Endoscopic surgery of the Achilles tendon

  • Phinit PhisitkulEmail author
Foot and Ankle (DE Bonasia and P Phisitkul, Section Editors)


The value of endoscopic surgery as a minimally invasive treatment is well recognized and includes less perioperative pain, less scarring, minimal blood loss, and faster recovery. While open surgery on the Achilles tendon is notorious for wound complications, the tendon is situated in a well-formed tunnel allowing surgical procedures to be performed endoscopically. Various endoscopic techniques have been successfully applied to the treatment of non-insertional Achilles tendinopathy, Haglund’s syndrome, Achilles tendon rupture, and equinus contracture. Although the evidence is currently limited, results from authors acquainted with the techniques have been encouraging. Both an understanding of surgical anatomy of the hindfoot and familiarity in soft tissue endoscopy are required to achieve successful outcomes while minimizing complications.


Achilles Tendinopathy Endoscopy Gastrocnemius recession Achilles tendon rupture Equinus contracture Calcaneoplasty Musculoskeletal Foot and ankle 



No potential conflict of interest relevant to this article was reported.


Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Garrett Jr WE, Swiontkowski MF, Weinstein JN, et al. American Board of Orthopaedic Surgery Practice of the Orthopaedic Surgeon: Part-II, certification examination case mix. J Bone Joint Surg Am. 2006;88(3):660–7.PubMedCrossRefGoogle Scholar
  2. 2.
    Ferkel R. Historical Developments. In: Whipple T, editor. Arthroscopic surgery: the foot & ankle. Philadelphia: Lippincott-Raven; 1996. p. 255–72.Google Scholar
  3. 3.
    Sarrafian S. Functional Anatomy of the Foot and Ankle. In: Sarrafian S, editor. Anatomy of the foot and ankle. Philadelphia: J.B. Lippincott; 1993. p. 474–602.Google Scholar
  4. 4.
    Kujala UM, Sarna S, Kaprio J. Cumulative incidence of achilles tendon rupture and tendinopathy in male former elite athletes. Clin J Sport Med. 2005;15(3):133–5.PubMedCrossRefGoogle Scholar
  5. 5.
    Lim J, Dalal R, Waseem M. Percutaneous vs. open repair of the ruptured Achilles tendon–a prospective randomized controlled study. Foot Ankle Int. 2001;22(7):559–68.PubMedGoogle Scholar
  6. 6.
    Haji A, Sahai A, Symes A, Vyas JK. Percutaneous versus open tendo achillis repair. Foot Ankle Int. 2004;25(4):215–8.PubMedGoogle Scholar
  7. 7.
    Cummins EJ, Anson BJ, et al. The structure of the calcaneal tendon (of Achilles) in relation to orthopedic surgery, with additional observations on the plantaris muscle. Surg Gynecol Obstet. 1946;83:107–16.PubMedGoogle Scholar
  8. 8.
    Carr AJ, Norris SH. The blood supply of the calcaneal tendon. J Bone Joint Surg Br. 1989;71(1):100–1.PubMedGoogle Scholar
  9. 9.
    el-Khoury GY, Brandser EA, Saltzman CL. MRI of tendon injuries. Iowa Orthop J. 1994;14:65–80.PubMedGoogle Scholar
  10. 10.
    Saltzman C, Bonor S. Tendon problems of the foot and ankle. In: Lutter L, Mizel M, Pfeffer G, editors. Orthopaedic knowledge update: foot and ankle. Rosemont: American Academy of Orthopaedic Surgeons; 1994. p. 270.Google Scholar
  11. 11.
    Kolodziej P, Glisson RR, Nunley JA. Risk of avulsion of the Achilles tendon after partial excision for treatment of insertional tendonitis and Haglund’s deformity: a biomechanical study. Foot Ankle Int. 1999;20(7):433–7.PubMedGoogle Scholar
  12. 12.
    Theobald P, Bydder G, Dent C, et al. The functional anatomy of Kager’s fat pad in relation to retrocalcaneal problems and other hindfoot disorders. J Anat. 2006;208(1):91–7.PubMedCrossRefGoogle Scholar
  13. 13.
    Canoso JJ, Liu N, Traill MR, Runge VM. Physiology of the retrocalcaneal bursa. Ann Rheum Dis. 1988;47(11):910–2.PubMedCrossRefGoogle Scholar
  14. 14.
    Komi PV. Relevance of in vivo force measurements to human biomechanics. J Biomech. 1990;23 Suppl 1:23–34.PubMedCrossRefGoogle Scholar
  15. 15.
    Maganaris CN, Narici MV, Maffulli N. Biomechanics of the Achilles tendon. Disabil Rehabil. 2008;30(20–22):1542–7.PubMedCrossRefGoogle Scholar
  16. 16.
    Shadwick RE. Elastic energy storage in tendons: mechanical differences related to function and age. J Appl Physiol. 1990;68(3):1033–40.PubMedCrossRefGoogle Scholar
  17. 17.
    Pollock CM, Shadwick RE. Relationship between body mass and biomechanical properties of limb tendons in adult mammals. Am J Physiol. 1994;266(3 Pt 2):R1016–21.PubMedGoogle Scholar
  18. 18.
    Ker R, Alexander R, Bennett M. Why are mammalian tendons so thick? J Zool Lond. 1988;216:309–24.CrossRefGoogle Scholar
  19. 19.
    Cumming W, Alexander R, Jayes A. Rebound resilience of tendons in the feet of sheep. J Exp Biol. 1978;74:75–81.Google Scholar
  20. 20.
    Bennett M, Ker R, Dimery N, Alexander R. Mechanical properties of various mamallian tendons. J Zool Lond. 1986;209:537–48.CrossRefGoogle Scholar
  21. 21.
    DiGiovanni CW, Kuo R, Tejwani N, et al. Isolated gastrocnemius tightness. J Bone Joint Surg Am. 2002;84-A(6):962–70.PubMedGoogle Scholar
  22. 22.
    Whittle M. Gait analysis: an introduction. Oxford: Butterworth-Heinemann; 1996.Google Scholar
  23. 23.
    Lavery LA, Armstrong DG, Boulton AJ. Ankle equinus deformity and its relationship to high plantar pressure in a large population with diabetes mellitus. J Am Podiatr Med Assoc. 2002;92(9):479–82.PubMedGoogle Scholar
  24. 24.
    Downey MS, Banks AS. Gastrocnemius recession in the treatment of nonspastic ankle equinus. A retrospective study. J Am Podiatr Med Assoc. 1989;79(4):159–74.PubMedGoogle Scholar
  25. 25.
    • Maskill JD, Bohay DR, Anderson JG. Gastrocnemius recession to treat isolated foot pain. Foot Ankle Int. 2010;31(1):19–23. Twenty-nine patients (34 feet) who had chronic foot pain without any structural abnormality other than an isolated gastrocnemius contracture underwent a gastrocnemius recession and were available for follow-up at an average of 19.5 (range, 7 to 44) months. The average pain score improved from 8/10 to 2/10. Ninety three percent of patients were satisfied with the results of the procedure..PubMedCrossRefGoogle Scholar
  26. 26.
    Mueller MJ, Sinacore DR, Hastings MK, et al. Effect of Achilles tendon lengthening on neuropathic plantar ulcers. A randomized clinical trial. J Bone Joint Surg Am. 2003;85(8-A):1436–45.PubMedGoogle Scholar
  27. 27.
    Laborde JM. Neuropathic plantar forefoot ulcers treated with tendon lengthenings. Foot Ankle Int. 2008;29(4):378–84.PubMedCrossRefGoogle Scholar
  28. 28.
    Saxena A. Endoscopic gastrocnemius tenotomy. J Foot Ankle Surg. 2002;41(1):57–8.PubMedCrossRefGoogle Scholar
  29. 29.
    Pinney SJ, Sangeorzan BJ, Hansen Jr ST. Surgical anatomy of the gastrocnemius recession (Strayer procedure). Foot Ankle Int. 2004;25(4):247–50.PubMedGoogle Scholar
  30. 30.
    Saxena A, Widtfeldt A. Endoscopic gastrocnemius recession: preliminary report on 18 cases. J Foot Ankle Surg. 2004;43(5):302–6.PubMedCrossRefGoogle Scholar
  31. 31.
    Trevino S, Gibbs M, Panchbhavi V. Evaluation of results of endoscopic gastrocnemius recession. Foot Ankle Int. 2005;26(5):359–64.PubMedGoogle Scholar
  32. 32.
    Grady JF, Kelly C. Endoscopic gastrocnemius recession for treating equinus in pediatric patients. Clin Orthop Relat Res. 2010;468(4):1033–8.PubMedCrossRefGoogle Scholar
  33. 33.
    Roukis TS, Schweinberger MH. Complications associated with uni-portal endoscopic gastrocnemius recession in a diabetic patient population: an observational case series. J Foot Ankle Surg. 2010;49(1):68–70.PubMedCrossRefGoogle Scholar
  34. 34.
    Barrett SL, Jarvis J. Equinus deformity as a factor in forefoot nerve entrapment: treatment with endoscopic gastrocnemius recession. J Am Podiatr Med Assoc. 2005;95(5):464–8.PubMedGoogle Scholar
  35. 35.
    DiDomenico LA, Adams HB, Garchar D. Endoscopic gastrocnemius recession for the treatment of gastrocnemius equinus. J Am Podiatr Med Assoc. 2005;95(4):410–3.PubMedGoogle Scholar
  36. 36.
    Saxena A, Gollwitzer H, Widtfeldt A, DiDomenico LA. Endoscopic gastrocnemius recession as therapy for gastrocnemius equinus. Z Orthop Unfall. 2007;145(4):499–504.PubMedCrossRefGoogle Scholar
  37. 37.
    Adelman V, Szczepanski J, Adelman R, Lincoln D. Endoscopic gastrocnemius recession ultrasound-guided analysis of length gained. Tech Foot Ankle Surg. 2009;8(1):24–9.CrossRefGoogle Scholar
  38. 38.
    Yeap EJ, Shamsul SA, Chong KW, Sands AK. Simple two-portal technique for endoscopic gastrocnemius recession: clinical tip. Foot Ankle Int. 2011;32(8):830–3.PubMedCrossRefGoogle Scholar
  39. 39.
    Tashjian RZ, Appel AJ, Banerjee R, DiGiovanni CW. Endoscopic gastrocnemius recession: evaluation in a cadaver model. Foot Ankle Int. 2003;24(8):607–13.PubMedGoogle Scholar
  40. 40.
    Rush SM, Ford LA, Hamilton GA. Morbidity associated with high gastrocnemius recession: retrospective review of 126 cases. J Foot Ankle Surg. 2006;45(3):156–60.PubMedCrossRefGoogle Scholar
  41. 41.
    Sammarco GJ, Bagwe MR, Sammarco VJ, Magur EG. The effects of unilateral gastrocsoleus recession. Foot Ankle Int. 2006;27(7):508–11.PubMedGoogle Scholar
  42. 42.
    Chimera NJ, Castro M, Manal K. Function and strength following gastrocnemius recession for isolated gastrocnemius contracture. Foot Ankle Int. 2010;31(5):377–84.PubMedCrossRefGoogle Scholar
  43. 43.
    de Jonge S, van den Berg C, de Vos RJ, et al. Incidence of midportion Achilles tendinopathy in the general population. Br J Sports Med. 2011;45(13):1026–8.PubMedCrossRefGoogle Scholar
  44. 44.
    Longo UG, Ronga M, Maffulli N. Achilles tendinopathy. Sports Med Arthrosc. 2009;17(2):112–26.PubMedCrossRefGoogle Scholar
  45. 45.
    Longo UG, Rittweger J, Garau G, et al. No influence of age, gender, weight, height, and impact profile in achilles tendinopathy in masters track and field athletes. Am J Sports Med. 2009;37(7):1400–5.PubMedCrossRefGoogle Scholar
  46. 46.
    Kingma JJ, de Knikker R, Wittink HM, Takken T. Eccentric overload training in patients with chronic Achilles tendinopathy: a systematic review. Br J Sports Med. 2007;41(6):e3.PubMedCrossRefGoogle Scholar
  47. 47.
    Clementson M, Loren I, Dahlberg L, Astrom M. Sclerosing injections in midportion Achilles tendinopathy: a retrospective study of 25 patients. Knee Surg Sports Traumatol Arthrosc. 2008;16(9):887–90.PubMedCrossRefGoogle Scholar
  48. 48.
    Maffulli N, Binfield PM, Moore D, King JB. Surgical decompression of chronic central core lesions of the Achilles tendon. Am J Sports Med. 1999;27(6):747–52.PubMedGoogle Scholar
  49. 49.
    Steenstra F, van Dijk CN. Achilles tendoscopy. Foot Ankle Clin. 2006;11(2):429–38. viii.PubMedCrossRefGoogle Scholar
  50. 50.
    Maffulli N, Longo UG, Oliva F, et al. Minimally invasive surgery of the achilles tendon. Orthop Clin North Am. 2009;40(4):491–8. viii–ix.PubMedCrossRefGoogle Scholar
  51. 51.
    Maquirriain J, Ayerza M, Costa-Paz M, Muscolo DL. Endoscopic surgery in chronic achilles tendinopathies: A preliminary report. Arthroscopy. 2002;18(3):298–303.PubMedCrossRefGoogle Scholar
  52. 52.
    Parekh SG, Wray 3rd WH, Brimmo O, et al. Epidemiology and outcomes of Achilles tendon ruptures in the National Football League. Foot Ankle Spec. 2009;2(6):283–6.PubMedCrossRefGoogle Scholar
  53. 53.
    • Chiodo CP, Glazebrook M, Bluman EM, et al. Diagnosis and treatment of acute Achilles tendon rupture. J Am Acad Orthop Surg. 2010;18(8):503–10. This clinical practice guideline form AAOS is based on a series of systematic reviews of published studies on the diagnosis and treatment of acute Achilles tendon rupture. None of the 16 recommendations made by the work group was graded as strong; most are graded inconclusive; four are graded weak; two are graded as moderate strength; and two are consensus statements. The two moderate-strength recommendations include the suggestions for early postoperative protective weight bearing and for the use of protective devices that allow for postoperative mobilization.PubMedGoogle Scholar
  54. 54.
    • Khan RJ, Carey Smith RL, Surgical interventions for treating acute Achilles tendon ruptures. Cochrane Database Syst Rev, 2010;(9):CD003674. A systematic review was performed on all randomised and quasi-randomised trials comparing surgical versus non-surgical treatment or different surgical methods for acute Achilles tendon ruptures in adults. Twelve trials involving 844 participants were included. Open surgical treatment of acute Achilles tendon ruptures significantly reduces the risk of rerupture compared with non-surgical treatment, but produces significantly higher risks of other complications, including wound infection. The latter may be reduced by performing surgery percutaneously.Google Scholar
  55. 55.
    Assal M, Jung M, Stern R, et al. Limited open repair of Achilles tendon ruptures: a technique with a new instrument and findings of a prospective multicenter study. J Bone Joint Surg Am. 2002;84-A(2):161–70.PubMedGoogle Scholar
  56. 56.
    Ceccarelli F, Berti L, Giuriati L, et al. Percutaneous and minimally invasive techniques of Achilles tendon repair. Clin Orthop Relat Res. 2007;458:188–93.PubMedGoogle Scholar
  57. 57.
    Turgut A, Gunal I, Maralcan G, et al. Endoscopy, assisted percutaneous repair of the Achilles tendon ruptures: a cadaveric and clinical study. Knee Surg Sports Traumatol Arthrosc. 2002;10(2):130–3.PubMedCrossRefGoogle Scholar
  58. 58.
    Halasi T, Tallay A, Berkes I. Percutaneous Achilles tendon repair with and without endoscopic control. Knee Surg Sports Traumatol Arthrosc. 2003;11(6):409–14.PubMedCrossRefGoogle Scholar
  59. 59.
    Lui TH. Endoscopic-assisted Achilles tendon repair with plantaris tendon augmentation. Arthroscopy. 2007;23(5):556 e1–5.Google Scholar
  60. 60.
    Tang KL, Thermann H, Dai G, et al. Arthroscopically assisted percutaneous repair of fresh closed achilles tendon rupture by Kessler’s suture. Am J Sports Med. 2007;35(4):589–96.PubMedCrossRefGoogle Scholar
  61. 61.
    Chan KB, Lui TH, Chan LK. Endoscopic-assisted repair of acute Achilles tendon rupture with Krackow suture: an anatomic study. Foot Ankle Surg. 2009;15(4):183–6.PubMedCrossRefGoogle Scholar
  62. 62.
    Doral MN, Bozkurt M, Turhan E, et al. Percutaneous suturing of the ruptured Achilles tendon with endoscopic control. Arch Orthop Trauma Surg. 2009;129(8):1093–101.PubMedCrossRefGoogle Scholar
  63. 63.
    Haglund P. Beitrag zur Klinik der Achillessehne. Z Orthop Chir. 1928;49:49–58.Google Scholar
  64. 64.
    Jerosch J, Nasef NM. Endoscopic calcaneoplasty–rationale, surgical technique, and early results: a preliminary report. Knee Surg Sports Traumatol Arthrosc. 2003;11(3):190–5.PubMedGoogle Scholar
  65. 65.
    Green AH, Hass MI, Tubridy SP, et al. Calcaneal osteotomy for retrocalcaneal exostosis. Clin Podiatr Med Surg. 1991;8(3):659–65.PubMedGoogle Scholar
  66. 66.
    Jones DC, James SL. Partial calcaneal ostectomy for retrocalcaneal bursitis. Am J Sports Med. 1984;12(1):72–3.PubMedCrossRefGoogle Scholar
  67. 67.
    Miller AE, Vogel TA. Haglund’s deformity and the Keck and Kelly osteotomy: a retrospective analysis. J Foot Surg. 1989;28(1):23–9.PubMedGoogle Scholar
  68. 68.
    Leach RE, DiIorio E, Harney RA. Pathologic hindfoot conditions in the athlete. Clin Orthop Relat Res. 1983;177:116–21.PubMedGoogle Scholar
  69. 69.
    Nesse E, Finsen V. Poor results after resection for Haglund’s heel. Analysis of 35 heels in 23 patients after 3 years. Acta Orthop Scand. 1994;65(1):107–9.PubMedCrossRefGoogle Scholar
  70. 70.
    Pauker M, Katz K, Yosipovitch Z. Calcaneal ostectomy for Haglund disease. J Foot Surg. 1992;31(6):588–9.PubMedGoogle Scholar
  71. 71.
    van Dijk CN, van Dyk GE, Scholten PE, Kort NP. Endoscopic calcaneoplasty. Am J Sports Med. 2001;29(2):185–9.PubMedGoogle Scholar
  72. 72.
    Jerosch J, Schunck J, Sokkar SH. Endoscopic calcaneoplasty (ECP) as a surgical treatment of Haglund’s syndrome. Knee Surg Sports Traumatol Arthrosc. 2007;15(7):927–34.PubMedCrossRefGoogle Scholar
  73. 73.
    Scholten PE, van Dijk CN. Endoscopic calcaneoplasty. Foot Ankle Clin. 2006;11(2):439–46. viii.PubMedCrossRefGoogle Scholar
  74. 74.
    van Sterkenburg MN, Muller B, Maas M, et al. Appearance of the weight-bearing lateral radiograph in retrocalcaneal bursitis. Acta Orthop. 2010;81(3):387–90.PubMedCrossRefGoogle Scholar
  75. 75.
    Jerosch J, Sokkar S, Ducker M, Donner A. Endoscopic Calcaneoplasty (ECP) in Haglund’s Syndrome. Indication, Surgical Technique, Surgical Findings and Results. Z Orthop Unfall. 2011.Google Scholar

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© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  1. 1.Orthopaedic DepartmentUniversity of Iowa Hospitals and ClinicsIowa CityUSA

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