I want to ask about the other modalities of treatment after failed either conservative or PRP injection of a chronic achilles tendinopathy. Other modalities rather than physiotherapy that has failed, injection that has failed. What can we do surgically to these patients? Well, there's a number of other treatment options. So traditionally, my treatment algorithm is conservative therapy. So you correct any biomechanical problems they have. You do your physiotherapy, which generally in my experience, achilles patients don't tolerate particularly well. And then you go, I traditionally put them through shockwave. And if they fail that, if they're suitable, and then if they fail that, they get a PRP injection or overdistension, depending on what their imaging shows. And if overdistension has a fairly high success rate, but it's a rule of 70. So if you take 100 patients, 70% of them will succeed with conservative. Of the 30, 70% of them will get better with injection. Of that 30% that are left after that, you're then looking at surgery. So it's a very small group at the bottom. And then your choice is tendon stripping. So some of them will have plantar adhesion, like James Calder showed. Some of them will have severe paratenonitis, which you can strip. Some of them will have nodular. We know nodular achilles tendinopathy is the best surgically. You can excise the nodule and then PRP the tendon on the way out, which is what I typically do. And then if you have severe tendinosis, I do an FHL transfer. Rick, anything to add? Anything to add to that chronic achilles tendinopathy? No, I agree with all which is said. I think those are all good treatment protocols. Any other questions? Can you put that first case up and we'll stump the chumps here? Get some… Yes, sir. We love questions. Our friend from Italy. Introduce yourself. Professor Ferker, you didn't speak about the massive allograft implantation or OCL. Because I think that the real problem is not only the extension but the deep depth of the damage. So what do you think about this kind of treatment? Using allografts for osteochondral lesions? I think if they're large, if they're quite large and with big cysts, that's another approach. Instead of using a bone graft with a MACE, you could do an in-block resection or resect a large portion of that and put an allograft. Which way is better? I don't think we know. I don't think there's been a good study to compare those two, but the results of the allografts from Bill Bugbee and some of the other people overall have been pretty good with long-term follow-up around five to seven years. So I do recommend those to some of my patients that have very large cystic lesions, particularly if they take about a third or more of the articular surface for sure. The second question is for Stephen Kears about your experience in the peroneal tendon. In my experience, very often you can find a dissection of the peroneal tendon. In that case, how can you assess arthroscopically? Well, I suppose then that's the differential between whether you're using it as a diagnostic aid when you're doing another arthroscopy or whether you're going to repair what your preferred method of peroneal tendon repair is. So typically if I find a tear, I know John would probably debride it, but I typically open it and tubularize it. But at least I haven't done that in a—I haven't opened the tendon in a patient who didn't have a tear. So the scope lets me identify the location of the tear. I can size my incision then based on where the tear physically is and do the smallest incision I can to repair the tendon. That's my personal practice, but I know that other people do more than that. But, I mean, again, for adhesions or groove deepening, groove deepening is quite an invasive procedure, and to be able to do that arthroscopically is a big advantage. Good? Okay.

chronic Achilles tendinopathy

treatment options

PRP injection

surgical options

peroneal tendon tears