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Background: Treatment of chronic painful insertional Achilles tendinopathy is known to be challenging. If non-surgical treatment does not give sufficient relief of symptoms, surgery may be indicated. Treatment with ultrasound (US)- and colour Doppler (CD)-guided wide-awake-local-anaesthetic-no-tourniquet (WALANT) surgery for insertional Achilles tendinopathy is a new approach with promising clinical results. This study aimed to evaluate clinical results of this new approach on patients suffering from insertional Achilles tendinopathy.

Methods: Forty-eight consecutive patients with 53 symptomatic tendons (33 men with 34 tendons, mean age 49.3 ± 12.0 years; 14 women with 18 tendons, mean age 55.0 ± 7.4 years) and a duration of more than 12 months with painful insertional Achilles tendinopathy (including tendon, bursae, bone, and plantaris pathology) were included. US- and CD-guided WALANT surgery with removal of pathological bursae, bone, and tendons was used. Immediate weight-bearing loading was allowed, followed by a structured rehabilitation protocol for the first 12 weeks after surgery. VISA-A scores before and after surgery and a questionnaire that evaluated subjective satisfaction with the treatment and current activity level were used.

Results: In total, 42/48 patients with 46/53 tendons participated in a 3-year follow-up (mean 34 ± 9 months) by an independent examiner; 39/42 patients with 43/46 tendons were satisfied (n = 37) with the treatment. The mean VISA-A score increased significantly from 41.9 ± 18.2 pre-operatively to 87.7 ± 18.2 post-operatively (p < 0.001). There were three surgical complications, two superficial wound infections, and one minor wound rupture.

Conclusions: Patients who suffered from chronic painful insertional Achilles tendinopathy treated with US- and CD-guided WALANT surgery followed by immediate weight-bearing showed high patient subjective satisfaction rates and better functional scores at the 3-year follow-up with a low complication rate. This novel treatment approach warrants more study, including randomised trials comparing it against traditional surgical procedures according to Nunley and Keck and Kelly.

To assess the level of agreement among experts on the heel raise exercise parameters that influence midportion and insertional Achilles tendinopathy (AT) rehabilitation outcomes.

An international expert panel in AT rehabilitation was invited to complete a three-round Delphi survey. In the first two rounds, experts were asked to review a pregenerated list of exercise parameters (based on the heel raise exercise) and rate their perceived influence on rehabilitation outcome, using a 5-point Likert scale. For each parameter, consensus criteria for major influence on rehabilitation were (a) median≥4, (b) ≥75% of scoring 4 or 5 and (c) IQR≤1. The third round aimed to rank the exercise parameters according to importance (from most to least important) during rehabilitation.

17 experts participated in the entire Delphi process. A total of 16 exercise parameters were assessed, of which 4 (intensity of contraction, total time under tension, number of repetitions and sets, type of contraction) reached consensus as having a major influence on rehabilitation for midportion AT and 3 reached consensus for insertional AT (range of ankle dorsiflexion during the exercise, intensity of contraction, number of repetitions and sets). The rankings of parameters that reached consensus showed that contraction intensity was perceived as the most important variable for midportion AT rehabilitation, while range of ankle dorsiflexion was deemed the most important variable for insertional AT rehabilitation.

This study identified key exercise parameters for mid-portion and insertional AT rehabilitation based on expert opinion. This information should assist practitioners in optimising their approach to deliver more effective, patient-specific exercises for AT rehabilitation.

Purpose: The objective was to describe the location, examination procedures, diagnoses, and treatment for gradual-onset Achilles tendon pain in male professional football (soccer) players.

Patients and Methods: Forty-seven teams were followed prospectively for at least one season from 2013/14 to 2017/18. Time-loss injuries were recorded by the teams’ medical staffs. For all non-contact Achilles tendon injuries, a specific Achilles tendon form was sent to teams.

Results: There were 88 time-loss injuries recorded with gradual-onset Achilles tendon pain amongst 72 players; 22 (25%) of them were severe lasting more than four weeks including one career-ending injury. The specific form was returned for 78 injuries (89%) with 55 cases (71%) having midportion and 23 cases (29%) insertional pain. There were 51 cases (65%) being examined with ultrasound and 29 cases (37%) with magnetic resonance imaging, both modalities being used in 18 cases (23%). Tendinopathy was the most frequently reported main diagnosis both for midportion and insertional pain with 60 cases (77%), but multiple diagnoses were recorded in 21 cases (27%). Surgery was performed in six cases (8%), and the majority of players were exposed to several non-surgical treatments in various combinations, with eccentric training and cryotherapy being most frequent with 52 cases (72%) each.

Conclusion: Tendinopathy was the most frequent diagnosis both for midportion and insertional pain. Imaging was carried out for most injuries. A majority of injuries were managed non-surgically, with eccentric training and cryotherapy being the most frequently applied treatments.

Objectives: Jumper's knee, or proximal patellar tendinopathy, is commonly seen among athletes in leg explosive sports, and for a subgroup surgical treatment is needed. The aim of this study was to identify what type of sports were most frequent among athletes treated surgically for Jumper's knee at an international tendon clinic during a consecutive 13-year period.

Methods: The study included 344 consecutive patients (306 males, mean age 27 years, range 17-58; 38 females, mean age 24 years, range 18-44) from 21 different countries seeking help for therapy-resistant jumper's knee. There were 274 elite athletes, 168 being full-time professionals. All were diagnosed to have tendinopathy in the proximal patellar tendon and were operated on with ultrasound- and Doppler-guided arthroscopic shaving surgery.

Results: The single most common sport was football (n = 95, 28%), followed by rugby (n = 37, 11%) and handball (n = 32, 9%), with 117 (34%) playing at a professional level. The rest of the athletes participated in 17 other different elite sports and nine recreational sports (running/jogging, padel, squash, biking, gym training, bowling, cheerleading, dancing, and ultimate frisbee).

Conclusions: Football was the most common sport among patients requiring surgical treatment for jumper's knee, constituting 28% of all patients, and together with rugby and handball they constituted almost half of all patients. There was a wide sport distribution with 29 different team and individual sports represented.

To develop a core outcome set for Achilles tendinopathy (COS-AT) for use in clinical trials we performed a five-step process including (1) a systematic review of available outcome measurement instruments, (2) an online survey on truth and feasibility of the available measurement instruments, (3) an assessment of the methodological quality of the selected outcome measurement instruments, (4) an online survey on the outcome measurement instruments as COS and (5) a consensus in-person meeting. Both surveys were completed by healthcare professionals and patients. The Outcome Measures in Rheumatology guidelines with a 70% threshold for consensus were followed. We identified 233 different outcome measurement instruments from 307 included studies; 177 were mapped within the International Scientific Tendinopathy Symposium Consensus core domains. 31 participants (12 patients) completed the first online survey (response rate 94%). 22/177 (12%) outcome measurement instruments were deemed truthful and feasible and their measurement properties were evaluated. 29 participants (12 patients) completed the second online survey (response rate 88%) and three outcome measurement instruments were endorsed: the Victorian Institute of Sports Assessment-Achilles questionnaire, the single-leg heel rise test and evaluating pain after activity using a Visual Analogue Scale (VAS, 0-10). 12 participants (1 patient) attended the final consensus meeting, and 1 additional outcome measurement instrument was endorsed: evaluating pain during activity/loading using a VAS (0-10). It is recommended that the identified COS-AT will be used in future clinical trials evaluating the effectiveness of an intervention. This will facilitate comparing outcomes of intervention strategies, data pooling and further progression of knowledge about AT. As COS-AT is implemented, further evidence on measurement properties of included measures and new outcome measurement instruments should lead to its review and refinement.

Purpose: Midportion Achilles tendinopathy is a relatively common condition. This study aimed to investigate the presence of a normal Achilles tendon, but a tendinopathic plantaris tendon, in a large and consecutive prospective sample of patients referred to a specialised tendon clinic for midportion Achilles tendon pain not responding to non-surgical treatment.

Patients and Methods: A total of 105 consecutive tendons were operated on in 81 patients (62 males) suffering from painful midportion Achilles tendon pain. Clinical examination, ultrasound (US) and colour Doppler (CD) examination, and wide awake local anaesthetic no tourniquet (WALANT) surgery were performed in all patients.

Results: For 19/105 (18%) tendons from 14 patients, clinical examination suspected plantaris tendinopathy alone as there was a distinct tenderness on the medial side, but no thickening of the Achilles tendon. US examination followed by surgery confirmed the diagnosis.

Conclusion: Midportion Achilles tendon pain is not always related to Achilles tendinopathy since pain related to the plantaris tendon alone was found in almost every fifth patient. Consequently, there is an obvious need for proper examination to identify the pain source and establish a correct diagnosis before treatment.

Background and Objectives: Patellar tendinopathy is difficult to treat, and when combined with partial rupture, there are additional challenges. The aim of this study was to evaluate the subjective outcome and return-to-sport status after ultrasound (US)- and colour doppler (CD)-guided wide awake local anaesthetic no tourniquet (WALANT) arthroscopic shaving in elite athletes.

Material and Methods: Thirty Swedish and international elite athletes (27 males) with a long duration (>1 year) of persistent painful patellar tendinopathy in 35 patellar tendons, not responding to non-surgical treatment, were included. All patients were treated with the same protocol of arthroscopic shaving, including bone removal and debridement of partial rupture, followed by at least 3 months of structured rehabilitation. The VISA-P score and a study-specific questionnaire evaluating physical activity level and subjective satisfaction with the treatment were used for evaluation.

Results: At the 2-year follow-up (mean 23, range 8–38 months), 25/30 patients (29/35 tendons) were satisfied with the treatment result and had returned to their pre-injury sport. The mean VISA-P score increased from 37 (range 7–69) before surgery to 80 (range 44–100) after surgery (p < 0.05). There was one drop-out (one tendon). There were no complications.

Conclusions: US- and CD-guided WALANT arthroscopic shaving for persistent painful patellar tendinopathy, including bone removal and debridement of partial rupture, followed by structured rehabilitation showed good clinical results in the majority of the elite-level athletes.

Background and Objectives: Chronic painful midportion Achilles combined with plantaris tendinopathy can be a troublesome condition to treat. The objective was to prospectively follow patients subjected to ultrasound (US)- and color doppler (CD)-guided wide awake, local anesthetic, no-tourniquet (WALANT) surgery in a private setting.

Material and Methods: Twenty-six Swedish patients (17 men and 9 women, mean age 50 years (range 29-62)) and eight international male patients (mean age of 38 years (range 25-71)) with combined midportion Achilles and plantaris tendinopathy in 45 tendons altogether were included. All patients had had >6 months of pain and had tried non-surgical treatment with eccentric training, without effect. US + CD-guided surgical scraping of the ventral Achilles tendon and plantaris removal under local anesthesia was performed on all patients. A 4-6-week rehabilitation protocol with an immediate full-weight-bearing tendon loading regime was used. The VISA-A score and a study-specific questionnaire evaluating physical activity level and subjective satisfaction with the treatment were used for evaluation.

Results: At the 1-year follow-up, 32/34 patients (43 tendons) were satisfied with the treatment result and had returned to their pre-injury Achilles tendon loading activity. There were two dropouts (two tendons). For the Swedish patients, the mean VISA-A score increased from 34 (0-64) before surgery to 93 (61-100) after surgery (p < 0.001). There were two complications, one wound rupture and one superficial skin infection.

Conclusions: For patients suffering from painful midportion Achilles tendinopathy and plantaris tendinopathy, US + CD-guided surgical Achilles tendon scraping and plantaris tendon removal showed a high satisfaction rate and good functional results 1 year after surgery.

Proximal patellar Tendinopathy, commonly denominated as Jumper´s Knee, is widely considered to be a challenge to treat (Abat et al. in J Exp Orthop. 3:34, 2016). The treatment of patellar tendinopathy focuses on reducing if not eliminating the pain and improving function. At present, there are a several distinct treatments oriented to that end, and a “gold-standard” treatment might be in sight. (Abat F, Alfredson H, Cucchiarini M, Madry H, Marmotti A, Mouton C, Oliveira JM, Pereira H, Peretti GM, Spang C, Stephen J, van Bergen CJA, de Girolamo L. Current trends in tendinopathy: consensus of the ESSKA basic science committee. Part II: treatment options. J Exp Orthop. 2018 Sep 24;5(1):38. https://doi.org/10.1186/s40634-018-0145-5.)

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.