Journal of Foot and Ankle Surgery (Asia Pacific)

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VOLUME 9 , ISSUE 1 ( January-March, 2022 ) > List of Articles

Original Article

Minimally Invasive Stripping for Achilles Tendon: A Novel Option to Treat the Tendinopathy of the Main Body

Rocco Aicale, Annarita Fraccascia, Nicola Poeta, Nicola Maffulli

Keywords : Achilles tendinopathy, Ankle joint, Minimally invasive, Stripping

Citation Information : Aicale R, Fraccascia A, Poeta N, Maffulli N. Minimally Invasive Stripping for Achilles Tendon: A Novel Option to Treat the Tendinopathy of the Main Body. J Foot Ankle Surg Asia-Pacific 2022; 9 (1):2-5.

DOI: 10.5005/jp-journals-10040-1189

License: CC BY-NC 4.0

Published Online: 31-12-2021

Copyright Statement:  Copyright © 2022; The Author(s).


Achilles tendinopathy (AT) is commonly defined as failed healing response characterized by an increase in noncollagenous matrix and proliferation of altered tenocytes and degradation of collagen fibers. Diagnosis is made by clinical evaluation, and magnetic resonance imaging (MRI) or ultrasonography (US) imaging is used for differential diagnosis or is not a clear case. The first line of management is conservative, while open or minimally invasive techniques are considered in the second line. Generally, after 6 months of nonoperative management, surgery is indicated. Minimally invasive stripping of the Achilles tendon in case of tendinopathy of the main body is effective, inexpensive, and technically simple. However, randomized controlled trials (RCTs) with a control group and more patients are needed to confirm clinical outcomes.

  1. Longo UG, Ronga M, Maffulli N. Achilles tendinopathy. Sports Med Arthrosc Rev 2009;17(2):112–126. DOI: 10.1097/JSA.0b013e3181a3d625.
  2. Aicale R, Tarantino D, Maffulli N. Basic science of tendons. In: Bio-orthopaedics [Internet]. Berlin, Heidelberg: Springer; 2017. pp. 249–273. Disponibile su:
  3. Maffulli N, Aicale R. Update on non-insertional Achilles tendinopathy. Fuß Sprunggelenk 2019;17(4):248–256. DOI: 10.1016/j.fuspru.2019.09.002.
  4. Maffulli N, Sharma P, Luscombe KL. Achilles tendinopathy: aetiology and management. J R Soc Med 2004;97(10):472–476. DOI: 10.1258/jrsm.97.10.472.
  5. Maffulli N, Via AG, Oliva F. Chronic Achilles tendon disorders: tendinopathy and chronic rupture. Clin Sports Med 2015;34(4):607–624. DOI: 10.1016/j.csm.2015.06.010.
  6. Tol JL, Spiezia F, Maffulli N. Neovascularization in Achilles tendinopathy: have we been chasing a red herring? Knee Surg Sports Traumatol Arthrosc 2012;20(10):1891–1894. DOI: 10.1007/s00167-012-2172-6.
  7. Aicale R, Tarantino D, Maffulli N. Non-insertional Achilles tendinopathy: state of the art. In: Canata GL, d'Hooghe P, Hunt KJ, et al. Sports injuries of the foot and ankle [Internet]. Berlin, Heidelberg: Springer Berlin Heidelberg; 2019. pp. 359s–367. Disponibile su:
  8. Aicale R, Oliviero A, Maffulli N. Management of Achilles and patellar tendinopathy: what we know, what we can do. J Foot Ankle Res 2020;13(1):59. DOI: 10.1186/s13047-020-00418-8.
  9. Alfredson H, Ohberg L, Forsgren S. Is vasculo-neural ingrowth the cause of pain in chronic Achilles tendinosis? An investigation using ultrasonography and colour Doppler, immunohistochemistry, and diagnostic injections. Knee Surg Sports Traumatol Arthrosc 2003;11(5):334–338. DOI: 10.1007/s00167-003-0391-6.
  10. Knobloch K. The role of tendon microcirculation in Achilles and patellar tendinopathy. J Orthop Surg 2008;3(1):18. DOI: 10.1186/1749-799X-3-18.
  11. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med 2009;43(6):409–416. DOI: 10.1136/bjsm.2008.051193.
  12. McLauchlan G, Handoll HH. Interventions for treating acute and chronic Achilles tendinitis. Cochrane Database Syst Rev 2001(2):CD000232. DOI: 10.1002/14651858.CD000232.
  13. Ames PRJ, Longo UG, Denaro V, et al. Achilles tendon problems: not just an orthopaedic issue. Disabil Rehabil 2008;30(20–22):1646–1650. DOI: 10.1080/09638280701785882.
  14. Thampatty BP, Wang JH-C. Mechanobiology of young and aging tendons: in vivo studies with treadmill running. J Orthop Res 2018;36(2):557–565. DOI: 10.1002/jor.23761.
  15. Kannus P, Józsa L. Histopathological changes preceding spontaneous rupture of a tendon. A controlled study of 891 patients. J Bone Joint Surg Am 1991;73(10):1507–1525. DOI: 10.2106/00004623-199173100-00009.
  16. Cook JL, Feller JA, Bonar SF, et al. Abnormal tenocyte morphology is more prevalent than collagen disruption in asymptomatic athletes’ patellar tendons. J Orthop Res 2004;22(2):334–338. DOI: 10.1016/j.orthres.2003.08.005.
  17. Parmar C, Meda KP. Achilles tendon rupture associated with combination therapy of levofloxacin and steroid in four patients and a review of the literature. Foot Ankle Int 2007;28(12):1287–1289. DOI: 10.3113/FAI.2007.1287.
  18. Bisaccia DR, Aicale R, Tarantino D, et al. Biological and chemical changes in fluoroquinolone-associated tendinopathies: a systematic review. Br Med Bull 2019;130(1):39–49. DOI: 10.1093/bmb/ldz006.
  19. Corrao G, Zambon A, Bertù L, et al. Evidence of tendinitis provoked by fluoroquinolone treatment: a case-control study. Drug Saf 2006;29(10):889–896. DOI: 10.2165/00002018-200629100- 00006.
  20. Magra M, Maffulli N. Nonsteroidal antiinflammatory drugs in tendinopathy: friend or foe. Clin J Sport Med 2006;16(1):1–3. DOI: 10.1097/01.jsm.0000194764.27819.5d.
  21. Magra M, Maffulli N. Molecular events in tendinopathy: a role for metalloproteases. Foot Ankle Clin 2005;10(2):267–277. DOI: 10.1016/j.fcl.2005.01.012.
  22. Magra M, Caine D, Maffulli N. A review of epidemiology of paediatric elbow injuries in sports. Sports Med Auckl NZ 2007;37(8):717–735. DOI: 10.2165/00007256-200737080-00005.
  23. Magra M, Hughes S, El Haj AJ, et al. VOCCs and TREK-1 ion channel expression in human tenocytes. Am J Physiol Cell Physiol 2007;292(3):C1053–C1060. DOI: 10.1152/ajpcell.00053.2006.
  24. Magra M, Maffulli N. Matrix metalloproteases: a role in overuse tendinopathies. Br J Sports Med 2005;39(11):789–791. DOI: 10.1136/bjsm.2005.017855.
  25. de Oliveira RR, Lemos A, de Castro Silveira PV, et al. Alterations of tendons in patients with diabetes mellitus: a systematic review. Diabet Med J Br Diabet Assoc 2011;28(8):886–895. DOI: 10.1111/j.1464-5491.2010.03197.x.
  26. Oliva F, Via AG, Maffulli N. Physiopathology of intratendinous calcific deposition. BMC Med 2012;10(1):95. DOI: 10.1186/1741-7015- 10-95.
  27. Oliva F, Berardi AC, Misiti S, et al. Thyroid hormones and tendon: current views and future perspectives. Concise review. Muscles Ligaments Tendons J 2013;3(3):201–203. DOI: 10.32098/mltj.03.2013.12.
  28. Mokone GG, Gajjar M, September AV, Schwellnus MP, Greenberg J, Noakes TD, et al. The guanine-thymine dinucleotide repeat polymorphism within the tenascin-C gene is associated with achilles tendon injuries. Am J Sports Med 2005;33(7):1016–1021. DOI: 10.1177/0363546504271986.
  29. Mokone GG, Schwellnus MP, Noakes TD, et al. The COL5A1 gene and Achilles tendon pathology. Scand J Med Sci Sports 2006;16(1):19–26. DOI: 10.1111/j.1600-0838.2005.00439.x.
  30. Aicale R, Tarantino D, Maccauro G, et al. Genetics in orthopaedic practice. J Biol Regul Homeost Agents 2019;33(2 Suppl. 1):103–117.
  31. Khan KM, Maffulli N. Tendinopathy: an Achilles’ heel for athletes and clinicians. Clin J Sport Med 1998;8(3):151–154. DOI: 10.1097/00042752-199807000-00001.
  32. Hutchison A-M, Evans R, Bodger O, Pallister I, Topliss C, Williams P, et al. What is the best clinical test for Achilles tendinopathy? Foot Ankle Surg 2013;19(2):112–117. DOI: 10.1016/j.fas.2012.12.006.
  33. Maffulli N, Oliva F, Loppini M, et al. The Royal London hospital test for the clinical diagnosis of patellar tendinopathy. Muscles Ligaments Tendons J 2017;7(2):315–322. DOI: 10.11138/mltj/2017.7.2.315.
  34. Williams JG. Achilles tendon lesions in sport. Sports Med Auckl NZ 1986;3(2):114–135. DOI: 10.2165/00007256-198603020-00003.
  35. Leadbetter WB. Cell-matrix response in tendon injury. Clin Sports Med 1992;11(3):533–578. DOI: 10.1016/S0278-5919(20)30507-X.
  36. Kader D, Saxena A, Movin T, et al. Achilles tendinopathy: some aspects of basic science and clinical management. Br J Sports Med 2002;36(4):239–249. DOI: 10.1136/bjsm.36.4.239.
  37. Sayana MK, Maffulli N. Eccentric calf muscle training in non-athletic patients with Achilles tendinopathy. J Sci Med Sport 2007;10(1):52–58. DOI: 10.1016/j.jsams.2006.05.008.
  38. Maffulli N, Peretti GM. Treatment decisions for acute Achilles tendon ruptures. Lancet Lond Engl 2020;395(10222):397–398. DOI: 10.1016/S0140-6736(19)33133-2.
  39. Paavola M, Kannus P, Paakkala T, et al. Long-term prognosis of patients with achilles tendinopathy. An observational 8-year follow-up study. Am J Sports Med 2000;28(5):634–642. DOI: 10.1177/03635465000280050301.
  40. Aicale R, Bisaccia RD, Oliviero A, et al. Current pharmacological approaches to the treatment of tendinopathy. Expert Opin Pharmacother 2020(12):1–11. DOI: 10.1080/14656566.2020. 1763306.
  41. Aicale R, Tarantino D, Maffulli N. Surgery in tendinopathies. Sports Med Arthrosc Rev 2018;26(4):200–202. DOI: 10.1097/JSA.0000000000000214.
  42. Maffulli N, Testa V, Capasso G, et al. Results of percutaneous longitudinal tenotomy for Achilles tendinopathy in middle- and long-distance runners. Am J Sports Med 1997;25(6):835–840. DOI: 10.1177/036354659702500618.
  43. Testa V, Maffulli N, Capasso G, et al. Percutaneous longitudinal tenotomy in chronic Achilles tendonitis. Bull Hosp Jt Dis N Y N 1996;54(4):241–244.
  44. Testa V, Capasso G, Benazzo F, et al. Management of Achilles tendinopathy by ultrasound-guided percutaneous tenotomy. Med Sci Sports Exerc 2002;34(4):573–580. DOI: 10.1097/00005768-200204000-00002.
  45. Longo UG, Ramamurthy C, Denaro V, et al. Minimally invasive stripping for chronic Achilles tendinopathy. Disabil Rehabil 2008;30(20–22):1709–1713. DOI: 10.1080/09638280701786922.
  46. Maffulli N, Oliva F, Maffulli GD, et al. Minimally invasive Achilles tendon stripping for the management of tendinopathy of the main body of the Achilles tendon. J Foot Ankle Surg 2017;56(5):938–942. DOI: 10.1053/j.jfas.2017.05.019.
  47. Maffulli N, Aicale R, Tarantino D. Autograft reconstruction for chronic Achilles tendon disorders. Tech Foot Ankle Surg 2017;16(3):117–123. DOI: 10.1097/BTF.0000000000000154.
  48. Tallon C, Coleman BD, Khan KM, et al. Outcome of surgery for chronic Achilles tendinopathy. A critical review. Am J Sports Med giugno 2001;29(3):315–320. DOI: 10.1177/03635465010290031101.
  49. Maffulli N, Longo UG, Kadakia A, et al. Achilles tendinopathy. Foot Ankle Surg 2020;26(3):240–249. DOI: 10.1016/j.fas.2019.03.009.
  50. Maffulli N, Longo UG, Denaro V. Novel approaches for the management of tendinopathy. J Bone Jt Surg - Ser A 2010;92(15):2604–2613. DOI: 10.2106/JBJS.I.01744.
  51. Paavola M, Orava S, Leppilahti J, et al. Chronic Achilles tendon overuse injury: complications after surgical treatment. An analysis of 432 consecutive patients. Am J Sports Med 2000;28(1):77–82. DOI: 10.1177/03635465000280012501.
  52. Maffulli N, Oliva F, Testa V, et al. Multiple percutaneous longitudinal tenotomies for chronic Achilles tendinopathy in runners: a long-term study. Am J Sports Med 2013;41(9):2151–2157. DOI: 10.1177/0363546513494356.
  53. Maquirriain J. Surgical treatment of chronic achilles tendinopathy: long-term results of the endoscopic technique. J Foot Ankle Surg 2013;52(4):451–455. DOI: 10.1053/j.jfas.2013.03.031.
  54. Pearce CJ, Carmichael J, Calder JD. Achilles tendinoscopy and plantaris tendon release and division in the treatment of non-insertional Achilles tendinopathy. Foot Ankle Surg 2012;18(2):124–127. DOI: 10.1016/j.fas.2011.04.008.
  55. Lohrer H, David S, Nauck T. Surgical treatment for achilles tendinopathy - a systematic review. BMC Musculoskelet Disord 2016;17(1):207. DOI: 10.1186/s12891-016-1061-4.
  56. Baltes TPA, Zwiers R, Wiegerinck JI, et al. Surgical treatment for midportion Achilles tendinopathy: a systematic review. Knee Surg Sports Traumatol Arthrosc 2017;25(6):1817–1838. DOI: 10.1007/s00167-016-4062-9.
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