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

Lorenzo Masci, Christoph Spang, Hans T M van Schie, Håkan Alfredson, Lorenzo Masci, Christoph Spang, Hans T M van Schie, Håkan Alfredson

Abstract

Objectives: The plantaris tendon has recently been described as a possible important factor in midportion Achilles tendinopathy. Ultrasound tissue characterisation (UTC) is a method to study tendon structure (matrix integrity). The effect of plantaris tendon removal on Achilles tendon structure was studied using UTC.

Design and setting: Prospective case series study at one centre.

Participants: Nine tendons in eight physically active and healthy patients (mean age 39 years) with chronic painful midportion Achilles tendinopathy were included. Preoperative two-dimensional ultrasound and UTC showed midportion Achilles tendinopathy (tendinosis) with medial tendon changes and suspected plantaris tendon involvement. Patients with previous operations to the Achilles tendon were excluded.

Interventions: Operative treatment consisted of excision of the plantaris tendon and scraping of the ventromedial surface of the Achilles tendon under a local anaesthetic.

Primary and secondary outcome measures: UTC examination and clinical scoring with the VISA-A questionnaire were performed preoperatively and 6 months postoperatively.

Results: At 6 months follow-up, UTC demonstrated a statistically significant (t=5.40, p<0.001) increase in the mean organised matrix (echo-type I+II) and a decrease in the mean disorganised matrix (echo-type III+IV). Seven out of eight patients were satisfied, and the VISA-A score had increased significantly (p<0.001) from 56.8 (range 34-73) preoperatively to 93.3 (range 87-100) postoperatively.

Conclusions: Excision of the plantaris tendon and scraping of the ventromedial Achilles tendon in chronic midportion tendinopathy seem to have the potential to improve tendon structure and reduce tendon pain. Studies on a larger group of patients and with a longer follow-up period are needed.

Keywords: Achilles tendinopathy; Achilles tendon scraping; Plantaris tendon; Plantaris tendon removal; Ultrasound Tissue Characterisation.

Figures

Figure 1
Figure 1
Examination using ultrasound tissue characterisation (UTC). The patient is positioned prone on an examination table with the affected ankle caudal to the edge of the examination bed. The examiner's knee is pushed against the patient's forefoot to achieve maximal dorsiflexion.
Figure 2
Figure 2
Surgical excision of the plantaris tendon. Visualisation (A), and release and removal of the plantaris tendon (B) close to the medial side of the Achilles tendon.
Figure 3
Figure 3
Scraping the ventromedial side of the Achilles tendon. The infiltrative fat tissue on the ventromedial side of the Achilles tendon has been scraped loose.
Figure 4
Figure 4
Ultrasound tissue characterisation (UTC) findings and VISA-A scores. VISA-A score and UTC findings before and 6 months after surgery in a patient with midportion Achilles tendinopathy and plantaris tendon involvement. Note the medially located changes (red pixels) on UTC.

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