establish a well-defined prognosis. However, the usefulness of measuring tendon structure for developing a prognosis has been questioned since structural abnormalities can exist without symptoms. Purpose: To determine whether initial measures of tendon morphology and mechanical properties were associated with patient-reported symptoms and calf muscle endurance at baseline, 6-month follow-up, and 1-year follow-up by prospectively following a cohort of individuals with Achilles tendinopathy. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 59 participants with midportion or insertional Achilles tendinopathy completed an initial assessment and follow-up assessments at 6 months and 1 year. At the initial assessment, patient-reported symptoms, calf muscle endurance, and Achilles tendon thickening were evaluated, and Achilles tendon mechanical properties were estimated. At the 6-month and 1-year follow-up assessments, patient-reported symptoms and calf muscle endurance were reevaluated. Results: Greater Achilles tendon thickening at the initial assessment was consistently associated with worse patient-reported symptoms and calf muscle endurance at each assessment. Changes in symptoms over the year were moderated by the initial shear modulus of the tendon, with a lower shear modulus associated with less improvement in symptoms. Lower viscosity at the initial assessment was also associated with worse calf muscle endurance at each assessment. Conclusion: Measures of tendon morphology and mechanical properties appear to be associated with patient-reported symptoms and calf muscle function for patients with Achilles tendinopathy.

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A Critical Analysis of Sagittal Plane Deformity Correction with Minimally Invasive Adult Spinal Deformity Surgery: A Two-Year Follow-Up Study

The Spine Journal ◽

10.1016/j.spinee.2015.07.113 ◽

2015 ◽

Vol 15 (10) ◽

pp. S126-S127

Author(s):

International Spine Study Group ◽

Gregory M. Mundis ◽

Jay D. Turner ◽

Vedat Deviren ◽

Juan S. Uribe ◽

...

Keyword(s):

Minimally Invasive ◽

Spinal Deformity ◽

Critical Analysis ◽

Sagittal Plane ◽

Adult Spinal Deformity ◽

Deformity Correction ◽

Follow Up Study ◽

Spinal Deformity Surgery ◽

Plane Deformity

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Short-Term Results of Endoscopic Percutaneous Longitudinal Tenotomy for Noninsertional Achilles Tendinopathy and the Presentation of a Simplified Operative Method

Foot & Ankle Specialist ◽

10.1177/1938640018790070 ◽

2018 ◽

Vol 12 (1) ◽

pp. 73-78

Author(s):

Michel Chraim ◽

Hamza M. Alrabai ◽

Sabine Krenn ◽

Peter Bock ◽

Hans-Jörg Trnka

Keyword(s):

Achilles Tendon ◽

Carpal Tunnel Release ◽

Case Series ◽

Achilles Tendinopathy ◽

Operation Technique ◽

Outpatient Basis ◽

Short Term ◽

Pain Visual Analog Scale ◽

Postoperative Thrombosis

Purpose: This study was aimed to review the short-term results of endoscopic percutaneous longitudinal tenotomy for noninsertional Achilles tendinopathy using the Centerline Endoscopic Carpal Tunnel Release instrument (Arthrex). This method simplifies the operation technique, allows a good endoscopic visualisation of the Achilles tendon with very promising results. Methods: We performed multiple percutaneous longitudinal tenotomies under local anesthesia in 24 patients (25 tendons) with Achilles tendinopathy or peritendinitis that had failed conservative treatment between January 2013 and September 2016. All ambulatory procedures consisted of paratenon release and longitudinal tenotomies. The results were reviewed in 22 patients (23 tendons) at an average follow-up period of 22.5 months (range 10-36 months). Patients’ satisfaction and functional outcomes were evaluated using the Victorian Institute of Sports Assessment–Achilles (VISA-A) questionnaire, the pain visual analog scale (VAS), and the functional foot index. Results: Initial results are very promising with excellent results in 12 patients, good results in 9 patients, and fair result in 1 patient. One patient developed a postoperative thrombosis of the operated limb. Another patient developed a hypertrophic painful scar of the incision wound. The VAS for pain decreased drastically after the index procedure and averaged to 0.2 (SD 0.447). The VISA-A questionnaire score had improved from 42 ± 7.2 points preoperatively to 96.8 ± 14.3 points postoperatively (P = .004). The functional foot index decreased from 84 (SD 30.517) to 33.4 (SD 6.452) on the follow-up examination. Conclusions: The endoscopic-assisted longitudinal tenotomies procedure of the Achilles tendon is easily feasible and can be performed on an outpatient basis, produces minimal complications and shows excellent results. The described technique is recommended for all surgeons especially for those familiar with endoscopy of the Achilles tendon. Levels of Evidence: Therapeutic, Level IV: Case Series

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