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The chronic painful midportion Achilles tendon has been difficult to treat for years, and has on occasions ended the career of high-level athletes. Traditionally, when conservative treatments failed these athletes, surgery was instituted. Surgical treatment of midportion Achilles tendinosis consisted of a dorsal approach, with a central longitudinal tenotomy and excision of tendinosis tissue.1,–,3 This often required a long postoperative rehabilitation of 3–6 months before that athlete was allowed to retry full tendon-loading activity. The results of intra-tendinous surgery is known to be unpredictable.
With the introduction of painful eccentric training in the late 1990s,4 a high proportion of recreationally active athletes became pain-free, but the treatment was less successful for high-level athletes. Using new research that demonstrated vessels and nerves on the ventral side of the Achilles,5,–,7 sclerosing polidocanol injections targeting the regions with vessels and nerves outside the ventral Achilles were introduced.8 This treatment relieved pain in many athletes and allowed for a return to full tendon loading activity, but often required multiple injection treatments with 6–8 weeks in between injection.
New surgical treatments
The need to find a one-stage procedure, which allowed for a rapid return to sports, led to the introduction of the mini-surgical scraping technique.9 This is based on the same principles as the sclerosing injections, targeting vessels and nerves on the ventral side of the midportion Achilles. In this issue, the short-term results of a large number of patients with a variety of activity levels is presented.10 Overall, the clinical results are very good, especially in athletes who perform high Achilles tendon loading activities. This treatment allows for a rapid return to high-level sports, and importantly, there have been very few complications. The effects on tendon thickness and structure are under evaluation, but preliminary results indicate that there is a remodelling with decreased tendon thickness and a more normal internal tendon structure, similar to the changes seen after sclerosing polidocanol injections.11
And in those that fail?
We have now treated more than 300 patients with this mini surgical scraping technique, and although the majority have become pain-free, there have been some that have not improved (seven failed to improve in the randomised study). Interestingly, when reoperating these tendons, five of these seven tendons had an invaginated plantaris tendon in the ventro-medial Achilles. Histological evaluation of the plantaris tendon showed classical tendinosis changes. After release and extirpation of the plantaris, the clinical outcomes were good. These findings indicate that the plantaris tendon may be a source of pain in patients with medial midportion symptoms. Interestingly, a recent study demonstrated that the plantaris tendon was stiffer and stronger than the Achilles tendon,12 and theoretically, if invaginated or located close to the Achilles, it might compress the Achilles. As with insertional tendinopathy,13 compression could possibly be a provocative factor in the midportion.
There may be application of some of these procedures to other tendons. Similar findings and treatment of neovessels and nerves on the deep side of the patellar tendon14 can provide good outcomes for patients suffering from patellar tendinopathy. A randomised pilot study by Lotta Willberg,15,16 presents promising results using ultrasound+Doppler-guided arthroscopic shaving in regions with high blood flow and nerves dorsal to the patellar tendon. Quick recovery after surgery and early return to high-level sports after this treatment seem possible. Long-term follow-ups of more athletes and evaluation of tendon thickness and structure are in progress.
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Footnotes
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Competing interests None.
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Provenance and peer review Not commissioned; not externally peer reviewed.