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Tendon Injuries

Achilles & peroneal tendon injuries: acute rupture management, chronic tendinopathy protocols, and surgical repair/reconstruction options.

Overview

Primary tendon repair is permissible only when strict criteria are met, including early presentation, minimal contamination, and favorable wound conditions; otherwise, secondary repair via tendon graft is recommended [5]. Most cases of Achilles tendon disorders are successfully treated nonoperatively [7], although a small subgroup of recalcitrant Achilles tendon disorders may benefit from surgical intervention [7]. Acute ruptures of the Achilles tendon can be treated by either nonoperative or operative means [73].

Surgical treatment of acute Achilles tendon ruptures is associated with decreased rerupture rates compared to nonoperative treatment [73]. Surgical treatment of acute Achilles tendon ruptures is associated with slightly improved strength and functional ability compared to nonoperative treatment [73]. Surgical treatment of acute Achilles tendon ruptures is associated with higher minor complication rates compared to nonoperative treatment [73]. Operative treatment of Achilles tendon ruptures decreases rerupture rates but increases the risk for minor complications when compared with nonoperative treatment [24].

Surgical repair of proximal hamstring tendon ruptures leads to improved patient outcomes in both acute and chronic repairs [11]. Patients treated with distal biceps tendon repair after a delay (>21 days) can expect similar functional outcomes to those treated acutely, despite a high rate of initial complications [12]. Primary repair of the ruptured distal triceps tendon was possible when performed within 12 weeks after the injury [13]. Primary repair of distal triceps tendon ruptures yields good, durable patient outcomes with minimal rerupture regardless of repair construct [75].

The technique of surgical repair of acute Achilles tendon rupture with an end-to-end tendon suture and tendon flap is safe and effective, allowing repair of defects up to 5 cm without weakening the tendon [9]. No re-ruptures or major complications were observed in the sample for the technique of surgical repair of acute Achilles tendon rupture with an end-to-end tendon suture and tendon flap [9]. Although functional and structural outcomes converge by 12 months, absorbable sutures confer early advantages in tendon morphology and gliding function during the initial healing phase compared to non-absorbable sutures [10].

At a minimum of 2 years postoperatively, most patients with massive rotator cuff tears with bony deficiency of the greater tuberosity treated with Achilles Tendon–Bone Block Allograft demonstrated improved clinical outcomes, tendon healing, and graft incorporation [3]. There is poor evidence (grade Cf) in support of Achilles, flexor hallucis longus, and peroneal tendoscopy for common indications [22].

Anatomy & Pathophysiology

Achilles tendon ruptures are characterized by tendon elongation, closed-chain movements, and sudden loading [25]. Differential elongation of the gastrocnemius tendon can abolish knee-ankle coupling and lead to unrecognized elongation despite apparent tendon approximation [85]. Increased knee flexion serves as a compensatory strategy for decreased ankle plantarflexion [53].

Gender differences exist in the architectural and mechanical properties of the medial gastrocnemius–Achilles tendon unit in vivo [58]. Males demonstrate better physical fitness, speed, and performance in power-based sports events from a morphology and biomechanics perspective compared to females [58]. Females perceive more limitations in foot and ankle function than males one year after Achilles tendon rupture [86]. Smokers experience less limitations in foot and ankle function than non-smokers one year after Achilles tendon rupture [86].

Tendon morphology and mechanical properties are associated with patient-reported symptoms and calf muscle function in patients with Achilles tendinopathy [87]. Attenuated muscle strength and function persist during walking for 2 to 5 years after Achilles tendon rupture treated nonsurgically [90]. Neuromuscular changes persist 3.5 years following open surgical repair of acute Achilles tendon rupture, manifesting as complex changes to produce maximum force output while protecting the previously injured tendon [91].

Anatomical features of the ankle act like domino pieces, where a lateral ankle sprain can initiate a cascade of damage to intra-articular ligaments and cartilage, leading to chronic instability and joint degeneration [78]. There may be an association between the biomechanics of bend sprinting and plantaris injury [72].

Classification

Öhberg Score: The modified, 4-graded Öhberg score is a reproducible instrument for assessing tendon structure and neovascularisation using greyscale ultrasound and colour Doppler [61].

Achilles Tendon Disorders: Revised terminology for Achilles tendon-related disorders is based on anatomic location, symptoms, clinical findings, and histopathology [15]. Two entities can be distinguished in Achilles tendinopathies: insertional tendinopathies and main body tendinopathies [65]. Classification of midportion and insertional tendinopathy and retrocalcaneal bursitis in the Achilles tendon should strictly be used as a clinical diagnosis [45]. Most Achilles tendon ruptures share characteristic injury features including Achilles tendon elongation, closed-chain movements, and sudden loading [25]. Nonruptured Achilles tendons and ruptured Achilles tendons are part of two distinct populations [28]. A data-driven model of Achilles tendon health supports assessment of clinical presentation over multiple domains [19].

Tendinopathy Grading: Tendinopathy can be graded into four distinct grades to guide management [49].

Gluteus Medius and Minimus Lesions: Treatment of gluteus medius and minimus lesions is based on the extent of injury to the tendon and muscle tissue [6].

Distal Biceps Tendon Tears: Classification of partial distal biceps tendon tears may have implications for operative and non-operative management [60].

Other Considerations: There is no clear consensus on what defines a chronic Achilles disorder or a uniform classification and treatment scheme [38]. Long-term preoperative nonsteroidal anti-inflammatory drug use does not impact revision rate after repair of rotator cuff, Achilles, distal biceps, or quadriceps tendon [2].

Clinical Presentation

Tendinopathies of the hand and wrist are common conditions diagnosed by history and examination [4]. The essential lesion in Achilles tendon ailments is a failed healing response rather than degeneration [32]. The term 'partial tears' is misleading in Achilles tendon ailments as actual tears are rare [32]. The combination of Achilles tendon pain, swelling, and impaired performance indicates the clinical diagnosis of Achilles tendinopathy [34]. Achilles tendinopathy is not an inflammatory condition in its chronic form [34].

Diagnostic Imaging: Ultrasonography can identify risk factors for the development of serious tendon disorders in asymptomatic athletes, allowing for the prediction of those at high risk of developing symptoms of tendinosis [14]. Elastography-ultrasound (EUS) can be used as the initial modality to screen for any tendon pathology in athletes and non-athletes prior to advanced imaging such as magnetic resonance imaging (MRI) [20]. Patients diagnosed with unilateral insertional or midportion Achilles tendinopathy or patellar tendinopathy exhibit bilateral changes in tendon structure [16]. The asymptomatic side should not be used as a reference in clinical practice for patients with unilateral Achilles or patellar tendinopathy [16].

Clinical Assessment Models: The revised terminology for Achilles tendon-related disorders based on anatomic location, symptoms, clinical findings and histopathology is used by the majority of orthopedic surgeons and is increasingly used in the literature [15]. A data driven model of Achilles tendon health supports assessment of the clinical presentation over multiple domains [19].

Peroneal and Extensor Injuries: Peroneal tendon injuries are underdiagnosed and should be considered in every patient who presents with chronic lateral ankle pain [17]. Closed rupture of the extensor indicis tendon can present as a swelling over the dorsum of the hand after trauma without causing any motor deficit [39].

Red-Flag Patterns: If symptoms such as pain occur with ossification of the Achilles Tendon, a fracture should be suspected [37].

Investigations

Plain radiography: The radiographic appearance of a bone fragment beneath the humeral head is a valuable sign for avulsion of the subscapularis tendon [99].

MRI: MRI revealed the highest overall diagnostic accuracy for the diagnosis of both insertional and midportion Achilles tendinopathy [82]. MRI confirmed separation where clinical findings are consistent with known tendon disruption is an indication for surgical reconstruction of degenerate abductor tendons [71]. MRI findings of varying injury grades did not significantly correlate with the final functional outcomes in patients with calf muscle strain injuries [80]. MRI might be worth considering in revision cases of olecranon bursitis, as 43% of those cases had previous surgery [96]. Patients with spontaneous rupture of the extensor pollicis longus tendon should have the contralateral side evaluated with physical examination and MRI, with prophylactic release if tenderness and tendinopathy are present [94].

Ultrasound: Ultrasonography can identify risk factors for the development of serious tendon disorders in asymptomatic athletes, allowing for the prediction of those at high risk of developing symptoms of tendinosis [14]. Elastography-ultrasound (EUS) can be used as the initial modality to screen any tendon pathology both in athlete and non-athlete, prior to advance imaging such as magnetic resonance imaging (MRI) [20]. There was no statistically significant difference in favor of one imaging modality over the others regarding multimodal ultrasound versus MRI for the diagnosis and monitoring of Achilles tendinopathy [82]. Ultrasound is superior to MRI for dynamic evaluation of stenosing synovitis of the extensor pollicis longus tendon [79].

Other Considerations: Tendinopathies of the hand and wrist are diagnosed by history and examination [4]. Peroneal tendon injuries should be considered in every patient who presents with chronic lateral ankle pain [17]. The roles of ultrasonography and magnetic resonance imaging during the healing process after Achilles tendon rupture are limited, due to a weak correlation with clinical findings [81]. Recovery from pain and restoration of function does not go hand in hand with the appearance of the affected tendon at imaging, indicating a dissociation between morphology and symptoms [98]. The shape and location of the adductor magnus origin can mimic the appearance of an intact hamstring tendon intraoperatively or on diagnostic imaging [88]. Surgical release is a viable treatment to prevent rupture of the extensor pollicis longus tendon in cases of stenosing synovitis [79].

Treatment

Non-Operative Management

Most cases of Achilles tendon disorders are successfully treated nonoperatively [7]. Non-insertional Achilles tendinopathy is often managed conservatively with excellent clinical results [18]. Extracorporeal shock wave therapy (ESWT) improves pain and functional outcomes in patients with Achilles tendinopathy compared to other nonsurgical treatments [36]. However, evidence on the efficacy of exercise therapy in patients with hand and wrist tendinopathies is limited [41]. A small subgroup of recalcitrant Achilles tendon disorder cases may benefit from surgical intervention [7].

In the setting of acute Achilles tendon rupture, platelet-rich plasma (PRP) injections have not demonstrated benefit. In nonsurgically managed acute Achilles tendon rupture, 4 PRP injections did not improve function and healing compared with placebo over 12 months [40]. Similarly, in adults with an acute Achilles tendon rupture, a single PRP injection did not improve muscle-tendon function at 24 weeks compared with placebo [48].

Operative Management: General Principles and Indications

Primary tendon repair is permissible only when strict criteria are met, including early presentation, minimal contamination, and favorable wound conditions [5]. When strict criteria for primary repair are not met, secondary repair via tendon graft is recommended [5]. Tendon lengthening and transfer are indicated for neuromuscular disorders, nerve injuries, and congenital or traumatic lesions [54].

Specific tendon ruptures show clear benefits for surgical intervention. Surgical treatment of acute pectoralis major ruptures is superior to nonsurgical treatment and results in improved functional outcomes and high levels of return to work and sport [63]. Surgical repair of proximal hamstring tendon ruptures leads to improved patient outcomes in both acute and chronic repairs [11].

Operative Management: Achilles Tendon Rupture

There is no consensus on the best treatment for Achilles tendon ruptures, and management remains controversial [35]. Operative treatment decreases rerupture rates but increases the risk for minor complications when compared with nonoperative treatment [24][44]. Surgical treatment is superior to nonsurgical treatment in the prevention of rerupture in the management of acute complete Achilles tendon rupture, with a number needed to treat surgically to prevent one rerupture of 5 (3–13, 95% confidence intervals) [51]. However, results from a propensity score–matched analysis indicated no differences in reoperation rates between operative and nonoperative management of Achilles tendon ruptures [42].

Operative treatment does not lead to a clinically relevant reduction in tendon elongation compared to non-operative treatment [55]. There is no indication that surgical treatment reduced calf muscle atrophy or tendon elongation after acute Achilles tendon rupture [62]. Outcomes after surgical and non-surgical treatment of Achilles tendon ruptures are comparable [35]. Functional rehabilitation and early weightbearing are increasingly preferred over traditional immobilization for Achilles tendon ruptures [35].

Regarding surgical technique, absorbable sutures confer early advantages in tendon morphology and gliding function during the initial healing phase of Achilles tendon rupture repair, although functional and structural outcomes converge by 12 months [10]. Intraoperative ultrasonography assistance is an efficient, reliable, and safe method for minimally invasive repair of acute Achilles tendon rupture [43]. Surgical repair of acute Achilles tendon rupture with an end-to-end tendon suture and tendon flap is safe and effective, allowing repair of defects up to 5 cm without weakening the tendon, with no re-ruptures or major complications observed [9].

Operative Management: Achilles Tendinopathy and Partial Tears

Insertional Achilles tendinopathy management is improved by recognizing coexisting pathologies and evolving surgical approaches [18]. Gastrocnemius release is an effective treatment option in the management of patients with Achilles tendinopathy who have gastrocnemius contracture and have previously failed to respond adequately to non-operative treatment [59]. In Achilles tendon partial tears recalcitrant to conservative treatment, operative intervention is highly successful in most cases, irrespective of the level of the injury [46]. No definite recommendations can be made regarding the surgical treatment of midportion Achilles tendinopathy [50].

Operative Management: Rotator Cuff and Other Tendon Repairs

At a minimum of 2 years postoperatively, most patients treated with an Achilles tendon–bone block allograft for massive rotator cuff tears with bony deficiency of the greater tuberosity demonstrated improved clinical outcomes, tendon healing, and graft incorporation [3].

Tendoscopy

There is poor evidence (grade Cf) in support of Achilles, flexor hallucis longus, and peroneal tendoscopy for common indications [22]. Tendoscopy is a safe and effective technique to treat various etiologies affecting the tendons traversing the hindfoot, offering advantages such as the ability to examine longer lengths of tendon in a minimally invasive manner with low morbidity and early recovery [47].

Biological Therapies

Biological treatment with bone marrow–derived mesenchymal stem cells for chronic patellar tendinopathy (with gap >3 mm) was safe with no adverse effects at 12-month follow-up, and participants showed highly statistically significant clinical improvement and improvement in tendon structure on MRI [1].

Complications

Biological Treatment Risks: Biological treatment with bone marrow–derived mesenchymal stem cells for chronic patellar tendinopathy (with gap >3 mm) showed no adverse effects at 12-month follow-up [1].

Pharmacologic Risk Factors: Long-term preoperative nonsteroidal anti-inflammatory drug use does not increase the revision rate within 2 years of primary tendon repair for rotator cuff, Achilles, distal biceps, or quadriceps tendons [2].

Proximal Hamstring Repair Complications: Surgical repair of proximal hamstring tendon ruptures is associated with an overall complication rate of 15.4% [69]. Proximal hamstring tendon repair is associated with a 4.6% rate of major complications [69].

Distal Biceps Repair Complications: Distal biceps tendon repair performed by newly trained surgeons has complication rates similar to large cohort studies, with nerve injury being the most common complication [64]. Delayed repair of distal biceps tendon ruptures (>21 days) is associated with a high rate of initial complications [12].

Distal Triceps Repair Timing: Primary repair of acute distal triceps tendon ruptures is possible when performed within 12 weeks after injury [13].

Achilles Tendon Repair Outcomes: Surgical repair of acute Achilles tendon rupture with an end-to-end tendon suture and tendon flap resulted in no re-ruptures or major complications in the studied sample [9]. Achilles tendon elongation after acute rupture was not found to have a detrimental effect on patient-reported outcome measures or functional strength at follow-up [23].

Tibialis Anterior Repair Outcomes: Treatment of traumatic tibialis anterior tendon rupture with a two-stage silicone tube and interposition hamstring tendons graft provides good functional outcomes even in delayed repairs complicated by infection [8].

Chronic Tendinopathy and Rupture Sequelae: Forty percent of patients with Achilles tendinopathy report ongoing pain even after five years of physiotherapy [21]. Patients undergoing treatment for chronic Achilles tendon rupture may experience disappointment and frustration, despite long-term satisfaction [30].

Stenosing Tenosynovitis Recurrence: Aberrant tendons in stenosing tenosynovitis at the radial styloid process may be hidden and require specific exploration to prevent recurrence [84].

Recovery

Light activity (weeks): Specific timelines for light activity are not defined in the available evidence. However, early advantages in tendon morphology and gliding function are observed during the initial healing phase of Achilles tendon rupture repair when absorbable sutures are used [10]. Clinicians should maintain a high index of suspicion of tendinopathy in patients taking fluoroquinolones who have had previous tendon repairs, particularly in the setting of unexplained changes in recovery trajectory [103].

Full activity (months): Functional and structural outcomes converge by 12 months in Achilles tendon rupture repair regardless of whether absorbable or non-absorbable sutures are used [10]. Patients treated with distal biceps tendon repair after a delay (>21 days) can expect similar functional outcomes to those treated acutely, despite a high rate of initial complications [12]. Primary repair of acute distal triceps tendon ruptures is possible when performed within 12 weeks after the injury [13].

Complete recovery / outcome plateau (months): Biological treatment with bone marrow-derived mesenchymal stem cells for chronic patellar tendinopathy (with gap >3 mm) is safe with no adverse effects at 12-month follow-up [1]. Participants with chronic patellar tendinopathy treated with bone marrow-derived mesenchymal stem cells showed highly statistically significant clinical improvement at 12-month follow-up [1]. Participants with chronic patellar tendinopathy treated with bone marrow-derived mesenchymal stem cells showed improvement in tendon structure on MRI at 12-month follow-up [1]. Most patients demonstrated improved clinical outcomes at a minimum of 2 years postoperatively after Achilles tendon-bone block allograft reconstruction for massive rotator cuff tears with bony deficiency of the greater tuberosity [3]. Tendon healing was demonstrated at a minimum of 2 years postoperatively after Achilles tendon-bone block allograft reconstruction for massive rotator cuff tears with bony deficiency of the greater tuberosity [3]. Graft incorporation was demonstrated at a minimum of 2 years postoperatively after Achilles tendon-bone block allograft reconstruction for massive rotator cuff tears with bony deficiency of the greater tuberosity [3]. Ultrasound-guided percutaneous tenotomy demonstrates sustained clinical and sonographic outcomes for recalcitrant lateral elbow tendinopathy at 7.5 years, including good sustainability of pain relief and functional recovery [68]. Sonographic evidence of tissue healing is present at 7.5 years following ultrasound-guided percutaneous tenotomy for recalcitrant lateral elbow tendinopathy [68].

Rehabilitation protocol: The natural history of Achilles tendinopathy is typically a long protracted course where management focuses on physiotherapy [21]. Exercises improve function in the majority of patients with Achilles tendinopathy [21]. There was no difference in tendon lengthening at final follow-up between traditional and accelerated rehabilitation groups following Achilles tendon repair [102]. There was a trend toward lengthening at 6 weeks in the accelerated rehabilitation group following Achilles tendon repair [102].

Functional milestones: 40% of patients with Achilles tendinopathy report ongoing pain even after five years of therapy [21]. Evidence of a detrimental effect of tendon elongation on PROMs or functional strength at follow-up was not found in a general population after acute Achilles tendon rupture [23]. Greater Achilles tendon cross-sectional area seen on ultrasound 6 weeks after surgical repair had good clinical prediction for long-term functional outcome [26]. Follow-up studies on eleven of eighteen tendons treated with the plantaris tendon as a reinforcing membrane revealed excellent results [27]. Patients undergoing treatment for chronic Achilles tendon rupture experience disappointment and frustration but report long-term satisfaction [30]. Functional results were fair following surgical repair of spontaneously ruptured posterior tibial tendons [70].

Other Considerations: Long-term preoperative NSAID use does not increase revision rates within 2 years of primary repair of rotator cuff, Achilles, distal biceps, or quadriceps tendons [2]. Treatment of traumatic tibialis anterior tendon rupture with a two-stage silicone tube and interposition hamstring tendons graft provides very good functional outcomes in young adults, even in delayed repairs complicated by infection [8]. Symptom duration did not influence baseline measures of tendon health in patients with Achilles tendinopathy [95]. Sequential release of each muscle in irreparable rotator cuff tears results in a predictable and consistent gain in tendon mobility, with an average of 6.47 mm and 5.38 mm for each quartile of muscle release [101]. Dermal allograft reconstruction was used to treat patients with chronic or subacute pectoralis major tendon ruptures [104].

Key Evidence

  • [L2] The 12-month follow-up outcomes indicated that biological treatment was safe, there were no adverse effects, and participants showed highly statistically significant clinical improvement and improvement in tendon structure on MRI. (10.1177/23259671231184400)
  • [L3] Patients with a diagnosis of and coding for long-term preoperative NSAID use do not have greater revision rates within 2 years of primary tendon repair than patients without this diagnosis. (10.1016/j.asmr.2024.101034)
  • [L4] At a minimum of 2 years postoperatively, most patients demonstrated improved clinical outcomes, tendon healing, and graft incorporation. (10.1177/23259671211073719)
  • [L5] Primary tendon repair is permissible only when strict criteria are met, including early presentation, minimal contamination, and favorable wound conditions; otherwise, secondary repair via tendon graft is recommended. (10.2106/00004623-195941040-00001)
  • [L5] Treatment of these lesions is based on the knowledge of pathomechanics involved and the extent of injury to the tendon and muscle tissue. (10.1016/j.asmr.2021.10.024)
  • [L5] Most cases of Achilles tendon disorders are successfully treated nonoperatively, while a small subgroup of recalcitrant cases may benefit from surgical intervention. (10.1177/03635465020300022501)
  • [L4] This method should be considered for the treatment of complicated cases in young adults, as it provides a very good functional outcome even in delayed tendon repairs complicated by infection. (10.1007/s00167-013-2544-6)
  • [Paper] The technique is safe and effective, allowing repair of defects up to 5 cm without weakening the tendon, with no re-ruptures or major complications observed in this sample. (10.1016/j.injury.2015.05.014)
  • [L3] Although functional and structural outcomes converge by 12 months, absorbable sutures confer early advantages in tendon morphology and gliding function during the initial healing phase. (10.1186/s13018-025-06491-8)
  • [L2] Surgical repair of proximal hamstring tendon ruptures leads to improved patient outcomes in both acute and chronic repairs. (10.1007/s00167-017-4475-0)
  • [L3] Despite a high rate of initial complications, patients treated with distal biceps tendon repair after a delay (>21 days) can expect similar functional outcomes to those treated acutely. (10.1016/j.jse.2017.02.025)
  • [Abstract] Primary repair of the ruptured tendon was possible when performed within 12 weeks after the injury. (10.1016/j.jse.2014.11.027)
  • [L2] Ultrasonography can identify risk factors for the development of serious tendon disorders in asymptomatic athletes, allowing for the prediction of those at high risk of developing symptoms of tendinosis. (10.1177/03635465020300040701)
  • [L4] The revised terminology for Achilles tendon-related disorders based on anatomic location, symptoms, clinical findings and histopathology is used by the majority of orthopedic surgeons and is increasingly used in the literature. (10.1007/s00167-021-06566-z)
  • [L3] These results stress the importance of monitoring both symptomatic and asymptomatic tendon structures and in addition highlight that the asymptomatic side should not be used as reference in clinical practice. (10.1007/s00167-019-05495-2)
  • [L5] Peroneal tendon injuries are underdiagnosed and should be considered in every patient who presents with chronic lateral ankle pain. (10.5435/00124635-200905000-00005)
  • [L5] Non-insertional Achilles tendinopathy is often managed conservatively with excellent clinical results, while insertional Achilles tendinopathy management is improved by recognizing coexisting pathologies and evolving surgical approaches. (10.1302/0301-620x.95b10.31881)
  • [L4] A data driven model of Achilles tendon health supports assessment of the clinical presentation over multiple domains. (10.1186/s12891-022-05702-1)
  • [L4] EUS can be used as the initial modality to screen any tendon pathology both in athlete and non-athlete, prior to advance imaging such as magnetic resonance imaging (MRI). (10.1177/2325967119s00483)
  • [L4] On the basis of the current literature available, there is poor evidence (grade Cf) in support of Achilles, flexor hallucis longus, and peroneal tendoscopy for the common indications. (10.1016/j.arthro.2014.02.022)
  • [L4] In a general population, evidence of a detrimental effect of tendon elongation on PROMs or functional strength at follow-up was not found in this review. (10.1007/s00167-020-06010-8)
  • [L3] Operative treatment of Achilles tendon ruptures decreases rerupture rates but increases the risk for minor complications when compared with nonoperative treatment. (10.1177/2325967115579188)
  • [L4] Most Achilles tendon ruptures share characteristic injury features, that is, Achilles tendon elongation, closed-chain movements, and sudden loading. (10.1177/2325967123s00320)
  • [L2] Greater Achilles tendon cross-sectional area seen on ultrasound 6 weeks after surgical repair had good clinical prediction for long-term functional outcome. (10.1177/23259671231205326)
  • [L4] Follow-up studies on eleven of eighteen tendons so treated revealed excellent results. (10.2106/00004623-196648020-00005)
  • [L4] Nonruptured Achilles tendons, even at an advanced age, and ruptured Achilles tendons are clearly part of two distinct populations. (10.1177/03635465000280061401)
  • [L4] We emphasize the need for increased awareness of the occurrence of Achilles tendon rupture in patients with an atypical patient history. (10.1186/s13018-022-03103-7)
  • [L5] The present Editorial tries to clarify issues regarding the diagnosis and management of Achilles tendon ailments, emphasizing that the essential lesion is a failed healing response rather than degeneration, and that the term 'partial tears' is misleading as actual tears are rare. (10.1186/s13018-024-04560-y)
  • [L5] The combination of Achilles tendon pain, swelling, and impaired performance indicates the clinical diagnosis of Achilles tendinopathy, which is not an inflammatory condition in its chronic form. (10.2106/00004623-200211000-00024)
  • [L5] There is no consensus on the best treatment for Achilles tendon ruptures, and management remains controversial; however, functional rehabilitation and early weightbearing are increasingly preferred over traditional immobilization, with outcomes after surgical and non-surgical treatment being comparable. (10.3390/jfmk5040095)
  • [L2] ESWT improves pain and functional outcomes in patients with Achilles tendinopathy compared to other nonsurgical treatments. (10.1177/2325967120903430)
  • [L5] There is no clear consensus on what defines a chronic Achilles disorder or a uniform classification and treatment scheme. (10.5435/00124635-200901000-00002)
  • [L4] The clinical importance of this case lies in its presentation as a swelling over the dorsum of the hand after trauma, causing a diagnostic dilemma, as the rupture of the extensor indicis tendon does not cause any motor deficit. (10.1177/1753193412439271)
  • [L1] In nonsurgically managed acute Achilles tendon rupture, 4 PRP injections did not improve function and healing compared with placebo over 12 months. (10.2106/jbjs.21.00242)
  • [L1] Evidence on the efficacy of exercise therapy in patients with hand and wrist tendinopathies is limited. (10.1016/j.jht.2023.08.016)
  • [L3] Results indicated no differences in reoperation rates between operative and nonoperative management of Achilles tendon ruptures. (10.1177/23259671231152904)
  • [L4] It is an efficient, reliable, and safe method for acute Achilles tendon rupture. (10.1186/s13018-020-01776-6)
  • [L1] Operative treatment of Achilles tendon ruptures decreases rerupture rates but increases the risk for minor complications when compared to non-operative treatment. (10.1177/2325967115s00146)
  • [L4] The classification of midportion and insertional tendinopathy and retrocalcaneal bursitis in AT should strictly be used as a clinical diagnosis, as more specific pathologies may be identified during surgical evaluations. (10.1177/2325967114562371)
  • [L3] In Achilles tendon partial tears recalcitrant to conservative treatment, operative intervention is highly successful in most cases, irrespective of the level of the injury. (10.1186/s13018-020-01856-7)
  • [L4] Tendoscopy is a safe and effective technique to treat the various etiologies affecting the tendons traversing the hindfoot, offering advantages such as the ability to examine longer lengths of tendon in a minimally invasive manner with low morbidity and early recovery. (10.1016/j.arthro.2017.08.156)
  • [L1] In adults with an acute Achilles tendon rupture, a single PRP injection did not improve muscle-tendon function at 24 weeks compared with placebo. (10.2106/jbjs.20.00993)
  • [L5] The authors propose a pathophysiology-based treatment algorithm grading tendinopathy into four distinct grades to guide management and future investigation. (10.1177/2325967116670635)
  • [L4] In terms of the surgical treatment of midportion Achilles tendinopathy, no definite recommendations can be made. (10.1007/s00167-014-3407-5)
  • [Letter] Surgical treatment is superior to nonsurgical treatment in the prevention of rerupture in the management of acute complete Achilles tendon rupture, with a number needed to treat surgically to prevent one rerupture of 5 (3–13, 95% confidence intervals). (10.1177/03635465020300062801)
  • [L2] Increased knee flexion seemed to be a compensatory strategy for decreased ankle plantarflexion. (10.1177/03635465221129284)
  • [L5] Tendon lengthening and transfer are indicated for neuromuscular disorders, nerve injuries, and congenital or traumatic lesions. (10.1016/j.otsr.2014.07.033)
  • [L3] This finding suggests that operative treatment does not lead to a clinically relevant reduction in tendon elongation compared to non-operative treatment and it should therefore not be used as an argument in the choice of treatment. (10.1007/s00167-020-06391-w)
  • [L4] Gender differences exist in the architectural and mechanical properties of the medial gastrocnemius–Achilles tendon unit in vivo, with males demonstrating better physical fitness, speed, and performance in power-based sports events from a morphology and biomechanics perspective. (10.3390/life11060569)
  • [L4] The results of this review suggest gastrocnemius release to be an effective treatment option in the management of patients with Achilles tendinopathy, who have gastrocnemius contracture and have previously failed to respond adequately to non-operative treatment. (10.1007/s00167-022-07039-7)
  • [L3] Classification of tears may have implications for operative and non-operative management. (10.5397/cise.2023.00458)
  • [L4] The modified, 4-graded, Öhberg score was found to be a reproducible instrument for assessment of tendon structure and neovascularisation. (10.1007/s00167-014-3270-4)
  • [L1] Also, no indication was found that surgical treatment reduced calf muscle atrophy or tendon elongation. (10.1016/j.jisako.2023.03.024)
  • [L5] Surgical treatment of acute ruptures is superior to nonsurgical treatment and results in improved functional outcomes and high levels of return to work and sport. (10.5435/jaaos-d-21-00541)
  • [L4] Complication rates after distal biceps tendon repair performed by newly trained surgeons were similar to those previously reported in large cohort studies, with nerve injury as the most common complication. (10.1016/j.jse.2022.09.014)
  • [L4] Two entities can be distinguished: insertional tendinopathies and main body tendinopathies. (10.1016/j.otsr.2009.09.006)
  • [L4] At long term follow up, ultrasound-guided percutaneous tenotomy demonstrates good sustainability of pain relief and functional recovery that was previously achieved, accompanied with sonographic evidence of tissue healing at 7.5 years. (10.1177/2325967120s00420)
  • [L1] Proximal hamstring tendon repair is associated with an overall complication rate of 15.4%, including a 4.6% rate of major complications. (10.1177/2325967123s00208)
  • [L4] The functional results were fair following surgical repair of the ruptured tendon. (10.2106/00004623-196951040-00014)
  • [L4] Surgical reconstruction of degenerate abductor tendons should be considered in the presence of an MRI confirmed separation where clinical findings are consistent with the known tendon disruption. (10.1016/j.arth.2019.11.012)
  • [L4] There may be an association between the biomechanics of bend sprinting and plantaris injury. (10.1007/s00167-014-3409-3)
  • [L5] Acute ruptures of the Achilles tendon can be treated by either nonoperative or operative means, with surgical treatment associated with decreased rerupture rates and slightly improved strength and functional ability, though minor complication rates are higher. (10.5435/00124635-199809000-00007)
  • [L3] Primary repair of distal triceps tendon ruptures yields good, durable patient outcomes with minimal rerupture regardless of repair construct. (10.1016/j.jse.2017.08.006)
  • [L5] The authors hypothesize that anatomical features of the ankle act like domino pieces, where a lateral ankle sprain can initiate a cascade of damage to intra-articular ligaments and cartilage, leading to chronic instability and joint degeneration. (10.1002/ksa.12538)
  • [L4] They emphasize that ultrasound is superior to MRI for dynamic evaluation and that surgical release is a viable treatment to prevent tendon rupture. (10.1016/j.jhsa.2011.02.004)
  • [L3] MRI findings of varying injury grades did not significantly correlate with the final functional outcomes in this non-athletic population. (10.1186/s12891-024-08119-0)
  • [L1] The roles of ultrasonography and magnetic resonance imaging during the healing process after Achilles tendon rupture are limited, due to a weak correlation with clinical findings. (10.1007/s001670100245)
  • [L2] There was no statistically significant difference in favor of one imaging modality over the others, but MRI revealed the highest overall diagnostic accuracy for the diagnosis of both insertional and midportion Achilles tendinopathy. (10.1177/23259671211006826)
  • [L4] A cure can be expected if all stenosed tendons are found and freed, particularly noting that aberrant tendons may be hidden and require specific exploration to prevent recurrence. (10.2106/00004623-195133020-00006)
  • [L5] This differential elongation can abolish knee-ankle coupling and lead to unrecognized elongation despite apparent tendon approximation. (10.1007/s00167-021-06580-1)
  • [L2] Females appear to perceive more limitations than males, while smokers unexpectedly experience less limitations in foot and ankle function. (10.1007/s00167-019-05586-0)
  • [L2] Measures of tendon morphology and mechanical properties appear to be associated with patient-reported symptoms and calf muscle function for patients with Achilles tendinopathy. (10.1177/2325967120917271)
  • [L5] Its shape and location can mimic the appearance of an intact hamstring tendon intraoperatively or on diagnostic imaging, potentially misleading surgeons and radiologists. (10.1177/2325967115625055)
  • [L3] Attenuated muscle strength and function were present during walking as long as 2 to 5 years after rupture, as determined by 3-dimensional gait analysis. (10.1177/2325967113504734)
  • [L3] The results provide evidence on neuromuscular changes 3.5 years following open Achilles tendon repair, where complex changes manifest to produce maximum force output whilst protecting the previously injured tendon. (10.1007/s00167-021-06512-z)
  • [Case_report] They recommend evaluating the contralateral side with physical examination and MRI in patients with spontaneous rupture, with prophylactic release if tenderness and tendinopathy are present. (10.1016/j.jhsa.2018.09.011)
  • [L3] Symptom duration did not influence baseline measures of tendon health. (10.1177/23259671231164956)
  • [L4] They suggest that MRI might be worth considering in revision cases, as 43% of those cases with clinical signs of olecranon bursitis had previous surgery. (10.1016/j.arthro.2014.11.005)
  • [L5] Recovery from pain and restoration of function does not go hand in hand with the appearance of the affected tendon at imaging, indicating a dissociation between morphology and symptoms. (10.1007/s00167-023-07339-6)
  • [Case_report] Avulsion of the subscapularis tendon may be more common than literature suggests, and the radiographic appearance of a bone fragment beneath the humeral head is a valuable sign. (10.2106/00004623-198769090-00024)
  • [L5] Sequential release of each muscle resulted in a predictable and consistent gain in tendon mobility, with an average of 6.47 mm and 5.38 mm for each quartile of muscle release. (10.1016/j.asmr.2023.100756)
  • [L1] Although there was a trend toward lengthening at 6 weeks in the accelerated group, there was no difference in tendon lengthening at final follow-up between the groups. (10.1016/j.arthro.2019.11.008)
  • [Case_report] Clinicians should maintain a high index of suspicion of tendinopathy in patients taking fluoroquinolones who have had previous tendon repairs, particularly in the setting of unexplained changes in recovery trajectory. (10.1177/1558944717701237)
  • [L4] This was the first large series to observe patients with chronic or subacute PM tendon tears treated with dermal allograft reconstruction. (10.1177/2325967117745834)

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2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

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