INJURY CLINIC

Sports Med 2000 Feb; 29 (2): 135-146 0112-1642/00/0002-0135/$20.00/0 Adis International Limited. All rights reserved.

Chronic Achilles Tendinosis

Recommendations for Treatment and Prevention
Hkan Alfredson1 and Ronny Lorentzon2
1 Department of Surgical and Perioperative Science, Ume University, Ume, Sweden 2 Department of Musculoskeletal Research, National Institute for Working Life, Ume, Sweden

Contents
Abstract . . . . . . . . . . . . . . . . . . . . 1. Definition of Terms . . . . . . . . . . . . . . . 2. Treatment . . . . . . . . . . . . . . . . . . . . 2.1 Conservative Treatment . . . . . . . . . 2.1.1 Directed at Aetiological Factors 2.1.2 Symptomatic Approach . . . . . 2.1.3 Combination Treatment . . . . . 2.1.4 Recent Studies . . . . . . . . . . . 2.2 Surgical Treatment . . . . . . . . . . . . 2.3 Postoperative Rehabilitation . . . . . . 2.4 Complications of Surgery . . . . . . . . 3. Prevention . . . . . . . . . . . . . . . . . . . . 4. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 136 137 138 138 138 139 139 141 142 143 143 144

Abstract

Chronic Achilles tendinosis is a condition with an unknown aetiology and pathogenesis that is often, but not always, associated with pain during loading of the Achilles tendon. Histologically, there are no inflammatory cells, but increased amounts of interfibrillar glycosaminoglycans and changes in the collagen fibre structure and arrangement are seen. In situ microdialysis has confirmed the absence of inflammation. It is a condition that is most often seen among recreational male runners aged between 35 and 45 years, and it is most often considered to be associated with overuse. However, this condition is also seen in patients with a sedentary lifestyle. Chronic Achilles tendinosis is considered a troublesome injury to treat. Nonsurgical treatment most often includes a combination of rest, NSAIDs, correction of malalignments, and stretching and strengthening exercises, but there is sparse scientific evidence supporting the use of most proposed treatment regimens. It has been stated that, in general, nonsurgical treatment is not successful and surgical treatment is required in about 25% of patients. However, in a recent prospective study, treatment with heavy load eccentric calf muscle training showed very promising results and may possibly reduce the need for surgical treatment of tendinosis located in the midportion of the Achilles tendon. The short term results after surgical treatment are frequently very good, but in the few studies with long term follow-up there are signs of a possible deterioration with time. Calf muscle strength takes a long time to recover and, furthermore, a prolonged progressive calcaneal bone loss has been shown on the operated side up to 1 year after surgical treatment.

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The Achilles tendon is the largest and strongest tendon in the human body. It has been shown to have a high capacity to withstand tensional forces, and during direct measurements on the human Achilles tendon, forces of 9kN (corresponding to 12.5 times bodyweight) have been recorded during running at a speed of 6 m/sec.[1] Chronic painful conditions located in the Achilles tendon are relatively common, especially among runners.[2-14] The aetiology of chronic painful conditions in the tendon is unknown, but in athletes it is often associated with overuse from repetitive loading.[15-18] However, these conditions are also seen in individuals who are not physically active.[12,19] In a large group of patients with chronic Achilles tendinopathy, strm[19] found that physical activity was not correlated with histopathology. He suggested that physical activity could be more important in provoking the symptoms than being the cause of the actual lesion. Suggested aetiological factors include:[4,5,7,10,18-22] aging with a decreased blood supply and decreased tensile strength muscle weakness and imbalance insufficient flexibility male gender overweight malalignments leg length discrepancy training errors with overloading improper equipment systemic diseases drug adverse events (fluoroquinolones, corticosteroids). Although clinically it is often not difficult to obtain a diagnosis, there are many possible differential diagnoses: anomalous soleus muscle, os trigonum syndrome, tenosynovitis or dislocation of the peroneal tendons, tenosynovitis of the plantar flexors, tarsal tunnel syndrome, tumours of the Achilles tendon (xanthomas) and neuroma of the suralis nerve.[10] Therefore, besides the clinical examination, ultrasonography,[23,24] magnetic resonance imaging[25] and biopsy[26] have been shown to be helpful tools for a correct diagnosis and a
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solid establishment of the clinical diagnosis in scientific studies. 1. Definition of Terms The nomenclature for a chronic painful condition in the Achilles tendon is confusing, and most often does not reflect the pathology of the tendon disorder.[26] Terms such as tendinitis and tendonitis are often used, even though inflammatory cell infiltration in the tendon is not shown in biopsies.[6,27-29] Also, a recent investigation using a microdialysis technique confirmed that there were no signs of inflammation (normal prostaglandin E2 levels).[30] Local degenerative changes in the tendon have been named tendinosis.[31] However, the term degenerative does not have a standard description but is instead associated with a variety of histological entities, such as: hypoxic degeneration, mucoid or myxoid degeneration, hyaline degeneration, fatty degeneration, fibrinoid degeneration, fibrocartilaginous metaplasia, bony metaplasia, calcification, abnormal tendon structure, nodular thickening, irregular fibre structure, poor fibre orientation, greyish discolouration of ground substance and tendon oedema, focal hypercellularity, vascular proliferation in the tendon, or different combinations of these entities.[6,10,18,28,29,31,32] Degenerative changes are not always associated with pain, and have been shown histologically in one-third of asymptomatic individuals.[33] strm and Rausing[34] used the term chronic tendinopathy and Rolf and Movin[12] used achillodynia for patients with a long duration of a painful condition in the Achilles tendon. Ljungqvist,[35] Denstad and Roaas[36] and strm[19] proposed that the term partial rupture should be used for an injury where a clearly discernible partial discontinuity in the tendon can be demonstrated during the surgical procedure. In recent literature the term tendinosis has most often been used for patients with chronic painful conditions in the tendon, and where radiographic images or ultrasonography show a tendon disorder.[37-39] Recently, in a thesis by Movin,[26] the characteristic morphological features of tendinosis
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were shown to be changes in the collagen fibre structure and arrangement and an increased amount of interfibrillar glycosaminoglycans. The terms tendinosis and partial rupture are difficult to distinguish, especially in patients with a long duration of symptoms where the clinical findings and imaging findings are frequently identical. However, a partial rupture is most often associated with a sudden onset of pain, while in tendinosis there is a gradually increasing painful condition. However, a gradually increasing painful condition in the tendon might have started with a minor partial rupture and, therefore, tendinosis and partial rupture may in fact be co-existing or may possibly be regarded as the same condition. This was also discussed in a recent survey by strm and Rausing,[34] who showed that when examining the histopathology in biopsies from patients with chronic tendinopathy, the partial ruptures were always surrounded by a noninflammatory degenerative lesion (tendinosis). However, it is not known whether the changes in the tendon associated with tendinosis precede the partial rupture, or if the partial rupture initiates the tendinosis. In conclusion, we believe that the terms tendinitis, tendonitis, degenerative changes, chronic tendinopathy, achillodynia and partial rupture (if the cases with a sudden onset of severe pain are excluded) most likely all imply changes in the Achilles tendon that can be defined as tendinosis. Clinical reports on patients with chronic Achilles tendon pain often demonstrate changes both in the paratendineal tissue and in the tendon itself.[12,28,31,34,39] In a survey of 163 patients with chronic Achilles tendon pain, strm and Rausing[34] reported surgical findings showing tendon pathology associated with partial rupture in 19%, tendinosis in 67%, and paratendinous pathology in 40% of the patients. In a study by Movin et al.[40] on 40 patients with chronic mid-portion achillodynia and an ultrasonographically widened tendon, macroscopically abnormal paratenon was found in 19 patients (48%) and tendinosis was found in all 40 patients. Tendinosis is most often associated with chronic painful conditions located in the midportion (1.5 to 7cm proximal to the insertion in the
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Fig. 1. A painful localised swelling in the tendon is a common clinical finding of chronic Achilles tendinosis.

calcaneus) of the tendon, but also exists in the proximal and distal (tendon-bone junction) parts of the tendon. In the tendon-bone junction, it has to be taken into account that there are other structures than the tendon and paratendinous structures that may cause a painful condition. There might be a retrocalcaneal or superficial bursitis,[41] an impingement between the posterior part of the calcaneus and the Achilles tendon (Haglunds deformity),[42,43] a bone fragment (calcification or avulsion fragment) or sometimes a mixture of tendon, bursae and bone pathology.[10] Tendinosis may also exist in patients with acute or subacute Achilles tendon pain, but there are no histopathological data available on this group of patients. Therefore, in the remainder of this article, we will focus on the treatment of patients with a long duration of symptoms from a painful condition located in the mid-portion of the Achilles tendon, i.e. chronic Achilles tendinosis. A painful localised swelling in the tendon is a common clinical finding of this condition (fig. 1). 2. Treatment When discussing the recommendations for treatment, the terms tendinitis, tendonitis, degenerative changes, chronic tendinopathy, partial rupture, achillodynia and tendinosis are all used in the literature, but in patients with a long duration
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of symptoms they can probably be considered as the same, or close to the same, condition. It is important to realise that there is sparse scientific evidence for most of the conservative treatments proposed in section 2.1 and used in patients with chronic painful conditions in the Achilles tendon. The limited number of prospective scientific studies, and the absence of studies comparing different types of conservative treatment regimens in a randomised manner, are a major disadvantage when evaluating the effects of specific treatment regimens.
2.1 Conservative Treatment

Nichols[7] emphasised the importance of rest, and suggested a period of rest with a duration depending on how much the Achilles tendon pain was restricting the specific activity. If pain restricts performance, a complete or modified (with alternative training methods) rest should be recommended.
Decreased Flexibility

Stretching exercises have been proposed as an essential treatment method for many years.[4,5,41,47,53]
Muscle Weakness

Most authors recommend a conservative treatment regimen as the initial strategy.[4,5,7,10,16,18,44,45]

2.1.1 Directed at Aetiological Factors

The initial treatment can be directed towards presumed aetiological factors.

Biomechanical Divergences

This includes correction of excessive pronation,[4,5,20,46,47] correction of underpronation by using a heel lift on the lateral side,[48] correction of forefoot or rearfoot varus[5,49] and heel lifts for relaxation of tight calf muscles.[4,5] strm[19] has shown, in a thesis including 362 consecutive patients with chronic Achilles tendinopathy and 147 control patients, that biomechanical abnormalities were not important in chronic Achilles tendinopathy. He questioned the value of orthotics in the treatment of this condition. In a randomised prospective study including 33 patients with sports-induced Achilles tendinitis, no benefit of treatment with viscoelastic pads could be demonstrated.[50]
Training Errors

A progressive eccentric strength training programme has been proposed for tendon injuries in general.[16] Appel[54] suggested that a strength training programme, consisting of isometric and gradually increasing dynamic exercises, should be initiated as soon as possible after injury to prevent atrophy caused by pain-induced immobilisation. Renstrm[55] and Jzsa and Kannus[18] underline the importance of minimising the period of immobilisation and thereby minimising muscle atrophy. Weak and easily fatigued muscles lose their ability to absorb shock and thereby increase the risk for further injuries in the muscle-tendon unit.[56]
Poor Equipment

Proper footwear with a good shock-absorbing capacity and a sole structure that allows normal motion may prevent injuries.[46,52,57]
2.1.2 Symptomatic Approach

Initial treatment can also be directed towards a symptomatic approach.

Corticosteroid Injections

James et al.[20] and Clancy (in DAmbrosia and Drez[51]) have noticed an association between increased mileage and interval training, running on sloping, hard or slippery roads, and Achilles tendon injuries. Welsh and Clodman[4] warned against indoor track running on a hard surface. Too much training too soon was stated by Brody[52] to be a cause of Achilles tendon injuries, and periods of modified rest with alternative training methods such as swimming and bicycling were recommended.
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The use of corticosteroid injections in the treatment of painful conditions in the Achilles tendon is controversial.[18,58] Several authors have found frequent partial ruptures after corticosteroid injections were used to treat chronic painful conditions.[21,28,35,59,60] In a retrospective study of 342 patients with chronic tendinopathy, treatment with corticosteroid injections was shown to predict a partial rupture.[14] Leppilahti et al.[8] reported that 72 out of 150 patients who were surgically treated for chronic Achilles tendon pain had previously been treated with corticosteroid injections, indicating a poor effect of corticosteroids on this condition.
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However, it may well be that the more severe cases in that study were those treated with corticosteroids, and were then eventually surgically treated. Therefore, it may be difficult to discern a cause-effect relationship from that type of investigation. In any case, it does not seem logical to use corticosteroid injections in the treatment of a condition where there are no signs of inflammation, either histologically or by the microdialysis technique.[30]
NSAIDs

NSAIDs are frequently being used as part of the initial treatment.[6,29,38,61] However, in a randomised, double-blind, placebo-controlled study of 70 patients with chronic painful tendinopathy, oral medication with piroxicam was shown to have similar results to placebo.[62] For the purpose of pain control, other medications, with fewer adverse effects, can be used.
Other Treatments

Local cold therapy,[5] heat,[63] massage,[64] ultrasound,[65] electrical stimulation[66] and laser therapy[67] have all been suggested to be effective treatment modalities for chronic Achilles tendon pain, but there are, to our knowledge, no well controlled clinical studies that confirm their effects.
2.1.3 Combination Treatment

Most commonly, initial treatment consists of a combination of attack points. Many different designs of combined rehabilitation models have been proposed. Most of them include a combination of rest (complete or modified), orthotic treatment (heel lift, change of shoes, corrections of malalignment), medication (NSAIDs, corticosteroids, cold therapy), stretching and massage, and strength training.[4,5,7,16,18,21,44] For the treatment of running athletes with Achilles tendinitis, Welsh and Clodman[4] suggested a combination of modified rest, local cold therapy (cold pack) and NSAIDs, followed by stretching exercises, correction of improper shoes, application of a heel lift and correction of training regimen. Clement et al.[5] have reported good results with a treatment regimen focusing on avoiding immobilisation, control of inflammation and pain, strength train Adis International Limited. All rights reserved.

ing and stretching for the gastrocnemius/soleus muscle-tendon unit, and control of biomechanical parameters. However, more than 20% of the patients were lost to follow-up. An initial treatment consisting of relative rest, NSAIDs, cold therapy, heel lifts, correction of biomechanical abnormalities and rehabilitation of the gastrocnemius/soleus muscle-tendon unit was recommended by Nichols.[7] Sandmeier and Renstrm[44] emphasised modification of training programmes, change of shoes, stretching and strengthening programs. El Hawary et al.[68] stated that, theoretically, the chronically injured tendon will heal in much the same way as the acute tendon injury. However, this theory has not been proven and it is difficult to know the stage of healing of the tendon because the precise time of injury is unknown. They proposed that the rehabilitation programme should follow the stage of healing, with rest, NSAIDs and cold therapy in the inflammatory phase, a gradual introduction of stress on the tendon during the proliferation phase, and a progressive stress on the tendon during the remodelling phase. Saltzman and Tearse[69] proposed a combination of rest, ice massage, NSAIDs and a heel lift, followed by alternative training methods such as aqua jogging and bicycling, and a gradual and structured return to previous activity. They also emphasised the importance of identifying training errors and correction of possible muscle stiffness and weakness. However, we re-emphasise that all the proposals mentioned above are not based on reliable scientific evidence.
2.1.4 Recent Studies

In a recent prospective, uncontrolled pilot study,[45] we reported excellent results in 15 recreational athletes with chronic Achilles tendinosis who were treated with a specially designed heavy load eccentric calf muscle training programme. In all patients, localised changes in the tendon (at the 2 to 6cm level from the insertion into the calcaneus), corresponding to the painful area, were seen on ultrasonography. All patients had tried conventional treatment (rest, NSAIDs, change of shoes, orthoses, physical therapy, ordinary training programmes)
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Fig. 2. Heavy load eccentric calf muscle training programme for patients with chronic Achilles tendinosis. (a) From an upright body position and standing with all bodyweight on the ventral half-part of the foot, with the ankle joint in plantar flexion lifted by the noninjured leg, the calf muscle was loaded eccentrically by having the patient lower the heel beneath the lever. (b) Eccentric calf muscle loading with the knee straight. (c) Eccentric calf muscle loading with the knee bent. (d) Elevating the load by adding weight in a backpack. (e) Elevating the load by adding weight in a weight machine.

without any effect on the Achilles tendon pain, and were on the waiting list for surgical treatment. The patients performed their eccentric exercises (fig. 2) twice daily, 7 days per week, for 12 weeks. After the 12-week training regimen, all 15 patients had no pain during running and jogging and had returned to their previous (before injury) activity level. No patients were operated on. The pain score (visual analogue scale 0 to 100mm) during activity (running) decreased from an average of 81.2 before the eccentric training regimen to 4.8 after the regimen. This group of patients has now been followed for around 2 years. One patient regained the Achilles tendon pain and was operated on, and the other 14 patients are still experiencing no pain during running and jogging and are active at their desired activity level. We have continued to treat patients who have been diagnosed with chronic Achilles tendinosis (at the 2 to 6cm level) with this type of programme, and out of the last 66 patients, only 4 patients (6%) have needed surgical treatment (unpublished data). We have no exact explanation for the good results but, theoretically, it could be the effects of loadinginduced hypertrophy and increased tensile strength in the tendon, or perhaps an effect of stretching, with a lengthening of the muscle-tendon unit and consequently less strain during ankle joint motion. Furthermore, the heavy load eccentric training regSports Med 2000 Feb; 29 (2)

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imen is painful to perform (in the early period the patients often experience severe pain during the exercise) and this training may induce some kind of alteration of pain perception from the tendon. Further studies on the possible mechanisms that can explain the effects of eccentric calf muscle training on Achilles tendon pain are needed, and extensive research is continuing at our clinic. Since the preliminary study described above[45] had no control groups, we have started a prospective randomised study comparing the eccentric training regimen with a concentric training regimen. We recently performed a preliminary analysis of 42 patients (21 patients in each training group) from that study. The results of that analysis confirmed our previous results with eccentric training, and also showed significantly better results with the eccentric training regimen compared with the concentric training regimen (unpublished data). There are major differences between the eccentric training regimen that Curwin and Stanish[16] proposed for tendon injuries in general, and our method with heavy load eccentric training proposed for chronic Achilles tendinosis.[45] Curwin and Stanish proposed eccentric training with gradually increasing speed, but emphasised that the exercise should be performed without experiencing any pain. Our proposal is that the eccentric exercise should be performed at a slow pace, and that the load should be of a magnitude great enough to be associated with pain in the tendon. We gradually increase the load when the patient can perform the exercise without experiencing any pain.
2.2 Surgical Treatment

Fig. 3. Straight longitudinal skin incision medial to the Achilles tendon during surgical treatment of chronic Achilles tendinosis.

Nonsurgical treatment (excluding the preliminary evidence of our eccentric training) is not always successful in patients with chronic painful conditions located in the Achilles tendon, and it is a general opinion that surgical treatment is needed in about 25% of these patients.[10] Frequency of surgery increases with patient age, duration of symptoms and occurrence of tendinopathic changes.[10] It is a difficult injury to treat. In general, about 20% of surgically treated patients require re-operation,
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and about 3 to 5% of patients have to give up their athletic career because of therapy-resistent pain in the Achilles tendon.[10] As mentioned in section 1, the nomenclature used in the literature for chronic painful conditions in the Achilles tendon is heterogenous, and we have included tendinitis, tendonitis, degenerative changes, chronic tendinopathy, achillodynia, partial rupture and tendinosis in the description of the different surgical approaches and postoperative rehabilitation. Furthermore, in the different reports the exact location of the painful condition is not always defined and, consequently, there could be a mixture of lesions situated in the midportion of the tendon and in the tendon-bone insertion. Various surgical techniques are being used. Most authors describe a technique using a straight longitudinal skin incision medial to the Achilles tendon (fig. 3),[6,9,12,29,32,35,51,69-72] and a few use a lateral incision.[11,34,39,72] The paratenon is incised with excision of macroscopic adhesions, and if the paratenon is macroscopically hypertrophic, parts of the paratenon are also excised.[6,11,12,28,29,32,34,39,51,69-72] A central longitudinal tenotomy is used for visualisation and excision of the macroscopic abnormal tissue in the tendon.[6,9,11,12,28,29,32,34-36,39,51,69-72] Most authors describe the use of a side-to-side suture (absorbable) to repair the area of excision, but if there has been an extensive debridement in the
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tendon some authors propose the use of reinforcement with a turned down tendon flap.[29,35,51,70,71] Maffuli et al.[13] recently reported promising results with percutaneous longitudinal tenotomy in middle and long distance runners with Achilles tendinitis (41 out of 52 patients had tendinous lesions) in whom conservative treatment had not been successful. The surgical technique is described as performance of multiple longitudinal incisions (sometimes called scarification) in the area of maximum swelling (checked by ultrasonography), and the probable effect is described as an improvement of the local circulation and thereby a return to a normal biochemistry in the tendon.
2.3 Postoperative Rehabilitation

There is a large variation in descriptions of and, unfortunately, often sparse information on, the methods used for postoperative rehabilitation. In the immediate postoperative period, some authors suggest immobilisation in a cast[6,11,12,29,34,35,39,72] (most often partial to full weight bearing), in a walking booth[69] or in a walker splint[9] for a different period of time (ranging from 2 to 8 weeks), whereas others propose nonweight-bearing rangeof-motion exercises.[9,13,32,71] Maffuli et al.[13] allowed full weight bearing after 2 to 3 days and jogging after 2 weeks. After the cast has been removed, range-of-motion and stretching exercises, preferably supervised by a physiotherapist, are recommended by most authors.[6,11,12,29,39,69,72] Ljungqvist[35] and Nelen et al.[29] have proposed the use of a heel lift the first weeks. Strength training for the calf muscles was started as soon as a normal range of motion has been regained. Most authors recommend a gradual return to sports when strength has been regained.[9,32,34,35,69,71,72] However, prospective strength measurements have only been reported in 3 studies: Alfredson et al.[11,39] and Maffuli et al.[13] Nelen et al.,[29] strm and Rausing[34] and Rolf and Movin[12] allowed a return to competitive sports around 3 months after surgery, and Leadbetter et al.[32] 3 to 6 months after surgery. Schepsis et al.,[71] Soma and Mandelbaum,[9] Alfredson et al.[11,39] and
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Saltzman and Tearse[69] recommend a return to competitive sports around 5 to 6 months after surgery. At our clinic, we have shown in 2 prospective studies that despite the patients undergoing a supervised stepwise increasing flexibility and strength (concentric and eccentric) training programme, it took a long time to recover calf muscle strength (both concentric and eccentric strength) on the injured side after surgery.[11,39] The injured side was significantly weaker compared to the noninjured side 6 to 12 months after surgery. There was no obvious advantage in recovery of muscle strength with a short immobilisation time (2 weeks)[39] versus a longer (6 weeks)[11] period. However, the patients in both studies were experiencing no pain during running and jogging and were and participating in sports at their pre-injury activity level around 6 months after surgery. In another prospective study,[73] we also demonstrated that there was a prolonged progressive calcaneal bone loss at the operated side in patients surgically treated for chronic Achilles tendinosis. Around the time when the patients were pain free and returned to their sports (after 6 to 12 months), the calcaneus had a relatively low bone mass (16 to 18% lower on the injured side) and might possibly be vulnerable to heavy loadings. Maffuli et al.[13] measured isometric muscle strength, and showed that isometric endurance was still markedly reduced 6 months after surgery. The results after surgical treatment have been reported to be satisfactory, with good short term results obtained in 80 to 100% of patients. However, there are few prospective studies and few studies with a long term follow-up. In a report by Leppilahti et al.[8] with follow-up during a 4-year period, 29 out of 52 patients (56%) who underwent surgery for tendinosis in the midportion of the Achilles tendon had an excellent or good result. Schepsis et al.[71] reported in a long term follow-up (range 1 to 13 years) study, including 15 competitive or serious recreational runners with tendinosis, that 67% of these patients had a satisfactory result. In that report there were signs of a deterioration with time. In a follow-up (range 2 to 7 years) report
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by Nelen et al.[29] on 50 patients surgically treated for tendinosis, 40 patients (80%) had an excellent or good result. Morberg et al.[72] reported that 20 out of 25 patients (80%) surgically treated for chronic pain from a partial rupture in the midportion of the Achilles tendon had an excellent or good result at follow-up (range 1.5 to 11 years) postoperatively. After percutaneous longitudinal tenotomy,[13] 37 out of 48 patients (77%) had an excellent or good result at follow-up ranging from 1.5 to 5 years after surgery. In a report by Rolf and Movin,[12] a follow-up (range 1 to 4.2 years) on 40 patients surgically treated for intratendinous pathology showed excellent or good results in 77% of patients.
2.4 Complications of Surgery

Relatively few complications to surgery have been reported. Nelen et al.[29] reported a complication rate of 4.7%, including 6 patients with skin edge necrosis, 1 patient with superficial wound infection and 1 patient with thrombophlebitis, out of 170 surgically treated patients. In a study by Leppilahti et al.,[8] a complication rate of 8% in 150 surgically treated patients was reported, including 5 patients with skin edge necrosis (3 patients needed skin flap plasty), 4 patients with a superficial wound infection and 3 patients with a compression of the sural nerve. Maffuli et al.[13] reported 1 superficial infection and 4 subcutaneous haematomas in 48 patients surgically treated with percutaneous longitudinal tenotomy. However, Rolf and Movin[12] reported a relatively high complication rate (13%) in 60 surgically treated patients, consisting of 2 deep and 2 superficial infections, 2 lower leg deep vein thromboses and 1 total Achilles tendon rupture. 3. Prevention It is a general opinion that overuse injuries are caused by an interplay between intrinsic and extrinsic factors. However, it is important to keep in mind that there are few prospective controlled studies, and that most hypotheses lack substantiating evidence. Most authors seem convinced that the chronic painful condition in the Achilles tendon is a result of overuse and is often combined with
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biomechanical abnormalities.[2-10,16,18,21,32,44,46,51] Therefore, identification and correction of risk factors associated with training and biomechanical alignment of the lower extremities are emphasised in the prevention strategies. However, it is interesting to notice that this condition is also seen in patients who do not participate in sports activities or other strenuous leg-loading activities.[12,19] Furthermore, in a large group of patients with chronic tendinopathy, no correlation was found between physical activity and the histopathology.[19] In that study, it was also shown that biomechanical abnormalities were not important in chronic Achilles tendinopathy, and the value of orthotics in the treatment of chronic tendinopathy was questioned. The importance of strength and flexibility training for the calf muscles is stressed by most authors.[10,18,44,46] It is known that muscle strength and flexibility decreases with age, and that chronic painful conditions in the Achilles tendon most commonly occur in middle-aged individuals.[10] In our studies of middle-aged patients (mean age 40.9 years) with chronic Achilles tendinosis,[39] we found that calf muscle strength on the injured side was significantly lower, both concentrically and eccentrically, compared with the noninjured side. These findings indicate that concentric and eccentric calf muscle training could be important in the prevention of chronic Achilles tendinosis. However, we do not know whether the relatively low calf muscle strength was the cause of tendinosis, or whether the changes in the tendon associated with tendinosis and Achilles tendon pain was the cause for the low muscle strength. It seems possible that muscle strength is involved in some way in this condition, and strength training, both concentric and especially eccentric (which also increases the flexibility), may be helpful for prevention. Although not all patients are active in sports, there is a strong association between sports, especially running sports, and chronic painful conditions in the Achilles tendon. Often the combination too much training too soon is seen. It is tempting to believe that the activity of a certain individual (whether participating in sports or not) has exceeded
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the structural or metabolic capacity of the tendon in some way. But, what part of the tendon capacity has been exceeded? It is known that the tendon cells have the enzyme chains for all the 3 main pathways (tricarboxylic acid cycle, anaerobic glycolysis, pentose phosphate shunt) of energy metabolism,[18] and it is also known that the metabolic pathways used for production of energy in the tendon change from aerobic to more anaerobic with aging.[18,46] Aging is also associated with decreased strength. Therefore, theoretically, it is possible that the tendon needs to gradually be adapted to more anaerobic demands, and also to be strengthened. During heavy load eccentric calf muscle training, the extension and high tension of the tendon might, theoretically, cause ischaemic conditions in the tendon. This has also been indicated during dynamic ultrasonography examinations in patients with chronic Achilles tendinosis, where we have seen that during stretching of the tendon the diameter of the associated blood vessels decreases (unpublished data). Theoretically, this might be one explanation for the good preliminary results achieved with heavy load eccentric calf muscle training in patients with chronic Achilles tendinosis.[45] Furthermore, in recreational athletes (mean age 44.3 years) with chronic Achilles tendinosis, a significant increase in both eccentric and concentric calf muscle strength has been demonstrated after a 12-week heavy load eccentric training regimen.[45] Therefore, it seems possible that eccentric calf muscle training could be included in strategies for prevention of chronic painful conditions in the Achilles tendon, and that training regimens for different sports or recreational activities will include a gradual adaption to eccentric loadings. In a recently finished experimental study at our clinic,[30] we demonstrated that it was possible to use the microdialysis technique to investigate metabolic events in the Achilles tendon. This is, to our knowledge, the first time that microdialysis has been performed in a human tendon. A microdialysis catheter was inserted into the Achilles tendon in patients with painful chronic Achilles tendinosis and in patients with normal Achilles tendons. We
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found that in tendons with tendinosis there were significantly higher concentrations of the excitatory neurotransmitter glutamate (central and peripheral pain registration), but not prostaglandin E2 (inflammation), compared with normal tendons. These results indicate that glutamate may be involved in the pain mechanism, and further underlines that there is no inflammation (normal prostaglandin E2 levels) in this chronic condition. The possibility of using the microdialysis technique in tendon tissue most certainly opens up a window to study metabolic events in tendons, and thereby allows for a better understanding of the normal and abnormal tendon. 4. Conclusions We believe that a diagnosis of chronic Achilles tendinosis can be suggested by clinical examination and confirmed by changes in the tendon shown by radiographic images and ultrasonographic techniques. The characteristic morphological features of chronic Achilles tendinosis consist of changes in the collagen fibre structure and arrangement, and an increased amount of interfibrillar glycosaminoglycans. There are no signs of inflammation, either histologically or by the microdialysis technique. This condition is most often seen in male recreational runners aged 35 to 45 years. However, it is also seen in sedentary individuals, and no clear statistical correlation between physical activity and histopathology has been demonstrated. Tendinosis is often, but not always, associated with pain in the Achilles tendon, but the background to why the changes in the tendon are associated with pain is unknown. Tendinosis is a difficult condition to treat, and in about 25% of patients conservative treatment is not successful (excluding the results of our heavy load eccentric training) and surgical treatment is required. There are many different conservative treatment regimens that have reported good results, but there are few prospective clinical studies and no clinical studies where comparisons between different treatment regimens have been done in a randomised manner. In a prospective uncontrolled
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study on recreational athletes with chronic Achilles tendinosis, the short term results of heavy load eccentric calf muscle training were very promising. After 2 years of follow-up, only 1 out of 15 patients (7%) needed surgical treatment. The short term results of surgical treatment are very encouraging; the few long term follow-up reports have shown poorer, although still acceptable, results. It has been shown to take a long time to recover calf muscle strength after surgical treatment, and postoperative treatment is probably of importance for the result. Prospective randomised studies comparing different models of conservative treatment, methods for surgical treatment and postoperative treatment models are needed for a better evaluation of the treatment alternatives. Further research investigating metabolism in the resting and active tendon, and investigations of the pain mechanism associated with tendinosis, are also of the utmost importance. In this regard, we hope that the recent application of the microdialysis technique to tendon tissue will lead to a better understanding of the pathogenesis of this disorder. References
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Correspondence and offprints: Dr Hkan Alfredson, Department of Surgical and Perioperative Science, Ume University, S-90187 Ume, Sweden. E-mail: hakan.alfredson@idrott.umu.se

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