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Objectives: Chronic painful insertional Achilles tendinopathy is known to be difficult to manage. The diagnosis is not always easy because multiple different tissues can be involved. The plantaris tendon has recently been described to frequently be involved in chronic painful mid-portion Achilles tendinopathy. This study aimed to evaluate possible plantaris tendon involvement in patients with chronic painful insertional Achilles tendinopathy., Methods: Ninety-nine consecutive patients (74 males, 25 females) with a mean age of 40 years (range 24-64) who were surgically treated for insertional Achilles tendinopathy, were included. Clinical examination, ultrasound (US)+Doppler examination, and surgical findings were used to evaluate plantaris tendon involvement., Results: In 48/99 patients, there were clinical symptoms of plantaris tendon involvement with pain and tenderness located medially at the Achilles tendon insertion. In all these cases, surgical findings showed a thick and wide plantaris tendon together with a richly vascularised fatty infiltration between the plantaris and Achilles tendon. US examination suspected plantaris involvement in 32/48 patients., Conclusion: Plantaris tendon involvement can potentially be part of the pathology in chronic painful insertional Achilles tendinopathy and should be considered for diagnosis and treatment when there is distinct and focal medial pain and tenderness., Level of Evidence: IV case series., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

There is a need for effective therapeutic options for resistant patellar tendinopathy. Ultrasound (US)-guided arthroscopic debridement has demonstrated promising clinical results., Objectives: To prospectively evaluate pain, function, tendon structure and adverse events after US and colour Doppler (CD)-guided arthroscopic debridement for persistent painful patellar tendinopathy., Materials and Methods: Twenty-three consecutive patients (19 males and 4 females, mean age 28 years (±8), symptom duration 25 months (±21)), who had failed conservative management including progressive loading, were included. US+CD and ultrasound tissue characterisation (UTC) examination verified the clinical diagnosis and quantified baseline tendon structure. Patients were treated with US+CD-guided arthroscopic debridement followed by a specific rehabilitation protocol. Outcomes were VISA-P score for pain and function and UTC for tendon structure. Adverse events were specifically elicited., Results: At 6-month follow-up, mean VISA-P score increased from 40 (±21.0) to 82 (±15) (mean deviation (MD)=42.0, 95% CI 32 to 53, d =2.4), while organised echo pixels (combined UTC type I+II) increased from 55.0% (±17.0) to 69.0% (±15.0) (MD=14.0, d =0.7, 95% CI 2 to 21). Both outcomes exceeded minimum detectable change values. Twenty-one participants returned to their prediagnosis activity levels, and there were no significant adverse events., Conclusions: US-guided patellar tendon debridement for persistent patellar tendinopathy improved symptoms and tendon structure without complications at 6-month follow-up. A majority (21/23) of the patients returned to their preinjury activity level. Further studies with longer follow-ups, preferably randomised and controlled, are needed., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Surgical removal of the plantaris tendon can cure plantaris-associated Achilles tendinopathy, a condition in which Achilles and plantaris tendinopathy coexist. However, rare cases with plantaris tendinopathy alone are often misdiagnosed due to a normal Achilles tendon., Design and Setting: Prospective case series study at one centre., Participants: Ten consecutive patients (9 men and one woman, mean age 35 years, range 19-67) with plantaris tendon-related pain alone in altogether 13 tendons were included. All had had a long duration (median 10 months, range 3 months to 10 years) of pain symptoms on the medial side of the Achilles tendon mid-portion. Preoperative ultrasound showed thickened plantaris tendon but a normal Achilles tendon., Interventions: Operative treatment consisting of ultrasound-guided excision of the plantaris tendon., Primary and Secondary Outcome Measures: Scores from Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A)were taken preoperatively and postoperatively (median duration 10 months). Patient satisfaction and time until full return to sports activity level was asked by a questionnaire., Results: The VISA-A scores increased from 61 (range 45-81) preoperatively to 97 (range 94-100) postoperatively (p<0.01). Follow-up results at 10 months (range 7-72 months) on 9/10 patients showed full satisfaction and return to their preinjury sports or recreational activity., Conclusion: The plantaris tendon should be kept in mind when evaluating painful conditions in the Achilles tendon region, especially when no Achilles tendinopathy is present. Excision of the plantaris tendon via a minor surgical procedure in local anaesthesia results in a good outcome., Competing Interests: Competing interests: None declared.

Objectives: The plantaris tendon has recently been described as a possible important factor in midportion Achilles tendinopathy. Ultrasound tissue characterisation (UTC) is a method to study tendon structure (matrix integrity). The effect of plantaris tendon removal on Achilles tendon structure was studied using UTC., Design and Setting: Prospective case series study at one centre., Participants: Nine tendons in eight physically active and healthy patients (mean age 39 years) with chronic painful midportion Achilles tendinopathy were included. Preoperative two-dimensional ultrasound and UTC showed midportion Achilles tendinopathy (tendinosis) with medial tendon changes and suspected plantaris tendon involvement. Patients with previous operations to the Achilles tendon were excluded., Interventions: Operative treatment consisted of excision of the plantaris tendon and scraping of the ventromedial surface of the Achilles tendon under a local anaesthetic., Primary and Secondary Outcome Measures: UTC examination and clinical scoring with the VISA-A questionnaire were performed preoperatively and 6 months postoperatively., Results: At 6 months follow-up, UTC demonstrated a statistically significant (t=5.40, p<0.001) increase in the mean organised matrix (echo-type I+II) and a decrease in the mean disorganised matrix (echo-type III+IV). Seven out of eight patients were satisfied, and the VISA-A score had increased significantly (p<0.001) from 56.8 (range 34-73) preoperatively to 93.3 (range 87-100) postoperatively., Conclusions: Excision of the plantaris tendon and scraping of the ventromedial Achilles tendon in chronic midportion tendinopathy seem to have the potential to improve tendon structure and reduce tendon pain. Studies on a larger group of patients and with a longer follow-up period are needed.