Change search
ReferencesLink to record
Permanent link

Direct link
Achilles tendinopathy - do plantaris tendon removal and Achilles tendon scraping improve tendon structure?: A prospective study using ultrasound tissue characterisation
Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB), Anatomy.
2015 (English)In: BMJ Open Sport & Exercise Medicine, ISSN 2055-7647, Vol. 1, no 1, e000005Article in journal (Refereed) Published
Abstract [en]

Objectives The plantaris tendon has recently been described as a possible important factor in midportion Achilles tendinopathy. Ultrasound tissue characterisation (UTC) is a method to study tendon structure (matrix integrity). The effect of plantaris tendon removal on Achilles tendon structure was studied using UTC.

Design and setting Prospective case series study at one centre.

Participants Nine tendons in eight physically active and healthy patients (mean age 39 years) with chronic painful midportion Achilles tendinopathy were included. Preoperative two-dimensional ultrasound and UTC showed midportion Achilles tendinopathy (tendinosis) with medial tendon changes and suspected plantaris tendon involvement. Patients with previous operations to the Achilles tendon were excluded.

Interventions Operative treatment consisted of excision of the plantaris tendon and scraping of the ventromedial surface of the Achilles tendon under a local anaesthetic.

Primary and secondary outcome measures UTC examination and clinical scoring with the VISA-A questionnaire were performed preoperatively and 6 months postoperatively.

Results At 6 months follow-up, UTC demonstrated a statistically significant (t=5.40, p<0.001) increase in the mean organised matrix (echo-type I+II) and a decrease in the mean disorganised matrix (echo-type III+IV). Seven out of eight patients were satisfied, and the VISA-A score had increased significantly (p<0.001) from 56.8 (range 34–73) preoperatively to 93.3 (range 87–100) postoperatively.

Conclusions Excision of the plantaris tendon and scraping of the ventromedial Achilles tendon in chronic midportion tendinopathy seem to have the potential to improve tendon structure and reduce tendon pain. Studies on a larger group of patients and with a longer follow-up period are needed.

Place, publisher, year, edition, pages
2015. Vol. 1, no 1, e000005
National Category
Physiology Sport and Fitness Sciences
URN: urn:nbn:se:umu:diva-103307DOI: 10.1136/bmjsem-2015-000005OAI: diva2:812815
Available from: 2015-05-20 Created: 2015-05-20 Last updated: 2015-05-20Bibliographically approved
In thesis
1. The plantaris tendon in relation to the Achilles tendon in midportion Achilles tendinopathy: studies on morphology, innervation and signalling substances
Open this publication in new window or tab >>The plantaris tendon in relation to the Achilles tendon in midportion Achilles tendinopathy: studies on morphology, innervation and signalling substances
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Midportion Achilles tendinopathy (tendinosis) is a troublesome painful condition, often characterised by pain, local swelling, tenderness and functional disability. Despite extensive research, the pathogenesis is poorly understood and treatment remains challenging. Features related to the peritendinous connective tissue can be of importance. Recently it has been suggested that the plantaris tendon might be involved in this condition. Furthermore, it has been hypothesised that tendon pain and the tendinosis-related tissue changes in tendinopathy might be mediated by signalling substances such as glutamate and acetylcholine. A clinical observation, not scientifically evaluated, has been that unilateral treatment for bilateral Achilles tendinosis can lead to an effect on the contralateral side.

     The aim of this work was to examine the morphology and innervation patterns in the plantaris tendon and the peritendinous connective tissue in between the Achillles and plantaris tendons in midportion Achilles tendinopathy, and to evaluate if plantaris tendon removal has an effect on Achilles tendon structure. Another aim was to determine if unilateral treatment for Achilles tendinopathy targeting the peritendinous connective tissue can result in bilateral recovery. Furthermore the presence of non-neuronal cholinergic and glutamate systems was examined.

     Sections of plantaris tendons with adjacent peritendinous connective tissue from patients with midportion Achilles tendinopathy were stained for morphology (H&E), and innervation patterns were evaluated using antibodies against general nerve marker (PGP9.5), sensory (CGRP) and sympathetic (TH) nerve fibres and Schwann cells (S-100β). Furthermore immunostainings against non-neuronal aceylcholine (ChAT) and glutamate signalling components (glutamate, VGluT2, NMDAR1) were performed. Plantaris tendon cells were cultured and also stained for glutamate signalling components, and were stimulated with glutamate and glutamate receptor agonist NMDA. Furthermore, Ultrasound Tissue Characterisation (UTC) was used to monitor the integrity of the Achilles tendon collagen structure after plantaris tendon removal.

     Plantaris tendons exhibited tendinosis-like tissue patterns such as hypercellularity, collagen disorganisation and large numbers of blood vessels. The peritendinous connective tissue between the plantaris and Achilles tendons contained large numbers of fibroblasts and blood vessels and to some extent macrophages and mast cells. A marked innervation was found in the peritendinous connective tissue and there were also nerve fibres in the loose connective tissue spaces within the tendon tissue proper. Most nerve fibres were identified as sensory fibres. Some nerve fascicles in the peritendinous connective tissue showed absence of axons but homogenous reactions for Schwann cell marker. Tenocytes and cells in the peritendinous connective tissue expressed ChAT, glutamate, VGluT2 and NMDAR1. Tendon cells in vitro expressed VGluT2, NMDAR1 and glutamate. UTC showed significant improvement of Achilles tendon integrity 6 months after surgical plantaris tendon removal and scraping procedure. Eleven out of thirteen patients reported of a bilateral recovery after unilateral surgical treatment.

     The results of this work show that plantaris tendons exhibit tendinosis-like tissue changes, internal innervation and features that suggest occurrence of glutamate and acetylcholine production and signalling. Plantaris removal improves Achilles tendon structure suggesting possible compressive/shearing interference between the Achilles and plantaris tendons in tendinopathy. The peritendinous connective tissue shows marked innervation, which thus might transmit pain when being compressed. The partial absence of axons indicates a possible nerve degeneration. On the whole, the study gives new evidence favouring that the plantaris tendon and the peritendinous connective tissue might be of importance for pain and the tendinopathy process in midportion Achilles tendinopathy.

Place, publisher, year, edition, pages
Umeå: Umeå University, 2015. 71 p.
Umeå University medical dissertations, ISSN 0346-6612 ; 1729
Plantaris tendon, Achilles tendon, Achilles tendinopathy, innervation, morphology
National Category
Cell and Molecular Biology Orthopedics Sport and Fitness Sciences
urn:nbn:se:umu:diva-103292 (URN)978-91-7601-290-1 (ISBN)
Public defence
2015-06-12, BiA201, Biologihuset, Umeå University, Umeå, 09:00 (English)
Available from: 2015-05-21 Created: 2015-05-19 Last updated: 2015-05-21Bibliographically approved

Open Access in DiVA

fulltext(641 kB)76 downloads
File information
File name FULLTEXT01.pdfFile size 641 kBChecksum SHA-512
Type fulltextMimetype application/pdf

Other links

Publisher's full text

Search in DiVA

By author/editor
Spang, Christoph
By organisation
PhysiologySport and Fitness Sciences

Search outside of DiVA

GoogleGoogle Scholar
Total: 76 downloads
The number of downloads is the sum of all downloads of full texts. It may include eg previous versions that are now no longer available

Altmetric score

Total: 101 hits
ReferencesLink to record
Permanent link

Direct link