Football Was the Most Common Sport among 344 Consecutive Athletes Treated Surgically for Jumper's Knee at an International Tendon Clinic.

Objectives: Jumper's knee, or proximal patellar tendinopathy, is commonly seen among athletes in leg explosive sports, and for a subgroup surgical treatment is needed. The aim of this study was to identify what type of sports were most frequent among athletes treated surgically for Jumper's knee at an international tendon clinic during a consecutive 13-year period. Methods: The study included 344 consecutive patients (306 males, mean age 27 years, range 17-58; 38 females, mean age 24 years, range 18-44) from 21 different countries seeking help for therapy-resistant jumper's knee. There were 274 elite athletes, 168 being full-time professionals. All were diagnosed to have tendinopathy in the proximal patellar tendon and were operated on with ultrasound- and Doppler-guided arthroscopic shaving surgery. Results: The single most common sport was football (n = 95, 28%), followed by rugby (n = 37, 11%) and handball (n = 32, 9%), with 117 (34%) playing at a professional level. The rest of the athletes participated in 17 other different elite sports and nine recreational sports (running/jogging, padel, squash, biking, gym training, bowling, cheerleading, dancing, and ultimate frisbee). Conclusions: Football was the most common sport among patients requiring surgical treatment for jumper's knee, constituting 28% of all patients, and together with rugby and handball they constituted almost half of all patients. There was a wide sport distribution with 29 different team and individual sports represented.

Tendinopathic Plantaris but Normal Achilles Tendon Found in About One-Fifth of Patients Not Responding to Conservative Achilles Tendon Management - Results from a Prospective WALANT Surgical Case Series on 105 Tendons.

Purpose: Midportion Achilles tendinopathy is a relatively common condition. This study aimed to investigate the presence of a normal Achilles tendon, but a tendinopathic plantaris tendon, in a large and consecutive prospective sample of patients referred to a specialised tendon clinic for midportion Achilles tendon pain not responding to non-surgical treatment. Patients and Methods: A total of 105 consecutive tendons were operated on in 81 patients (62 males) suffering from painful midportion Achilles tendon pain. Clinical examination, ultrasound (US) and colour Doppler (CD) examination, and wide awake local anaesthetic no tourniquet (WALANT) surgery were performed in all patients. Results: For 19/105 (18%) tendons from 14 patients, clinical examination suspected plantaris tendinopathy alone as there was a distinct tenderness on the medial side, but no thickening of the Achilles tendon. US examination followed by surgery confirmed the diagnosis. Conclusion: Midportion Achilles tendon pain is not always related to Achilles tendinopathy since pain related to the plantaris tendon alone was found in almost every fifth patient. Consequently, there is an obvious need for proper examination to identify the pain source and establish a correct diagnosis before treatment.

Ultrasound- and Doppler-Guided WALANT Arthroscopic Surgery for Patellar Tendinopathy with Partial Rupture in Elite Athletes-A 2-Year Follow-Up of a Prospective Case Series.

Background and Objectives: Patellar tendinopathy is difficult to treat, and when combined with partial rupture, there are additional challenges. The aim of this study was to evaluate the subjective outcome and return-to-sport status after ultrasound (US)- and colour doppler (CD)-guided wide awake local anaesthetic no tourniquet (WALANT) arthroscopic shaving in elite athletes. Material and Methods: Thirty Swedish and international elite athletes (27 males) with a long duration (>1 year) of persistent painful patellar tendinopathy in 35 patellar tendons, not responding to non-surgical treatment, were included. All patients were treated with the same protocol of arthroscopic shaving, including bone removal and debridement of partial rupture, followed by at least 3 months of structured rehabilitation. The VISA-P score and a study-specific questionnaire evaluating physical activity level and subjective satisfaction with the treatment were used for evaluation. Results: At the 2-year follow-up (mean 23, range 8-38 months), 25/30 patients (29/35 tendons) were satisfied with the treatment result and had returned to their pre-injury sport. The mean VISA-P score increased from 37 (range 7-69) before surgery to 80 (range 44-100) after surgery (p < 0.05). There was one drop-out (one tendon). There were no complications. Conclusions: US- and CD-guided WALANT arthroscopic shaving for persistent painful patellar tendinopathy, including bone removal and debridement of partial rupture, followed by structured rehabilitation showed good clinical results in the majority of the elite-level athletes.

Ultrasonography- and Doppler-Guided Surgical Treatment for Insertional Achilles Tendinopathy: Results From a Case Series in a Southern Sweden County Hospital.

Background: Treatment with ultrasonography (US)- and color Doppler (CD)-guided mini surgery for insertional Achilles tendinopathy has shown good clinical results in a sports medicine setting. The aim in this study was to introduce this new methodology at a county hospital and study the clinical results on a traditional orthopaedic population. Methods: Twenty-six consecutive patients (12 men, mean age 61 years; 14 women, mean age 56 years) with a long duration (>12 months) of pain symptoms from insertional Achilles tendinopathy (a combination of bursae, bone, and tendon pathology) were included. US- and CD-guided surgical removal of bursae, bone, and tendon pathology, performed with local anaesthesia, was used. After surgery, there was immediate weightbearing loading without immobilization, followed by a structured rehabilitation protocol for 12 weeks. The VISA-A and SEFAS scores plus a questionnaire evaluating satisfaction with treatment and activity level was used for evaluation. Results: At the 1-year follow-up, there were 3 dropouts. Twenty-one patients were satisfied. Their VISA-A score had increased significantly from 26 to 81 (P < .001), and the SEFAS score from 17 to 38 (P < .001). Two patients were not satisfied. There were 3 complications, 2 superficial skin infections, and 1 wound rupture. Conclusion: For patients with chronic painful insertional Achilles tendinopathy, the US- and CD-guided surgical treatment method followed by immediate weightbearing loading showed a high satisfaction rate and improved functional scores at the 1-year follow-up in a majority of the patients. There are advantages using this method compared to other more tendon invasive surgical methods in use for this condition. Level of Evidence: Level IV, case series.

Combined Midportion Achilles and Plantaris Tendinopathy: A 1-Year Follow-Up Study after Ultrasound and Color-Doppler-Guided WALANT Surgery in a Private Setting in Southern Sweden.

Background and Objectives: Chronic painful midportion Achilles combined with plantaris tendinopathy can be a troublesome condition to treat. The objective was to prospectively follow patients subjected to ultrasound (US)- and color doppler (CD)-guided wide awake, local anesthetic, no-tourniquet (WALANT) surgery in a private setting. Material and Methods: Twenty-six Swedish patients (17 men and 9 women, mean age 50 years (range 29-62)) and eight international male patients (mean age of 38 years (range 25-71)) with combined midportion Achilles and plantaris tendinopathy in 45 tendons altogether were included. All patients had had >6 months of pain and had tried non-surgical treatment with eccentric training, without effect. US + CD-guided surgical scraping of the ventral Achilles tendon and plantaris removal under local anesthesia was performed on all patients. A 4-6-week rehabilitation protocol with an immediate full-weight-bearing tendon loading regime was used. The VISA-A score and a study-specific questionnaire evaluating physical activity level and subjective satisfaction with the treatment were used for evaluation. Results: At the 1-year follow-up, 32/34 patients (43 tendons) were satisfied with the treatment result and had returned to their pre-injury Achilles tendon loading activity. There were two dropouts (two tendons). For the Swedish patients, the mean VISA-A score increased from 34 (0-64) before surgery to 93 (61-100) after surgery (p < 0.001). There were two complications, one wound rupture and one superficial skin infection. Conclusions: For patients suffering from painful midportion Achilles tendinopathy and plantaris tendinopathy, US + CD-guided surgical Achilles tendon scraping and plantaris tendon removal showed a high satisfaction rate and good functional results 1 year after surgery.

Is There a Relationship Between Quadriceps Tendinopathy and Suprapatellar Plica? An Observational Case Series.

Purpose: Chronic painful quadriceps tendinopathy is a relatively rare condition known to be difficult to manage. Conservative management is first-line treatment and if that fails open intra-tendinous revision surgery followed by a long rehabilitation period is used. There is sparse research on etiology and new treatment methods. This observational study aimed to evaluate the intra-articular findings in patients with chronic painful quadriceps tendinopathy resistant to conservative management. Patients and Methods: Seven male athletes (mean age 33 years, range 22-40) suffering from chronic painful quadriceps tendinopathy in altogether 10 tendons, not responding to conservative management including heavy strength training, were included. Clinical examination and ultrasound scanning were used for diagnosis. Arthroscopy was used for evaluation of the inside of the knee. Results: In all 10 knees, there were obliterating major plica formations in the suprapatellar pouch. Conclusion: Obliterating plica formations in the suprapatellar pouch may be involved in the aetiology and pathology in quadriceps tendinopathy.

Sharp pain in a normal Achilles tendon of a professional female football player was related to a plantaris tendon in a rare position: a case report.

BACKGROUND: Plantaris tendinopathy and plantaris-associated Achilles tendinopathy can be responsible for chronic pain in the Achilles tendon midportion, often accompanied by medial tenderness. As conservative treatments are less successful for this patient group, proper diagnosis is important for decision making. This report presents a case with plantaris tendinopathy in a rare (superficial) location. CASE PRESENTATION: This article describes a pain history and treatment timeline of a professional Swedish female soccer player (32 years old, Northern European ethnicity, white) who suffered from sharp pain in the Achilles tendon midportion and tenderness on the medial and superficial side for about 2 years. Conservative treatments, including eccentric exercises, were not successful and, to some extent, even caused additional irritation in that region. Ultrasound showed a wide and thick plantaris tendon located on the superficial side of the Achilles tendon midportion. The patient was surgically treated with local removal of the plantaris tendon. After surgery there was a relatively quick (4-6 weeks) rehabilitation, with immediate weight bearing, gradual increased loading, and return to running activities after 4 weeks. At follow-up at 8 weeks, the patient was running and had not experienced any further episodes of sharp pain during change of direction or sprinting. CONCLUSIONS: The plantaris tendon should be considered as a possible source of Achilles tendon pain. This case study demonstrates that the plantaris tendon can be found in unexpected (superficial) positions and needs to be carefully visualized during clinical and imaging examinations.

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.

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.

Isolated Lumbar Extension Resistance Exercise in Limited Range of Motion for Patients with Lumbar Radiculopathy and Disk Herniation-Clinical Outcome and Influencing Factors.

(1) Background: Reconditioning of the paraspinal lumbar extensor muscles by isolated lumbar extension resistance exercises (ILEX) has shown good clinical results for patients with chronic unspecific low back pain. However, the clinical value and safety for patients with specific spine pathologies is unclear. In this study, clinical outcome and influencing factors were retrospectively analyzed for patients with lumbar disk herniation (LDH) and radiculopathy. (2) Methods: 189 consecutive patients (123 men and 66 women; mean age, 36 years) with clinically diagnosed LDH and relative indications for surgery started a 9-week rehabilitation program (2x/week) including ILEX in limited range of motion (ROM) adjusted to patients' symptoms. Patients diagnosed with advanced levels of spine degeneration were excluded. Pain/radiculopathy (PR), influence on mental health (IOMH), satisfaction rates were measured via Numeric Rating Scales (NRS, 0-10), and overall clinical outcome was stated in % (100% = full recovery). Isometric extension strength was tested before and after the program. (3) Results: 168 patients (88.9%) completed the program. For 162 out of 168 patients (96.4%) there was a significant reduction of clinical symptoms, whereas 6 patients reported no changes in symptoms. Scores (mean) for symptom intensity decreased from 4.2 (±1.5) to 1.9 (±1.5) (p < 0.001), the impact on mental health decreased from 5.9 (±2.3) to 2.4 (±2.0) (p < 0.001). There was a (weak) correlation between lower scores for PR and IOMH before the study and better clinical outcomes; PR also weakly correlated with satisfaction. Other factors such as age, strength increase, level/location and number of LDH did not have a significant impact on the clinical results. (4) Conclusion: The results indicate that ILEX in limited ROM can be an effective treatment for the majority of patients with LDH. For patients with high pain levels, the results are less consistent, and surgery may be considered.

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

OBJECTIVES: Chronic 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. METHODS: Ninety-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. RESULTS: In 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. CONCLUSION: Plantaris 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 EVIDENCE: IV case series.

Partial Achilles Tendon Rupture-A Neglected Entity: A Narrative Literature Review on Diagnostics and Treatment Options.

Partial ruptures in the Achilles tendon are rather uncommon and are often misinterpreted as aggravated Achilles tendinopathy, and not always considered as a differential diagnosis. The aim of this literature review was to characterize typical symptoms, to provide an overview of available diagnosis and treatment options, and to give reference points for future research. There were few studies and sparse knowledge of scientific value, making it difficult to give evidence-based recommendations. Based on the few studies and the authors' clinical experience, a diagnosis should be based on a patient's history with a typical sharp onset of pain and inability to fully load the tendon. Previous intratendinous cortisone injections might be present. Clinical findings are a localized tender region in the tendon and often weakness during heel raises. Ultrasound and Doppler examinations show a region with an irregular and bulging superficial tendon line, often together with localized high blood flow. Magnetic resonance Imaging (MRI) shows a hyperintense signal in the tendon on T1 and T2-weighted sequences. First-line therapy should be a conservative approach using a 2 cm heel lift for the first 6 weeks and avoiding tendon stretching (for 12 weeks). This is followed by a reduced heel lift of 1 cm and progressive tendon loading at weeks 7-12. After 12 weeks, the heel lift can be removed if pain-free, and the patient can gradually start eccentric exercises lowering the heel below floor level and gradually returning to previous sport level. If conservative management has a poor effect, surgical exploration and the excision of the partial rupture and suturing is required. Augmentation procedures or anchor applications might be useful for partial ruptures in the Achilles insertion, but this depends on the size and exact location. After surgery, the 12 to 14-week rehabilitation program used in conservative management can be recommended before the patient's return to full tendon loading activities.

Ultrasound-guided tendon debridement improves pain, function and structure in persistent patellar tendinopathy: short term follow-up of a case series.

There is a need for effective therapeutic options for resistant patellar tendinopathy. Ultrasound (US)-guided arthroscopic debridement has demonstrated promising clinical results. OBJECTIVES: To prospectively evaluate pain, function, tendon structure and adverse events after US and colour Doppler (CD)-guided arthroscopic debridement for persistent painful patellar tendinopathy. MATERIALS AND METHODS: Twenty-three consecutive patients (19 males and 4 females, mean age 28 years (±8), symptom duration 25 months (±21)), who had failed conservative management including progressive loading, were included. US+CD and ultrasound tissue characterisation (UTC) examination verified the clinical diagnosis and quantified baseline tendon structure. Patients were treated with US+CD-guided arthroscopic debridement followed by a specific rehabilitation protocol. Outcomes were VISA-P score for pain and function and UTC for tendon structure. Adverse events were specifically elicited. RESULTS: At 6-month follow-up, mean VISA-P score increased from 40 (±21.0) to 82 (±15) (mean deviation (MD)=42.0, 95% CI 32 to 53, d=2.4), while organised echo pixels (combined UTC type I+II) increased from 55.0% (±17.0) to 69.0% (±15.0) (MD=14.0, d=0.7, 95% CI 2 to 21). Both outcomes exceeded minimum detectable change values. Twenty-one participants returned to their prediagnosis activity levels, and there were no significant adverse events. CONCLUSIONS: US-guided patellar tendon debridement for persistent patellar tendinopathy improved symptoms and tendon structure without complications at 6-month follow-up. A majority (21/23) of the patients returned to their preinjury activity level. Further studies with longer follow-ups, preferably randomised and controlled, are needed.

Surgical treatment of insertional Achilles tendinopathy: results after removal of the subcutaneous bursa alone-a case series.

BACKGROUND: Insertional Achilles tendinopathy is well known to be difficult to treat, especially when there is intra-tendinous bone pathology. This study is a case series on patients with chronic insertional Achilles tendon pain and major intra-tendinous bony pathology together with bursa and tendon pathology, treated with excision of the subcutaneous bursa alone. METHODS: Eleven patients (eight men and three women) with a mean age of 44 years (range 24-62) and a chronic (>6 months) painful condition from altogether 15 Achilles tendon insertions were included. In all patients, ultrasound examination showed intra-tendinous bone pathology together with pathology in the tendon and subcutaneous bursa, and all were surgically treated with an open excision of the whole subcutaneous bursa alone. This was followed by full weight-bearing walking in a shoe with open heel for 6 weeks. RESULTS: At follow-up 21 (median, range 12-108) months after surgery, 9/11 patients (12/15 tendons) were satisfied with the result of the operation and 10/11 (13/15 tendons) were back in their previous sport and recreational activities. The median VISA-A score had improved from 41 (range 0-52) to 91 (range 33-100) (p<0.01). CONCLUSION: In patients with chronic painful insertional Achilles tendinopathy with intra-tendinous bone pathology, tendon and bursa pathology, open removal of the subcutaneous bursa alone can relieve the pain and allow for Achilles tendon loading activities. The results in this case series highlight the need for more studies on the pain mechanisms in insertional Achilles tendinopathy and the need for randomised studies to strengthen the conclusions. LEVEL OF EVIDENCE: IV Case series.

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.

Sonographically Guided Plantaris Tendon Release: A Cadaveric Validation Study.

BACKGROUND: The plantaris tendon (PT) has been implicated in the pathogenesis of symptoms in a subset of patients with Achilles region pain syndromes and traditionally has been managed via open surgical resection. Although the PT can be visualized on ultrasound, a minimally invasive technique for sonographically guided PT release has not been formally described. OBJECTIVE: To validate a technique to perform sonographically guided PT release in an unembalmed cadaveric model. DESIGN: Prospective, cadaveric laboratory investigation. SETTING: Procedural skills laboratory in a tertiary medical center. SUBJECTS: Twenty unembalmed cadaveric knee-ankle-foot specimens (10 right, 10 left) obtained from 16 donors (6 male, 10 female) ages 55-96 years (mean 82.6 years) with body mass indexes of 14.1-33.2 kg/m2 (mean 23.3 kg/m2 ). METHODS: After simulated local anesthesia and sonographically guided hydrodissection of the plantaris tendon-Achilles tendon interval, a single experienced operator performed sonographically guided PT release on each specimen using an in-plane, lateral-to-medial approach, a commercially available, disposable 3.0-mm hook knife, and either a 17-5 MHz or 15-7 MHz linear array transducer. Each specimen was subsequently dissected to assess for PT release and iatrogenic injury. MAIN OUTCOME: Status of the PT, Achilles tendon, and regional neurovascular structures as determined by dissection. RESULTS: All 20 PT releases were completed in a single attempt through a 3- to 5-mm incision. Dissection confirmed complete PT release in all specimens without damage to the adjacent Achilles tendon or regional neurovascular structures. CONCLUSION: Sonographically guided PT release is technically feasible and can be performed while avoiding injury to the Achilles tendon and regional neurovascular structures. Additional research is warranted to further define the role of sonographically guided PT release in patients with suspected PT-mediated Achilles region pain syndromes. LEVEL OF EVIDENCE: IV.

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

OBJECTIVES: Surgical 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 SETTING: Prospective case series study at one centre. PARTICIPANTS: Ten 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. INTERVENTIONS: Operative treatment consisting of ultrasound-guided excision of the plantaris tendon. PRIMARY AND SECONDARY OUTCOME MEASURES: Scores 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. RESULTS: The 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 activity. CONCLUSION: The 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.

Achilles insertion bone pathology not related to pain in a triathlete with cystic fibrosis.

This report concerns the unusual case of a 48-year old, world-class triathlete who has won 11 ironman competitions. She has reached the top level of international endurance sport in spite of being diagnosed with cystic fibrosis. This patient presented with Achilles pain and severe bony pathology at her left Achilles insertion. Traditionally this condition is treated via tendon detachment and re-attachment or intra-tendinous surgery, followed by a protracted rehabilitation. These procedures were considered risky due to this patient's chronic disease with vulnerability to immobilization. Instead, she was treated by surgical removal of the superficial bursa alone, under local anaesthetic. This allowed the patient to become active and load her Achilles tendon immediately, and resulted in a significant symptomatic improvement. This case illustrates that despite the presence of severe tendon and bone pathology at the Achilles insertion, pain may originate in the superficial bursa; a structure ignored by traditional operations.

Clinical presentation and surgical management of chronic Achilles tendon disorders - A retrospective observation on a set of consecutive patients being operated by the same orthopedic surgeon.

BACKGROUND: Non-invasive treatment is not always successful in patients with Achilles tendon disorders, and surgical treatment is instituted as the next step. There is sparse knowledge about the diagnoses, pain levels before surgery, surgically confirmed pathologies and postoperative complications in large patient groups. AIMS: To study the diagnoses, pain scores before surgery, macroscopic surgical findings and postoperative complications in a series of patients treated for Achilles disorders. MATERIAL AND METHODS: One surgeon operated on 771 Achilles tendons of 481 men and 290 women during a 10-year period. The clinically and ultrasound confirmed diagnoses, pre-operative pain and functional scores (Visual Analogue Scale, VAS, range 0-100; Victorian Institute Sports Tendon Assessment - Achilles questionnaire, VISA-A), macroscopic findings during surgery and postoperative complications, were retrospectively collected from a database. RESULTS: Clinically, by ultrasound and during surgery midportion Achilles tendinopathy was confirmed in 519 (67%) patients, 41% of them had a thickened plantaris tendon located close the Achilles tendon. Partial midportion rupture was found in 31 (4%) patients, chronic midportion rupture in 12 (2%) patients and insertional Achilles tendinopathy, including superficial and retro-calcaneal bursitis, Haglund deformity, distal Achilles tendinopathy, plantaris tendon pathology, and bone spurs, in 209 (27%) patients. The mean pre-operative pain scores for midportion Achilles tendinopathy were 73 (VAS) and 45 (VISA-A), and for insertional Achilles tendinopathy 77 (VAS) and 39 (VISA-A). For midportion Achilles tendinopathy there were 14 (3%), and for insertional Achilles tendinopathy 10 (5%), postoperative complications. CONCLUSIONS: Patients presenting high pain scores from midportion Achilles tendinopathy were the most common. Plantaris tendon involvement is a frequent observation. For insertional Achilles tendinopathy the combination of pathology in the subcutaneous and retrocalcaneal bursa, a Haglund deformity and distal Achilles tendinopathy/tendinosis was most frequent. SERIES STUDY, LEVEL OF EVIDENCE: 4.

Low recurrence rate after mini surgery outside the tendon combined with short rehabilitation in patients with midportion Achilles tendinopathy.

BACKGROUND: There is a general opinion that a structured and specific rehabilitation is needed after treatment of midportion Achilles tendinopathy to minimize recurrence of the condition. There is sparse knowledge about the recurrence rates in large patient materials after specific treatments for midportion Achilles tendinopathy. AIM: This study aimed to investigate the recurrence rates in a large number of patients with chronic painful midportion Achilles tendinopathy that had been surgically treated with the ultrasound (US) and Doppler (DP)-guided mini-surgical scraping technique. Postoperatively, a relatively simple rehabilitation protocol, including a range of movement exercises and gradually increased walking and biking before allowing free activity, was used. MATERIALS AND METHODS: From a database, information about the recurrence rates after US + DP-guided mini-surgical scraping, performed by a single surgeon on 519 tendons with US + DP-verified chronic painful midportion Achilles tendinopathy, was obtained. RESULTS: Recurrence of painful midportion Achilles tendinopathy was found in 26 of 519 (5%) operated tendons, 13 from women and 13 from men. In 13 tendons, a close by located plantaris tendon was extirpated during the reoperation. CONCLUSION: In this large material on patients treated with US + DP-guided mini-surgical scraping for midportion Achilles tendinopathy, there were few recurrences, although only a simple and nonspecific rehabilitation protocol was used.

A pilot study on biomarkers for tendinopathy: lower levels of serum TNF-α and other cytokines in females but not males with Achilles tendinopathy.

BACKGROUND: Achilles tendinopathy is a painful musculoskeletal condition that is common among athletes, and which limits training capacity and competitive performance. The lack of biomarkers for tendinopathy limits research into risk factors and also the evaluation of new treatments. Cytokines and growth factors involved in regulating the response of tendon cells to mechanical load have potential as biomarkers for tendinopathy. METHODS: This case-control study compared serum concentration of cytokines and growth factors (TNF-α, IL-1ß, bFGF, PDFG-BB, IFN-γ, VEGF) between individuals with chronic Achilles tendinopathy and controls. These were measured in fasting serum from 22 individuals with chronic Achilles tendinopathy and 10 healthy controls. Results were analysed in relation to gender and physical activity pattern. RESULTS: TNF-α concentration was lower in the entire tendinopathy group compared with the entire control group; none of the other cytokines were significantly different. TNF-α levels were nevertheless highly correlated with the other cytokines measured, in most of the subgroups. Analysed by gender, TNF-α and PDGF-BB concentrations were lower in the female tendinopathy group but not the male tendinopathy group. A trend was seen for lower IL-1ß in the female tendinopathy group. Physical activity was correlated with TNF-α, PDGF-BB and IL-1ß to varying extents for control subgroups, but not for the female tendinopathy group. No correlations were seen with BMI or duration of symptoms. CONCLUSIONS: This pilot study indicates a lower level of TNF-α and PDGF-BB, and to some extent IL-1ß among females, but not males, in the chronic phase of Achilles tendinopathy. It is suggested that future studies on tendinopathy biomarkers analyse male and female data separately. The lack of correlation between cytokine level and physical activity in the female tendinopathy group warrants further study.