The plantaris tendon and a potential role in mid-portion Achilles tendinopathy

NewsBot · Feb 19, 2011

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The plantaris tendon and a potential role in mid-portion Achilles tendinopathy: an observational anatomical study.
van Sterkenburg MN, Kerkhoffs GM, Kleipool RP, Niek van Dijk C.
J Anat. 2011 Mar;218(3):336-41. doi: 10.1111/j.1469-7580.2011.01335.x.

The source of pain and the background to the pain mechanisms associated with mid-portion Achilles tendinopathy have not yet been clarified. Intratendinous degenerative changes are most often addressed when present. However, it is questionable if degeneration of the tendon itself is the main cause of pain. Pain is often most prominent on the medial side, 2-7 cm from the insertion onto the calcaneus. The medial location of the pain has been explained to be caused by enhanced stress on the calcaneal tendon due to hyperpronation. However, on this medial side the plantaris tendon is also located. It has been postulated that the plantaris tendon might play a role in these medially located symptoms. To our knowledge, the exact anatomy and relationship between the plantaris- and calcaneal tendon at the level of complaints have not been anatomically assessed. This was the purpose of our study. One-hundred and seven lower extremities were dissected. After opening the superficial fascia and paratendon, the plantaris tendon was bluntly released from the calcaneal tendon moving distally. The incidence of the plantaris tendon, its course, site of insertion and possible connections were documented. When with manual force the plantaris tendon could not be released, it was defined as a 'connection' with the calcaneal tendon. In all specimens a plantaris tendon was identified. Nine different sites of insertion were found, mostly medial and fan-shaped onto the calcaneus. In 11 specimens (10%) firm connections were found at the level of the calcaneal tendon mid-portion. Clinical and histological studies are needed to confirm the role of the plantaris tendon in mid-portion Achilles tendinopathy.
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NewsBot · May 31, 2011

Midportion Achilles tendinosis and the plantaris tendon
Håkan Alfredson
Br J Sports Med doi:10.1136/bjsports-2011-090217

Objectives When re-operating patients with midportion Achilles tendinosis, having had a poor effect of ultrasound (US) and Doppler-guided scraping, the author found the involvement of the plantaris tendon to be a likely reason for the poor result. The aim of this study was to investigate the occurrence of a plantaris tendon in close relation to the Achilles tendon in consecutive patients with midportion Achilles tendinosis undergoing treatment with US and Doppler-guided scraping.

Material and methods This study includes 73 consecutive tendons with chronic painful midportion Achilles tendinosis, where US+Doppler examination showed thickening, irregular tendon structure, hypo-echoic regions, and localised high blood flow outside and inside the ventral Achilles midportion. The tendons were treated with US+Doppler-guided scraping, via a medial incision. If there was a plantaris tendon located in close relation to the medial Achilles, it was extirpated.

Results An invaginated, or ‘close by located’, enlarged plantaris tendon was found in 58 of 73 (80%) tendons. Preliminary clinical results of the combined procedure, US + Doppler-guided surgical scraping and extirpation of the plantaris tendon, are very promising.

Conclusions A thickened plantaris tendon located in close relation to the medial Achilles seems common in patients with chronic painful midportion tendinosis. The role of the plantaris tendon in midportion Achilles tendinosis needs to be further evaluated and should be kept in mind when treating this condition.
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NewsBot · Oct 22, 2011

The role of Plantaris Longus in Achilles tendinopathy: A biomechanical study
F. Lintz, A. Higgs, M. Millett, T. Barton, M. Raghuvanshi, M.A. Adams, I.G. Winson
Foot and Ankle Surgery
Volume 17, Issue 4, December 2011, Pages 252-255

Background
The Plantaris Longus Tendon (PLT) may be implicated in Achilles (AT) tendinopathy. Different mechanical characteristics may be the cause. This study is designed to measure these.

Methods
Six PLT and six AT were harvested from frozen cadavers (aged 65–88). Samples were stretched to failure using a Minimat 2000™ (Rheometric Scientific Inc.). Force and elongation were recorded. Calculated tangent stiffness, failure stress and strain were obtained. Averaged mechanical properties were compared using paired, one-tailed t-tests.

Results
Mean stiffness was higher (p < 0.001) in the PLT, measuring 5.71 N/mm (4.68–6.64), compared with 1.73 N/mm (1.40–2.22) in AT. Failure stress was also higher (p < 0.01) in PLT: 1.42 N/mm2 (0.86–2.23) AT: 0.20 N/mm2 (0.16–0.25). Failure strain was less (p < 0.05) in PLT: 14.1% (11.5–16.8) than AT: 21.8% (14.9–37.9).

Conclusions
The PLT is stiffer, stronger than AT, demonstrating potential for relative movement under load. The stiffer PLT could tether AT and initiate an inflammatory response.
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NewsBot · Jul 17, 2014

Prediction of the Presence of Plantaris Tendon Through
Examination of Palmaris Longus Tendon. Is There a Link?
KOSE, O.; EGE, T.; DEMIRALP, B.; SANAL, T.; BEK, D. & BASBOZKURT, M.
Int. J. Morphol., 32(2):589-592, 2014.
SUMMARY:

The purpose of this study was to investigate the relationship between palmaris longus (PL) and plantaris (P)
tendons and test the clinical usefulness of symmetry patterns between these tendons in Turkish population. This prospective study
comprised a total of 240 adult patients (120 men and 120 women) who were admitted to our outpatient clinic with bilateral knee
complaints that required bilateral knee MR examination during two years. Standard test (Schaefer’s test, oppose the thumb to the little
finger while flexing the wrist) was used to assess the presence of the PL tendon both with inspection and palpation. Knee MRI was used
to determine the presence of P muscle belly on both sides. We have analyzed symmetric distribution pattern using Mc-Nemar test. The
PL was absent unilaterally in 34 subjects (14.2%), while it was absent bilaterally in 17 subjects (7.1%). The P was absent unilaterally in
51 subjects (21.3%), while it was absent bilaterally in 10 subjects (4.2%). If PL was absent in one hand, the chance of having an
ipsilateral P tendon was 70.6%. If PL was present in one hand, the chance of having an ipsilateral P tendon was 87.6%. The Mc-Nemar
test for symmetry yielded a p value of 0.841 for ipsilateral PL and P muscles. A clear-cut link between Palmaris longus and plantaris
tendons could not be demonstrated in this study. Both muscles show different variations independent from each other.
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NewsBot · Nov 8, 2014

Plantaris injuries in elite UK track and field athletes over a 4-year period: a retrospective cohort study
Noel Pollock, Paul Dijkstra, James Calder, Robin Chakraverty
Knee Surgery, Sports Traumatology, Arthroscopy; November 2014

Purpose
The plantaris tendon is present in 98–100 % of people, and a potential relationship between the plantaris tendon and the development of Achilles tendinopathy has been postulated. There are no studies on the epidemiology of plantaris injuries in a sporting population. This retrospective cohort study presents the incidence, nature and outcome of plantaris injuries in elite British track and field athletes.
Method
All 214 elite athletes supported by the British Athletics Medical team from 2009 to 2013 were included in this cohort study. An injury was recorded if a plantaris injury was diagnosed and confirmed with imaging or surgical findings. Patient demographics, injury details and return to competitive elite track and field were recorded.
Results
There were 33 new plantaris injuries, with an annual plantaris injury incidence of 3.9–9.3 %. There were significantly more right-sided plantaris injuries in bend running sprinters (15 right-sided vs. 4 left-sided). 74 % of the athletes who had a plantaris injury also had Achilles tendinopathy at some point during the study period. Seventeen plantaris tendons were surgically removed from 13 athletes during the course of the study with 12 of the 13 athletes returning to the same level on the Tegner activity scale.
Conclusion
This retrospective cohort study demonstrates that plantaris injuries are common in elite track and field athletes and may be underreported in the literature. There may be an association between the biomechanics bend sprinting and plantaris injury. Elite athletes may benefit from appropriate preventative and management strategies implemented by coaching and medical teams.
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NewsBot · Nov 22, 2014

Plantaris excision in the treatment of non-insertional Achilles tendinopathy in elite athletes
James D F Calder, Richard Freeman, Noel Pollock
Br J Sports Med doi:10.1136/bjsports-2014-093827

Background Achilles tendinopathy is a serious and frequently occurring problem, especially in elite athletes. Recent research has suggested a role for the plantaris tendon in non-insertional Achilles tendinopathy.

Aim To assess whether excising the plantaris tendon improved the symptoms of Achilles tendinopathy in elite athletes.

Methods This prospective consecutive case series study investigated 32 elite athletes who underwent plantaris tendon excision using a mini-incision technique to treat medially located pain associated with non-insertional Achilles tendinopathy. Preoperative and postoperative visual analogue scores (VAS) for pain and the foot and ankle outcome score (FAOS) as well as time to return to sport and satisfaction scores were assessed.

Results At a mean follow-up of 22.4 months (12–48), 29/32 (90%) of athletes were satisfied with the results. Thirty of the 32 athletes (94%) returned to sport at a mean of 10.3 weeks (5–27). The mean VAS score improved from 5.8 to 0.8 (p<0.01) and the mean FAOS improved in all domains (p<0.01). Few complications were seen, four athletes experienced short-term stiffness and one had a superficial wound infection.

Conclusions The plantaris tendon may be responsible for symptoms in some athletes with non-insertional Achilles tendinopathy. Excision carries a low risk of complications and may provide significant improvement in symptoms enabling an early return to elite-level sports.
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NewsBot · May 12, 2015

Achilles tendinopathy—do plantaris tendon removal and Achilles tendon scraping improve tendon structure? A prospective study using ultrasound tissue characterisation
Lorenzo Masci, Christoph Spang, Hans T M van Schie, Håkan Alfredson
BMJ Open Sp Ex Med 2015

Objectives The plantaris tendon has recently been described as a possible important factor in midportion Achilles tendinopathy. Ultrasound tissue characterisation (UTC) is a method to study tendon structure (matrix integrity). The effect of plantaris tendon removal on Achilles tendon structure was studied using UTC.

Design and setting Prospective case series study at one centre.

Participants Nine tendons in eight physically active and healthy patients (mean age 39 years) with chronic painful midportion Achilles tendinopathy were included. Preoperative two-dimensional ultrasound and UTC showed midportion Achilles tendinopathy (tendinosis) with medial tendon changes and suspected plantaris tendon involvement. Patients with previous operations to the Achilles tendon were excluded.

Interventions Operative treatment consisted of excision of the plantaris tendon and scraping of the ventromedial surface of the Achilles tendon under a local anaesthetic.

Primary and secondary outcome measures UTC examination and clinical scoring with the VISA-A questionnaire were performed preoperatively and 6 months postoperatively.

Results At 6 months follow-up, UTC demonstrated a statistically significant (t=5.40, p<0.001) increase in the mean organised matrix (echo-type I+II) and a decrease in the mean disorganised matrix (echo-type III+IV). Seven out of eight patients were satisfied, and the VISA-A score had increased significantly (p<0.001) from 56.8 (range 34–73) preoperatively to 93.3 (range 87–100) postoperatively.

Conclusions Excision of the plantaris tendon and scraping of the ventromedial Achilles tendon in chronic midportion tendinopathy seem to have the potential to improve tendon structure and reduce tendon pain. Studies on a larger group of patients and with a longer follow-up period are needed.
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toomoon · May 12, 2015

I love a paper that includes the words "potential" and "seems" in relation to outcomes.. especially where surgery is involved!

Craig Payne · May 26, 2015

There is no abstract for this and the paper is not in English, but the title looks interesting:

Marked innervation but also signs of nerve degeneration in between the Achilles and plantaris tendons and presence of innervation within the plantaris tendon in midportion Achilles tendinopathy
Spang, Christoph; Harand, WM; Alfredsson, H; Forgren, S
Artikel i tidskrift (Övrigt vetenskapligt) Accepted

NewsBot · Jun 8, 2015

Craig Payne said: ↑

There is no abstract for this and the paper is not in English, but the title looks interesting:

Marked innervation but also signs of nerve degeneration in between the Achilles and plantaris tendons and presence of innervation within the plantaris tendon in midportion Achilles tendinopathy
Spang, Christoph; Harand, WM; Alfredsson, H; Forgren, S
Artikel i tidskrift (Övrigt vetenskapligt) Accepted
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Here is that abstract:

OBJECTIVES: The plantaris tendon is increasingly recognised as an important factor in midportion Achilles tendinopathy. Its innervation pattern is completely unknown.

METHODS: Plantaris tendons (n=56) and associated peritendinous tissue from 46 patients with midportion Achilles tendinopathy and where the plantaris tendon was closely related to the Achilles tendon were evaluated. Morphological evaluations and stainings for nerve markers [general (PGP9.5), sensory (CGRP), sympathetic (TH)], glutamate NMDA receptor and Schwann cells (S-100β) were made.

RESULTS: A marked innervation, as evidenced by evaluation for PGP9.5 reactions, occurred in the peritendinous tissue located between the plantaris and Achilles tendons. It contained sensory and to some extent sympathetic and NMDAR1-positive axons. There was also an innervation in the zones of connective tissue within the plantaris tendons. Interestingly, some of the nerve fascicles showed a partial lack of axonal reactions.

CONCLUSION: New information on the innervation patterns for the plantaris tendon in situations with midportion Achilles tendinopathy has here been obtained. The peritendinous tissue was found to be markedly innervated and there was also innervation within the plantaris tendon. Furthermore, axonal degeneration is likely to occur. Both features should be further taken into account when considering the relationship between the nervous system and tendinopathy.
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NewsBot · Oct 24, 2015

PLANTARIS MUSCLE, ITS LOCATION AND SIZE IN THE REGION OF THE ACHILLES TENDON: AN OBSERVATIONAL CADAVERIC STUDY
PD Kirwan, HP French and T Duffy
Bone Joint J 2015 vol. 97-B no. SUPP 11 18

Introduction Traditionally Plantaris has been considered of little clinical importance and absent in 8?20% of the population. Recent evidence indicates that it is present in 98?100% of the population and that it may have a contributing role in Achilles tendinopathy due to its close anatomical relationship.

The aim of this study was to establish whether Plantaris was present in a sample of cadaveric limbs, to establish its position in relation to the Achilles tendon and to conduct measures of its thickness and width.

Materials and Methods Forty eight cadaveric limbs which had been previously dissected were assessed. Plantaris was looked for in the region of the medial Achilles. If it could not be identified here, Gastrocnemius was reflected back to reveal Plantaris tendon beneath, and was then followed distally. All Plantaris tendon measurements were taken 2- 6 cm from the Achilles insertion using a vernier caliper.

Results Plantaris was present in all of the forty three limbs which were appropriate for assessment. Plantaris was positioned ventromedial to the Achilles tendon in 33 (77%) and medial to the Achilles in 9 (21%) of the limbs. The average width of the Plantaris tendon was 2.8mm (range 1.2?4.9mm) and its average thickness was 0.9mm (range 0.2?1.5mm).

Discussion Plantaris was present in all limbs in keeping with recent studies. This is the first known study, which measures Plantaris tendon in the region of the midportion Achilles. Future studies are planned to compare these measurements with tendinopathic plantaris tendons.
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NewsBot · Dec 5, 2015

Plantaris Excision and Ventral Paratendinous Scraping for Achilles Tendinopathy in an Athletic Population
Harvinder S. Bedi et al
Foot & Ankle International December 4, 2015

Background: Achilles tendinopathy is a frequent problem in high-level athletes. Recent research has proposed a combined etiologic role for the plantaris tendon and neovascularization. Both pathologies can be observed on ultrasound imaging.1,13 However, little is known about the change in structure of the Achilles tendon following the surgical treatment of these issues. The purpose of the study was to assess if excising the plantaris and performing ventral paratendinous “scraping” of the neovascularization improved symptoms of Achilles tendinopathy and whether there was a change in the fibrillar structure of the tendon with ultrasound tissue characterization (UTC) following this operation.
Methods: This prospective consecutive case series included 15 professional/semiprofessional athletes (17 Achilles tendons) who underwent plantaris excision and paratendinous scraping to treat noninsertional Achilles tendinopathy. The plantaris tendon was excised if adherent to the Achilles tendon, and the area of neovascularization for scraping was demarcated on preoperative imaging. Preoperative and postoperative Victorian Institute of Sports Assessment-Achilles (VISA-A) scores were taken. UTC was performed on 11 of 17 tendons preoperatively and postoperatively. The mean follow-up was for 25 months.
Results: Fourteen of 15 patients had a successful outcome after the surgery. The mean VISA-A improved from 51 to 95 (p=.0001). There was a statistically significant (p=.04) improvement in the aligned fibrillar structure of the tendon confirmed with UTC scanning following surgery from 90% (?8) to 96% (?5).
Conclusion: This group of high-level athletes derived an excellent clinical result from this operation. Furthermore, UTC scanning offered an objective method to evaluate the healing of Achilles tendons.
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NewsBot · Feb 25, 2016

How to diagnose plantaris tendon involvement in midportion Achilles tendinopathy - clinical and imaging findings
Lorenzo Masci, Christoph SpangEmail author, Hans T. M. van Schie and H?kan Alfredson
BMC Musculoskeletal Disorders 2016 17:97

Background
The purpose of this investigation was to evaluate if clinical assessment, Ultrasound + Colour Doppler (US + CD) and Ultrasound Tissue Characterisation (UTC) can be useful in detecting plantaris tendon involvement in patients with midportion Achilles tendinopathy.

Methods
Twenty-three tendons in 18 patients (14 men, mean age: 37 years and 4 women: 44 years) (5 patients with bilateral tendons) with midportion Achilles tendinopathy were surgically treated with a scraping procedure and plantaris tendon removal. For all tendons, clinical assessment, Ultrasound + Colour Doppler (US + CD) examination and Ultrasound Tissue Characterisation (UTC) were performed.

Results
At surgery, all 23 cases had a plantaris tendon located close to the medial side of the Achilles tendon. There was vascularised fat tissue in the interface between the Achilles and plantaris tendons. Clinical assessment revealed localised medial activity-related pain in 20/23 tendons and focal medial tendon tenderness in 20/23 tendons. For US + CD, 20/23 tendons had a tendon-like structure interpreted to be the plantaris tendon and localised high blood flow in close relation to the medial side of the Achilles. For UTC, 19/23 tendons had disorganised (type 3 and 4) echopixels located only in the medial part of the Achilles tendon indicating possible plantaris tendon involvement.

Conclusions
US + CD directly, and clinical assessment indirectly, can detect a close by located plantaris tendon in a high proportion of patients with midportion Achilles tendinopathy. UTC could complement US + CD and clinical assessment by demonstrating disorganised focal medial Achilles tendon structure indicative of possible plantaris involvement.
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NewsBot · May 12, 2016

Anatomic study suggests that the morphology of the plantaris tendon may be related to Achilles tendonitis
Łukasz Olewnik, Grzegorz Wysiadecki, Michał Polguj, Mirosław Topol
Surgical and Radiologic Anatomy pp 1-7 2016

Purpose
Achilles tendinopathy is a significant clinical lower limb issue observed in recent years. Neither the location nor the mechanism behind the pain has yet been sufficiently explained. Patients frequently experience pain on the medial side of the calcaneal tendon, and between 2 and 7 cm above the calcaneal tuberosity, which may suggests that the plantaris tendon plays an important role. The purpose of this study was to determine the anatomical relationships between the course of the plantaris tendon and the calcaneal tendon, as well as the type of insertion of the plantaris tendon.
Methods
The tests were carried out on 50 randomized lower limbs (23 left and 27 right) fixed in 10 % formalin solution.
Results
Five insertion types of the plantaris tendon were identified in relation to the calcaneal tendon: four with their insertion on the calcaneal tuberosity (Types 1, 2, 3, 5), while the fifth (Type 4) had its insertion in the crural fascia. In addition, two variants of the course of the plantaris tendon were identified, the most common being termed Variant A, in which the tendon crosses the space between the gastrocnemius and the soleus muscles, thus reaching the medial crural region, and is located on the medial side of the calcaneal tendon (84 % cases). The course of the Variant B is similar to the course of the Variant A, but upon leaving the space located between the gastrocnemius and soleus muscle, it turned to the medial crural region and ran directly anterior to the calcaneal tendon (12 %). The plantaris muscle was found to be absent in two lower limbs (4 %). The most frequent insertion type of the plantaris tendon into the calcaneal tuberosity is fan-shaped, occurring on the medial side of the Achilles tendon (Type 1?44 % cases).
Conclusion
The course of the plantaris tendon and its mobility range in relation to the calcaneal tendon may be likely to affect the occurrence of pains in the lower medial part of the leg (Achilles tendinopathy).
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NewsBot · May 19, 2016

This clinical trial was just registered:
Plantaris Release for Non-insertional Achilles Tendinopathy

The plantaris tendon is recognised as an important factor in non-insertional Achilles tendinopathy (NIAT). A biomechanical study found the plantaris tendon is stiffer and stronger than the Achilles tendon (AT), thus reducing its capacity to elongate in response to loading. This is hypothesized to result in friction between the AT and plantaris in some NIAT patients. Current treatment is conservative management: physiotherapy and high volume injection of the paratenon. However 29% of patients fail to respond to conservative management and those with plantaris related symptoms require its surgical excision and stripping of the ventral aspect of the AT through a 3cm medial incision. This is performed in theatres under general anaesthetic with good or excellent results reported in 90% of cases.

Purely cutting the plantaris tendon using a minimally invasive endoscopic technique has also been successful. The plantaris tendon is easily visualized under ultrasound scan (USS) and tenotomy of tendons under USS guidance is performed elsewhere. Tenotomy of the plantaris tendon under USS guidance would necessitate a 5mm incision and may be performed under local anaesthetic as an out-patient. The current study thus plans a randomised clinical trial to compare outcomes (VISA-A scores and ultrasound tissue characterisation scans) from patients with NIAT undergoing plantaris release using an open surgical procedure with those undergoing a minimally invasive US guided procedure. The former is known to provide good clinical outcomes; however the latter could significantly reduce post-operative scarring, recovery times and costs. Findings will ensure ethical, quality and cost effective patient care.
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NewsBot · May 31, 2016

Cadaveric study of the anatomical and histological relationships between the Achilles and plantaris tendons
Joanna Goral et al
April 2016; The FASEB Journal; vol. 30 no. 1 Supplement 1043.6

Rationale The purpose of this study was to investigate whether the proximity in anatomical locations of the Achilles (AT) and plantaris (PT) tendons promotes histopathological changes common to both tendons and their shared paratenon. The Achilles and plantaris tendons (ATs and PTs, respectively) share close anatomical locations in the foreleg, which has led to a proposed association between pathological findings in these tendons. Previous studies have identified such an association in specimens with known tendinopathy. This study aimed to determine whether similar correlation could be found in a group of cadavers without any record of tendon pathology.

Materials and methods The subjects in this study were 20 donor cadavers (11 females and nine males) fixated in formalin, provided by the Department of Anatomy at Midwestern University. The mean age was 81 (?12). Twenty left, and 19 right legs were dissected. The ATs and PTs were assessed based on their gross anatomical characteristics, then samples of the tendons were harvested from two sites, one where the ATs and PTs ran closely together and a second where the PT was unassociated with the AT. The collected specimens were fixed, processed for paraffin embedding, sectioned, and stained with hematoxylin and eosin for histological analysis. Tissues were examined for the presence of inflammatory cells and for the evidence of stress-induced conversion of the tendons’ dense connective tissue into fibrocartilage.

Results In four specimens (10.2%) the ATs and PTs ran separately, in eight (20.5%) specimens they were fused, and in three specimens the plantaris muscle was absent (7.7%). In the rest of the specimens the ATs and PTs were closely associated, but not fused. Histologically, no distinct evidence of inflammation was found at either the related or unrelated AT and PT sites. A presence of fibrocartilage with chondrocytes within the AT was noted in six (15.4%) specimens.

Conclusion The results of this study did not demonstrate any significant histopathologic changes in the areas of close contact between the ATs and PTs. The presence of fibrocartilage in the Achilles but not in the plantaris tendons suggests that the AT may be more affected by compression-induced stress than the PT. These findings suggest that within the control group, close contact between AT and PT does not result in interrelated histopathologic changes. However, it is possible that histopathology may be observed in patients with mid-portion Achilles tendinopathy.
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NewsBot · Oct 25, 2016

Differential Plantaris-Achilles Tendon Motion: A Sonographic and Cadaveric Investigation
Jay Smith, M.D., Håkan Alfredson, M.D., Lorenzo Masci, M.D., Jacob L. Sellon, M.D., Charonn D. Woods, M.D.
PM & R Article in Press

Objective
To determine whether differential, multidirectional motion exists between the plantaris tendon (PT) and Achilles tendon (AT) as documented by dynamic ultrasound (US) and post-dissection examination in an unembalmed cadaveric model.

Design
Prospective, cadaveric laboratory investigation.

Setting
Procedural skills laboratory in a tertiary medical center.

Subjects
20 unembalmed knee-ankle-foot specimens (9 right, 11 left) obtained from 6 male and 10 female donors ages 55-96 years (mean 80 years) with BMI’s of 14.1 to 33.2 kg/m2 (mean 22.5 kg/m2).

Methods
A single, experienced operator used high resolution dynamic US to qualitatively document differential PT-AT motion during passive ankle dorsiflexion-plantarflexion. Specimens were then dissected and passive dorsiflexion-plantarflexion was repeated while directly visualizing differential PT-AT motion.

Main Outcome
Presence or absence of multidirectional differential PT-AT motion.

Results
All 20 specimens exhibited smooth, but variable amplitude multidirectional differential PT-AT motion. Whereas US readily demonstrated medial-lateral and anterior-posterior PT motion relative to the AT, differential longitudinal motion was only appreciated upon dissection and direct inspection. Many specimens exhibited partial or complete encasement of the PT between the gastrocnemius portion of the AT and the soleus aponeurosis.

Conclusion
Some degree of multidirectional differential PT-AT motion appears to be a normal phenomenon, and PT motion can be sonographically evaluated in both the medial-lateral and anterior-posterior directions. The existence of normal differential PT-AT motion suggests that alterations in PT motion or repetitive stress within the PT-AT interval may produce symptoms in some patients presenting with Achilles region pain syndromes. The PT should be evaluated in all patients presenting with Achilles, plantaris, or calf pain syndromes. Future research would benefit from the development of a sonographic classification system for PT anatomy and motion with the goal of differentiating normal versus pathologic states and identifying risk factors for symptom development.
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NewsBot · Jan 20, 2017

The plantaris tendon
A NARRATIVE REVIEW FOCUSING ON ANATOMICAL FEATURES
AND CLINICAL IMPORTANCE
C. Spang, et al
Bone Joint J 2016;98-B:1312–19. (full text)

In recent years, the plantaris tendon has been implicated in the development of chronic
painful mid-portion Achilles tendinopathy. In some cases, a thickened plantaris tendon is
closely associated with the Achilles tendon, and surgical excision of the plantaris tendon
has been reported to be curative in patients who have not derived benefit following
conservative treatment and surgical interventions.
The aim of this review is to outline the basic aspects of, and the recent research findings,
related to the plantaris tendon, covering anatomical and clinical studies including those
dealing with histology, imaging and treatment
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NewsBot · Feb 17, 2017

Plantaris Excision Reduces Pain in Midportion Achilles Tendinopathy Even in the Absence of Plantaris Tendinosis.
Calder JD, Stephen JM, van Dijk CN
Orthop J Sports Med. 2016 Dec 13;4(12):2325967116673978. doi: 10.1177/2325967116673978. eCollection 2016.

BACKGROUND:
It is becoming increasingly apparent that the plantaris can contribute to symptoms in at least a subset of patients with midportion Achilles tendinopathy. However, the nature of its involvement remains unclear.
PURPOSE:
To determine whether excised plantaris tendons from patients with midportion Achilles tendinopathy display tendinopathic changes and whether the presence of such changes affect clinical outcomes.
STUDY DESIGN:
Case series; Level of evidence, 4.
METHODS:
Sixteen plantaris tendons in patients with midportion Achilles tendinopathy recalcitrant to conservative management underwent histological examination for the presence of tendinopathic changes. All patients had imaging to confirm the presence of the plantaris tendon adherent to or invaginated into the focal area of Achilles tendinosis. Visual analog scale (VAS) and Foot and Ankle Outcome Score (FAOS) results were recorded pre- and postoperatively.
RESULTS:
Sixteen patients (mean age, 26.2 years; range, 18-47 years) underwent surgery, with a mean follow-up of 14 months (range, 6-20 months). The plantaris tendon was histologically normal in 13 of 16 cases (81%). Inflammatory changes in the loose peritendinous connective tissue surrounding the plantaris tendon were evident in all cases. There was significant improvement in mean VAS scores (P < .05) and all domains of the FAOS postoperatively (P < .05).
CONCLUSION:
The absence of any tendinopathic changes in the excised plantaris of 13 patients who clinically improved suggests plantaris involvement with Achilles tendinopathy may not yet be fully understood and supports the concept that this may be a compressive or a frictional phenomenon rather than purely tendinopathic.
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NewsBot · May 4, 2017

Persistent pain in the Achilles mid-portion? Consider the plantaris tendon as a possible culprit!

NewsBot · Aug 12, 2017

Paratendinous Scraping and Excision of Plantaris for Achilles Tendinopathy.
Jowett, Charlie R.J. FRCS(Tr&Orth); Richmond, Anneka BSc; Bedi, Harvinder S. FRACS
Techniques in Foot & Ankle Surgery: Post Author Corrections: August 10, 2017

Recent research has suggested a combined role of the plantaris tendon and neovascularization for Achilles tendinopathy recalcitrant to nonoperative management. The aim of our study was to determine if addressing both these issues improved symptoms of Achilles tendinopathy. We report on the results of a prospective case series involving 2 cohorts of patients between February 2011 and February 2015 undergoing this combined technique. One cohort included recreational athletes (group A), the second included patients who undertook minimal recreational activity (group B). In group A there were 19 patients (25 tendons). The mean age at surgery was 44 years (range, 20 to 55 y). The mean follow-up was 21 months (range, 7 to 38 mo). Patients were satisfied with the results in 21 of the 25 tendons (84%). The mean Victorian Institute of Sports Assessment-Achilles improved from 51 to 90 following surgery (P<0.001). One case was revised. In group B there were 7 patients (9 tendons). Patients were satisfied in 7 of the 9 cases. These results support the use of this combined procedure in recreational athletes with failed nonoperative management. We believe surgery provides a healthier environment for conservative load-based rehabilitation. In the nonathletic population results are less consistent.
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NewsBot · Dec 19, 2017

Differential Motion and Compression Between the Plantaris and Achilles Tendons: A Contributing Factor to Midportion Achilles Tendinopathy?
Stephen JM et al
Am J Sports Med. 2017 Dec 1:363546517745291. doi: 10.1177/0363546517745291.

BACKGROUND:
The plantaris tendon (PT) has been thought to contribute to symptoms in a proportion of patients with Achilles midportion tendinopathy, with symptoms improving after PT excision.

HYPOTHESIS:
There is compression and differential movement between the PT and Achilles tendon (AT) during ankle plantarflexion and dorsiflexion.

STUDY DESIGN:
Descriptive laboratory study.

METHODS:
Eighteen fresh-frozen cadaveric ankles (mean ± SD age: 35 ± 7 years, range = 27-48 years; men, n = 9) were mounted in a customized testing rig, where the tibia was fixed but the forefoot could be moved freely. A Steinmann pin was drilled through the calcaneus, enabling a valgus torque to be applied. The soleus, gastrocnemius, and plantaris muscles were loaded with 63 N with a weighted pulley system. The test area was 40 to 80 mm above the os calcis, corresponding to where the injury is observed clinically. Medially, the AT and PT were exposed, and a calibrated flexible pressure sensor was inserted between the tendons. Pressure readings were recorded with the ankle in full dorsiflexion, full plantarflexion, and plantargrade and repeated in these positions with a 5 N·m torque, simulating increased hindfoot valgus. The pressure sensor was removed and the PT and AT marked with ink at the same level, with the foot held in neutral rotation and plantargrade. Videos and photographs were taken to assess differential motion between the tendons. After testing, specimens were dissected to identify the PT insertion. One-way analysis of variance and paired t tests were performed to make comparisons.

RESULTS:
The PT tendons with an insertion separate from the AT demonstrated greater differential motion through range (14 ± 4 mm) when compared with those directly adherent to the AT (2 ± 2 mm) ( P < .001). Mean pressure between the PT and AT rose in terminal plantarflexion for all specimens ( P < .001) and was more pronounced with hindfoot valgus ( P < .001).

CONCLUSION:
The PT inserting directly into the calcaneus resulted in significantly greater differential motion as compared with the AT. Tendon compression was elevated in terminal plantarflexion, suggesting that adapting rehabilitation tendon-loading programs to avoid this position may be beneficial.

CLINICAL RELEVANCE:
The insertion pattern of the PT may be a factor in plantaris-related midportion Achilles tendinopathy. Terminal range plantarflexion and hindfoot valgus both increased AT and PT compression, suggesting that these should be avoided in this patient population.
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NewsBot · Jun 6, 2018

The Plantaris Muscle Tendon and Its Relationship with the Achilles Tendinopathy
Ł. Olewnik et al
BioMed Research International
Volume 2018, Article ID 9623579, 9 pages

Purpose. Although the plantaris muscle (PM) is vestigial in humans, it has a significant clinical role in procedures such as grafting. However, recent reports suggest its potential involvement in the tendinopathy of the midportion of the Achilles tendon. The aim of the study is therefore to evaluate morphological variation of the PM with regard to its potential conflict with the Achilles tendon. Material and Methods. Classical anatomical dissection was performed on 130 lower limbs (71 right, 59 left) fixed in 10% formalin solution. The morphology of the PM was assessed regarding the relationship between the course of the plantaris tendon and the calcaneal tendon. Results. The PM was present in 89.2% of cases. The findings indicate the presence of a new type of PM tendon insertion in which the tendon is inserted into the tarsal canal flexor retinaculum, potentially affecting the tendinopathy of the tibialis posterior muscle. In 26 cases (22.4%), insertion blended with the Achilles tendon (Type II), which may increase the risk of Achilles tendinopathy. Conclusion. The anatomical variation of PM tendon morphology may create a potential conflict with the Achilles tendon and the tibialis posterior tendon, thus increasing the possibility of tendinopathy.
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NewsBot · Oct 20, 2018

Study of anatomical variations of plantaris muscle in cadavers
Neeraj Kumar et al
INTERNATIONAL JOURNAL OF SCIENTIFIC RESEARCH

Background: e plantaris muscle consists of a small, thin muscle belly, and a long thin tendon. e aim of this study was to identify the
agenesis and the variations of its origin and insertion.
Materials and Methods: e present study was conducted by the Department of Anatomy, TSM Medical College & Hospital, Lucknow. e
plantaris muscle was dissected in 15 adult embalmed cadavers (30 lower limbs), 4 females and 11 males, the average age of the cadavers was
between 40-70 years.
Result:In our present study mean length of the muscle belly was 7.59 cm, mean girth of muscle belly was 0.42 cm and mean length of the tendon
was 32.37 cm. Agenesis of plantaris was observed bilaterally in a male cadaver, with the incidence of 6.66%.
Conclusion:Earlier it was thought that the plantaris muscle is vestigial and degenerating structure. Recent studies revealed that it can be used
as a autograft material in plastic & reconstructive surgeries
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NewsBot · Jan 16, 2019

The Plantaris Muscle Tendon and Its Relationship with the Achilles Tendinopathy.
Olewnik Ł et al
Biomed Res Int. 2018 May 31;2018:9623579. doi: 10.1155/2018/9623579. eCollection 2018.

PURPOSE:
Although the plantaris muscle (PM) is vestigial in humans, it has a significant clinical role in procedures such as grafting. However, recent reports suggest its potential involvement in the tendinopathy of the midportion of the Achilles tendon. The aim of the study is therefore to evaluate morphological variation of the PM with regard to its potential conflict with the Achilles tendon.

MATERIAL AND METHODS:
Classical anatomical dissection was performed on 130 lower limbs (71 right, 59 left) fixed in 10% formalin solution. The morphology of the PM was assessed regarding the relationship between the course of the plantaris tendon and the calcaneal tendon.

RESULTS:
The PM was present in 89.2% of cases. The findings indicate the presence of a new type of PM tendon insertion in which the tendon is inserted into the tarsal canal flexor retinaculum, potentially affecting the tendinopathy of the tibialis posterior muscle. In 26 cases (22.4%), insertion blended with the Achilles tendon (Type II), which may increase the risk of Achilles tendinopathy.

CONCLUSION:
The anatomical variation of PM tendon morphology may create a potential conflict with the Achilles tendon and the tibialis posterior tendon, thus increasing the possibility of tendinopathy.
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NewsBot · Jan 25, 2019

Sonographically Guided Plantaris Tendon Release: A Cadaveric
Validation Study
Q9 Jay Smith, MD, Ha˚kan Alfredson, MD, Lorenzo Masci, MD, Jacob L. Sellon, MD,
Charonn D. Woods, MD
Abstract

Background: The plantaris tendon (PT) has been implicated in the pathogenesis of symptoms in a subset of patients with Achilles
region pain syndromes and traditionally has been managed via open surgical resection. Although the PT can be visualized on
ultrasound, a minimally invasive technique for sonographically guided PT release has not been formally described.
Objective: To validate a technique to perform sonographically guided PT release in an unembalmed cadaveric model.
Design: Prospective, cadaveric laboratory investigation.
Setting: Procedural skills laboratory in a tertiary medical center.
Subjects: Twenty unembalmed cadaveric kneeeankleefoot specimens (10 right, 10 left; 6 male, 10 female) from 16 donors ages
55-96 years (mean 82.6 years) with body mass indexes of 14.1-33.2 kg/m2 (mean 23.3 kg/m2).
Methods: After simulated local anesthesia and sonographically guided hydrodissection of the plantaris tendoneAchilles tendon
interval, a single experienced operator performed sonographically guided PT release on each specimen using an in-plane, lateralto-medial approach, a commercially available, disposable 3.0-mm hook knife, and either a 17-5 MHz or 15-7 MHz linear array
transducer. Each specimen was subsequently dissected to assess for PT release and iatrogenic injury.
Main Outcome: Status of the PT, Achilles tendon, and regional neurovascular structures as determined by dissection.
Results: All 20 PT releases were completed in a single attempt through a 3- to 5-mm incision. Dissection confirmed complete PT
release in all specimens without damage to the adjacent Achilles tendon or regional neurovascular structures.
Conclusion: Sonographically guided PT release is technically feasible and can be performed while avoiding injury to the Achilles
tendon and regional neurovascular structures. Additional research is warranted to further define the role of sonographically
guided PT release in patients with suspected PT-mediated Achilles region pain syndromes
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NewsBot · Jan 29, 2019

Plantaris tendon and association with mid-portion
Achilles tendinopathy. Is the plantaris tendon a
contributing factor in mid-portion Achilles
tendinopathy?
Lorenzo Masci et al
Apunts Med Esport. 2018.

Plantaris tendon is implicated in some cases of load-resistant Achilles tendinopathy.
The tendon courses close to the medial Achilles tendon mid-portion prior to insertion onto
the medial calcaneus, although there is variation in course and insertion. Clinical suspicion of
plantaris involvement includes persistent medial Achilles pain unresponsive to a rehabilitation
programme and imaging revealing a thickened plantaris tendon and/or focal medial Achilles
tendinosis. Potential mechanisms include compression or shearing forces between the plantaris
and Achilles tendons. Initial treatment should consist of a modified loading programme avoiding
end-range loading. Resistant cases may be amenable to surgical excision of the plantaris
demonstrating good clinical outcomes in the short and long term, although the evidence is
limited to case series. Percutaneous methods show promise but require further evaluation.
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NewsBot · Feb 3, 2019

Results of minimally invasive Achilles tendon
scraping and plantaris tendon removal in
patients with chronic midportion Achilles
tendinopathy: A longer-term follow-up
study
Anna Ruergård et al
AGE Open Medicine Volume 7: 1–7 2019

Background: Treatment with ultrasound and colour Doppler–guided minimally invasive Achilles tendon scraping and plantaris
tendon removal has shown promising short-term results in patients with chronic painful midportion Achilles tendinopathy.
Methods: In a follow-up study, 182 consecutive patients (241 tendons) who had undergone Achilles tendon scraping and
plantaris tendon removal were contacted on telephone by an independent investigator. The patients who answered the
telephone call were included, and they answered a questionnaire on telephone and then also sent their written answers. The
questionnaire included information about patient satisfaction with the result of the treatment, time to return to full Achilles
tendon loading activity, and a pain score (Visual Analogue Scale-VAS).
Results: The follow-up period was 5.8 years (mean) (range of 2–13 years) after surgery. Altogether, 110 patients (136
Achilles tendons), 52 years (mean)(range 18-73) old at surgery could be reached and were included. In total, 81 tendons
were operated with the Achilles scraping procedure alone, and for 55 Achilles operations also a plantaris tendon removal
was performed. For 93% of the operated tendons, the patients were satisfied with the surgical outcome and the VAS had
decreased from 74 preoperatively to 8 postoperatively. Nine male patients (9 tendons), five operated with scraping+plantaris
removal, had remaining tendon pain during loading and were not satisfied. Their VAS score ranged from 22 to 91. For 21%
of the operated tendons, some occasional mild discomfort not preventing from full tendon loading, was reported. There
were no differences in pain reduction and satisfaction rates between men and women, and between Achilles scraping alone
and scraping plus plantaris removal.
Conclusion: Ultrasound and colour Doppler–guided surgical Achilles tendon scraping and plantaris tendon removal in
patients with chronic painful midportion Achilles tendinopathy show remaining good clinical outcomes and high satisfaction
rates in this longer-term follow-up.
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NewsBot · Apr 27, 2019

Plantaris tendon and association with mid-portion Achilles tendinopathy. Is the plantaris tendon a contributing factor in mid-portion Achilles tendinopathy?
Lorenzo Masci et al
Vol. 54. Num. 201.

Plantaris tendon is implicated in some cases of load-resistant Achilles tendinopathy. The tendon courses close to the medial Achilles tendon mid-portion prior to insertion onto the medial calcaneus, although there is variation in course and insertion. Clinical suspicion of plantaris involvement includes persistent medial Achilles pain unresponsive to a rehabilitation programme and imaging revealing a thickened plantaris tendon and/or focal medial Achilles tendinosis. Potential mechanisms include compression or shearing forces between the plantaris and Achilles tendons. Initial treatment should consist of a modified loading programme avoiding end-range loading. Resistant cases may be amenable to surgical excision of the plantaris demonstrating good clinical outcomes in the short and long term, although the evidence is limited to case series. Percutaneous methods show promise but require further evaluation.
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NewsBot · May 29, 2019

Prevalence of Coexistent Plantaris Tendon Pathology
in Patients with Mid-Portion Achilles Pathology:
A Retrospective MRI Study
Sachin Khullar et al
Sports 2019, 7, 124

Co-existence of Plantaris tendinopathy (PT) in patients with mid-Achilles tendinopathy
(Mid-AT) is of clinical significance. This study aims to describe the MRI-based pathological
characteristics of co-existing PT and Mid-AT. One-hundred MRI studies of patients diagnosed
with Mid-AT were retrospectively analysed by an experienced musculoskeletal radiologist. Presence
or absence of a Plantaris tendon, co-existing PT with Mid-AT, insertional characteristics of Plantaris
tendon, and maximum anteroposterior thickness of the tendon in Mid-AT (axial images) were
evaluated. When PT co-existed with Mid-AT, the location of the tendon pathologies in relation
to calcaneal insertion was assessed (sagittal images) and their association was analysed using the
coefficient of variation (CV) and Pearson’s correlation coefficient. Plantaris was present in 84 cases
(84%), and Mid-AT and PT co-existed in 10 cases (10%). A greater variability in the location of
Plantaris pathology (CV = 42%) than Achilles tendinopathy (CV = 42%) was observed. The correlation
coefficient also revealed a low and non-significant association between the location of two pathologies
when they exist together (r = +0.06; p = 0.88). Clinical evaluation of Achilles tendon pain needs
careful consideration into the possible co-existence of Plantaris pathology. The considerable difference
observed in the location of PT and Mid-AT suggest possible isolated pathologies and differentials for
Achilles tendon pain.
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NewsBot · Dec 5, 2019

It is possible to release the plantaris tendon under ultrasound guidance: a technical description of ultrasound guided plantaris tendon release (UPTR) in the treatment of non-insertional Achilles tendinopathy.
Hickey B et al
Knee Surg Sports Traumatol Arthrosc. 2019 Sep;27(9)

PURPOSE:
Open plantaris tendon excision and ventral paratendinous stripping is a recognised treatment option in selected patients with non-insertional Achilles tendinopathy. The aim of this study was to develop a minimally invasive outpatient technique of ultrasound guided plantaris tendon release (UPTR).

METHODS:
A 19 gauge needle, 15 gauge scalpel blade, hook knife (Smith and Nephew, Boston, MA, USA) and a beaver blade (Arthrex, Naples, FL, USA), were used under ultrasound guidance to identify and divide the plantaris tendon in 12 cadaveric legs. Specimens were dissected to identify whether division of the plantaris tendon had been successful. UPTR was subsequently performed on patients.

RESULTS:
The 15 gauge scalpel blade, hook knife (Smith and Nephew, Boston, MA, USA) and beaver blade (Arthrex, Naples, FL, USA) were all able to cut the plantaris tendon. However, on dissection the hook knife (Smith and Nephew, Boston MA) caused less damage to surrounding structures. Subsequently, the plantaris tendon was successfully divided in three patients using UPTR technique without complication.

CONCLUSION:
UPTR is a viable technique for treating plantaris related non-insertional Achilles tendinopathy.
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NewsBot · Jan 14, 2020

MORPHOLOGY OF PLANTARIS LONGUS WITH SPECIAL REFERENCE
TO ITS CLINICAL IMPORTANCE
Kumari Savita, et al
Int J Anat Res 2019, Vol 7(4.2):7101-04. ISSN 2321-4287

Background: Plantaris is small fusiform muscle, with its long, slender tendon. Actually it’s a vestigial muscle in
human beings hence its rupture does not result in any significant loss of function. Muscle tear associated with
bleeding and swelling leads to a posterior compartment syndrome. It can mimic other serious conditions like
DVT, ruptured baker’s cyst and calf neoplasms.
The present study aims to find out the various patterns of proximal and distal attachment of plantaris muscle,
which will help the clinician deciding in diagnosis and the plastic & orthopaedic surgeons for different types of
reconstructive surgeries.
Materials and Methods: Forty-eight limbs from 24 embalmed cadavers of known sex(male) & age (40-75 years)
were dissected in the department of anatomy of Lady Harding medical college, New Delhi during 2016-2017.
Plantaris muscle identified with its proximal and distal attachment. Length of muscle belly & tendon were
recorded.
Result: In the present study out of 48 limbs specimens, Plantaris muscle was absent in 12.5%. Its proximal
attachment to lateral supracondylar ridges observed in 29% & with lateral head of gastrocnemius muscle &
fibrous capsule in 58.3%. Its distal attachment deep to tendocalcaneus was noted in 25% and superficial to
tendocalcaneus in 62.4%. Length of muscle belly was 7- 9 cm in 37% and tendon length was 34- 36cm in 37.5%.
Conclusion: The Morphological aspects of the attachment of plantaris play a significant role in the Pathologies
associated with Calf & knee region. Their exact attachment is importance for reconstructive surgeries to the
repair of ankle joint injury and flexor tendon replacement in hand.
KEY WORDS: Plantaris Muscle, Morphology, Fusiform muscle.
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