Topic Progress:

There are a number of surgical procedures used to manage tendinopathy. Unfortunately, the evidence base for these procedures is disappointing. There are no level-one studies that compare different surgical techniques.17 As a result, surgery should not be considered until there has been a failed trial of non-surgical treatments. A minimum of three to six months of non-operative treatment is generally suggested.

The goal of surgery is to promote tendon repair. The traditional approach is to excise fibrotic adhesions, remove degenerated nodules, and make multiple longitudinal incisions in the tendon to locate and excise intra-tendinous lesions. More recently, less invasive procedures (involving arthroscopy) have been promoted that focus instead on the disruption of the neovascularity associated with long-standing symptomatic tendinopathy. These newer treatments may allow a more rapid return to football.

The outcome after surgery for tendinopathy can be unpredictable. A review of 23 studies on the outcome of surgical treatment of patellar tendinopathy showed that the favourable outcome of surgery varied widely between 46% and 100%.18 In Achilles tendinopathy, most authors report excellent or good results in about 70% of cases.19

Novel techniques

Surgical techniques are always evolving as clinicians look for more effective, and less invasive ways to treat tendon pain. A new procedure for treating some patients with Achilles tendinopathy involving release of the plantaris tendon has been described. It is suggested that in some patients, the plantaris tendon can mechanically interfere with the Achilles. These patients are reported to have more medial Achilles tendon pain. In these athletes, release and excision of the plantaris tendon, together with the scraping procedure, has shown good clinical results.20