Page 1 of 4 Critical review Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY) For citation purposes: Alfredson H. Intratendinous surgery and injection treatment for midportion Achilles tendinopathy: a critical review. OA Sports Medicine 2013 Nov 26;1(3):22. Competng interests: none declared. Confict of interests: none declared. All authors contributed to concepton and design, manuscript preparaton, read and approved the fnal manuscript. All authors abide by the Associaton for Medical Ethics (AME) ethical rules of disclosure. Treatment Techniques Intratendinous surgery and injection treatment for midportion Achilles tendinopathy: a critical review H Alfredson* Abstract Introduction Treatment of chronic painful mid- portion Achilles tendinopathy is known to be difficult. Multiple non- tendon-invasive and tendon-invasive methods are used. When traditional non-invasive treatments fail, it has become increasingly popular to try injections of PRP and autologous blood, and intratendinous open sur- gery is indicated finally. There is lit- tle, if any, scientific evidence from human studies backing up intraten- dinous injection treatment, and in- tratendinous surgical treatment can also be questioned. The aim of this critical review is to discuss intraten- dinous surgery and intratendinous treatment with injection for midpor- tion Achilles tendinopathy. Discussion Based on a recent research using immunohistochemical analyses of tissue biopsies from patients with midportion Achilles tendinopathy, new non-tendon-invasive treatment methods combined with short reha- bilitation periods have been invent- ed. These methods have shown good clinical results, few complications and decreased tendon thickness along with improved tendon struc- ture, over time. The knowledge about innervation patterns, tendon cells and poten- tials in the soft tissue on the ventral (deep) side of the Achilles tendon midportion, along with good results using treatment methods focussing on the outside of the tendon, ques- tions the use of tendon-invasive treatment methods for midportion Achilles tendinopathy. Conclusion A new science backing invasive treat- ment outside the tendon and newly- invented methods such as ultrasound and Doppler-guided surgical scrap- ing treatment have shown promising results. Introduction Although multiple treatment meth- ods are used, treatment of midpor- tion Achilles tendinopathy is known to be difficult 1 . Both conservative and surgical treatment methods are used, which can be divided into non- Achillestendon-invasive, and Achilles tendon-invasive methods. Among the non-tendon-invasive conservative methods, painful eccen- tric calf muscle training is considered to be the most beneficial 2,3 . There are also indications that shock wave treatment 3 and ultrasound (US) + Doppler (DP)-guided sclerosing po- lidocanol injections 4 are beneficial. Tendon-invasive conservative meth- ods include injection treatments with Platelet Rich Plasma (PRP) 5,6 and autologous blood (peri-or intra- tendineously) 7,8 . Stem cell injection treatment is also being used, but there are no studies on humans 9 . Surgical treatments include non- tendon-invasive procedures such as US and DP-guided scraping 10 and scraping combined with plantaris tendon removal 11 . Among the tendon- invasive methods, tenotomy with ex- cision of degenerative tendon tissue is the most commonly used 12–14 , which is sometimes combined with a flexor hallucis longus transfer procedure 15 . Morphologically, in the thickened and painful tendinopathy tendon, there is an altered tendon structure, including irregular fibre bundle ar- rangement and local high concen- trations of glucosaminoglycans (GAGs), hypercellularity and neo- vascularisation 14 . Specific studies on the cells in the hyper-cellular region have shown that some of these cells produce transmitter and pain sub- stances, and seem to have a more stemcell-like function 16–18 . Using US and DP, a localised high blood flow has been found outside and inside (in close relation to regions with structural changes) the ventral side in tendinopathy tendons, but not in normal Achilles tendons 19 . Immu- nohistochemical analyses of tissue specimens, obtained with US and DP guidance, outside and inside the region with tendon changes, have shown multiple sympathetic, but also sensory, nerves outside, but very few nerves inside, the Achilles tendon 20 . This critical review specifically questions the use of Achilles tendon invasive treatment methods without having a scientifically verified back- ground. Discussion The author has referenced some of his own studies in this review. These referenced studies have been con- ducted in accordance with the Dec- laration of Helsinki (1964) and the protocols of these studies have been approved by the relevant ethics com- mittees related to the institution in which they were performed. All hu- man subjects, in these referenced studies, gave informed consent to participate in these studies. *Corresponding author Email: hakan.alfredson@idrott.umu.se Department of Surgical and Perioperative Sci- ence, Sports Medicine Unit, Umeå University, SE-90187 Umeå, Sweden