Single-Puncture Endoscopic-Assisted Radiofrequency Microtenotomy for Recalcitrant Midsubstance Achilles Tendinopathy: The SPEAR Technique

Midsubstance Achilles tendinopathy may remain symptomatic despite prolonged nonoperative management. Radiofrequency microtenotomy has been described using open and percutaneous approaches; however, conventional percutaneous techniques rely predominantly on surface localization and tactile feedback and may require repeated skin punctures to distribute treatment across the pathological tendon. We describe the single-puncture endoscopic-assisted radiofrequency microtenotomy (SPEAR) technique. Achilles tendoscopy is first performed to evaluate the symptomatic tendon segment and selectively treat pathological peritendinous tissue and adhesions when present. A single central cutaneous puncture is then created over the treatment field. Using this entry site as a pivot, the TOPAZ MicroDebrider is sequentially redirected beneath the cutaneous envelope to deliver a 3 × 4 grid of radiofrequency applications, with probe-tendon contact confirmed endoscopically before each activation. The longitudinal extent of the grid can be scaled according to the length of the symptomatic tendon segment. SPEAR combines the limited cutaneous disruption of percutaneous radiofrequency microtenotomy with the visual control and pathology-directed treatment afforded by Achilles tendoscopy. This article describes a reproducible technical modification for selected patients with recalcitrant midsubstance Achilles tendinopathy.