Aims. In the context of tendon degenerative disorders, the need for innovative conservative treatments that can improve the intrinsic healing potential of tendon tissue is progressively increasing. In this study, the role of pulsed electromagnetic fields (PEMFs) in improving the tendon healing process was evaluated in a rat model of collagenase-induced Achilles tendinopathy. Methods. A total of 68 Sprague Dawley rats received a single injection of type I collagenase in Achilles tendons to induce the tendinopathy and then were daily exposed to PEMFs (1.5 mT and 75 Hz) for up to 14 days - starting 1, 7, or 15 days after the injection - to identify the best treatment option with respect to the phase of the disease. Then, 7 and 14 days of PEMF exposure were compared to identify the most effective protocol. Results. The daily exposure to PEMFs generally provided an improvement in the fibre organization, a decrease in cell density, vascularity, and fat deposition, and a restoration of the physiological cell morphology compared to untreated tendons. These improvements were more evident when the tendons were exposed to PEMFs during the mid-acute phase of the pathology (7 days after induction) rather than during the early (1 day after induction) or the late acute phase (15 days after induction). Moreover, the exposure to PEMFs for 14 days during the mid-acute phase was more effective than for 7 days. Conclusion. PEMFs exerted a positive role in the tendon healing process, thus representing a promising conservative treatment for tendinopathy, although further investigations regarding the clinical evaluation are needed. Cite this article: Bone Joint Res 2020;9(9):613–622

Background Achilles tendinopathy is prevalent in athletes and individuals with an active lifestyle. It causes significant morbidity, which at times leads to changes in exercise habits. Recently, the VISA-A questionnaire, based on a visual analogue score to assess pain and activity, has been devised as a clinical tool to assess the severity of Achilles tendinopathy (minimum score – 0, maximum possible score – 100). Aim To assess the clinical progress in patients with Achilles tendinopathy using the VISA-A questionnaire. Method Thirty-four patients (18 males, mean age 44 years, range 23–67; 16 females, mean age 51 years, range 20–76) were selected to complete the VISA-A questionnaire, after a diagnosis of Achilles tendinopathy had been made at first and subsequent visits to a specialised outpatient clinic. Results The average pre-treatment VISA-A score was 39 (SD 22.8, range 3–82, 95% CI: 31–47). The patients received intensive physiotherapy, including graded progressive eccentric calf strengthening exercises, and were offered a peritendinous injection of Aprotonin and local anaesthetic if physiotherapy was ineffective. Surgery was performed in six patients when six months of conservative management failed to produce improvements. The average post-treatment VISA-A scores at the latest follow up was 50 (SD 26.5, range 1–97, 95% CI: 40.8–59.3), with a mean difference between pre and post-treatment scores of 11.5 (SD 18.8 range -28.5–67.5, 95% CI: 4.9–18). The mean VISA-A score in patients offered surgery was 36, and 20 in patients who received a peri-tendinous injection of Aprotonin and local anaesthetic. Conclusion The VISA-A score can identify patients who need more aggressive management, and can be used to monitor their progress

Objectives. To conduct a pilot randomised controlled trial to evaluate the feasibility of conducting a larger trial to evaluate the difference in Victorian Institute of Sports Assessment-Achilles (VISA-A) scores at six months between patients with Achilles tendinopathy treated with a platelet-rich plasma (PRP) injection compared with an eccentric loading programme. Methods. Two groups of patients with mid-substance Achilles tendinopathy were randomised to receive a PRP injection or an eccentric loading programme. A total of 20 patients were randomised, with a mean age of 49 years (35 to 66). All outcome measures were recorded at baseline, six weeks, three months and six months. Results. The mean VISA-A score for the injection group at the primary endpoint of six months was 76.0 (95% confidence interval (CI) 58.3 to 93.7) and for the exercise group was 57.4 (95% CI 38.1 to 76.7). There was no statistically significant difference between these scores (p = 0.171), which was expected from such a pilot study. Conclusions. This pilot study has been key to providing data to inform a larger study and shows that the methodology is feasible. Cite this article: Bone Joint Res 2013;2:227–32

Background:. Achilles pathology is a serious and frequently occurring problem, especially in elite athletes. Recent research has suggested a role for the plantaris tendon in non-insertional achilles tendinopathy. We report on the outcomes after excision of the plantaris tendon in elite athletes. Aim:. To assess whether or not excising the plantaris tendon improves the symptoms of Achilles tendinopathy in elite athletes. Methods:. A group of 32 elite athletes who underwent plantaris tendon excision to treat medially located pain associated with non-insertional Achilles tendinopathy were investigated. Outcomes were assessed with pre and post-operative Visual Analogue Scores (VAS) for pain and the Foot and Ankle Outcome Score (FAOS) as well as time to return to sport and satisfaction scores. Results:. At a mean follow-up of 22.4 months (12–48), 29/32 (90%) of athletes were satisfied with the results. 30/32 athletes (94%) returned to sport at a mean of 10.3 weeks (5–27). The mean VAS score improved from 5.8 to 0.8 (p<0.01) and the mean FAOS improved in all domains (p<0.01). Conclusions:. The plantaris tendon may be responsible for symptoms in some patients with non-insertional Achilles tendinopathy. Excision using a mini-incision technique carries a low risk of complications and may provide significant improvement in symptoms enabling an early return to elite level sports

Objective: To report the outcome of surgery for chronic recalcitrant Achilles tendinopathy in sedentary and athletic subjects. Design: Case control study. Participants: We matched each of the 61 non-athletic patients with a diagnosis of tendinopathy of the Achilles tendon with an athletic patient with tendinopathy of the main body of the Achilles tendon of the same sex who was within two years of age at the time of operation. A match according was possible for 56 patients (23 males and 33 females). 48 sedentary subjects and 45 athletic subjects agreed to participate. Main Outcome Measure: Outcome of surgery, return to sport, complication rate. Results: Non-athletic patients were shorter and heavier than athletic patients. They had greater BMI, calf circumference, side-to-side calf circumference differences, and subcutaneous body fat than athletic patients. Of the 48 sedentary patients, only 25 reported an excellent or good result. Of these, three had undergone a further exploration of the Achilles tendon. The remaining patients could not return to their normal levels of activity. In all of them, pain significantly interfered with daily activities. Conclusions: Non-athletic subjects experience more prolonged recovery, more complications, and a greater risk of further surgery than athletic subjects with recalcitrant Achilles tendinopathy. Key words: Achilles tendinopathy, surgery

Eighty-one patients treated surgically for non-insertional Achilles’ tendinopathy between 1987 and 1999 by one surgeon were reviewed by a comprehensive postal questionnaire. Fifty-six patients (73 tendons) returned a questionnaire at an average of 58.7 months after surgery. The duration of preoperative symptoms averaged 24.6 months. In all cases, conservative treatment was first attempted but failed to alleviate symptoms. Twenty (35.7%) of these patients were involved in competitive or serious recreational sport. There were 34 men and 22 women with a mean age of 42.5 years (range: 23 to 66). All patients who had insertional tendinopathy or retrocalcaneal bursitis were excluded from this study. The surgical procedure consisted of excision of the paratenon circumferentially and early mobilisation. All patients had the same post operative treatment. There were 77.5% excellent, 6.4% good, 6.4% fair and 6.4% poor results. Eleven percent developed complications post operatively. We concluded that surgical decompression of the Achilles’ tendon is a very effective treatment for patients with non-insertional Achilles’ tendinopathy who have failed conservative treatment

Achilles tendinopathy is classically defined as a tendinosis devoid of an inflammatory cell population. However, recent literature suggests inflammation as a mediator in the pathogenesis. These finding were mainly based on semi-quantative immunohistochemistry. We therefore used flow cytometry to obatain a more accurate identification and quantification of the different cell types involved. Thirty-two samples were obtained from twelve patients with chronic tendinopathic lesions undergoing Achilles tendon surgery. Samples obtained from three patients with hemiplegia requiring surgical release due to spastic Achilles tendons served as control. We used two panels to identify the myeloid and lymphoid population targeting the following markers: CD45, CD3, CD8, CD4, CD19, CD11b, CD56, CD14, CD16, Vα7.2, 6b11, CD161, TCRγδ. To assess the presence of fibroblasts CD90 was targeted. The mean count of CD45+ hematopoietic cells in the tendinopathic samples was significantly higher than in the control samples, respectively 13.27% and 3.24% of the total cell count (P<0.001). The mean fraction of CD3+ cells present in the complete cell population was significantly higher in pathological samples than in control samples, respectively 1.70% and 0.37% (P<0.05). Presence of CD19+ B cells was not reported. The mean fraction of γδ T cells was significantly higher in tendinopathic samples compared to blood samples of the same patient and consisted of 12.9% and 5.8% γδ T cells respectively (P<0.05). These findings support an inflammatory cell infiltration in midportion Achilles tendinopathy that show similarities to enthesitis in SpA. This implies a potential target to investigate in novel treatment modalities

Achilles tendinopathy is characterised by chronic degeneration of the Achilles tendon, usually secondary to injury or overuse. Extracorporeal shockwave treatment (ESWT) is of potential benefit in refractory cases where conservative management with analgesia, physiotherapy and corticosteroid injection have been unsuccessful. Patients with refractory Achilles tendinopathy enrolled between October 2010 and October 2011 received three sessions of ESWT over three weeks. Patients completed visual analogue scale (VAS) scores for pain at rest and on activity and the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire pre-treatment. These outcome measures and a six-point Likert satisfaction scale were reassessed at six and 16 weeks post treatment. 51 patients completed follow up. Mean age was 56 (34–80) years and mean length of symptoms 34 (4–252) months. Significant improvement (p<0.05) in VAS scores (rest and activity) and VISA-A scores was observed between baseline and 16 weeks. Mean Likert score was 3 (somewhat improved) at 16 weeks. Patients suffering Achilles tendinopathy for longer than 25 months had significantly less improvement than those affected for a shorter period. This study suggests that ESWT improves subjective and objective outcomes in patients with refractory Achilles tendinopathy

Achilles tendinopathy is chronic degeneration of the Achilles tendon, usually secondary to injury or overuse. It involves a triad of pain, swelling and impaired function. Primary treatment is rest, analgesia, corticosteroid injections and physiotherapy (eccentric training and heel pads to correct gait). Some patients remain symptomatic and further treatment options need considering. NICE produced a document from the Interventional Procedures Advisory Committee in 2009 which reviewed the literature and evidence for extracorporeal shockwave treatment (ESWT). Low energy shock wave treatment (SWT) is thought to stimulate soft tissue healing, inhibit pain receptors and promote angiogenesis. NICE guidance was that ESWT could be used in refractory Achilles tendinopathy if used for clinical governance, audit or research. Patients with refractory Achilles tendinopathy were enrolled between October 2010 and 2011. They received three sessions of ESWT over three week. Patients completed visual analogue scale (VAS) scores for pain at rest and on activity and the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire pre-treatment. These outcome measures and a six-point Likert satisfaction scale (six points, high is worsening) were reassessed at 6 and 16 weeks post treatment. 51 patients completed follow up. The mean age was 56 (34–80) years and mean length of symptoms 34 (4–252) months. There was a significant improvement (p<0.05) in VAS scores observed from baseline and 16 weeks post treatment. This was also the case in the VISA-A scores. The mean Likert score was 3 (somewhat improved) at 16 weeks but there was no statistical significance. This study suggests that ESWT improves subjective and objective outcomes in patients with refractory Achilles tendinopathy. Patients over 60 possibly have a worse outcome along with patient who had symptoms for over 25 months. Follow up scores at one year are due to be collected and the data will be submitted to NICE

Tendon-related pathologies such as tendinopathy represent a relevant clinical and socioeconomic issue. The most innovative and conservative therapeutic approaches are meant to stimulate the intrinsic healing capability of the tissue. In this study, the use of pulsed electromagnetic fields (PEMFs) was investigated in a rat model of Achilles tendinopathy as a potential therapy. Achilles tendinopathy was chemically induced in eighty-six Sprague Dawley rats by injecting collagenase Type I within the tendon fibers. Fifty-six of them were stimulated with PEMFs (8 hours/day, 1.5 ± 0.2 mT; 75 Hz), divided in different experimental groups basing on the starting-time of PEMFs exposure (after 0, 7, 15 after Collagenase injection) and its duration (7, 15 or 30 days). Thirty animals were left unstimulated (CTRL group). According to the different time points, explanted tendons were evaluated through histological and immunohistochemical analyses in term of matrix deposition, fiber re-organization, neovascularization and inflammatory reaction. The most effective PEMF stimulation was demonstrated in the 15 days of treatment. However, when PEMF were applied immediately after the collagenase injection, no significant therapeutic results were found. On the contrary, when PEMF were applied after 7 and 15 days from the collagenase injection, they promoted the deposition of extracellular matrix and tendon fiber re-organization, reducing both the inflammatory reaction and vascularization, with significant differences compared to the CTRL group (p<0.05). Therefore, these results suggest an effective activity of PEMFs stimulation that provides a satisfying restoration of the damaged tissue, although the most performing protocol of application still needs to be identified

Summary Statement. ASTM therapy is commonly used to treat Achilles tendinopaty. However, there was no report to evaluate the biomechanical effects, especially the dynamic viscoelasticity. We have shown that ASTM treatment was biomechanically useful for chronic Achilles tendinopathy in an animal model. Introduction. Achilles tendinopathy is a common chronic overuse injury. Because Achilles tendon overuse injury takes place in sports and there has been a general increase in the popularity of sports activities, the number and incidence of Achilles tendon overuse injury has increased. Augmented Soft Tissue Mobilization (ASTM) therapy is a modification of traditional soft tissue mobilization and has been used to treat a variety of musculoskeletal disorders. ASTM therapy is thought to promote collagen fiber realignment and hasten tendon repair. It might also change the biomechanical behavior of the injured tendon, especially the dynamic viscoelasticity. The purpose of this study is to evaluate the effect of ASTM therapy in a rabbit model of Achilles tendinopathy by quantifying dynamic biomechanical properties and histologic features. Patients & Methods. The hind limbs of 12 rabbits were used, and 24 Achilles tendons were injected with collagenase to produce tendon injury. One hind limb of each animal was then randomly allocated to receive ASTM therapy, while the other received no treatment and served as a control. ASTM was performed on the Achilles tendon for 3 minutes on postoperative days 21, 24, 28, 31, 35, and 38. The Achilles tendons were harvested 10 days after the last treatment. Specimens were examined with dynamic viscoelasticity and light microscopy. Results. The mean±SD cross-sectional area for the treated and untreated tendons was 12.30±5.47 mm. 2. and 9.57±8.36 mm. 2. , respectively. The difference between the treated and untreated tendons was statistically significant (P<.01). At all dynamic loading frequencies, the storage modulus in the untreated tendons tended to be higher than that in the treated tendons. At 0.1 Hz and 10 Hz, in the untreated tendons was significantly higher than that in the treated tendons (P=.05). The loss modulus was significantly lower in the treated tendons than in the untreated tendons (P<.05). There was no significant difference in tan δ between the treated and untreated tendons. HE stain showed that the untreated tendon fiber was wavy and kinking and displayed a disordered collagen arrangement. In contrast, the tendon fiber was well aligned in the treated tendons. In the immunohistochemically stained specimens, the type III collagen showed higher color intensity in the untreated tendons than in the treated tendons. Discussion/Conclusion. We have shown that ASTM was a biomechanically useful treatment for chronic Achilles tendinopathy. Biomechanical and histologic data showed the treated Achilles tendons had better biomechanical function and histologic outcomes than the untreated tendons

Introduction. The COL5A1 gene encodes for the α1 chain of type V collagen, a minor fibrillar collagen that is an important regulator of collagen fibrillogenesis. Several polymorphisms, including rs12722 (C/T), within the 3′-UTR of COL5A1 are associated with chronic Achilles tendinopathy and other musculoskeletal soft tissue injuries as well as exercise-related phenotypes. It is hypothesised that polymorphisms within the 3′-UTR regulate the amount of the α1(V) chain synthesised and type V collagen production. This in turn influencing the mechanical properties of tendons and other musculoskeletal soft tissues. In our laboratories, two major functional forms, namely the T- and C-allelic forms of the COL5A1 3′-UTR, were identified and associated predominately with severe chronic Achilles tendinopathy and healthy asymptomatic control individuals, respectively. Materials and Methods. To further investigate the functional differences between the two major 3′-UTR functional forms as well as to start mapping the regions which are responsible for the tendinopathic phenotype, skin biopsies from donors having a known genotype at rs12722 and primary fibroblast cell lines were established in order to quantify COL5A1 and COL1A1 expression levels in a pilot study. Lastly, in preliminary RNA EMSAs, biotinylated C- and T-allelic RNA probes for a specific 57bp functional region within the 3′-UTR were incubated with either fibroblast nuclear or cytoplasmic protein extracts to investigate putative distinguishing RNA:RBP complex formation. Results. An overall higher relative mRNA expression of both COL5A1 (p<0.001) and COL1A1 (p=0.0015) were observed in primary skin fibroblasts from donors having a rs12722 TT genotype compared to donors with a CC genotype. A unique RNA:RBP complex was also identified with the C-allelic probe. Discussion. These novel results have important implications for our understanding of the proposed role of type V collagen in the aetiology of tendon and other musculoskeletal soft tissue injuries, as well as, other exercise-related phenotypes

Introduction: The results of treatment of Achilles tendinopathy are described in the sporting community little is known of the long-term results in the general population. Our aim was to assess these results in a district general hospital setting. Materials/Methods: Patients who had undergone treatment for Achilles tendinopathy were identified from hospital records and assessed by postal questionnaire. This consisted of two parts (the VISA-A and a section about occupation, duration of symptoms prior to referral, prior sporting activities, and satisfaction). This was sent out with a stamped addressed return envelope, in the case of non-reply this was followed by a second one, and finally the patient was contacted by phone. Clinical notes of responders were reviewed. Results: 71 patients were identified and the response rate was 83% with an equal, male to female split. Average age was 45; mean time to follow up was 8 years. Patients had undergone a wide variety of treatments (73% physiotherapy, 45% heel raises, 24% steroid injection {there were no ruptures reported}, and 12% operative). Duration of symptoms prior to referral ranged from 2 weeks to 27yrs. 78% were very satisfied or satisfied. 46% undertook sport prior to onset of symptoms, and at the time of follow up 40% undertook sport. 81% did not change their occupation. Average VISA-A score was 50 (range 10–90). Discussion: Despite an average VISA-A score of 50 (excellent 90–100, good 75–85, fair 60–70, poor< 50), after a follow period up of 8 years, most patients were satisfied with the treatment they had received. We could find no correlation between treatment and eventual outcome. Conclusion: Patients generally have continued symptoms from their Achilles Tendinopathy, many years later, despite standard treatments, which is reflected in poor VISA-A scores

Introduction. Achilles tendinopathy (AT) is a highly prevalent injury in athletes and non-athletes with an unknown aetiology. Genetic risk factors have been a recent focus of investigation. The aim of this systematic review was to determine which loci have been linked with mid-portion AT and could potentially be used as biomarkers in tendinopathy risk models or as preventative or therapeutic targets. Materials and Methods. Eight electronic bibliographic databases were searched from inception to April 2015 for cross-sectional, prospective cohort and case-control studies that included empirical research investigating genes associated with mid-portion AT. Potential publications were assessed by two independent reviewers (AAC and PRJ) for inclusion and quality. Quality was evaluated using a validated scale. Results. Twelve candidate gene studies and three pathway-based genetic association studies that investigated genetic risk factors for AT were identified. According to Ariëns's criteria, there was strong evidence for the COL5A1 gene. There was some evidence for 6 of the other genes investigated: COL5A3, TNC, CASP8, MIR608, GDF5, MMP3 and TIMP2 genes. There was inconclusive evidence for the following genes: COL3A1, COL5A2, COL11A1, COL11A2, COL12A1, COL1A1, COL27A1, COL14A1, COMP, THBS2, ADAMTS2, ADAMTS5, ADAMTS14, ADAM12, TGFβ1, IL-1β, IL-1RN, IL-6, NOS2 and NOS3. There was some evidence for combinations of functional variants of different genes and pseudohaplotypes constructed from many functional variants. The quality of included studies varied (3/9 to 7/9), and the average quality assessment score was 5.5/9 (61%). Discussion. There are genetic differences between subjects with and without AT. To further elucidate these findings, prospective studies are needed to investigate the increased risk associated with specific genetic findings. Modifying training loads or preventative exercise may be used to mitigate increased risk, although it needs to be highlighted that a genetic association does not necessarily mean an individual will develop Achilles tendinopathy. Gene therapy may have a role in tendon healing, but further research is necessary to develop risk models and establish the most advantageous genes to transfer

Introduction. Chronic Achilles tendinopathy is a common overuse injury. There are several modalities of treatment, reflecting difficulties in its management. In particular, due to the well-recognised morbidity associated with surgical decompression, treatment has steered towards a less invasive route. Dry needling has been efficacious in managing other tendinopathies. This study therefore assessed dry needling and percutaneous hydrostatic decompression of the Achilles tendon as a novel treatment for this condition. Methods. Twenty-two patients with 27 sonographically-confirmed chronic Achilles tendinopathy were prospectively enrolled. All were symptomatic for >6 months and have failed alternative conservative treatments. Ultrasound-guided dry needling of neovascular areas and paratenon hydrostatic decompression was performed by a dedicated musculoskeletal radiologist on a 6-weekly basis until symptomatic resolution or no improvement was evident. Sonographic assessment of the tendon's thickness and neovascularity was undertaken. Following treatment, a standardized physiotherapy regime was adopted. At baseline and 6 weeks post-final procedure, visual analogue scores (VAS) at rest and during activity were obtained. Telephonic interviews were carried out 12 and 24 months post-treatment. Results. 24 tendons (in 19 patients) were successfully treated - 1 patient had spontaneous symptomatic resolution and 2 progressed to surgical intervention. The mean number of treatment sessions was 2. There was no significant change in neovascularity or tendon thickness after treatment. Therapeutic intervention led to a significant improvement in VAS at rest (42 v 18.4, p=0.0005) and during activity (74 v 33.7, p< 0.0001). At 12 months, 77% of patients were >80% satisfied with their outcome of the procedure, with 85% of patients able to return to their sporting interests. At 24 months, 90% of patients were >80% satisfied with their outcome, with nearly half having complete symptomatic resolution. Conclusion. Dry needling and percutaneous paratenon decompression under ultrasound guidance shows promise as an alternative treatment for this chronic condition

Introduction. Chronic mid body Achilles tendinopathy is a common problem. There is no consensus on treatment. The aim of this review was to assess the effectiveness of physiotherapy interventions (non surgical and non pharmacological) for this condition. Methods. A systematic review of the literature was conducted. A search of published and grey literature databases was undertaken (1999- December 2010). Two reviewers independently assessed the studies for eligibility using a strict inclusion and exclusion criteria. All eligible articles were assessed critically using the Pedro score. Data on cohort characteristics, diagnostic criteria, treatment intervention, outcome measures and results was extracted. A narrative research synthesis method was adopted. Results. 209 studies were identified. Nine publications met the review inclusion criteria. Methodological quality was adequate for all nine studies; however, blinding was a limitation for most. Interventions investigated were; Exercises (n = 2), Low level laser therapy (n = 1), Low energy shockwave treatment (SWT) (n = 3), Air cast brace (n = 2) and Insoles (n = 1). Some evidence exists for eccentric exercises in combination with SWT or Laser. However, contrary to other reviews, eccentric exercises were not found to be superior to other physiotherapy treatments. Conclusions. There is insufficient evidence to determine which method of physiotherapy is most appropriate for a chronic Achilles tendinopathy. Further well designed randomised controlled trials assessing physiotherapy interventions with specific diagnostic criteria and appropriate outcome tools are required to determine the efficacy of physiotherapy for the condition

Introduction. The mainstay of treatment in non-insertional Achilles tendinopathy is non-operative, however between 1/4 and 1/3 of patients fail this. The main symptom is pain which appears to be related to new nerve endings that grow into the tendon with the neovessels from the paratenon. Treatments which strip the paratenon from the tendon are showing promise including formal paratenon stripping via Achilles tendinoscopy. The pain and swelling in Achilles tendinopathy is usually on the medial side leading to the postulation that the plantaris tendon may have a role to play. Methods. We report a consecutive series of 11 patients who underwent Achilles tendinoscopy with stripping of the paratenon and division of the plantaris tendon, above the level of the tendinopathic changes in the Achilles. All patients had failed conservative treatment for at least 6 months and requested surgical intervention. The patients were scored with the SF-36, AOS and AOFAS hindfoot questionnaires pre-operatively and at a minimum of 2 years post operatively. They also recorded their level of satisfaction with the treatment at final follow up. Results. The mean AOFAS scores significantly improved from 68 pre-op to 92 post op (p = 0.0002) as did the AOS scores for both pain (28% pre-op to 8% post op (p=0.0004)) and disability (38% pre-op to 10% post op (p=0.0005). The mean SF-36 scores also improved but were not statistically significant (pre-op 76 post op 87 (P = 0.059). There were no complications. 8 of the 11 patients were satisfied, the other 3 somewhat satisfied. Conclusion. The results of Achilles tendinoscopy and division of the plantaris tendon are encouraging but further studies are required to compare it to other treatments. It is minimally invasive and low risk so should not affect the ability to perform a formal open procedure if unsuccessful

We evaluated sensitivity, specificity, reproducibility and predictive value of palpation, of the painful arc sign, and of the ‘Royal London Hospital test’ in 10 patients with Achilles tendinopathy, and in 14 asymptomatic subjects using a test-retest study design. Ten male athletes on the waiting list for exploration of one of their Achilles tendons for tendinopathy of the main body of the tenon attended a special clinic. Each was invited to bring at least one athlete of the same sex in the same discipline aged within two years of themselves, with no history and no symptoms of AT. A total of 14 controls were thus recruited. Pain and tenderness following performance of palpation, the painful arc sign, and the ‘Royal London Hospital test’ were recorded. There were no statistically significant differences at the 5% level among the effects of investigator or between morning and afternoon measurements for any of the three assessment methods. There was no evidence of a difference of the three assessment methods (p> 0.05). When the three methods were combined, the overall sensitivity was 0.586 (CI 0.469 – 0.741) and the overall specificity was 0.833 (CI 0.758 – 0.889). In patients with tendinopathy of the Achilles tendon with a tender area of intratendinous swelling which moves with the tendon and whose tenderness significantly decreases or disappears when the tendon is put under tension, a clinical diagnosis of tendinopathy can be formulated, with a high positive predictive chance that the tendon will show ultrasonographic and histological features of tendinopathy

Introduction: Achilles tendinopathy is a source of significant pain and disability. While many patients respond to non-operative treatment, a proportion will require operative treatment. Both open decompression and percutaneous longitudinal tenotomy have been described. We describe a new technique and present the results of percutaneous circumferential decompression of the tendon, dividing adhesions between the paratenon and the tendon. Methods: We followed up 10 patients for a mean of 10 months (5–19) post operatively. They were scored pre and post operatively using the tegner activity score, the puddu score and an analogue pain score. The functional result was also assessed with the SF12 questionnaire. Results: All patients reported significant improvements in pain (p=0.007), tegner (p=0.007) and puddu (p=0.005) scores. They would all undergo the procedure again. The SF12 scores were not significantly different from a normal population. Discussion: We believe that this technique addresses the underlying pathology, giving excellent results without the potential complications of an open decompression

Background. Most patients with Achilles tendinopathy (AT) are treated successfully with physiotherapy ie eccentric calf training. In some patients gastrocnemius contracture persists. Three other publications have reported improvement in AT following gastrocnemius release, but this is the first series of patients to have proximal medial gastrocnemius release (PMGR) for AT. The purpose of this study was to review patients with refractory non-insertional and insertional AT treated by PMGR with a minimum followup of 18 months. Method. Sixteen PMGRs were performed over a two year period. Nine patients (10 PMGRs) were available for followup. The mean age of patients was 45 (Range, 25 to 63) years, with five female and four male subjects. The average followup period was 2.5 (range, 1.7 to 3.3) years. The sample was divided into non-insertional and insertional tendinopathy, with five PMGRs per group. Outcome measures were VAS scores, VISA-A scores, AOFAS ankle-hindfoot score and overall satisfaction. Complications and further procedures were also recorded. Results. At an average of 2.5 years follow-up, two-thirds of patients were highly satisfied. The non-insertional tendinopathy group enjoyed better results than the insertional group: mean improvement in VISA-A scores were 59% (non-insertional) vs 22% (insertional); mean AOFAS scores improved by 29% (non-insertional) vs 15% (insertional). The improvement in the non-insertional group was statistically significant (p < 0.05) in all three outcome measures. Our findings further support that insertional tendinopathy is more resistant to calf stretching/lengthening treatments. Conclusion. In contrast to open or percutaneous debridement of the Achilles tendon, PMGR is a day surgical procedure that is well tolerated with excellent wound healing. Patients with non-insertional tendinopathy who have failed conservative treatment can expect significant improvement with VISA-A scores normalising after the procedure. We recommend PMGR for patients suffering recalcitrant non-insertional AT in whom gastrocnemius contracture persists despite an eccentric stretching program