Vol.2, No.1, 21-25 (2014) Pain Studies and Treatment
Major physical but also psychological effects after
pain relief from surgical scraping in patients with
Achilles tendinopathy—A 1-year follow-up study
Anna Ruergård, Håkan Alfredson*
Department of Surgical and Perioperative Science Sports Medicine, University of Umeå, Umeå, Sweden;
*Corresponding Author: hakan.alfredsson@idrott.umea.se
Received 19 November 2013; revised 26 December 2013; accepted 17 January 2014
Copyright © 2014 Anna Ruergård, Håkan Alfredson. This is an open access article distributed under the Creative Commons Attribu-
tion License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited. In accordance of the Creative Commons Attribution License all Copyrights © 2014 are reserved for SCIRP and the owner of
the intellectual pro per ty Anna Ruergård, Håkan A lfredson. All Copyright © 2014 are guarded by law and by SCIRP as a guardian.
Treatment with Ultrasound (US) and Color Dop-
pler (CD)-guided surgical scraping has shown
good short-term clinical results in patients with
chronic painful midportion Achilles tendinopa-
thy. The objective was to prospectively follow
the patients 1-year after surgery. Materia l: Sixty-
four tendons in 47 patients (28 men and 19 wo-
men, mean age 52 (+/12 years) on different ac-
tivity levels) were in local anaestesia operated
with US+CD-guided surgical scraping. In 43/64
tendons, there was also removal of the plantaris
tendon. Methods: Questionnaires evaluating ac-
tivity level, VAS for pain during activity, satis-
faction with treatment result, and the SF-36
score (quality of life), were used before and
1-year after surgery. Results: At follow-up, the
mean VAS for pain during activity had decreased
from 62 (+/20) before surgery to 15 (+/15) after
surgery (p < 0.001). All patients were satisfied
with the result and had returned to full tendon
loading activity. There were no complications.
Both the physical and psychological parameters
in the SF-36 score had improved significantly.
Conclusions: For patients with chronic painful
midportion Achilles tendinopathy, US+CD-guid-
ed surgical scraping, often combined with plan-
taris tendon removal, seems to be an efficient
treatment method to rec over physically and psy-
Achilles; Tendinopathy; Midportion; Surgical
The Achilles tendon is the strongest and thickest ten-
don in the human body [1], but not/seldom exposed to
injury. Achilles tendinopathy is a disorder that has been
shown to be relatively common among runners [2-8].
There is often a chronicity, and the pain is mostly located
in the mid-porti o n of the Achilles tendon ( 55% - 60%) [8,
9]. The aetiology is unknown, but has been suggested to
be associated with overuse [4,6,7]. Running surface and
increased running distance have been proposed as causa-
tive factors [4,7]. However, non-active individuals also
suffer from midportion tendinopathy [10,11,12], and high
blood lipids have been shown to be relatively common
among these patients [12]. Men and women have been
found to be equally affected by Midpor tion Achilles ten -
dinopathy [13].
Neovascularisation/regions with high blood flow have
been found in patients with painful Achilles tendinopathy,
but not in normal tendons, therefore these regions have
been discussed to play a role in pain [14,15]. A lso, biop-
sies from the regions with Ultrasound (US) and Color
Doppler (CD) verified neovascularisation/high blood flow
have shown nerves in close relation to blood vessels out-
side, but not inside, the tendons [16 ].
Treatment has been known to be difficult, but new
methods like painful eccentric calf muscle training [17-
20] and US + CD-guided sclerosing polidocanol injec-
tion treatment [21-23] targeting the regions with neoves-
sels/high blood flow outside the tendon, has been shown
to be successful in a high proportion of the patients. Re-
cently, US + CD-guided surgical scraping, targeting the
regions with neovessels/high blood flow outside the ten-
don, was demonstrated to give very good clinical re-
sults, with a quick return to high loading Achilles tendon
activities [24].
Copyright © 2014 SciRes. O PEN A CCESS
A. Ruergård, H. Alfredson / Pain S tudies and Treatment 2 (2014) 21-25
Originating from the pop litea l surface of the femur, the
thin rudimentary plantaris muscle is found [25], and its
normally thin tendon has been shown to not seldom be
dramatically thickened and located in close relation to
the medial side of the Achilles midportion in patients
with Achilles tendinopathy [26,27]. Therefore, the plan-
taris tendon is thought to be involved in midportion ten-
dinopathy [24,26,28,29], possibly causing mechanical
interference. Promising clinical results has been seen
after surgical treatment combining the US+CD-guided
scraping with removal of the plantaris tendon [24,26].
The aim with this 1-year prospective study was to
evaluate tendon p ain during activity, patients satisfaction
with the treatment result, and quality of life one year
after treatment with US and CD-guided surgery in pa-
tients with mid-portion Achilles tendinopathy .
2.1. Participants
Ethics approval was obtained from the regional ethical
board for medical research at the Umeå University, Swe-
den. Informed consent was obtained from all patients
included in this study.
Sixty-four tendons in 47 consecutive Swedish patients
(28 men and 19 women, mean age 52 +/ 12 years) w ere
included. The patients activity levels differed from non-
actives (n = 6), recreational athletes (n = 36), elite recre-
ational athletes (n = 4) to elite level athlete (n = 1). In-
clusion criteria were: patients with a long (>3 months)
duration of Achilles tendon pain, eccentric training with-
out effect or inability to perform eccentric training be-
cause of back, hip, knee or ankle problems.
Duration of symptoms varied from three to 36 months
with an average of 11 months.
2.2. Clinical Examination
Clinical examination demonstrated a nodular thicken-
ing in the Achilles midportion, with tendern ess located at
the ventral and sometimes also medial side of the thick-
All patients were examined with high resolution grey
scale-ultrasound (US) and Color Doppler (CD) (Acuson
Segoia, Siemens), using a linear multifrequency (8 - 13
MHz) probe . CD was used to diagnose regions with high
blood flow, and to locate where the blood flow entered
the tendon. Both Achilles tendons were examined. In all
painful tendons US + CD examination showed a thick-
ened Achilles midportion, with irregular tendon structure
and locally high blood flow outside and inside the re-
gions with structural tendon changes.
2.3. Surgery
Ultrasound and Doppler-guided surgical scraping +
extirpation of the plantaris ten don.
After washing, a 5 - 10 ml of a local anaesthetic (Xy-
locain + Adrenaline, 5 mg/ml) was injected on the medial
and ventral side of the Achilles midpor tion. The skin was
then draped with a sterile paper-cover, exposing only the
midportion of the Achilles tendon.
A longitudinal skin incision (1 - 2 cm) was placed on
the medial side of the Achilles midportion, and the ten-
don was carefully identified. If a plantaris tendon was
found invaginated into the medial Achilles, or located
close by the medial or ventro-medial side, it was fol-
lowed and released distally and proximally, cut in both
ends, and extirpated. There was often a richly vascula-
rized fat tissue inter-positioned between the Ach illes and
the plantaris tendon. After removing the plantaris tendon,
the traditional scraping procedure was performed [24]. In
the regions with ultrasound and Doppler verified changes
and high blood flow the tendon was completely released
from the ventral soft tissue, by sharp dissection with a
knife, staying close to the ventral tendon. This was fol-
lowed by hemostasis, using diatermia. The skin was clos-
ed by single no n-resorbable sutures.
2.4. Postoperative Rehabilitation
Day 1 (Surgery day): Rest, elevated foot.
Day 2: ROM (Range of movement), light stretching,
and short walks.
Day 3 - 7: Gradually increased walking activity.
Day 8 - 14: Light bicycling.
After 2 weeks: Sutures out, gradually increased load
up to free activity.
2.5. Outcome Measures
A visual analogue scale (VAS) was used to evaluate
the amount of tendon pain during the patients individual
tendon loading activity (walking, recreational sport or
high level sport etc.). This is a 100 mm self-rep orting
scale were no pain is recorded as 0 and worst pain 100.
The 100 mm scale was also used to evaluate patients
satisfaction with the treatment result. Not satisfied at all
was recorded as 0 and full satisfaction was recorded as
For evaluation of the patients quality of life, the Swe-
dish version of the SF-36 (The Short Form 36 Health
Survey) was used. This questionnaire is divided into
eight sections with altogether 36 questions. The eight
sections consists of PF = Physical Functioning, RP =
Role-Physical, BP = Bodily Pain, GH = General Health,
VT = Vitality, SF = Social Functioning, RE = Role-
Emotional and MH = Mental Health, showing different
aspects in the patients qu ality of life. The results ar e then
calculated and range from a scale of 0 - 100, where 100
is representing the peak of life quality, in each section.
Copyright © 2014 SciRes. OPEN ACCESS
A. Ruergård, H. Alfredson / Pain S tudies and Treatment 2 (2014) 21-25
VAS for pain during activity and the SF-36 questionnaire
were used before surgical treatment and at the 1-year
2.6. Statistical Methods
SPSS (Statistical Package of Social Science) that has
been shown to be useful and reliable was used to analyze
the data (SPSS Inc., Chicago, Illinois, USA). All calcu la-
tions were measured on group level. Paired students
T-test was selected to identify differences before and one
year after surgery. Level of significance was set to p <
There were no complications related to the surgical
3.1. Tendon Pain during Achilles
Tendon-Loading Activity
At the 1 year follow-up, there was a significant (p <
0.001) decrease in the mean VAS for tendon pain during
activity, from 62 (+/−20) before surgery to 15 (+/− 15)
after surgery (Figure 1).
3.2. Satisf ac t i o n with Treatment Result
All patients were back in their habitual Achilles ten-
don loading activities. The mean satisfaction with the
result of the treatment was 88% (ranging from 33% to
3.3. Quality of Life One Year after Surgery
The results from the SF-36 questionnaire showed that
especially the ph ysical health was signif icantly improved
one year after surgery. Parameters: Physical functioning-
PF: from 71 (+/−20) before to 85 (+/−20) after (p <
0.001), Role Physical-RP: from 46 (+/−42) before to 81
Figure 1. Pain during Achilles tendon-loading activity. Visual
Analogue Scale (VAS) for tendon pain during tendon loading
activity, before and 1-year after surgery. ***= p < 0.001.
(+/−33) after (p < 0.001), Bodily Pain-BP: from 48
(+/−14) before to 71 (+/−23) after (p < 0.001), General
health- GH from 78 (+/− 17) before to 74 (+/−21) after
(p > 0.05), Vitality-VT: from 61 (+/−19) before to 64
(+/−22) after (p > 0.05), Social Functioning-SF: from 85
(+/−19) before to 89 (+/−20) a fter (p > 0.05), Role Emo-
tion-RE: from 73 (+/−40) before to 91 (+/−26 ) afte r (p <
0.05), and Mental health-MH: from 81 (+/− 15) before to
82 (+/− 16) after (p > 0.05) (Figure 2).
This 1-year follow-up study of patients with midpor-
tion Achilles tendinopathy, operated with the US + CD-
guided mini surgical scraping procedure [24,26], showed
very good clinical results with a major reduction of the
pain levels in satisfied patients back in full Achilles ten-
don loading activities. Interestingly, the treatment had
positive effects not only physically, but also psycho-
logically. To the best of our knowledge, this is the first
study investigating quality of life pre- and postopera-
tively in patients with th is diagnosis . We use the Swedish
version of the SF-36 (The Short Form 36 Health Survey)
questionnaire that shows different aspects of the individ-
ualsquality of life, and has been proved to be a reliable
method [ 30]. The sections with most sig nificant improve-
ment after surgery in our study were related to physical
function, showing that the patients were able to enjoy
physical activities without limitations and experienced
less pain in their daily life. The psychological parameter
Role Emotion-RE also improved significantly after sur-
gery, showing that emotional problems interfered less
with daily activities or work after, compared to before
treatment. It is interestin g to notice that patients suffering
from chronic painful midportion Achilles tendinopathy
suffer not only physically, but also psychologically. This
has, to the best of our knowledge, never been demon-
Figure 2. SF- 36 Score. Before surgery and 1-year aft er s urgery.
*= p < 0.05, **= p < 0.01, ***=p < 0 .001.
Copyright © 2014 SciRes. OPEN ACCESS
A. Ruergård, H. Alfredson / Pain S tudies and Treatment 2 (2014) 21-25
strated before, and indicates that it might be important to
try to cure these patients as soon as possible before the
emotional problems interferes to much with daily life
The mini surgical scraping procedure has in a previous
study been shown to be a successful treatment method
[24], but the results in this study, with all patients being
satisfied are unexpectedly good. Howev er, looking at the
scor es , it is important to notice that there is a wide range
(from 33% satisfied to 100% satisfied) in how satisfied
the patients are with the treatment result.
There are many advantages with this US+CD-guided
mini surgical procedure performed outside the tendon.
The operation is performed under local anesthesia, mini-
mizing risks related to general or spinal anaestesia. The
patients start walking the first day after the operation,
and only very few patients, having very heavy Achilles
tendon loading occupations, need to be on sick-leave for
a couple of weeks. Most patients are back in full Achilles
tendon loading sports within 4 - 6 weeks after the opera-
tion. There are very few complications related to this
treatment metho d, but awareness of proper wound car e is
To be able to reliably find the target for the surgical
scraping, US- and CD-guidance is needed. Combining
these two techniques makes it possible to minimize the
skin incision, and the tissue trauma during the scraping
procedure. This is, however, also complicating, because
US and CD equipment, and education how to use it and
interpret the findings, are needed. This might, initially,
limit the use of this treatment method, but in the longer
perspective we hope and believe, that US- and CD-
guided procedures will be more used. Altogether, the
benefits achieved motivate further, and most likely in-
creased, use of this treatment method.
In 2/3 (43/64) of the patients in the current study there
was also involvement of a nearby located plantaris ten-
don. From a cadaver study, it is known that the plantaris
tendon was most often lo cated about 1 cm away from the
medial side of the Achilles, but in about 10% of the spe-
cimens, the plantaris was located very close to and some-
times even inserting into the Achilles [25]. In a previous
study on patients with midportion Achilles tendinopathy,
undergoing the scraping procedure, it was demonstrated
that in a high proportion of the patients the plantaris ten-
don was found to be thickened, located close to, and pos-
sibly interfering, with the medial side of the Achilles ten-
don [26]. The findings in that study led to a routinely re-
moval of the plantaris in cases where it was found to be
located close to the medial Achilles. Histological exami-
nation of the excised thickened plantaris tendons showed
similar tendinosis changes as been demonstrated for the
Achilles tendinopathy tendons [26].
Comparing the surgical scraping method, with by us
the previously often used sclerosing polidocanol injec-
tion treatment, the major advantage with surgery is that
only one treatment is needed, compared to multiple in-
jection treatments (2 - 3 injections with 8 weeks in be-
tween). Consequently, the surgical scraping method
saves time, and economically it is also cheaper than 3
injection treatments.
A weakness with this study is that it is only a 1-year
follow-up. The results could maybe fade over time, but
on the other hand previous research on this surgical me-
thod shows that the failures tend to show up within the
first six months [24,26]. Another weakness is the use of
only a questionnaire follow-up. It would have been ideal
to also perform a clinical and ultrasoun d follow-up, but it
is unfortunately not possible due to logistical reasons.
For further studies, we b elieve that long term follo w-ups,
including ultrasound and Doppler examination are of im-
portance. There are indications that the tendon thickness
and structure improve over time in patients being pain-
free after this type of surgical treatment, and this re-
modeling would be interesting to study closer.
The results from the VAS and SF-36 scores show that
there are major individual variations, but based on our
experiences from having done multiple scientific studies
on similar patient materials, we strongly believe that the
scores are representative for patients with chronic painful
midportion Achilles tendinopathy .
In conclusion, this study shows that US + CD-guided
surgical scraping, often combined with plantaris tendon
removal, has beneficial effects both physically and psy-
chologically for p atients with chronic painful midpor tion
Achilles tendinopathy. This study showed a very high
1-year success rate with this treatment method.
We would like to thank Dr Peter Larsson for valuable help with the
statistical analyses.
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