- Describes pathology of the combined tendon of the gastro-soleus complex, which inserts onto the calcaneum.
- Three stages of injury:
- Tendonosis with or without paratenonitis.
- Rupture – partial or full. A complete tear may be acute or chronic, sometimes with no prior symptoms.
- Relate to the stage of the injury:
- Localised tenderness proximal to the insertion, and crepitus on ankle movement.
- Tendonosis Nodular thickening and degenerative change within the tendon presents as focal thickening within the tendon, which is only tender in the presence of paratenonitis.
- Rupture – classically a middle-aged patient (M>F) who undergoes a sudden, forceful contraction of gastro-soleus during infrequently performed sporting activity – ‘I thought I was kicked in the back of the leg’. The classic gap may not be palpable, but Simmonds Test will be abnormal in the vast majority of ruptures (>95%).
- USS and MRI can be used in the diagnosis of all three stages of Achilles tendonopathy.
- Normal tendon
- uniform thickness<7 mm.
- fusiform swelling.
- heterogeneous echo pattern.
- hypoechoic foci (mucoid degeneration).
- Normal tendon
- In an acute full-thickness tear, in the presence of good clinical signs there is no need for imaging; if there is doubt over partial continuity, then both USS and MRI are diagnostic.
- Stage 1 – NSAIDs, identify/eliminate triggers, stretching (eccentric loading), orthoses to correct any hindfoot malalignment (varo-valgus) and ‘off load’ the tendon by a heel raise.
- Controversial role for local anaesthetics steroid injection into the paratenon.
- Operative treatment in the form of tenosynovectomy is only required if the above fails.
- Stage 2 – In addition to the above, longitudinal tendon opening and excision of central necrotic tissue is performed, to promote healing within the degenerate area.
- Stage 3 – Chronic rupture needs surgical reconstruction. Acute tears can be managed operatively (open or percutaneous repair) or nonoperatively by functional bracing or traditional serial casting.
- James R. D. M., Erskine J. H., Rakesh R. M. (2008). Musculoskeletal Radiology. A-Z Musculoskeletal and Trauma Radiology, 1st edition, Cambridge University Press, Cambridge, 1, 1-176.