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 was an avid runner, hiker, and rock climber but had been unable to engage in these activities in previous months due to worsening symptoms. On physical examination, the midportion of the right Achilles tendon was markedly thickened and tender to palpation. The patient was unable to perform a single-leg calf raise because of pain. Type of Probe Used: 3-14 MHz linear array transducer Unlabeled Long Axis View of the Achilles Tendon Midportion Unlabeled Long Axis View of the Achilles Tendon Midportion Unlabeled Long Axis View of the Achilles Tendon Midportion Tear Measurement Unlabeled Long Axis View of the Achilles Tendon Midportion Tear Measurement, measuring approximately 11.05 mm from proximal to distal. Unlabeled Long Axis View of the Achilles Tendon Midportion Tear with Doppler Unlabeled Long Axis View of the Achilles Tendon Midportion Tear with Color Doppler demonstrating multiple intratendinous neovessels consistent with chronic and severe tendinopathy. Labeled Long Axis View of the Achilles Tendon Midportion Labeled Long Axis View of the Achilles Tendon Midportion 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 Unlabeled Short Axis View of the Achilles Tendon Midportion Unlabeled Short Axis View of the Achilles Tendon Midportion Unlabeled Short Axis View of the Achilles Tendon Midportion Thickness Measurement Unlabeled Short Axis View of the Achilles Tendon Midportion Thickness Measurement, measuring approximately 14.81 mm. Unlabeled Short Axis View of the Achilles Tendon Midportion Tear Measurement Unlabeled Short Axis View of the Achilles Tendon Midportion Tear Measurement showing the depth and width of the largest intrasubstance partial tear measuring approximately 3.65 mm by 4.45mm. Unlabeled Short Axis View of the Achilles Tendon Midportion with Doppler Unlabeled Short Axis View of the Achilles Tendon Midportion with Color Doppler, demonstrating multiple intratendinous neovessels consistent with chronic and severe tendinopathy. Labeled Short Axis View of the Achilles Tendon Midportion Labeled Short Axis View of the Achilles Tendon Midportion 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 Short Axis View of the Achilles Tendon Midportion Cyst Aspiration Unlabeled Short Axis View of the Achilles Tendon Midportion Cyst Aspiration using an 18-gauge, 1.5-inch needle. Unlabeled Short Axis View of the Achilles Tendon Midportion Bone Marrow Concentrate Injection Unlabeled Short Axis View of the Achilles Tendon Midportion Midportion Bone Marrow Concentrate Injection showing the 22-gauge, 1.5-inch needle advancing with a lateral-to-medial approach through the tendon before injecting the bone marrow concentrate. Unlabeled Short Axis View of the Achilles Tendon Midportion Bone Marrow Concentrate Immediately Post-Injection Unlabeled Short Axis View of the Achilles Tendon Midportion Bone Marrow Concentrate Immediately Post-Injection demonstrating that the hyperechoic connective tissue matrix fills the partial tears. #13 - Video View Video Short-axis cine of the midportion Achilles tendon showing the ultrasound-guided percutaneous ultrasonic tenotomy using a lateral-to-medial approach. 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 Ohberg 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 or well-circumscribed intrasubstance regions may represent cystic transformation from prior partial tearing. This finding supports chronicity and may influence management by identifying tendons with more advanced chronic structural change. A complete scan should measure tendon thickness, describe hypoechogenicity and fibrillar disruption, assess Doppler signal, and also describe the location and extent of partial tearing. Symptoms and load tolerance serve as the primary return to activity factors rather than imaging alone. References: 1. Chimenti RL, Neville C, Houck J, Cuddeford T, Carreira D, Martin RL. Achilles pain, stiffness, and muscle power deficits: midportion Achilles tendinopathy revision - 2024. J Orthop Sports Phys Ther. 2024;54(12):CPG1-CPG32. doi:10.2519/jospt.2024.0302 2. Gatz M, Spang C, Alfredson H. Partial Achilles tendon rupture - a neglected entity: a narrative literature review on diagnostics and treatment options. J Clin Med. 2020;9(10):3380. doi:10.3390/jcm9103380 3. Docking SI, Ooi CC, Connell D. Tendinopathy: is imaging telling us the entire story? J Orthop Sports Phys Ther. 2015;45(11):842-852. doi:10.2519/jospt.2015.5880
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