Rebecca Aspden, HMS III Gillian Lieberman, MD

Achilles Tendon Rupture

Rebecca Aspden, Harvard Medical School Year III Gillian Lieberman, MD

November 15, 2004

Rebecca Aspden, HMS III Gillian Lieberman, MD

Achilles tendon: Largest tendon in body. Formed from conjoined tendons of gastrocnemius and soleus muscles. Inserts on calcaneus. Contributes to plantar flexion of foot.
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Rebecca Aspden, HMS III Gillian Lieberman, MD

Types of Achilles Tendon Injury

Peritendinosis (peritendinitis)
Edema and scarring of paratenon (fatty areolar tissue

around tendon). Acute pain and swelling. Seen in runners who increase their training or run on uneven surfaces.

Tendinosis
Intrasubstance degeneration of tendon itself.

Tears (partial or complete)

Vulnerable zone of avascularity 2-6 cm above calcaneal

insertion.
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Rebecca Aspden, HMS III Gillian Lieberman, MD

Who gets tears?

Average age 35-40. Sports act is often triggering factor.

Weekend Warrior

In elderly underlying systemic disease or long-term corticosteroid medication may contribute. Chronic degeneration of tendon (tendinosis) may be predisposing factor.

Rebecca Aspden, HMS III Gillian Lieberman, MD

Our patient
Mr. S is a 37 year-old man who was playing basketball at the local YMCA on Saturday afternoon. Even though Mr. S was a serious athlete in college, in the years since graduation he only makes it to the gym once a week for a pick-up game with his buddies from the office. As he was starting to chase after the ball, Mr. S felt a sudden pain in his left calf and heard a snap. He thought he had been shot! He could not walk and immediately limped to the sideline.

Rebecca Aspden, HMS III Gillian Lieberman, MD

Diagnosis
Diagnosis of Achilles Tendon rupture can almost always be made clinically.

Look for:
Palpable gap in tendon Positive Thompson test Difficulty standing on toes Tenderness
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Rebecca Aspden, HMS III Gillian Lieberman, MD

Imaging Options
Plain films are not very helpful. In questionable cases ultrasound can provide definitive diagnosis (particularly good in differentiating partial from complete rupture). MRI helpful in planning surgery and in identifying intratendon abnormalities such as tears, tendinosis, and retrocalcaneal bursitis.
Helps surgeon decide whether to approximate tendon

ends or use allograft.

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Rebecca Aspden, HMS III Gillian Lieberman, MD

Plain film of torn Achilles

PACS, BIDMC

Rebecca Aspden, HMS III Gillian Lieberman, MD

Longitudinal sonogram showing partial-thickness tear

Hartgerink et al.

Tendon is markedly thickened and hypoechoic.

Rebecca Aspden, HMS III Gillian Lieberman, MD

Longitudinal sonogram showing full-thickness tear

Hartgerink et al.

This ultrasound shows posterior shadowing (due to sound beam refraction at frayed tendon ends) and 9 mm of retraction with tendon debris between calipers. Another sign of tear on ultrasound is fat herniation. 10

Rebecca Aspden, HMS III Gillian Lieberman, MD

Tendons on MRI
Proton Density Normal Degenerated (tendinosis) Torn DARK BRIGHT BRIGHT T2 DARK DARK BRIGHT

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Rebecca Aspden, HMS III Gillian Lieberman, MD

NORMAL - axial
Proton density T2

PACS, BIDMC

PACS, BIDMC

Achilles tendon
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Rebecca Aspden, HMS III Gillian Lieberman, MD

NORMAL - sagittal
Proton density T2

PACS, BIDMC

PACS, BIDMC

Achilles tendon

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Rebecca Aspden, HMS III Gillian Lieberman, MD

Tendons on MRI
Proton Density DARK BRIGHT BRIGHT T2 DARK DARK BRIGHT
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Normal
Degenerated

(tendinosis) Torn

Rebecca Aspden, HMS III Gillian Lieberman, MD

DEGENERATED - axial
Proton density T2

PACS, BIDMC

PACS, BIDMC

slightly increased signal

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Rebecca Aspden, HMS III Gillian Lieberman, MD

DEGENERATED - sagittal
Proton density T2

PACS, BIDMC

PACS, BIDMC

thickened tendon

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Rebecca Aspden, HMS III Gillian Lieberman, MD

Tendons on MRI
Proton Density DARK BRIGHT BRIGHT T2 DARK DARK BRIGHT
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Normal Degenerated (tendinosis) Torn

Rebecca Aspden, HMS III Gillian Lieberman, MD

TEAR - axial
Proton density T2

tear

intact plantaris tendon

PACS, BIDMC

PACS, BIDMC

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Rebecca Aspden, HMS III Gillian Lieberman, MD

TEAR - sagittal
Proton density T2

PACS, BIDMC

PACS, BIDMC

avulsed piece of bone

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Rebecca Aspden, HMS III Gillian Lieberman, MD

Torn

Summary - sagittal
Degenerated

PACS, BIDMC

Normal

PACS

PACS, BIDMC

Proton Density Images

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PACS, BIDMC

Rebecca Aspden, HMS III Gillian Lieberman, MD

Torn

Summary - axial
Degenerated

PACS, BIDMC

Normal
PACS, BIDMC

Proton Density Images

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PACS, BIDMC

Rebecca Aspden, HMS III Gillian Lieberman, MD

Treatment for Achilles tendon rupture

Surgery followed by early mobilization has had better results than just immobilizing tendon with cast for 8 weeks. Active rehabilitation phase after surgery is 6 months long. Most patients can return to pre-injury activity including sports.
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Rebecca Aspden, HMS III Gillian Lieberman, MD

Conclusion
Achilles tendon rupture is often seen in middle-aged men who exercise infrequently. Diagnosis is usually made without imaging but US can be used in questionable cases. MRI is used in surgical planning.

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Rebecca Aspden, HMS III Gillian Lieberman, MD

References
Anderson, J., J.W. Read, and J. Steinweg. Atlas of Imaging in Sports Medicine. Sydney: McGraw-Hill Australia, 1998. Andrews, J.R., B. Zarins, and K.E. Wilk, ed. Injuries in Baseball. New York: Lippincott-Raven Publishers, 1998. Halpern, B., S.A. Herring, D. Alcheck, and R. Herzog. Imaging in Musculoskeletal and Sports Medicine. Malden, MA: Blackwell Science, 1997. Hartgerink. P. et al. Full- versus Partial-Thickness Achilles Tendon Tears: Sonographic Accuracy and Characterization in 26 Cases with Surgical Correlation. Radiology 220: 406-412, 2001. Kerr, Roger. Magnetic Resonance Imaging of the Foot and Ankle. Seminars in Roentgenology 35(3): 306-318, 2000. Kjaer, M. et al, ed. Textbook of Sports Medicine. Malden, MA: Blackwell Science, 2003. Moore, K.L. and A.F. Dalley. Clinically Oriented Anatomy. New York: Lippincott Williams & Wilkins, 1999. Southmayd, William and Marshall Hoffman. Sports Health. New York: Quick Fox, 1981.
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Rebecca Aspden, HMS III Gillian Lieberman, MD

Acknowledgements
Thanks to Larry Barbaras, Gillian Lieberman, Pamela Lepkowski, Alice Fisher, and Mary Hochman. Without their encouragement, inspiration, and technical help, this presentation would not have been possible.

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