the surgical treatment of tendinitis

TENDINITISII: CUNICAL CONSIDEMTIONS
027L59r9t92$0.00 + .20
THE SURGICALTREATMENT
OF TENDINITIS
Clinical Rationaleand Biologic Basis
Wayne B. Leadbetter, MD, Pekka A. Mooar, MD,
Gregory J. Lane, MD, and Steven |. Lee, BA
The surgical treatment of overuse tendon iniuries has become an accepted
t5-17,a.D.
s.3' 3s,.3,
clinical alternative in the face of failed nonoperative care.z.12,
*.il Altlrough spontaneous tendon rupture constifutes an absolute requirement
for tendon repair,il.sz a the operative treatment of chronic tendon injury or
tendinitis is often performed on a tendon in continuity.re D Such treatment is
predicated upon the persistence of pain and the loss of athletic performance.
In recent years, timely surgical intervention has aided the recovery of such
notable sports figutes as basketball star lary Bird (Achilles tendinosis),dt
distance runners ]oan Benoit Samuelsons and Mary Decker Slaney (Achilles
peritendinitis and tendinosis), and quarterback )oe Montana (medial elbow
common flexor tendinosis and strain).5oAlthough usually considered a last
resort, surgery is now thought to offer some hope of inciting a renewed healing
response wherever repetitive microtraumatic load or use exceeds cell-matrix
adaptive capability. Yet, the adequacy of healing as the result of surgical tendon
treatrrent has been poorly documented histologically; what evidence exists
suggests normal tissue is not achieved,t rou This article reviews the surgical
rationale and currently recommended techniques in heating what is often a
prerupture condition of the involved tendon. The authors'clinical experiences
as well as a preliminary analysis of wound healing patterns in a longitudinal
interual tcnotomyrabbit tendo-Achillis model will be discussed.
From the Departmentof OrthopaedicSurgery(WBL),GeorgetownUniversity,Washington, DC; Departmentof Surgery(WBL),UniformedServicesUniversityof the Health
Sciences,Bethesda,Maryland; and ShadyGrove Centerfor SportsMedicine and
Rehabilitation(WBL), Rockville,Maryland;and Medical Collegeof Pennsylvanla
(PAM, GrL, SJL),Philadelphia,Pennsylvania
CLINICSIN SPORTSMEDICTNE
VOLUME 11. NUMBER4. OCTOBER1992
t-
679
680
LEADBETTER
et al
OBJECTIVESOF SURGERY IN CHRONIC OVERUSE
TENDONINJUFY
An analysis of currently recommended surgical procedures in cfuonic
overuse tendon injury reveals a variety of surgical goals: (1) to alter the tissue
structure and restore shength by inducing scar repair; (2) to remove a nidus of
offending aberrant tissue, e.9., chronic granulation tissue, degenerative tendon,
hyperhopNc synovium, calcific deposit (Figs. 1-3); (3) to encourage r€vascularization of tendon tissue; (4) to relieve extrinsic pressure, either bony or softtissue; (5) to relieve tensile overload; (6) to discover and repair gross interstitial
tendon rupture; (71 to replace or augment injured terrdon strrcture, e.g.,
kansfers, grafts.
These objectivesare achieved through such techniques as (1) intratendinous
or paratendinous excision, (2) decompression, (3) synovectomy or bursectomy,
(4) multiple linear tendon incisions, a procedure we have called,Iangitttdiial
intenul tenotonry, (5) tensile "release," (6) direct repair of partial inlerstitial
rupture, and (7) tendon transfer or graft (Iable l).
There are many limitations inherent to present surqical approaches. The
crux of the difficulty in the diagnosis of spoits-induced-soft-tiizue injury and
tendinopathy is that the exact nature and extent of the pathology is diffiCult to
assessuntil the time of surgery, Ideally, aberrant pathologic tissue is eradicated
and the environment of the tendon improved; however, the processof inflammation and slar repair after surgical wounding leads to a podrly regulated scar
response 1n! _not a true regeneration (i,e., identical replacemint of tisstre by
new tissue).a Surgery necessitatesthe disruption of normal tissue as an avenue
by which to arcess the abnormal tissue. The creation of surgical adhesions is a
common, undesired risk, This is exemplified in the casesof Benoit and DeckerSlaney, b-oth of whom have had repeated procedures.s It is simplistic to claim
"bad
scar" is replaced by "godd scar"-as a result of surgicai intervention.
-that
More often, structurally inadequate or excessively inflamedtssue is replaced
by a.woven, immature, and disorganized collagen fabric that may be adiquate
{, e Piiced under the repetitive derninds of sports
but is not normal tissue.?.22.
Flgute1. Typlcalintjatondlnousdystrophiccalclflcationof Achillestendonand calcaneal
plantarfa8claspur.occurringat sit€sof degoneration,
thesereactionsaretha,,tombston€s"
of lendonlnJury.
TI.{ESURGICALTREATMEM' OF TENDINITIS
l ! '
r ' l
granulatlontissuecharacterized
Figure3. Chronlcinflammatory
by abortlvescar repair,
scatteredmacrophage-likeInllammatorycells and ilbroblastsrlch In cell mediatorsand
increasedmicrovasculature
(hematoxylln-eosln),
withaccompanylng
noclceptorInnervations
582
LEADBETTM ei aI
Flgure4, End-stage
muclnoidor hyallnnecrosisIn lendinousleslon(Alcianblue).
performance, such tissue may be very sensitive to transitional stress and of
vulnerable durability. t+ts
According to Schneider,t there are four fundamental etiologic criteria in
sports-inducedchronic sofFtissueinjury surgery: (l) the movement and strain
patterns specific to the different kinds of sports or tfaining; (2) structural
weaknessesof the human anatomy, e.9., critical zones of vascularization,
tendon tunnels, muscular compartments with potential risk of ischemia; (3)
structural variance of human anatomy, e.g., anomalous tendon structure,
persistent femoral anteversion, hyperpronation of tl're foot, abuormal configuration, abnormal variant of the subacromialarch; and (4) biomechanical insufficienry of certain soft tissues, e.g., regeneration Iimits in dense connective
tissue, aging characteristics.
Thus, in the chronically
chronicall injured tendon, the surgeon is often operating
patholosic tissue affected
uponn a pathologic
afiected not only
onlv by
bv sports-induced
soorts-iiduced trauma but
tut also
als6
by aging. There is often pathologic
,ogicevidenceof a possiblehypoxic degenerative
process affecting intercellular
i
organelles, especially
especiallv the mitochondria,
mitochondria. as well
a-scollagenliber orientation and matrix integrity,r.:e' rt Lipid deposition, nuclear
chromatin cha_nge,and areas of variable-ceilutar activity iricluding cellular
necrosis as well as apparent increased-protein synthesis with rapid deposition
of variable fiber siz-e-collagenhave bien docrimented (Fig. 4j.r". ", ti *nurt
present in the young athlete, these are the characteristiis of a markedlv
deranged cell-ma_hixhomeostasig.l3
These aberrant changes can be documentei
to- sgme extent throughout the aging tendon tissue, not only at the focal site
of the-tendinosis or painful lesion.r' In addition, a genetic predisposition has
been theorized as a contributing factor in failed healing resfonse or predisposition to tendon breakdown-the mesenchymal syniirom-e.uoSomd type'of
abnormality in ceuular biology or fibrogenesi! is alsb theorized to existin this
subgroup,of patients. Repair and functional improvement under such conditions can be unpredictable.
THE SURGICALTREATMENTOF TENDINITTS
683
Table1. coMMoNsuRclcALTECHNTQUES
rNTHETREATMENT
oF ovERUsE
TENDON
INJURY
Technlque
Intratendinous
or paratendlnous
excision
Decomoresslon
rsectomy
Synovectomy-bu
Longitudinal
intornaltenotomy(linear
tendonincision)
Tensile"release"
Fepalr
Drillingor scarificatlon
of bon€tendon
attachment
Tondontranster
TyplcalAppllcatlon
PersislentossicleIn Osgood-Schlatter's
disea8e
Rotatorcuffcalciflctendinosis
Debridem€nt
chronicgranulatlon
tissue
(e.9.,lateraletboweplcondyre,
gubacromlal
spac6)
Rehocalcan€al
bursectomv
Excislonof accessorytarsirlnavicular
Subacromlal
impingament
syndrome
Haglund's
syndrome
De Quervaln's
tenovaqinifl
s
TriggerflngerreleaseAchlllesparatenonitis
(fibrosheath
lnflammation)
Subacromlal
inipingement
Fetrocalcaneal
bursectomy
renovagtnfts
Achlllostendinosls
Patellatondlnosle
Elbowsxtensoror flexorodgln
- injury
Plantarfasclitls(fasciosls)
Rolatorcuff
Elbowextensor
or flaxorodgininjury
Achillestendoninterstltlaltair
Elbowextensoror flexororlgininjury
Patellabone(Sinding-LarseiJohansson)
Posteriortlblaltendinosiswith
attenuation
SURGICALPRECEDENT_SPECIFIC
ANATOMIC
SITES
AchlllesTendon
The Achillestendonhasprovidedan_extensive
bodyof literatureaddressing
ir.61n
the surgical treatrncnt of overuse tendon iniury.3.Izlt,sz,s.17'4247,ts'
fibrosheath inflammation or peritendinitis, exi:loration
with release solely of
-or
the fibrosheath combined with synovectomy
lysis
of adhesions provides
-adrieved
predictable benefit.12'n,sLimited successmay be
even with simple
percutaneousfibrosheath releaseunder local anesthesiaperformed throusli a
small transverse incision with scissor technique (S. James-,personal commirnication). The rationale for synovectomy is further supporied by findinss of
deran-gementin synovial inflamrnation biochemistry ii chronic paratenoiynovitis.n
A common lonn of Achilles tendinitis that leads to surgery is the localized
fusiforrn swelling owing to focal areas of degeneration (teridinosis) within the
tendon.rsMost authors advocatelongitudinal incisions of the Achilles tendon
(longitudinal internal tenotomy) as well as tendon sheath release,u,,t 3r.s
Significant findir,gs indude so-calledmucinoid degeneration,small intratendinous calciurn deposits, and persistent inflammatory repair tissue.s.{r. s The
optimal number of incisions that correlateswith best recovery is not established.
684
LEADBETTER
er al
From one central incision to several longitudinal incisions have been recommended, Turn-down repairs are advocated whenever large interstitial defects
are encounteredor extensivepathologictissueresectionis required.12.3'Excision
of the retrocalcanealbursa in association with partial excision of tl're posteriorsuperior tuberosity of the calcaneus can be perforrned successfully in the
competitive mnner.
Jones and Jarnesa identify several important technical points: (1.) rnedial
and lateral incisions are mandatory to avoid leaving a potentially irritating ridge
along the oppositc calcaneal border, which in most cases will become symptomatic; (2) an inadequate amount of bone removal for the patient to be rendered
asymptomatic is a common error; and (3) a ledge must not be left under the
Achilles tendon at its insertion into the calcaneus.Ippolito and Ricciardi-Pollinir^
reported complete resolution in three casesof retrotalcaneal bursectomy without calcanealostectomy in the nonattrlete.
Torg et al6r have described reliance on the radiologic assessment of the
prominence of the posterior calcaneal superior tuberosi$ in the surgical
heatment of posterior heel pain. For a working knowledge of the so-called
parallel pitch lines (PPLs), the reader is referred to the original article. Most
surgeons rely on a high degree of clinical suspiciolr and the localization of the
findings on physical examination as well as a preoperative radiologic assessment
such as magnetic resonaltce imaging (MRI) to differentiate bursal and tendon
pathology.a
Nelen et al,{7 in a series of 170 patients with chronic Adrilles tendinitis,
obtained remar*ably consistent resulls despite varying surglcal treahnent and
diagnosis. Of 93 caseswith peritendinitis treated with fibrosheath release, 58olo
achieved excellent results. In those caseswith tendinosis, 26 patients following
longitudinal internal tenotomy were treated with side-to-side suture wrth STV|
excellentresults, whereas 24 patietrts with a turn-down tendon flap procedure
achieved 507oexcellent results,rz
Palella Tendon
. The ryrg1gl treaqmentglpatella tendinitis (rendinosis) or junrper,skneewas
described by Blazina in 7973,?
Colosimo and Bassettrthave provided an excellent review of the diagnosis
and Eeatment advocating a linear internal tenotomy with excision 5f the
pathologic t_endontissue, The pathology was characteriied,by a notable absence
of acute inllammation and was consiitent with persistent-nricrotraumatically
*d"SS{ degeneration partial tissue necrosis and failure of regeneration. For
the highly competitive
-athlete it was believed that only surlical treatmenr
provided lorrg-lasting relief in refractory cases.They poini out ihe controversy
that exists in the numerous surgical piocedures retohmended for this condition, which have included extenlor mechanism realignment as well as drilling
of the.infeligr pole of the
-patella with reattachmenfof the patella tendon. Iil
their first 52 cases treated surgically, they report
42 patients had complete
-subse<1uint
'In
relief, two had no relief, and eighi required
explorations.
a
slbsequent series of 15 highly competitive high school and iollege athletes,
the linear intenral tenotomy approach resultedln complete relicf in"L2 patients
with return to previous level ofactivity, fwo athletes a-dvancingto professional
basketball competition. One failure iri a pole-vaulter resulted-in giving up of
the sport. Another patient:required two subsequent k'ee exploiatioris with
more foci of aberrant tissue being found.
THESURGICAL
TREATMENT
OFTENDINITIS 685
Ferretti et al, described histologic findings in patella tendinosis as localized
Thes-econsistEd of'pseudorysti. ."riti". "t tf,"
:t_ il-u ,Po"gfndon.junction.
borderline betwcen the rnineralized fibrocartilage ahd bone, the disappearance
"blue
of the
line" marking this area increased tlickness *itn,ny*o^![."ri"a
hyaline metaplasia of the insertional Jibrocartilage, mineralizafion and ossifi_
cation of fibrocartilage, and ossification of the fidrocartilage f;, rro--iri" ,o"u
of provisional calcification. These findings are somewnZi airu"cl-rrom tte
intratendinous.pathollgy-{e-scribedby otrier authors. A comprete r.r"-otio"
orsporrs_acflvrryul lr or lu surgically treated patients resulied after inierior
pole patella
4.ril]i"g .along wirh eicision of the aifected por" ind ,ui"utu-oiit "
tendon fi'orn its junclion. Longitudinal scarification and excision of deeeneritive
tendon tissue was recommended-only when the patient tua pi""io?s ,t.roia
injection. Proximal realignrnent of the quadriceps inechanis* ,i,i, ia"o"ut"a
if
'Excision
extensor malalignment was present cfihically.
of the tetai'nea ".rl"r"
in Osgood-Schlatter-diseaseis predictably beneficial (Fig. S).
An unusual indication for-surgery in overuse pitela ligament iniury was
described recently by scranton ind Ferrar.E witfi findin;s oi,"u1,"'olrttraumatic mucoid cysls.of the patella ligament in six athlJtes. tto.,operliiu"
treatment was srrccessfulin two cases, with operative excision required foiihe
remairrder- In this diagnosis, the pper"tive technique called for ond toneitudinat
lncBron rateral to the patella tendon to prevent the formation of postdperative
a.dhesions- operative treatment was successful in all cases, with ;;;;;;g"
time of return to sports of approimately 5 months,
A
concept
, ,
.nqr.l
.has^been trre peie'taneous needring of the tend.inosis
lesion to incite repair (G. Snook, persbnal communication)I
Flgure 5. Patellatendon osslcl€ln previous Osgood-Schlatter's
condition.Exclsional
treatment
is usuallysuccessful,
686
et ol
LEADBETTER
Tennls Elbow
The surPical obiective in the treatment of lateral or medial epicondylitis or
overuse-indiced tendinosis at the elbow has been a legacy of controversy.re'{6
Nirschl and Pettronee have establishedthe prevalenceof the tendinosis lesion
in the extensor carpal radialis brevis tendon as well as in the medial flexor
origin in these cases.Surgical techniques that targeted the orbicular ligament,
synlovialfringe, intra-articular exploration,tzor joint degeneration"'have largely
beenabando-nedin favor of the tindinosis concept.l6Chronic granulation tissue
often accompaniesintratendinous pathology and should be excised.In describing these findings, the term angiofibroblasHchypelplasia merits use only as a
de-scriptiveterm as there are presently no distinguishing pathologic characteristics.lnterstitial tears are found in associationwith tendinosis (Fig. 5). hr 88
cases of lateral epicondylitis, Nirschl and Pettrone rePorted 97,7Va ovetall
improvement rate, with 85.2% of the patients returning to f'ull activity including
vigioroussports. The surgical technique recommended limited resection of the
extensor cilpal radialis tjrevis tendon with removal of tendinosis pathology,
combined in some cases with lateral epicondyle decortication or drilling and
interstitial tear repair, Involvement of the extensor digitorurn longus tendon
was also occasionallyfound and treated in a similar fashion.
Despite this well-established rationale, it is interesting to note the excellent
results reported by Yeager and TurneF with a percutaneousextensor tenotomy
technique for chronic lateral epicondyle extensor tendon injury. In a series of
149 percutaneous tenotomies performed in the office, a 93.5Vosuccessrate is
reported.
Neviaser et alt described an outpatient procedure for lateral epicondylitis
under local anesthesiainvolving extensor tendon fascial incision, dissection of
the common extensor from the lateral epicondyle, and lysing of adhesions
between the extensor tendon and lateral elbow capsule using a periosteal
Flgure 6, PartialInterslitialtear of exlensorcarpi radlalisbrevistendonin the area ol
tendlnosls;
the lateralepicondyleelbow.
THESURCICAL
TREA]MENT
OFTENDINITIS 687
elevator. The pafient
awake, and intraoperative
stress testing with
Tl_uilr.
forced dorsiflexion of the--wrist
i,.*aulr.ulJa ur,i"*.rrur"
of pain reliefand a
guide to the extent "f
fn". p*."aui.
is continued until the wrist
extension against force is:i:q:lil.
totally painle'ss.arrlg-puuunts
obtained an excellent
result, with a follow-up ranging ir"r" rs;o;tl;fo
, u.*u.
Shoulder
Surgical intervention in,.r-otllgr..uff pathology
has.historically focused on
the excision of calcific deposits, rototo, cutf r"patlr,
orsubacromial
impi.senieni
dis"'J;!:'
ifi fffi:iiff::x'il"-:XTf
the rotaror cuff tendo-r:rcomplex.parall.liil'#ff
th";f ;i;h.r
peripheral
tendon! and.
as such have been the focus'of siin'"t;";-r;;.
;itnougi, dyshophic intratcndinorrs calcification *uu.oll._:,::rotu" ,pontuneouriy
uoout the shoulder,s it is
sti' considered useftrl in
.recalcitrant"ui.r to ux.ir.. the.offendingdeposit.n.$
pres'mabry the linear incision
required in;;h il;"tendlnous exproration
mav
produce
rhesamescarrepairbenefit.secn-in
;il;;Iil;;il:iff#ii
ofienaccomptisr,"a
uyiffiartialarthroscopic
debrlde_
il?::.ffrf"fr*:t"T_:*
Foot and Ankle
poste'io' tibiar te'di'itir,.^1y u"
treatabre
by tendonsheathreleaseand
synovectorny,inseltional reattachment,
or tenddnhansfer.zf"t.rrtiii"f-t..ii
may resporrdto a combinatio*of partialdebridement,
tenoiysir,diiiaffi;;;:
ment, and tL'notomyif not.severhyattenuated
u"a ir tnJ.eaiui-;;;h;;';;
decornpensateq.
Gig' z)' whe.n fdr^a-il';;;"iiation witn accessorytarsal
.avicular,exccllentresults.can.be
expected
with excision
"f th".;.;;i,
i;;;i
na.vicularand .repa.irof the insertionsire.np"rti"r .a.urJ-;il;i;'f;
retrocalca^ealbr.rr.sitiscan be successfulin the treitme;f-;ilil;;;;
athlcte.tn,ol
Picrson a.d Inglisru reported relief in the caseof a nonathlete
heated for
.
stenosing teuosynovitis.of the peroneuslongus tendonwith *uri.ar,-wuit
o_
pl'ry or rne perolleal tubercrewiflr,an accornpanying
os perineum.Triitnent
consistcd of rcrnoval of the os perineum und ddcotipres'sionoi ir,.
f.ro-r.u,
longus tendon,
Plantar fascia rclease is currently advocatedonly in highty selectedcasess;
whether *eleasc of te^sion, ne.rve.d-ecompression,
,ernouj of "d;i
;il;;
or scar'_rcpair of microtears is the reasbn for clinical improvement is noi
''
estnblished,
Hand and Other Sltes
The flcxor a.d exte.sor tendons of the wrist and fingers may require
ope_rative releasc of the tendon fibrocompartment or sten6sing fil5rossious
pullcy-.owirrg to pain, pcrsistentsynovitis,br mechanicaldysfunEtion(triggering). Witt ct al"r reported a 38% unsatisfactorytr.eatmeniof de euervl-in,s
tetrosyrr.ovitisby steroid injection
of 30 patients
-and irnmobilization;22 (73V0)
witlr failcd rcsponse were found to have a separate compartrnent-for the
extensor pollicis brevis. In addition to anatomicvariation, the-surgicalrationale
Flguro7. lnterstilialtearposterlortiblaltendonhaatedby exclslonof detachedfragment'
teiotomy,lenolysis,anddistalinsertlonadvancemant'
is iustified bv pathobiologicevidence of metaplasia and accumulation of
or.itutefn"r* arid tendon-thickerring at points of compressiorr at points of
62
'iersistErit extrinsic pressurein tendon'a'
of_inciting.improvedvascularity
concept
the
of
[n an unusual ipplication
good results in a prosPectivestudy
and repair, Roosths fiis describedachieving
"nonipecific gluteal tendinosis or strain"
of neaily i00 patients suffering from
puniture technique perforating the site
ieedling
a
multiple
by heatinent ivith
oi tendinosis in the insertion of the piriformis and ot the Postenol lntenor
origin of the gluteus maximus, This preliminary rePort awaits validation by
other investigators.
TENDONSURGICALHEALINGRESPONSE
To date, reports of tissue healing resPonse after tendon surgery have
addressedthe effectsof complete or partial iransverse tendotl laceration, Sucl-r
studies are not clearly applicible to the chronic overuse tendon injury. Results
in the animal modil io:nsistently confirm the persistence of incompletely
remodeled histology, alterations in biomechanicalproperties such as -stiffness,
and a deficit of ultihate load failure that may be as high as20Voto 307o, even
at I vear after woundinq.z il' 2 Restorationof continuity as determined by MRI
post6perativelyin the hinsected rabbit tendon Achillei does not coincide with
irltimite functional shength rehrrn uP to 7 weeks."
Burks et al,'oin determining the biomechanicaland tissue healing properties
in canine cenhal third patella donor sites for routine anterior cruciate ligament
sugery, provided infoimation that may be analogous to the expected tendon
effeits-of-a longitudinal internal tenotomy.t0There was a dramatic decreasein
ultimate tensile-shength (70% at 3 montirs and 607oof controls at 6 months)'
THIi5URCICAL
TREATMENT
OFTENDINITIS 689
The stiffnessand moduluswithin physiologicrangewereprominently
lowered
to 70% and 33voof.conrrols,respeitiirely,a-t6 mo;ths, Tiir""'J1."""'rr"i,
"il.
alteredgreatly,with a r.0%conhactualdecrease
i" h;gih. id.itlri="u""a
the
operated
tendons
increased
at 3 months2.ix. 0.Atd;;ilJz;'=
1r9a.of
0.8 times at 6 montrrsversusthat of conhols.Thesefindingr r"",rttu,i-rroL
u
healing responsethat involved nor onty rG Hr;;J;"i".i,it"
:'cllT-tilf"
bur also the enhre ru*111q,!.?tella tendon,with thickening";J ;ir;;;[".
p:tella. collagenfibEr array.r.In two arumars,excessivescar
pf ,f"Til
was
Deueveoro resut rn an actuarincreasedtensilestrengthtolerance,such
fi.dings
would supp.ortone surgicalobjectivein the remed! "i-.,h*,.;.;;d;;j;;.
The wounding pat.ern in this studywas similart6 tt"li" p.t.ir"l*&ii'ri,
s.r1{g!{y,measuring4 mm in width. The donor site bone fr6m ile
;;;d'",
tibia that was harvestedwith the graft is .ot u'like that rrom iiaumiirra-*.a
partial-resectionas in sindift-ia;;;:lofi;;;"
y$-rylhl
.Wl9,
syndrome,orlnleli_or
hypertrophied
tibial.tuberclepartial ,"..Ju*-ur'i1i'.h;;;,.
g-:q::*:S^:nl"ttefiisease.rmporta*tly;;+;t 6iii" aur..i'p.ouil.;;;';;"_
Ilclal ertect.
h ? similar,study.byCab_aud
et al,r of the removalof the medialthitd of
., canine
patetlatendon,.faityeload was muchlessadversely,iiu.-tear,yitf.
the
actualincreasein ultimateload to failureat g monthspostsurgery.s.rcti.Lsults
"*iit
are.nlorcoptimistic_and
imprythat adverseiatrogeniieffect,
iu" "".iJ.a
wirh irnprovedtendon tunction achievedby surfrcali.6;";;i'i"
;iai]iiiq
ho19v.91such.a configuredwound doesnbt as-closely
imitatepreieni'Aiii..r
tendinitissurgical.techniq.ue.
Becausethis study did rior i"r.tr,[-tili.ia"li"i_
ment, it is also believedthat lessweakeningof the preparationoccurred., As
a corollary,the effectsof extensivedecorticitionu"h ttiu,.iriii""-tion ui'uonu
tendon origins or insertio^s, as often advocatedin tendiniGs-swg"rlr,"..a
furtherstudy.
In humans,thereexistvirtually no biornechanical
dataand little supportino
evidenceas to the ultimateadequacyand character
or *ou"a t.ili"; ,t:;;;;3
in tendinitissurqerv.sequentialstudyand re-biopsy
tut t rutyu."ri;;p;;"
in.the.competitiie;thledr. Berg'r'epo'rted
on ttreiiitotogic uni iranr';d;.tJ,istics in the case of a 22-year-oldmale athletewith ."r.-u*proruto;;;iil"
patella tendon donor site defect after anterior cruciate-ds;me;f;;t*;t
reconstruction
at 8 monthspostoperatively.
Markedtendon"
remoduil"*'una
hyperhophyapproximatingdoubli in dianieterby MRI u*.rr,nunt, ur rf"il'u,
homogeneous.
scar response^1{ ",grl1linearcolligen alignmcnt,-ur ."ia."t
ln rneunrepalreor-cm detect.Similarlryperhophy
response
of donortendons
hasbeenfoul{ 11_
the pero.eus brevisiile arteicottate'iat
tlgamenr.eco;siilction of the ankle.$
LONGITUDINAL
INTEFNALTENOTOMY-PRELIMINARY
RESULTSIN THE RABBITACHILLESTENDONMODEL
The Achilles te^don is perhaps the rnost commonly operatedmaior
6! Yet there is an-absenceof informatioir
tendinitis site.3s'
oir th. ",rtei;l
wounding rggponle-occurringwith presentclinical procedures.Inlrial #oik
with tl're rabbit Achllles ten-donhai provided somibcouelationwith botl.r
observedpatient clinicalresponseand the previouslydiscussed
patellatendon
studies.
under the directionof one oJus (PAM),12skeletallymatureNew Zealand
white rabbits with approximatelyequal sex distributions(z female,5 male)
690
LFADBETTER
ct al
rvere examined. Each rabbit underwent sterile bilateral Achilles tendon procedures on one side; two parallel longitudinal tenotomies were performed' from
the musculotendinous junction to the distal calcanealinsertion to assure a
discernible r€sponse. On the opposite side of the same rabbit, a single control
incision of only the tendon sheath was performed from the musculo-tendinous
junction to the distal calcanealinsertion. Rabbitswere then sacrificed from 1
week to 34 weeks postoperatively and the Achilles tendon carefully harvested.
They were immediately measured and weighed, and their voiumes were
determined by displacement of saline in volumetric cylinders. They were
subsequentlyfixed in forrnalin for a minimum of 48 hourd. Tendons were then
crosssectionaUydivided under a dissecting microscopeon a grid, beginnine at
the tendinous insertion and serially advincing at i-cm int-crvars jroximillv
until reaching the musculotendinous junction. Thesefixed, sectionea'specimen's
were then stained with hematorylin and eosin, trichrome, and silver Bodian
stains. The stained specimens were subsequentlyanalyzed histolosicallv. Finally, theg cross'sectioned areas were measured by computer-assis'lediinage
analysis. The initial results are described.
Macroscoplc Analysis
- Gross-inspectionof the tendon cross sectionsrevealedthe tenotomv srouo
to have a broader diameter in the range of 1.5 to 3.0 times the control
itjnaoir
al PolLege of pdnnsytvaiiil;
Bf orthopaedic Surgery
bbit A-s:
12 weeks post-op.
*ig}gllengitudinal
tenoromy x 2)
rjedj,-.c.a_]
- gel.I ege pf pennsylv{;
Pgptr" 9.f. p-rlhopaedic
sgrEqry
Rabbit A-s:
12 weeks post-op
sheath)
betw€en.t€notomy
(op) anatendon
sheath(battom)
.f.fe_t13-a_.-pross.comparison
at 12
posloperarrve
wseKs
afterformarin
fixation.
AnobvbidrnclasedJi"reGi'oi-tn"t;,ilr;
speclmgn
is observed.
rilte
THESURGICAL
TREATMENTOF
TENDTNITTS 691
sheath group) (Fig. 8). W;lSlJ ana volume measurements
followed
by a similar
i'ii:T'}#"',:b'"*:ll:;-llf;
":*ifJ:ffi
t,:l:rui*triL"*;iJ$lrg
telative to,the control group With"tid; th" ;?;git
and volume differential
between tlre .cxperimental and .ont ot grorrpr'g.?
asrarbuto, 28.".urr,anincreasecr
however,
*.trflillto x|ilfftj,rf:ig#ji
z
t{
z
lI1
(a
f{
H
z
F
50
lrl
3
s
10
20
SURVIVAT WBEKS
A
z
120
H
z
r00
Ir
o
80
EI
x
U
z
lrl
E
$
40
F.l
tn
n
SURVIVALWEEKS
B
percentage
lncrease
In
the
of weight(A)andvolume(8) in thetonotomygroup
Igu.rg.9.
In felationto the controlgroup,Themostpronouncsd
increasewasat 1 to e weekd,which
was bellevodto bo secondaryto swellingand Inflammation,
Ovsrthe ensuing26 weeks,
therowas a gradualdecllneIn lhe weightandvolumerelationships.
Theparslstent
Incroase
In tho tenotomygroupover the controlgroupwasbelleved
to be secondiryto a permanant
lncreaseIn collagenflbrllcontent.
692
LEADBETTERet al
of approximately lOTo to 2070persisted between the tenotomy and the control
groups. This may represent an increased Pemanent collagen content in the
tenotomy group.
Computer-assistedimage analysis results showed tirat the tenotomy Broup
had a consistently larger cross-sectionalarea at all time intervals (1 to 12 weeks)
as compared with the control group. The largest cross-sectionalarea noted was
at 1 week for the tenotomy group at both 1 cm and 2 cm from the insertion
(Fig. i0). In general, there was a gradual, absolute decrease in the crosssectional areas within the tenotomy group over the l2-week interval at botir 1
cm and 2 cm ftom the insertion. This is in conftadistinction to the tendon
sheath group, which appeared to have a relatively constant cross-sectionalarea
over the l2-week period at both L cm and 2 cm from the insertion, Nonetheless,
at all time intervals, the cross-sectional areas of the tenotomy group werc
consistently greater than in the control group.
Hlstologlc Analysis
Sheath incisioru Incision of the sheath was shown to incite an intense
inflammatory reaction, with invasion of vascular channels and cellular proliferation and migration. With tirne, the inflammatory response subsided and
was replaced with granulation tissue, leaving a thickened tendon sheath with
dense encircling fibers.
Lotrgitudinal internal tenotonry: A typical acute inflanrmatory tlaumatic
wound healing process occurred followed by a reparative phase and early
remodeling,
The inflammatory stage consisted of a fibroblastic and vascular response
that involved all the surrou-ndingstructures of the tendon including the synovial
sheath, the subcutaneous tissue, and the deep adventitia and fascia. The
inflammatory response was most intense early after the surgery (J.to 2 weeks)
and consisted of inflammatory cellular migr.ation and proliferation pr-imarily
from the epitenon.
The reparative stage was noted by the onset of collagen production. 'fhis
was eyidenced by the synthesis of random, disorganized collagen fibrils as
earJyas 1 week postoperatively. libroblasts predominated in this phasc. The
collagen content increasedup to 4 to 6 weeks postoperatively (Fig. 11). Between
L0 and 12 weeks, there appeared to be complete healing of the tenotomy
incisions. The increased organized collagen fiber content persisted postoperatively, as evidence by the rabbits sacrificed as long as 8'months ('32 w?!eks)
after surgery. Whether this increased-organizedcollagen fiber content may lead
to gr€ater tensile stre.ngthof the tendon with loading remains to be confirrned
Dy olomecnanrcaltes$nt,
.These findings are consistent with the exuberant epitenon extrinsic fibrogenic response seen by other investigators in both hansverse as well as
longitudinal tendon lesioning.r,:. z The resulting surrounding fibrocallus is
clearly not normal tendon and remains distinct from the olippnal tendon
struchrre. There also appeared to be some hyperplasia of endoteion elements
and an accompanying increase in new vessels (angiogenesis). It is difficult to
draw certain conclusions from the rabbit Achilles tendorl model because its
bitendinous and sometimes tritendinous structure is unlike the human Achilles
tendon, In addition, the wounding has been performed on normal rabbit
tendon histology, not that of tendiiosis or paraienonitis, Further sfudies are
needed to clarifv these issues.
THE SUITGICALTREATMENTOF TENDIN]TIS
a20
z
,
u10
t
sb
El Taotomy
I
conuol
an
U
zo
z
F 0 ,
A30
E
;
tr
iro
z
H
(n
d
(n"^
El Terotomy
I
contol
z
o
o
z
lq
F 0
B
SURVIVAL WEEKS
Flgurs 10. comparisonbetweenthe tonotomyand control group crooo-sectional
areas
vorsustime at I cm (A) and 2 cm (B) from the insertlon.The cross-sectional
areagwere
normqllzedfor discrepanclesin rabbit slz6 by dlvldingeaoh cross-sectionalaroa by the
rabbit'ssacrilicedwelght.Therels an early maxlmumarea at I to 2 weeks,followed-bya
gradualdecllnein the tenotomyspecimens'
cross-seotional
areawithtime.In contrast,
ihe
tendonsheathgroupapp€arsto remalnrelativelyconslantover 1ime.
et al
LEADBETTER
Flgure 11' A, Tendonshsath(control)crosssectionfrom an B-week-postoperative
rabbit.
Note the hypertrophled
tendonshoalh (hematoxylin-eosin,
x400). b, Tenotomycrosssection from lhe-opposlteleg of the samerabbit.Notethe beginningof organlzedtollagen
fiber formatlon(hematoxylln-sosin,
x 400),
THE SURGICALTREATMENTOF TENDINITIS
flN
st,
t*
695
'ilr
{$
s
t
?
?
c
Ffoure 11 (Conttnued)C, Photo enlargementdepictlngrelatlvechangein cross'sectional
postoperatlvelongitudinalintemallenotomy,a - controlat 2
aiEa of raObittendo-A'chllies
woeks;b = operatodat 6 weeks;c : oporatedat 12 wesks.
SOME OBSERVATIONS FROM THE AUTHORS'
CLINICALEXPERIENCE
Although our overall experience with the s-urgical treatment of tendinitis
reflects that"of the literaturei it may prove helpful to underscore some salient
points.
Preoperatlve ApProach
It is important to recogrrize that the patient p-resenting with a tendon
complaint biings a legary of many weeks or months of abusive overuse or
rq 3r'$' e This can best
oveiload activitly, mosl often as a rbsult of overtraininS,e'
"Rule
tao
hard,
toosoon, too mttch,
often,
J66'5"*fps
of
be summarized'bv the
too little, too tnte; etc. (WBL). In this respect the patienfs presentation as
,,iniured,, is only the tip of an injury iceberg that preci-pitates as a clinical.crisis
wh'en symptomi have'finally bricohe intolerable andperformance inhibited'
Upon iiitiit presentafion, the history is critical in chronic overuse injury in
ditermining the sou.ces of overrraining. The physical examination tt* imPortant
in identifyiig the anatomic and functio.-nalmaladaqtation Pattems that must be
unraveled to- aChievc satisfactory recovery. h'ritial plain roentgenograms are
important to rule out coincidenf bone and other musculoskeletal conditions.
Aiothers, we have seen so-called sports hrmors presenting as athletic iniury.
Since, for the most part, initial plain roentgenoErams are negative, a common
er.o, i, in not repeafing the plaii roentgenograms 6 to 12 weeks after the initial
696
LEADBETTER
et al
visit, especially for revealing stress reactions in bone as well as periosteal stress
reactions at muscle tendon attachments.
After the initial evaluation, a variety of specific measures should be
prescribed to the athlete. Remember the mnemonic REST'M (Rest ancl Rehabilitation, Education, Support of the Injured Part, Training and Technique,
Modification of Activity, Modalities, and Medication). These principles arehot
unique and have been proposed and refined by many sports medicindauthors.r.,,
12'tt'rr'rr''6'38'rt'$'s
Rest may not cure, but its value in the initial heatmcnt of
overuse tendon injury is ldgion.t'atz,t',1.4, s.36Rest plays a vital role in cel!
matrix homeostasis,especially in aging. Although absolute immobilization is
harmful, the concept of protected activity and force overload sparing should
be promoted wherdver pbssible. Many authors point out the piifall o"f ,eco*mending surgical alternatives by default in the face of an inadequate rehabilitation program.r.12.r&3t,sLs
In this regard a great deal of tinre must be spent in
e.ducating the athlete to alter abusive behavior. Support of the injurdd part
through various bracing measures and orthotics, nnprbved alterations in tlainingand technique, and modification of activity all fall under the broad purview
of decreasing the overload and overuse in the involved anatomic stmc-ture. As
to specific modalities, ice remains the single most useful interventiou. Its
availability, lack of-expense, and rnargin of safety, and the ability of the athlete
to self-treatimmediately after activity add to iis appeal. We find the use of
most physical modaliHis to lack sufficient substaridation as to a significant
effect-on the promotion of soft-tissue healing. Generally, ii seems ulseful to
cool down inflamed and swollen structues, especially after exercise rehabilitation or activity, and to warm up inflexible and indblent sites of complaint
prior to activity, Medication is prescribed in as simple and cost-efficienf form
as possible.we have found little differenceamong nonsteroidal preparations.
Individual prescription is based on the athletd-s tolerance und'resporrs..
Medication is never a solution by itself, because it treats only the'initial
inflammatory symptoms of the undirlying injury. It has been useful in a lirnited
way to allow compliance with the remainder of the therapeutic prosram.
corticosteroid injection therapy remains controversial as to its tissue e?ec"tar-rd
abilily to promote healing. There is no question that in synovial strucfures with
Prominent immunologic and inflammatory activity, corticosteroid injection has
a dramatic impact, e.9., as in isolated paratenonitis or paratenon bursitis.
Leadbetterr'
!ras.provided-a.review and guidclines for the'appropriate use of
corticosteroid injection (Table 2).
We find that rnost athletes lose patience with the nor-roperativeproqram
after 6 to 12 weeks if they are noi making some appreciible proetesi. Ir,
situaHonsin which disability is prominent from the bnset and ihe"phvsical
examination implies that significant structural injury has already been iccumulated, appropriate supplemental radiologic imaeine, especiillv the MRI
arthrogram,srbursagrarn, oi tri-phase bone sian, is isefirl in screeriine further
the nature of the athlete's complaint. These tests may be obtained ear.iierthan
otherwise would be expected to predict more firmly lhe fikelihood of return ro
pl,ai'..This. yrgency is
-more intense in the highly competitive or professional
athlete. Although a reliance on exterrsive mdi6lo;ic asslssment in the absence
of a carefully carried out history and physical Jxamination is inappropriate,
early focusing on the-exactextenl of the athlete's injury and ideally il'imihating
some concern often improves compliance,builds ionfidet ce, and establishes
rapport with the athlete while providing further insight. Allowine the athlete
to participate in_the decision making bf tire trialalrd-error pro'cess that is
involved in the clinical treatment of soft-tissue iniury and tendinitis can be a
OF TENDIMTIS
TI{E SUITGICALTITEATMEN'T
697
Table 2. USE AND ABUSE OF CORTICOSTEROID INJECTION
Properuse
trial of rest,adjustedlevel of play, and conditloning
Six-weekpreinlection
Discrete,palpablesite of complaint(avoidtendon)
targetlissue
or inflammatory
Perltendinous
Limitot three injections,spacedweeks apart,givononly lf llrst led to demonstratad
improvement
Rest(protection)lor 2 to 6 weeks after injection
conditioning)
causo(e,9.,equipment,
mechanical
Avoldinceof contributlng
lmproperuse
Acutgtrauma
Intratendinous
injection
lnfection
(>3)
Multlpleinjections
Inlectionimmediatelybeforecompetitlon
Inlections
FrequentIntra-articular
Cllnlcaland
Inllammalion:
JA,GordonSL (sda):Sports-lnduced
FromLoadbefler
WB,Buckwalter
surgeons,1990iwith
ot orlhopaodlc
Academy
ParkRidgo,lL, Amerlcan
Basicscienceconcopts.
permisgion.
wise strategy. After all avenues have been exhausted but before secondary
disuse and- deconditioning have become prominent,r2 surgical treatment is
recommended based upon-the severity of the pain (Table 3)' Surgery is more
likely in casesdemonstiating rest pain br nocturnal pain or loss of performance.
A w'ord of cautiont Malicioris diagnoses, particularly neoplasms, ,can cause the
same symptom presentation' Radiologic screening is always Prudent'
Ln'the recovery phase after surgCry, it is critical to Protect-a_gainstabrupt
12'r'' 3r'-' s' s' 63Schemes such
transition and to einirhasize adequate ietraining."
as the return to running transitional program PloPosed by Brody (Table a)
exemplify proper sports"medicine pre3cription iftel inlury or surgery. Such
of cornpetition. The
ptog.i*6 cin tre cre'atedfor any spolts activity at any_level
-the
tendon injured attrlete
buu"*U upprouch to the periopirative assessment of
is summiiized by the algorithm in Figure 12.
Technique
In Achilles paratenonitis and tendinosis the pathologic lesion may be quite
ctiffuse. Discreti nodu.les., have been encountered infrequently that could be
excised as a whole. A rather homogenous lesion in- continuity is-often
presentlz,4r(Figs, 13 and 14), Longitudinlt intenlal tenotomy is performed most
bften throue1ia medial incision-to avoid placing hypertrophic sensitive scar
directlV posierior over the Achilles during shoe wear and to avoid injury to the
sural tierve (Fig. 15). Care is taken to protect and avoid underrnining the poorl_y
vascularized p"osteiior skin flap. No i,vound complications have occurred with
this techniqul. A mid-line iniision through the-tendon fibrosheath and substance of ttie tendon or, in some cases, tw6 parallel incisions with an ellipse of
tissue beinq removed has been performed. There has been an imprc-qsion that
*iitr itrcr"ui"a numbers of incisions, recovery has been slower and the wound
more sensitive (wBL). Incisions releasing only the fibrosheath in paratenonitis
recover most rapidly; those requiring pirtial-calcaneal.ostectomy heal slowly.
postoperativelv thei" is an impressive paratendinous inflammatory resPonse.
It is slspected that this is mosity apposltional and may not rePresent involve-
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699
LEADBSITER et al
TO RUNNING
Tabla4. RETURN
AFTERINJURY
with normaldailyactivitlesbefore
The runnermustbe tree ol paln and tendernass,
resumlng
hls or hertralnlngprogram.(Ona scaleof 0 to 10,on which0 is normaland
10 is th€ worst,the runneris askedto ralo hls or her palnwlth normalacllvilios;they
mustbo at 0).
(A) lf 0: Run everyother day for lwo weeks,th€n a maxlmumof 5 days a week for the
next four weeks,lf the prsvlouslovel was 4 to 6 milesper session,begin with one
mile.(lf previouslevslporsessionwaslessthan4, beginwith0.5mll€per sesslon).lf
weeklymlleageschedule:
no palnwithrunning,followtha following
1
0
1
0
1
0
2
0
2
0
2
0
3
0
3
2
0
3
3
0
4
3
0
4
4
0
5
4
0
5
5
0
6
5
0
€
t
c
.
(B) lf youhavBshortintervals
of palnwithrunning
A. No runnlngfor 2 waeks.
B. 10 mlnutetotalworkout,alternallng
4 minuterunand1 minutewalk.lf no paln,add
5 minutesevery3 days,worklngup to 30 minutes,thonprogressto the noxt stap.
lf you oxperlencepaln,cut back5 minutesandworkup.
C. 15 minutestotalworkout,alt€rnallng4Vzmlnulerunand % mlnutewalk, ll no pain,
add5 minutesevery3 days,workingup to 30 minutes,thenprogressto nextstep.
It you exparlencepain,cut back5 mlnutesandworkup.
pain,
D. Runsleadilytor 15 mlnutos,
addlng5 minutessvery3 days.lt you experience
cul back5 mlnutesand workup.
(C) lf you have palnalter running
A. Gutyourworkoutby 50% and progressby addlng10%a week.
B. ll you cut your wo.kout50% and sllll have pain,cut it by 50%agalnand progress
by addlng10oloa week.
(D) Bunnlngroutine
+ strelch+ runas prescribed
+ icemassage(10 minutes)
moistheat(5 mlnutes)
At nlght:moistheat(20 minutes)+ stretch
weight||ft
backexercises
Flom Brcdy DM: Techniquesin the evaluationand troatmenlof tho lnlurodrunner.OrthopClln
NorthAm 13:541-558,1982;with permisslon.
THE SURGICALTREATMENTOF TENDINITIS
Actlvity
Onsotof AbuslveOveruse/Ovorload
(Ovenrelnhg)
I
SubctlnlLtn1ury
Cumulatlve
lrlcrolrauma
I
t
Olnlcal Crlsis
(palient pregeni8
In otflce
ilnjur€d')
I
CaretulHlrtory dnd PhyelcalExam
InltlalPlaln X-Faye
I
Y
REST'M
Emphaslson Ecc€ntrlc
R€habllltatlon Ex€rclsgs
and Corrsc{ionof Functlonal
BiomechanlcalDotlclts
/"rnrmum3-6
UnimprovBd
Grade lV Palnsnd
Los6of Parformgnce
I
ApproprlateRadlologlolmaglng
(MRl, arthrogram,triphasebono soan)
+/
guroory
\
ReconslderDlagnosls
(Rsl€rr€dpaln, ovsru8o
musclelmbalance,
dynamicllmb dysfunction)
Figure 12. Algorithmfor the tr€atmentof overusetendoninjury' Surgicaltrealm€ntis only
therapsutlcplan.
in an extenslve
ons altornativa
702
LEADBETTERet al
Flgure 13. Typicalfusilormswellingin Achillestendinosls.
ment of the endotenon site in repair. A consistent tendon enlargement is seen
to double the contralateral unoperated Achilles tendon over a period of 3 to 5
weeks (Fig. L6) followecl by gadual resolution, as is seen in the animal model,
which may take months (Figs. 17 and 18). In our hands, the recovery has been
tedious and somewhat unpredictable in a given individual. Running, jumping,
and sudden ballistic activity capability lags for an average of 3 to 6 months.
Morning stiffness and pain in initiation or after activity may be preseut for
several months. Walking sports and intermittent sports can be pursued within
6 to 12 weeks, especially if the Achilles insertiou has not been disturbed. Some
form of immobilization or casting has been required in most cases in which
calcaneal ostectomy has been required to control postoperative pain and to
avoid equinus ankle contracture. A modified shortened Aircast elbow support
has been found useful as a force dissipator used above the site of operation or
lesion both in the nonoperative and operative care of Achilles tendinosis as
well as in the postoperative return to protected activity phase (Fig. 19).
In patella tendinitis a paramedian incision is used to avoid tendenress with
kneeling owing to sensitive scar (Fig. 20). A hyperemic paratenon (Fig. 21) with
"fish flesh-like" tendinosis
typical
tissue upon longitudinal internal tenotomy
is found within the tendon (Fig. 22). Performing this procedure under Iocal
anesthesia is advocated by Colosimo and Bassettr5may be helpful in localizing
the lesion. Unless dystrophic calcification or stress reaction of the inferior pole
of the patella is docirmented radiographically, the surgical wound is linrited to
the point of maximal tendon tenderness. Excision of a persistent ossicle in
(Textcontinuedon page708)
.THESURGICALTREATMENTOF TENDINITIS
Flguro 14. Operativegrossapp€aranceof Achilleslendlnosls.Note the diffuse natureof
the lesion,
et aI
LEADBETTER
Flgurs 15. LongitudinalInternaltenotomyAchillostendinosis,Notethe remarkablybenlgn
grossmorphologlc
app€arance;
however,biopsywill revealcharacterlstic
patholojy.
THE SURGICALTREATMENTOF TENDINITIS
t€notomy'Not€
Flgure 16. Postoperativeappoaranceat 6 we€ksafter longiludlnalinternal
hypertrophy'
fibrosheath
and/or
mirkedtendon
PoSr ot'
Qlu:r-s
aflerlonglludlnalInternaltenotomyol Achilles
Flgure17.Typicatappesranceof.hypertrophy
postoporallvB.
w6eks
tendonI to 15
et al
LEADBETTER
wllh
Flgure 18, Anotherpatientwlth persistenthypertrophy,4 monthspostoperatlvely,
Internaltenotomy'
longltudinal
Ac'trllles
Flgure 19. Use of moditledAircastbandsallowsprotectedactlvitypro-or postoperatlvely.
THE SURCICALTREATMENTOF TENDNITIS
Flgure 20. Typicalsurgicallechnlquein patellatendinosis.
Flgure 21. Patellatondonoperativesile; not€ Increasedvascularity'
708
LEADBETTERet al
Flgure22. OperativB
view ol longitudinalinternaltonotomypatellatondon;noto tendinosis
tissue(anow).
Osgood-Schlatter disease may also be performed. In heatment of persistent
Osgood-Schlatterdisease, relief of pain is predictable, but the surgery does not
result in certain cosmetic improvement owing to the generation ofhyi:ertrophic
scar (Fig.- 23). This is especially pertinent to the expcctations in the young
female athlete. Postoperative immobilization after patella tendon surgerv has
been a minimal requirement, with partial weight bearing allowed fo"r f to Z
weeks followed by progressive exerclse.
We-shongly believe that the observations of Clement et altain the management of nonoperative Achilles tendinitis apply as well as to postoperative
management in that an asymptomatic postoperative patient can easily precipitate,a severe relapse with too aggressive a transition in activity returri.t'This is
further understandable given the known persistent shuctural and biomechanical changes in_the operated tendon, Also important is an analysis of conhibuting structural or dynamic lower leg dysfunction, which is irften found to
have precipitated the tendon injury. An appropriate orthotic or shoe modification.with {ight elevation of the heel in Achilles tendon problems is usually
presoibed. One of us (WB!) has found the Aircast elbowband supplied in a
sho-rterfornr quite adaptable to force dissipation at the Achilles bofh in preand postoperativemanagement,
_ In the upper extremity, the technique of Nirschls provides reliable success
for extensor and flexor tendon origin injury, Interestingly, it would appear
THE SURGICALTREATMENTOF TENDINITIS
709
Noto resldualswelllngand scar
Flgule 23. PatientappearanceI weekspostoperatively.
hypertrophY.
procedures
from the consistently high successreported by a diverse nurnber of
excision
in treatine tennis e$owihat the comriron biolirgic pathway of adequate
of structu"rally insufficient tissue-i'e., tendinosis, accomP.aruedty 11"-.i-1,::t-
of Cloyll fa51o11
release
Par111t1tf
rn.*.iio."fUr"eding andthecoincicient
from platelets, vascu'[ar endothelial cells, and activated fibroblasts-Provloes
that
i.jr sufficient scar repair to restore function. Those procedures
if,"l.i""trr
are mo'st direct have continued to stand the test of time'to
coNcLustoN
The rationale for surgical heatnent of tendinitis is to induce a modulation
repair
of the tendon cell-matrix"environment by promoting a renewed.wound
ts not
cvcle or bv the removal of aberrant tissue' The end result of such eltorts
b"i iu*oJ.t.a tendon, and scar repaired tendon.is indeed
;i;;;;*-tiii;-;;
remove
diFferent.In this scnse, surgeons often serve as scar movers' laborlng to
In tleatment,
.*aarru, or to reinforce *e^-"knestusin the connective tissue fabric'
will be
th.;; ilr ; delcate Uutu"ce-oi rirts and benefits, because normal tissue
immobilipostoperative
of
obF.gatory
period.
u.,y
*J
i;;a;;a;"ttdum"g"d,
and the-effEcts 6f iisuse'" In the absence
ruJt bringr"*itlti;tt"Pfiy
;;il;;;
"l .""tt"U"a .tudi and with soinany.variabl.es surrounding,th:,P:-*:1"1i1tu"
rt nas
manaqement incliding extended rest, immobilization, and rehabUltarron,
improvement
clinical
for
responsible
PostoPfactors
that"the
Li". E*rf,"if*a
;;tt established.' The insidious onset of the condition' its
;;;;;i;';;;;;f
.ottoi"tutiu" nature, and the lack of opportunity for tissue reassess;h";*'t
'
surgicalinsight' 1l: ryLiy,:lt?:
*u"i-fottop.iatively haveslowed.
it
that
fact
empiric
the
reriains
iiiury
in
tendon
emolov oDerativetreatment
tt"i..i
..*r; the main atg,rmenl a'gainstsurgicaltreatment.remains
*"iti'f"
the fact that the majority of the atfrletesdo iot require such intervention and
710
et al
LEADBETTER
thatitdoesnotworkpredictablyineverycase-Nevertheless,awell-timed
tissue release
rrrni..f incision is the moJ po*"ifol sti^.ritts to,initial'e the local
this means to an
when
time
Unril
such
of
repair.
meaiatori
;rfl;;i;il.ett
surgeon"s decision.to oPerate should remain less
;i';t;;?.;;;;t-th"
influenced by dogma than judgmeut temPered by experrence'
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Wayne B. Leadbetter, MD
9711 Medical Center Drive, Suite 201
Rockv.ille,MD 20850