An operative approach to Achilles tendinopathy

Achilles tendinopathy is one of the most common overuse problems in running athletes. When conservative management is unsuccessful, surgery is indicated to increase the likelihood that the patient will return to high levels of sporting activity. Circulatory, metabolic, and mechanical factors are involved in the pathogenesis of the tendinopathy. In surgery for chronic paratendinopathy, we use different techniques depending on the extension of the adhesions and the thickening of the paratenon, removing the fibrotic rinds of the fascia and the hypertrophic parts of the paratenon, taking care not to disturb the mesotendon. In paratendinopathy associated with tendinopathy of the main body of the tendon and in isolated tendinopathy of the main body of the tendon, we free the tendon from fibrotic adhesions and remove the degenerated nodules. Longitudinal tenotomies are performed to try to re-establish tendon nutrition, or at least to cause tendon scarring. Moreover, to improve the blood supply in tendons with extensive degeneration, we have started to place a bundle of soleus muscle within the tendon itself. In insertional tendinopathy, the pre-Achilles bursa is removed, together with the lateral and medial outgrowth of bone and cartilage of the posterior border of the calcaneus, as is done with Haglund deformity, thus preventing further impingement of the tendon insertion.