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

Introduction. Plantar fasciopathy is a common cause of heel pain, and is usually treated in primary practice with conservative measures. Intractable cases can prove very difficult to treat. Currently plantar fasciopathy is not routinely imaged and treatment is empirical. At the Royal Surrey County Hospital patients with intractable plantar fasciopathy are managed in a unique ‘one-stop’ Heel Pain clinic. Here they undergo clinical assessment, ultrasound scanning and targeted therapy. Methods. Patients referred to the clinic since 2009, with symptoms lasting longer than 6 months and failed conservative management, were prospectively followed. Plantar fasciopathy was confirmed on ultrasound scanning. The ultrasound scans were used to classify the disease characteristics of the plantar fascia. Results. 125 feet (120 patients) were found to have plantar fascia disease. Ultrasound scans demonstrated 64% with typical insertional pathology only. The remaining 36% had atypical distal fascia involvement, with either pure distal disease or a combination of insertional and distal disease. Patients with atypical distal disease were found to have either distal thickening or discrete fibromata. Conclusion. The high proportion of atypical (non-insertional) disease in this cohort shows that ultrasound scanning is valuable in determining location and characterising the pathology in the plantar fascia. Atypical pathology would otherwise not be detected. We propose a new classification for plantar fasciopathy; insertional fasciopathy or non-insertional fasciopathy. This is in keeping with current classification of achilles tendinopathy. The main benefit of this Guildford Classification is in determining optimum treatments for recalcitrant plantar fasciopathies. Empirical treatment is not adequate for recalcitrant cases