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The source of pain and the background to the pain mechanisms associated with mid-portion Achilles tendinopathy have not yet been clarified. Intratendinous degenerative changes are most often addressed when present. However, it is questionable if degeneration of the tendon itself is the main cause of pain. Pain is often most prominent on the medial side, 2-7 cm from the insertion onto the calcaneus. The medial location of the pain has been explained to be caused by enhanced stress on the calcaneal tendon due to hyperpronation. However, on this medial side the plantaris tendon is also located. It has been postulated that the plantaris tendon might play a role in these medially located symptoms. To our knowledge, the exact anatomy and relationship between the plantaris- and calcaneal tendon at the level of complaints have not been anatomically assessed. This was the purpose of our study. One-hundred and seven lower extremities were dissected. After opening the superficial fascia and paratendon, the plantaris tendon was bluntly released from the calcaneal tendon moving distally. The incidence of the plantaris tendon, its course, site of insertion and possible connections were documented. When with manual force the plantaris tendon could not be released, it was defined as a 'connection' with the calcaneal tendon. In all specimens a plantaris tendon was identified. Nine different sites of insertion were found, mostly medial and fan-shaped onto the calcaneus. In 11 specimens (10%) firm connections were found at the level of the calcaneal tendon mid-portion. Clinical and histological studies are needed to confirm the role of the plantaris tendon in mid-portion Achilles tendinopathy.
Objectives When re-operating patients with midportion Achilles tendinosis, having had a poor effect of ultrasound (US) and Doppler-guided scraping, the author found the involvement of the plantaris tendon to be a likely reason for the poor result. The aim of this study was to investigate the occurrence of a plantaris tendon in close relation to the Achilles tendon in consecutive patients with midportion Achilles tendinosis undergoing treatment with US and Doppler-guided scraping.
Material and methods This study includes 73 consecutive tendons with chronic painful midportion Achilles tendinosis, where US+Doppler examination showed thickening, irregular tendon structure, hypo-echoic regions, and localised high blood flow outside and inside the ventral Achilles midportion. The tendons were treated with US+Doppler-guided scraping, via a medial incision. If there was a plantaris tendon located in close relation to the medial Achilles, it was extirpated.
Results An invaginated, or ‘close by located’, enlarged plantaris tendon was found in 58 of 73 (80%) tendons. Preliminary clinical results of the combined procedure, US + Doppler-guided surgical scraping and extirpation of the plantaris tendon, are very promising.
Conclusions A thickened plantaris tendon located in close relation to the medial Achilles seems common in patients with chronic painful midportion tendinosis. The role of the plantaris tendon in midportion Achilles tendinosis needs to be further evaluated and should be kept in mind when treating this condition.
Background
The Plantaris Longus Tendon (PLT) may be implicated in Achilles (AT) tendinopathy. Different mechanical characteristics may be the cause. This study is designed to measure these.
Methods
Six PLT and six AT were harvested from frozen cadavers (aged 65–88). Samples were stretched to failure using a Minimat 2000™ (Rheometric Scientific Inc.). Force and elongation were recorded. Calculated tangent stiffness, failure stress and strain were obtained. Averaged mechanical properties were compared using paired, one-tailed t-tests.
Results
Mean stiffness was higher (p < 0.001) in the PLT, measuring 5.71 N/mm (4.68–6.64), compared with 1.73 N/mm (1.40–2.22) in AT. Failure stress was also higher (p < 0.01) in PLT: 1.42 N/mm2 (0.86–2.23) AT: 0.20 N/mm2 (0.16–0.25). Failure strain was less (p < 0.05) in PLT: 14.1% (11.5–16.8) than AT: 21.8% (14.9–37.9).
Conclusions
The PLT is stiffer, stronger than AT, demonstrating potential for relative movement under load. The stiffer PLT could tether AT and initiate an inflammatory response.
The plantaris tendon and a potential role in mid-portion Achilles tendinopathy
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