Ultrasound and Color Doppler-Guided Surgery for Insertional Achilles Tendinopathy-Results of a Pilot Study


Background: Treatment of insertional achilles tendinopathy is known to be difficult. Eccentric calf muscle exercises and extracorporeal shockwave therapy have been proposed as the primary treatments for this condition, but surgery is indicated after failed conservative management. There is no consensus about the most efficient surgical treatment. Objectives: To evaluate a new ultrasound and color Doppler-guided surgical treatment for insertional achilles tendinopathy. Patients and methods: 24 consecutive patients (13 men and 11 women, mean age 47 years) with a long duration of insertional achilles tendon pain (median 18 months) were included in the study. The surgical procedure consisted of extirpation of the subcutaneous and retrocalcaneal bursa, scraping of the ventral distal achilles tendon and removal of prominent bone at the upper calcaneal tuberosity (Haglund’s deformity). In 13 patients, the plantaris tendon was also cut and excised. VAS for pain during activity, satisfaction with the treatment result and the SF-36 score to measure quality of life were used for evaluation. Results: The mean VAS had decreased from 72 before surgery to 19 after surgery (p < 0.001), and 20/24 (83%) patients were satisfied with the result and had returned to full tendon loading activity at the one-year follow-up. The SF-36 score had improved significantly. Conclusion: Ultrasound and color Doppler-guided surgical treatment seems to be a good method for treatment of chronic painful insertional achilles tendinopathy. Longer follow-up studies on larger materials are needed.

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H. Alfredson and M. Isaksson, "Ultrasound and Color Doppler-Guided Surgery for Insertional Achilles Tendinopathy-Results of a Pilot Study," Open Journal of Orthopedics, Vol. 4 No. 1, 2014, pp. 7-14. doi: 10.4236/ojo.2014.41002.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] U. Waldecker, G. Hofmann and S. Drewitz, “Epidemiologic Investigation of 1394 Feet: Coincidence of Hindfoot Malalignment and Achilles Tendon Disorders,” Journal of Foot and Ankle Surgery, Vol. 18, No. 2, 2012, pp. 119-123. http://dx.doi.org/10.1016/j.fas.2011.04.007
[2] H. Alfredson, “The Chronic Painful Achilles and Patellar Tendon: Research on Basic Biology and Treatment,” Scandinavian Journal of Medicine & Science in Sports, Vol. 15, No. 4, 2005, pp. 252-259.
[3] K. Knobloch, U. Yoon and P. M. Vogt, “Acute and Overuse Injuries Correlated to Hours of Training in Master Running Athletes,” Foot & Ankle International, Vol. 29, No. 7, 2008, pp. 671-676.
[4] M. S. Myerson and W. McGarvey, “Disorders of the Insertion of the Achilles Tendon and Achilles Tendinitis,” Journal of Bone and Joint Surgery-American Volume, Vol. 80A, No. 12, 1998, pp. 1814-1824.
[5] T. A. H. Jarvinen, P. Kannus, M. Paavola, T. L. N. Jarvinen, L. Jozsa and M. Jarvinen, “Achilles Tendon Injuries,” Current Opinion in Rheumatology, Vol. 13, No. 2, 2001, pp. 150-155.
[6] K. Mahlfeld, R. Kayser, A. Mahlfeld, H. Grasshoff and J. Franke, “Value of Ultrasonography as a Diagnostic Tool of the Achilles Tendon,” Ultraschall in Der Medizin, Vol. 22, No. 2, 2001, pp. 87-90.
[7] K. Knobloch, R. Kraemer, A. Lichtenberg, et al., “Achilles tendon and Paratendon Microcirculation in Midportion and Insertional Tendinopathy in Athletes,” American Journal of Sports Medicine, Vol. 34, No. 1, 2006, pp. 92-97. http://dx.doi.org/10.1177/0363546505278705
[8] L. Ohberg, R. Lorentzon and H. Alfredson, “Neovascularisation in Achilles Tendons with Painful Tendinosis but Not in Normal Tendons: An Ultrasonographic Investigation,” Knee Surgery Sports Traumatology Arthroscopy, Vol. 9, No. 4, 2001, pp. 233-238.
[9] C. N. van Dijk, M. N. van Sterkenburg, J. I. Wiegerinck, J. Karlsson and N. Maffulli, “Terminology for Achilles Tendon Related Disorders,” Knee Surgery Sports Traumatology Arthroscopy, Vol. 19, No. 5, 2011, pp. 835-841.
[10] S. Kang, D. B. Thordarson and T. P. Charlton, “Insertional Achilles Tendinitis and Haglund’s Deformity,” Foot & Ankle International, Vol. 33, No. 6, 2012, pp. 487-491. http://dx.doi.org/10.3113/FAI.2012.0487
[11] F. Lintz, A. Higgs, M. Millett, et al., “The Role of Plantaris Longus in Achilles Tendinopathy: A Biomechanical Study,” Journal of Foot and Ankle Surgery, Vol. 17, No. 4, 2011, pp. 252-255.
[12] P. Jonsson, H. Alfredson, K. Sunding, M. Fahlstrom and J. Cook, “New Regimen for Eccentric Calf-Muscle Training in Patients with Chronic Insertional Achilles Tendinopathy: Results of a Pilot Study,” British Journal of Sports Medicine, Vol. 42, No. 9, 2008, pp. 746-749.
[13] E. M. Roos, M. Engstrom, A. Lagerquist and B. Soderberg, “Clinical Improvement after 6 Weeks of Eccentric Exercise in Patients with Mid-Portion Achilles Tendinopathy—A Randomized Trial with 1-Year Follow-Up,” Scandinavian Journal of Medicine & Science in Sports, Vol. 14, No. 5, 2004, pp. 286-295.
[14] J. P. Furia, “High-Energy Extracorporeal Shock Wave Therapy as a Treatment for Insertional Achilles Tendinopathy,” American Journal of Sports Medicine, Vol. 34, No. 5, 2006, pp. 733-740.
[15] R. Kearney and M. L. Costa, “Insertional Achilles Tendinopathy Management: A Systematic Review,” Foot & Ankle International, Vol. 31, No. 8, 2010, pp. 689-694.
[16] M. L. Yodlowski, A. D. Scheller and L. Minos, “Surgical Treatment of Achilles Tendinitis by Decompression of the Retrocalcaneal Bursa and the Superior Calcaneal Tuberosity,” American Journal of Sports Medicine, Vol. 30, No. 3, 2002, pp. 318-321.
[17] S. W. Keck and P. J. Kelly, “Bursitis of the Posterior Part of the Heel; Evaluation of Surgical Treatment of 18 Patients,” The Journal of Bone and Joint Surgery. American Volume, Vol. 47, No. 2, 1965, pp. 267-273.
[18] N. Maffulli, V. Testa, G. Capasso and A. Sullo, “Calcific Insertional Achilles Tendinopathy—Reattachment with Bone Anchors,” American Journal of Sports Medicine, Vol. 32, No. 1, 2004, pp. 174-182.
[19] J. I. Wiegerinck, G. M. Kerkhoffs, M. N. van Sterkenburg, I. N. Sierevelt and C. N. van Dijk, “Treatment for Insertional Achilles Tendinopathy: A Systematic Review,” Knee Surgery, Sports Traumatology, Arthroscopy, 2012.
[20] D. D. Price, P. A. McGrath, A. Rafii and B. Buckingham, “The Evaluation of Visual Analogue Scales as Ratio Scale Measures for Chronic and Experimental Pain,” Pain, Vol. 17, No. 1, 1983, pp. 45-56.
[21] M. Sullivan, J. Karlsson and J. E. Ware, “The Swedish SF-36 Health Survey 1. Evaluations of Data Quality, Scaling Assumptions, Reliability, and Construct Validity: A Cross General Populations in Sweden,” Social Science & Medicine, Vol. 41, No. 10, 1995, pp. 1349-1358.
[22] J. E. Ware and C. D. Sherbourne, “The MOS 36-Item ShortForm Health Survey (SF-36) 1. Conceptual Framework and Item Selection,” Medical Care, Vol. 30, No. 6, 1992, pp. 473-483.
[23] R. X. Liu, J. Kuang, Q. Gong and X. L. Hou, “Principal Component Regression Analysis with SPSS,” Computer Methods and Programs in Biomedicine, Vol. 71, No. 2, 2003, pp. 141-147.
[24] G. Andersson, P. Danielson, H. Alfredson and S. Forsgren, “Nerve-Related Characteristics of Ventral Paratendinous Tissue in Chronic Achilles Tendinosis,” Knee Surgery, Sports Traumatology, Arthroscopy, Vol. 15, No. 10, 2007, pp. 1272-1279.
[25] H. Alfredson, “Ultrasound and Doppler-Guided MiniSurgery to Treat Midportion Achilles Tendinosis: Results of a Large Material and a Randomised Study Comparing Two Scraping Techniques,” British Journal of Sports Medicine, Vol. 45, No. 5, 2011, pp. 407-410.
[26] H. Alfredson, “Midportion Achilles Tendinosis and the Plantaris Tendon,” British Journal of Sports Medicine, Vol. 45, No. 13, 2011, pp. 1023-1025.
[27] S. C. Urwin, M. J. Parker and R. Griffiths, “General Versus Regional Anaesthesia for Hip Fracture Surgery: A Meta-Analysis of Randomized Trials,” British Journal of Anaesthesia, Vol. 84, No. 4, 2000, pp. 450-455.
[28] W. C. McGarvey, R. C. Palumbo, D. E. Baxter and B. D. Leibman, “Insertional Achilles Tendinosis: Surgical Treatment through a Central Tendon Splitting Approach,” Foot & Ankle International, Vol. 23, No. 1, 2002, pp. 19-25.
[29] I. Elias, S. M. Raikin, M. P. Besser and L. N. Nazarian, “Outcomes of Chronic Insertional Achilles Tendinosis Using FHL Autograft through Single Incision,” Foot & Ankle International, Vol. 30, No. 3, 2009, pp. 197-204.
[30] M. J. DeOrio and M. E. Easley, “Surgical Strategies: Insertional Achilles Tendinopathy,” Foot & Ankle International, Vol. 29, No. 5, 2008, pp. 542-550.

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