The goal is to work between the Achilles tendon and peritendineum. When the scope is introduced, and this is the image, you are not in the correct layer. The fibrous structure of the Achilles tendon is not yet visible, so release should be done more onto the tendon.
After repeated release with the blunt trocar and introduction of the scope, we now are in the correct layer. Adhesion is visible in this image.
Under direct vision the visible adhesions are released. Here we see a released peritendineum.
The medial, lateral and anterior sides of the tendon are also released with the blunt trocar.
With a shaver introduced through the proximal portal remnants of adhesions and peritendineum are removed. The shaver should be kept onto the tendon to prevent iatrogenic damage. Changing portals can be helpful. At the end of the procedure it must be possible to move the arthroscope over the complete symptomatic area of the Achilles tendon.
Pearls & Pitfalls
We start the procedure when the distal portal has already been made and the subcutaneous layers are spread with a mosquito clamp. Now we blindly release the peritendineum from the Achilles tendon with a blunt trocar, after which the arthroscope is introduced to make sure we're in the correct layer of tissue.