The Perfect Caper: Pulling Off The Minimally Invasive Achilles Tendinopathy Surgery

Stephen Barrett DPM FACFAS

With the adroit stealth and steeliness of a world-class bank robber, the surgeon slips the “garrote” atraumatically between the anterior surface of the Achilles tendon and the posterior aspect of Kager’s triangle. The implementer’s immense knowledge of the anatomical and histological terrain, perhaps greater than any other, allows him to completely avoid what most of his skilled contemporaries routinely and almost always seek during their mission.

He carefully slides the “garrote” distally without resistance and, with seemingly effortless technique, navigates perfectly with no direct line of sight. Yet he gets in and out, perhaps with greater reward than a thief, in sheer seconds and with virtually no disruption of the “crime scene.”

In this spellbinding plot, however, this “master thief” is not by any means a criminal. He is the hero. He is a researcher/surgeon who is successfully attempting to “steal” the mystical and truly unknown pain generators of Achilles tendinopathy away from their victims (in this case patients). Is he a modern day tendinopathic “Robin Hood” so to speak? Who is he? We will get to that in a second.

I know you’re thinking now: “What in the hell does this mean?” Let me try to explain …

After having had some time to reflect on my opportunity to participate last week at the Società Italiana Chirurghi Ortopedici Dell Ospedalità Privata (SICOOP) meeting in Modena, Italy, I realized I had just unknowingly witnessed perhaps the perfect minimally invasive “caper” executed in a long time in foot and ankle surgery. The topic was heel pain (“il dolore calcaneare”) and was organized by Professor Francesco Barca, MD.

By the way, I learned quickly that Modena (pronounced Mo-de-nà) is the world center of balsamic vinegar production. So in addition to learning more about this incredible gastronomic condiment, I had the great fortune to experience a different, albeit only slightly, perspective regarding the diagnosis and treatment of heel pain. That is, however, with the exception of the aforementioned caper I will refer to as “the Italian Job,” even though there is no calculated traffic jams, stunts with Mini Coopers or a resultant multimillion-dollar gold heist.

The garrote in this case is a 1-0 non-absorbable ligature threaded percutaneously just anterior to the Achilles tendon through two tiny medial and lateral incisions proximally and two incisions distally. By sliding this “weapon” from proximal to distal along the surface of the tendon, one can achieve a denervation, which interrupts the afferent pain generator signal coming from the tendinopathic area.1 At the same time, there is an interruption of the neovascularization, which is associated with the pain of tendinopathy.2,3

Contrast that with the conventional methods for this type of mission, which would likely involve removal of the nodular portion (to many surgeons the “jewel”) of the tendinopathy, linear tenotomies or a combination of both with much greater postoperative morbidity than occurs with this technique. The “crime scene,” if you need a cortical nudge at this point, is the posterior soft tissues of the proximal heel and that delicate veil of epidermis overlying the Achilles itself.

The sheer eloquence of simplicity embodied by this technique belies the extensive amount of research and clinical understanding that allows for planning and execution of such a minimally invasive surgical technique.

Although Professor Nicola Maffulli, MD, PhD, currently practices and researches in London, he is a native of Naples, which really fits well into my storyline. If you put his name and “tendon” into the “any fields” section of a PubMed search, you will hit a real treasure trove of goodies (something on the order of 256 but who is counting). That is, if you want to know more about tendinopathy and the innovative ways that are being developed to treat this nebulous and very prevalent condition.

This Italian Job could be a very important one for all of us out there trying to fight this difficult condition and it is something to start thinking about. Professor Maffulli’s work on tendinopathy will have and already has had far reaching positive ramifications for patients throughout the world. This Italian Job is simply a job well done. Grazie.


1. Longo UG, Ramamurthy C, Denaro V, Maffulli N. Minimally invasive stripping for chronic Achilles tendinopathy. Disabil Rehabil. 2008; 30(20-22):1709-1713.

2. Maffulli N, Longo UG, Denaro V. Novel approaches for the management of tendinopathy. J Bone Joint Surg Am. 2010; 92(15):2604-2613.

3. Divani K, Chan O, Padhiar N, Twycross-Lewis R, Maffulli N, Crisp T, Morrissey D. Site of maximum neovascularisation correlates with the site of pain in recalcitrant mid-tendon Achilles tendinopathy. Man Ther. 2010; 15(5):463-468.


I did the PubMed search as you suggested. Very interesting! Peeked my interest. I agree with the minimal invasive approach after many years of doing Achilles tendon surgery. I haven't searched yet but I bet the Chinese medical literature, much more difficult to interpret than Italian, will reveal similar techniques. Multiple, dry needling about the Achilles tendon may yield similar positive results.

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