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Treatment of chronic painful tendinopathy has been known to be difficult, but recent research on basic biology and new treatment methods have shown good clinical results and fast return to pre-injury tendon loading activities. What is then the key to success? Well, up in northern Sweden, at the Sports Medicine Clinic in Umeå, by a coincidence it was found that painful eccentric calf muscle training relieved the pain in patients with chronic painful midportion Achilles tendinopathy [1]. Furthermore, when the pain was gone the tendon thickness decreased and the structure was improved [2]. This started research on the basic biology and innervation patterns, and it was shown that the nerves where located mainly outside, and not inside, the Achilles midportion. Also, the nerves where located close to blood vessels, thereby you could trace the nerves by using Ultra Sound (US) with Colour Doppler (CD). Following treatment metods using first US +CD-guided sclerosing polidocanol injections, and now mini surgical scraping, targeting the blood vessels to get the nerves outside the tendon, has shown good clinical results, decreased tendon thickness and improved structure [3-7]. We learned a lot about where the nerves where located using the sclerosing injection treatment, but the method is operator dependant and time consuming (most often multiple treatments are required). Therefore, that method has now been substituted to the one-stage mini surgical approach. With this surgical approach a return to professional heavy Achilles tendon loading sport within 4-6 weeks is common. However, not all patients where cured with that approach, complaining from medial side pain, and in a following research project the pain was found to be caused by a nearby located plantaris tendon [6]. After local removal of the plantaris tendon the pain disappeared, and again the tendon thickness decreased and the structure improved.

Is it then the same for the more complicated Achilles insertion with multiple different tissues involved? Well, we have done research also on innervations patterns in patients suffering from chronic painful insertional Achilles tendinopathy, and found that the most nerve rich tissue was the superficial bursa, followed by the retro-calcaneal bursa, and very few nerves where found inside the Achilles tendon [8]. Following treatment metods, using US and CD examinations for correct diagnosis and guidance during treatment, was first sclerosing injections, followed by surgery. We found sclerosing injections to be not good enough, and focused on surgical treatment. For insertional Achilles tendinopathy there is a wide range of pathology, some patients have bursa pathology only, while others have bursae, bone (Haglund-like deformity, bone spurs, loose bone ossicles), Achilles tendon and plantaris tendon pathology thogether [9-11]. Guided by the US and CD findings, in local anaestesia, via open procedures only the pathological tissues (believed to cause pain) where removed. In patients with intra-tendinous bone formations and loose bone fragments, localised tenderness at pre-operative palpation indicated pain related pathology, and was an indication for removal. Removal was performed via US-guided minor longitudinal tenotomi. Postoperative follow-ups showed that the removed superficial bursa tissue was replaced by a 2-3 mm thick scar tissue layer, the retrocalcaneal bursa was replaced by a scar tissue that fills out the space between the deep side of the Achilles tendon and the upper calcaneus, and sites for tenotomies and intra-tendinous bone removal where within 6-12 weeks replaced with scar tissue difficult to differentiate from the adjacent tendon tissue. This type of surgical procedure allow for immediate weight bearing, but time is needed for proper filling of the defects and load tolerance, and a 10-12 week rehabiliation period is often needed before return to pre-injury Achilles tendon loading activity. By using this technique to remove only painful pathology the commonly used tendon detachment procedure (Nunley) and osteotomy procedure (Keck´n Kelly), requiring long periods with immobilisation and following rehabilitation, can often be avoided.

Althogether, finding where the pain comes from and remove the pain seem to be the important factors. If pain is removed the Achilles tendon seem to quickly respond in a favourable way, and for the insertion the scar tissue that replace the removed tissue seem to relatively quickly adapt to the new circumstances.

By using tendon provocative activity before careful clinical examination-including palpation for tenderness, US and CD examination, sometimes guided diagnostic injections using a local anaestetic, there is a good chance to find the tissues where the pain comes from.

1. Alfredson H, Pietilä T, Jonsson P, Lorentzon R. (1998) . Am J Sports Med 26:360-366.

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2. Öhberg L, Lorentzon R, Alfredson H (2004) . Br J Sports Med 38: 8-11.

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3. Alfredson H, Öhberg L (2005) . Knee Surg, Sports, Traumatol, Arthrosc 13: 338-344.

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4. Lind B, Öhberg L, Alfredson H (2006) Knee Surg, Sport Traumatol, Arthrosc 14: 1327-1332.

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5. Alfredson H (2011) Br J Sports Med 45:407-410.

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6. Spang C, Harandi VM, Alfredson H, Forsgren S (2015) . J Mus Skel Neur Interact 15:197-206.

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7. Masci L, Neal BS, Wynter Bee W, Spang C, Alfredson H (2021) . J Clin Med 10: 2690-2695.

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8. Andersson G, Backman L, Christensen J, Alfredson H (2017) . Histol Histopathol 32: 263-270.

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9. H Alfredson, C Spang (2020) BMJ Open Sport & Exercise Medicine 6: 2-7.

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10. Alfredson H, Masci L, Spang C (2021) BMJ OpenSport & Exercise Medicine 7: 34-39.

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11. Lindén L, Granath M, Hedlund P, Spang C, Alfredson H (2023) . Foot Ankle Orthop 8: 55-60.

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