Midportion Achilles Tendinopathy And Partial Tear

Midportion Achilles Tendinopathy And Partial Tear

Authors, Editors, Case Information Author: Alexandre Lavigne, MD Affiliation: Kansas City Orthopedic Alliance, University of Missouri PM&R, University of Montreal PM&R Co Author(s): Michael Khadavi, MD, RMSK Senior Editor: Carlton Covey, MD, MEd Clinical Vignette: A 55-year-old male presented with a one-year history of insidious onset right posterior ankle pain. He is an avid runner, hiker, and rock climber but has been unable to engage in these activities in recent months due to worsening symptoms. On physical examination, the midportion of the right Achilles tendon is markedly thickened and tender to palpation. The patient is unable to perform a single-leg calf raise because of pain. Type of Probe Used: 3-14 MHz linear array transducer Unalebed Short Axis Midportion Achilles Tendon Fluid Aspiration Unlabeled short-axis ultrasound image of the midportion Achilles tendon showing the ultrasound-guided cyst aspiration using an 18-gauge, 1.5-inch needle. Unlabeled Short Axis Midportion Achilles Tendon with Color Doppler Unlabeled short-axis ultrasound image of the midportion Achilles tendon using color Doppler, demonstrating multiple intratendinous neovessels consistent with chronic and severe tendinopathy. Unlabeled Short Axis Midportion Achilles Tendon BMC Injection Unlabeled short-axis ultrasound image of the midportion Achilles tendon showing the 22-gauge, 1.5-inch needle advancing with a lateral-to-medial approach through the tendon before injecting the bone marrow concentrate. Unalebeled Short Axis Midportion Achilles Tendon BMC Injection #2 Unalebeled short-axis ultrasound image of the midportion Achilles tendon demonstrating that the hyperechoic connective tissue matrix fills the partial tears. #5 - Video View Video Short-axis ultrasound video of the midportion Achilles tendon showing the ultrasound-guided percutaneous ultrasonic tenotomy using a lateral-to-medial approach. Labeled Measurement Short Axis Midportion Achilles Tendon Tear Short-axis ultrasound image of the midportion Achilles tendon showing the depth and width of the largest intrasubstance partial tear. Labeled Measurement Short Axis Midportion Achilles Tendon Diameter Short-axis ultrasound image of the midportion Achilles tendon showing the tendon thickness measurement. Labeled Measurement Long Axis Midportion Achilles Tendon Tear Long-axis ultrasound image of the midportion Achilles tendon showing the length of the intrasubstance partial tear. Labeled Long Axis Midportion Achilles Tendon Labeled long-axis ultrasound image of the midportion Achilles tendon showing increased thickness with the tendon exhibiting a convex shape and a longitudinal intrasubstance partial tear. The partial tear (solid arrow) is surrounded by hypoechogenic tendinotic tissue with loss of normal fibrillar architecture, while some healthy-appearing fibers remain, including deep to the tear. Labels: AT: Achilles tendon, FHL: Flexor hallucis longus, KFP: Kager's fat pad, solid arrow: partial tear Unalebeled Long Axis Midportion Achilles Tendon with Color Doppler Unlabeled long-axis ultrasound image of the midportion Achilles tendon using color Doppler, demonstrating multiple intratendinous neovessels consistent with chronic and severe tendinopathy. Unlabeled Short Axis Midportion Achilles Tendon Unlabeled short-axis ultrasound image of the midportion Achilles tendon. Labeled Short Axis Midportion Achilles Tendon Labeled short-axis ultrasound image of the midportion Achilles tendon showing increased thickness, hypoechogenicity, and a few intrasubstance partial tears. Labels: AT: Achilles tendon, FHL: flexor hallucis longus, KFP: Kager's fat pad, solid arrows: intrasubstance tears Unlabeled Long Axis Midportion Achilles Tendon Unlabeled long-axis ultrasound image of the midportion Achilles tendon. Interpretation Image Interpretation: Chronic midportion Achilles tendinosis with intrasubstance partial tearing. The tendon measures 15 mm in thickness and demonstrates diffuse hypoechogenicity, although the typical fibrillar pattern remains partially preserved. There is significant intratendinous Doppler signal within the zone of tendinosis, corresponding to a score of 4 on the modified Öhberg Scoring System. Multiple longitudinally oriented intrasubstance partial tears are identified, the largest measuring 10 mm in length by 4 mm in both width and depth. The chronicity of the tear has resulted in a well-demarcated, fluid-filled cystic transformation. The final images and video demonstrate the ultrasound-guided treatment of the midportion Achilles tendinopathy, including intra-tendinous cyst aspiration and percutaneous ultrasonic tenotomy, followed one week later by bone marrow concentrate and connective tissue matrix injections. Teaching Pearl: In chronic Achilles tendinopathy, anechoic, well-circumscribed regions visualized on both long- and short-axis views suggest cystic transformation of a prior intrasubstance tear. This finding not only confirms the chronicity of the pathology but can also influence management by identifying cases where aspiration may be warranted before proceeding with an orthobiologic injection. Khadavi M, Wingard A, Lavigne A, McCullough K. Debride, refill, fertilize: technique description with corresponding case report of a novel, minimally invasive treatment for Achilles tendon partial tears. Med Res Arch. 2025;13(3). doi:10.18103/mra.v13i3.6379.
NOTE: For more information, please contact the AMSSM, 4000 W. 114th Street, Suite 100, Leawood, KS 66211 (913) 327-1415.

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