Ultrasonography- and Doppler-Guided Surgical Treatment for Insertional Achilles Tendinopathy: Results From a Case Series in a Southern Sweden County Hospital

Abstract

Background: Treatment with ultrasonography (US)- and color Doppler (CD)-guided mini surgery for insertional Achilles tendinopathy has shown good clinical results in a sports medicine setting. The aim in this study was to introduce this new methodology at a county hospital and study the clinical results on a traditional orthopaedic population.

Methods: Twenty-six consecutive patients (12 men, mean age 61 years; 14 women, mean age 56 years) with a long duration (>12 months) of pain symptoms from insertional Achilles tendinopathy (a combination of bursae, bone, and tendon pathology) were included. US- and CD-guided surgical removal of bursae, bone, and tendon pathology, performed with local anaesthesia, was used. After surgery, there was immediate weightbearing loading without immobilization, followed by a structured rehabilitation protocol for 12 weeks. The VISA-A and SEFAS scores plus a questionnaire evaluating satisfaction with treatment and activity level was used for evaluation.

Results: At the 1-year follow-up, there were 3 dropouts. Twenty-one patients were satisfied. Their VISA-A score had increased significantly from 26 to 81 (P < .001), and the SEFAS score from 17 to 38 (P < .001). Two patients were not satisfied. There were 3 complications, 2 superficial skin infections, and 1 wound rupture.

Conclusion: For patients with chronic painful insertional Achilles tendinopathy, the US- and CD-guided surgical treatment method followed by immediate weightbearing loading showed a high satisfaction rate and improved functional scores at the 1-year follow-up in a majority of the patients. There are advantages using this method compared to other more tendon invasive surgical methods in use for this condition.

Level of evidence: Level IV, case series.

Keywords: bursa; insertional Achilles tendinopathy; surgery; ultrasound.

Figure 1.

Grayscale ultrasonographic pictures from a patient suffering from chronic painful insertional Achilles tendinopathy. (A) Grayscale ultrasonographic picture showing enlarged retrocalcaneal bursa (orange arrow), thickened tendinopathic distal Achilles tendon (marked with yellow line), and Haglund-like deformity of the upper calcaneus (green arrow). (B) Grayscale ultrasonographic picture showing enlarged and thickened subcutaneous bursa with high blood flow (asterisc) in bursa walls (white line). (C) Grayscale ultrasonographic picture showing intratendinous bone spur (white arrow) in the Achilles insertion.

Figure 2.

(A) Straight longitudinal incision on the lateral or medial side of the Achilles insertion. (B) The subcutaneous bursa is carefully released from the skin. (C) The subcutaneous bursa is carefully released from the tendon and removed.

Figure 3.

(A) The retrocalcaneal bursa is identified and removed. (B) The tendon is lifted, and the upper edge of the calcaneus is inspected to verify if there is impingement between the Achilles and the calcaneus. (C) The upper prominent edge of the calcaneus is removed to create space between the tendon and the calcaneus.

Figure 4.

(A) Intratendinous bone prominences were removed via a minor longitudinal tenotomy. (B) Removal of intratendinous bone prominence.

Figure 5.

The VISA-A scores before and 1 year after surgery. There was a significant (P < .001) improvement after surgery.

Figure 6.

The SEFAS scores before and 1 year after surgery. There was a significant (P < .001) improvement after surgery.