On admission, patients were taught to perform isometric contractions of their triceps surae (23). Patients were instructed to perform the isometric strength training at three different angles, namely at maximum dorsiflexion, maximum plantar flexion, and at a point midway between the two.
The foot was kept elevated on the first postoperative day, and nonsteroidal anti-inflammatory medication was given for pain control. Early active dorsi- and plantar-flexion of the ankle were encouraged (50). Patients were allowed to walk using elbow crutches weight-bearing as able. Full weight-bearing was encouraged after the second postoperative day, when the bandage was reduced to a simple adhesive plaster over the wounds and an elasticated compressive sock, to be removed at night. Stationary bicycling and isometric, concentric, and eccentric strengthening of the calf muscles was started at that stage under physiotherapist guidance.
Gentle jogging on an elastic trampoline was permitted after 2 wk, when the sock and the adhesive plaster were removed. Swimming and water running were encouraged from the second week. Gentle running was started 4–6 wk after the procedure and mileage gradually increased. Hill workouts or interval training was allowed after a further 6 wk, when return to normal training was allowed. Patients living within a 50-km radius from the operating institution were asked to attend supervised physiotherapy sessions twice a week until the attending physician judged that they did not need any longer. Patients living without the area were referred to a local physiotherapy center. The compliance to the physiotherapy program was ascertained by recording the number of visits that the patients made to the physiotherapy department. All but two patients discontinued physiotherapy by the 6th postoperative month.
Patients were assessed just before the procedure. In each patient, the follow-up time was a minimum of 12 months. Clinical examinations were performed at 2 and 6 wk, and 3, 6, and 12 months after surgery. On these occasions, all complications were recorded and treated. If a complication ensued, or if a patient did not report improvement in pain, they were followed up for at least 18 months postoperatively (range 18–36 months).
Patients were reviewed in a special clinic over four consecutive weeks at an average of 51 (SD 18.2; range 36–102) months from the operation. Of the 75 patients operated, 63 attended after having been contacted either by letter or telephonically at least once. The other 12 patients could not be traced, having been lost to follow-up after the 6th postoperative month. At the time of default from follow-up, six rated themselves good or excellent, two had emigrated just after the procedure, and we had no records of how they fared, and three had a poor result, but did not want to consider further surgery, as they had abandoned their sport.
Orthopaedic residents not otherwise involved in the management of the patients evaluated all patients on admission, at 6 wk, and 6 months after the operation, and at final follow-up. On these occasions, patients were asked to rate the results of the procedure according to the presence and severity of tenderness, pain at rest, and pain during motion (27).
Patients were asked whether they had ever been able to return to sports, and if so when, and the level of success that they had at the latest follow-up according to the criteria indicated hereinafter.
The outcome of treatment was rated as excellent if the pain had been completely relieved or the patient was satisfied with a full return to a sporting level comparable to his/her preinjury status without any significant symptoms.
A good result consisted of a full return to sport at the desired mileage and speed, and jump with only intermittent or mild discomfort.
Patients with a fair result had discomfort that did not allow return to preinjury level and thus dictated cessation of competitive sport activity. Patients were able to train at a reduced intensity twice or three times a week.
A poor result was attributed to patients who had given up their sport and had discomfort in activities of daily living. Patients were able to train only once or twice a week for a short time.
Before the operation, and at the 6th-wk and 6th-month visits, the patients were tested for their maximum isometric voluntary contraction (MIVC) bilaterally 16, and for isometric endurance, at two thirds of their own MIVC (21). Three contractions were allowed per each limb, and, if the two highest values were not within 5%, further attempts were made until two high and similar efforts were recorded. Most patients were able to produce a MIVC, according to these criteria, within the usual four contractions allowed (22). Results were expressed as percentage in respect to the unaffected side.
The data were entered in a commercially available database. Descriptive statistics are given. Descriptive statistics were calculated. Categorical results were analyzed using the chi-square test. ANOVA for repeated measures was used to evaluate any overall differences between baseline, early, and final results. A post hoc Student’s t-test for paired measures was applied to test the differences found. Significance was set at the 0.05 level.
In four patients, we realized at the time of the procedure that the area of tendinopathy extended beyond the 2.8-cm length that could be covered by a single tenotomy. In another three patients, clinical and US examination of the Achilles tendon just before the procedure revealed another area of localized tendinopathy. In these seven patients, another stab wound was produced, and the tendinopathic areas were addressed.
All patients were able to bear weight on the operated limb by the second postoperative day. Five patients developed a subcutaneous hematoma, probably due to a cut in one of the superficial veins crossing the posterior aspect of the ankle. All such hematomas resolved with a pressure bandage, which was removed 3–7 d later. In another patient, a superficial infection developed 1 wk after the percutaneous longitudinal tenotomy and was treated by oral administration of 500 mg of erythromycin (Bayer, Milan, Italy) three times a day for 1 wk, recovering uneventfully. At the 6-wk follow-up appointment, eight patients complained of hypersensitivity of the stab wound scar when kneeling down. They were counseled to rub hand cream over the scar several times a day, and became asymptomatic 3–6 wk from the prescription. No hypertrophic or keloid scars were noted at the latest follow-up. No patient complained of the appearance of the scar. Eleven patients complained of morning stiffness of the ankle in the early postoperative period, but they did not report the complaint at the 6-month evaluation.
All patients took part in at least 11 supervised physiotherapy sessions over an average of 5.8 months (range 7 wk to 9 months). The majority (44 of 75) of patients just discontinued attendance to the supervised physiotherapy program by their own accord, having undertaken an average 19 ± 11 session (range 11–44). There was no statistical difference in the number of supervised physiotherapy sessions undertaken by the patients who had an excellent or good result when compared with the patients who had a fair or poor result. However, there was a trend for this latter group of patients to have had a lesser number of supervised physiotherapy sessions.
At final review, 51 (SD 18.2; range 36–102) months from the operation, 63 patients attended: 35 patients were rated excellent, 12 good, 9 fair, and 7 poor. Of the 16 patients in whom the procedure was not successful, 8 had a pantendinopathy, 13 were runners (either middle distance or sprinters), and 3 were soccer players. Also, although the average interval between beginning of symptoms and operation in these patients was not significantly different from the whole group (21.6 vs 19.2 months), these patients had received more peritendinous injections (group average: 1.3; average in the patients with a fair or poor result: 2.7) and had been less compliant with their preoperative conservative management. Nine of these 16 patients underwent a formal exploration of the Achilles tendon 7–12 months after the index procedure (28). A nodular area of tendinopathy was identified by palpation and excised by sharp dissection. Five patients who underwent formal exploration had given up their original sport by the time of the latest review and were able to undertake occasional jogging, swimming, and cycling.
At the time of their best outcome, 62 subjects (83%) reported symptomatic benefit from surgery (Table 2) and had returned to sport. The median time to return to sport was 6.5 months (range 11 wk to 14 months), with only two of the subjects who had returned to sport doing so after 10 months. At final follow-up, 55 of the 63 patients followed up at an average of 51month from the operation continued to report symptomatic benefit (Table 2), and 47 of 63 were still able to practice sport.
The ultrasonographic pattern varied according to the time of examination. Before the operation, there were areas of altered echogenicity at and around the site of involvement, which was normally hypoechoic (14,23). Such areas of altered echogenicity were still visible after surgery in all of the patients even at the latest follow-up. There was no evidence of an association between dimensions of the tendons and presence of areas of altered echogenicity and clinical success. In the patients in whom the procedure was successful, the ultrasonographic appearance of the operated tendon had no bearing on training and competition.
The patients showed a MIVC of 82.6% (± 10.4) just before the operation (N = 75), 87.2% (± 8.8) at 6 wk (N = 73), 91.3% (± 10.1) at 6 months (N = 69), and 96.4% (± 10.3) at latest follow-up (N = 63). The results of the test at the 6th wk and 6th month were significantly different from baseline (P = 0.038), whereas the results of the test at the 6th wk and 6th month were not significantly different from each other (ANOVA). However, at the final follow-up, 51 (SD 18.2; range 36–102) months from the operation, the patients showed a significantly higher increase from baseline.
The patients showed an isometric endurance of 67.8% (± 9.5) just before the operation, 87.3% (± 7.1) at 6 wk, 92.1% (± 6.4) at 6 months, and 94.8% (± 12.7) at latest follow-up. The results of the test at the 6th wk and 6th month were significantly different from baseline and from each other, whereas the results at the 6th month and at the latest follow-up were not significantly different from each other (ANOVA; 0.01<P < 0.05).
Comparison between Patients with Tendinopathy and Patients with Pantendinopathy
A secondary analysis by ANOVA did not reveal any significant differences in postoperative recovery, pain, strength, and endurance between patients with a single intratendinous lesion and those with more diffuse tendinopathy or multiple areas of tendinopathy. However, there was a trend for patients with more diffuse tendinopathy or multiple areas of tendinopathy to have a stormier and longer rehabilitation period, with return to sport only 7–10 months after the procedure.
Treatment of chronic tendinopathy aims to allow patients to return to normal level of physical activity (9,12,13,16,18). Percutaneous needling of the tendon for such purpose has been recently reported, even though no results have been published (18), and open longitudinal tenotomy has been long established (17,36). US-guided percutaneous longitudinal tenotomy is simple, requires only local anesthesia, is performed without a tourniquet, and allowed the return to high sporting levels of the majority of the athletes with a tendinopathy of the main body of the tendon. Early postoperative mobilization probably prevents the formation of adhesions, and a single skin wound most likely limits morbidity. In most instances, the affected tendon remained thicker than the healthy one, and the clinical results are comparable to those reported using more extensive procedures (17).
When compared with our previous study using multiple percutaneous Achilles tenotomies (27), our success rate in patients with concomitant involvement of the paratenon and of the main body of the Achilles tendon (pantendinopathy) has improved. We believe that this has been the result of injection of the space between the tendon and the paratenon, to try and distend that space and break the adherences between the tendon and the paratenon. However, in our present practice, if Achilles tendinopathy patients have marked signs of paratenon involvement, multiple nodular involvement, or an area of tendinopathy longer than 3 cm, we recommend formal tendon exploration, with excision of the paratenon, excision of the pathological area, and multiple longitudinal tenotomies (28). Despite this advice, several patients still elect to undergo a minimally invasive procedure before undertaking more extensive surgery, probably influenced by the results experienced by their peers. Our experience would suggest that such previous surgery would not compromise the result of subsequent formal exploration, while giving at least some chance of success. However, we explain to the patients that the very chronic lesions have a lesser chance of success and that the healing potential of their tendons may have reached its limit (28).
A weakness of the present study is that we did not use a prospective randomized design to compare the procedure described here with prolonged conservative management, with open surgery for AT (28), and with our previously described “blind” multiple percutaneous longitudinal tenotomies (27). However, given the athletic population that we deal with, we did not feel that it was justified to prolong conservative measures in patients who had already suffered AT well before being referred to our care and in whom formal conservative management had been unsuccessful for at least 6 months. Open surgery may achieve excellent or good results, but we have shown that a remarkable large number of surgically managed subjects had not returned to sport 12 months after surgery (28). In the present study, considering the worse case scenario that all the patients that we were not able to contact for final review had experienced a fair or poor result, 47 of 75 athletes experienced an excellent or good result. When patients with a pantendinopathy are excluded, good and excellent results were achieved in a percentage of patients comparable to studies using formal exploration of the tendon.
The imaging appearance of the operated tendon is not an index of its clinical outcome (6). We do not advocate routine US imaging after such procedures, and careful questioning of the patients and clinical examination are sufficient to ascertain whether the operated tendon is still producing pain or is uncomfortable (15). At present, although we use US scanning for research purposes, we do not attach much importance to it unless the patients report symptoms (7,14,15).
In this study, we measured the isometric strength of the gastro-soleus muscle complex of the affected and normal sides (20). Strength measurements can be influenced by the pain experienced in the Achilles tendon when contracting the gastro-soleus complex (48). Under these conditions, muscle contractions may not be physiologically maximal, but they do represent the maximum ability of the patients to produce force in a pathological situation. To prove whether patients were producing a maximal effort, electromyography could have been used. However, this technique was not available to us, and we have no reasons to doubt the willingness of the athletes enrolled in this study to exert themselves maximally.
As shown in our previous studies, just before operation the isometric peak torque of the gastro-soleus complex was very similar to the normal contralateral one (27). However, the endurance capability of these muscles was significantly lower (1). This lack of “strength endurance” may account for biomechanical imbalance occurring during prolonged activity, which may thus exacerbate the condition (19). After rehabilitation, the performance of the injured side gradually approached the normal side. It would be beneficial to implement rehabilitation programs especially aimed to develop endurance as well as maximal strength.
In our present practice, we do not use corticosteroid injections in the management of tendinopathy (5). As the condition is degenerative, not inflammatory, the use of corticosteroids may well mask an important symptom (i.e., pain) and produce further deleterious mechanical stimuli that may promote greater tendon degenerationhy (43).
In this study, US has been used as an aid to precisely locate the hypoechogenic intratendinous area typical of Achilles tendinopathy to exactly place the tenotomy for a minimally invasive approach. However, some patients, albeit symptomatic, may not show any intratendinous abnormalities. As such patients were excluded from the study, we cannot comment on the use of US in this specific subgroup. There is no doubt that in Europe US is more widely used than in North America (32,33), where MRI is readily available. However, US is cheaper and requires shorter examination times than MRI. US is able to quickly and routinely compare the normal with the abnormal side, improving diagnostic sensitivity for subtle pathological change, provide an objective appreciation of diffuse change (e.g., tendon enlargement or atrophy), and provide a useful “control” for the interpretation of measurements on the symptomatic side. The real-time nature of US also allows assessment of soft tissue dynamics. Also, US is an “interactive” test: unlike MRI, the examiner is in the room with the patient, probing the affected part with the transducer and directly correlating the site of reported pain or tenderness with its scan appearance. This targeted approach can be invaluable in achieving a clinically relevant diagnosis, because all imaging modalities detect a high incidence of asymptomatic (often degenerative) pathology. However, US is also a particularly operator-dependent modality, and only achieves high levels of accuracy and reproducibility when the examining radiologists are well trained and experienced. Also, it should be stressed that a hypoechoic region on US does not constitute an absolute indication for Achilles tendon surgery, and the presence of a hypoechoic intratendinous region does not provide total assurance that the patient has Achilles tendinopathy. The ultrasound finding would contribute to the diagnostic algorithm, but clinical examination remains paramount (15).
In conclusion, percutaneous longitudinal US-guided internal tenotomy of the Achilles tendon is simple and can be performed on an outpatient basis. It, however, requires the use of high-resolution US to properly locate the tendinopathic area and to place the initial stab wound. Also, with this technique, it is not possible to collect samples of tendon material for biopsy, even though recent work has shown that symptomatic intratendinous areas are hypoechoic at ultrasound show tendinosis (31). Complications were minimal and led to no long-term morbidity. In our hands, it is an intervention in the treatment of chronic mid-substance Achilles tendinopathy when conservative treatment has failed. The technique was not as effective in patients with pantendinopathy. Additional studies on larger populations, not necessarily athletic, possibly using a randomized control trial design, with longer-term follow-up and on defined control groups are recommended.
We express our gratitude to Miss Linda Lothian for her help given in the preparation of the manuscript and to the Department of Medical Illustration, University of Aberdeen Medical School, for the help given in preparing the figures.
No benefit in any form has been received or will be received from a commercial party related directly or indirectly to the subject of this article.
Address for correspondence: N. Maffulli, Department of Trauma and Orthopaedic Surgery, Keele University School of Medicine, North Staffordshire Hospital, Thornburrow Drive, Hartshill, Stoke on Trent, Staffordshire, ST4 7QB, United Kingdom; E-mail: email@example.com.
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Keywords:© 2002 American College of Sports Medicine
TENDINOSIS; OUTCOME; MINIMALLY INVASIVE SURGERY