Achilles tendonopathy/rupture

Ultrasound of a normal Achilles tendon.Ultrasound of a normal Achilles tendon.
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Achilles tendonopathy/rupture

Characteristics

  • Describes pathology of the combined tendon of the gastro-soleus complex, which inserts onto the calcaneum.
  • Three stages of injury:
  1. Paratenonitis.
  2. Tendonosis with or without paratenonitis.
  3. Rupture – partial or full. A complete tear may be acute or chronic, sometimes with no prior symptoms.

Clinical features

  • Relate to the stage of the injury:
  1. Localised tenderness proximal to the insertion, and crepitus on ankle movement.
  2. 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.
  3. 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%).

Radiological features

  • USS and MRI can be used in the diagnosis of all three stages of Achilles tendonopathy.
  1. USS:
    1. Normal tendon
      1. uniform thickness<7 mm.
    2. Tendonosis
      1. fusiform swelling.
      2. heterogeneous echo pattern.
      3. hypoechoic foci (mucoid degeneration).
  • 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.

Management

  • 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.
  1. Controversial role for local anaesthetics steroid injection into the paratenon.
  2. 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.
Achilles tendonopathy. Note the fusiform swelling within the proximal tendon (asterisk).

Achilles tendonopathy. Note the fusiform swelling within the proximal tendon (asterisk).

Ultrasound of ruptured Achilles tendon. Note the echo-poor haematoma between the two ends of the ruptured tendon.

Ultrasound of ruptured Achilles tendon. Note the echo-poor haematoma between the two ends of the ruptured tendon.

Sagittal STIR MRI: High signal within the substance of the Achilles tendon, secondary to a partial rupture (arrow).

Reference

  1. 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.
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