Journal of Medical Imaging and Radiation Sciences

Journal of Medical Imaging and Radiation Sciences 41 (2010) 133-136

Journal de l’imagerie médicaleet des sciences de la radiation

www.elsevier.com/locate/jmir

Ultrasound Evaluation of Achilles Tendinopathy

Emmanuel Ehiwe, MSc, PgD Educ, PgC, PgD Uss, DIRa*,Chyke I. Ohuegbe, MSc, BScb, and Rasheed Arogundade, MB, FMCR, FWACSc

a Spire Harpenden Hospital, Hertfordshire, UKb In-Health Group, London Diagnostic Project, London, UK

c Lagos University Teaching Hospital, Lagos, Nigeria

ABSTRACT

Introduction: We sought to highlight the significance of ultrasoundin assessing injuries to the Achilles tendon.

Methods: Using a case study approach, we present two case reviewsinvolving insertional enthesopathy and tendonitis of the Achilles.

Results: Our study shows the lesions in the Achilles tendon and theperitendinous structures noted on clinical examination of the pa-tients reviewed were better characterized with the use of ultrasound.

Conclusion: This outcome is in line with information from availableliterature and current practice.

* Corresponding author: Emma Ehiwe, MSc, Pgd Educ, PgC, PgD Uss,

DIR, Senior Radiographer, Spire Harpenden Hospital, Hertfordshire UK AL5

4BP.

E-mail address: eehiwe2003@yahoo.com (E. Ehiwe).

1939-8654/$ - see front matter � 2010 Published by Elsevier Inc.

doi: 10.1016/j.jmir.2010.03.006

RESUME

Objectif: Faire ressortir l’importance de l’ultrason dans l’evaluationdes blessures au tendon d’Achille.

Methodologie: A partir d’une methode se rapprochant de l’etude decas, nous presentons deux cas sur l’enthesopathie des insertions et latendinite du tendon d’Achille.

Resultats et conclusion: Notre etude indique qu’il etait plus facilede definir les lesions du tendon d’Achille et des structures peritendi-

neuses releves par examen clinique des patients en utilisant l’ultrason.Le resultat est conforme a la documentation actuelle et a la pratique.

Introduction

The spectrum of Achilles tendon injuries range from inflam-mation of the peritendinous tissue (peritendinitis), structuraldegeneration of the tendon (tendinosis), and partial or com-plete tendon rupture [1–3]. Acute total rupture of the Achillesis easily diagnosed clinically, but the sensitivity of detectingchronic tendinosis, peritendinitis or partial tears is reportedto be about 0.7–0.8 [4, 5]. With sonographic features indic-ative of chronic Achilles tendinopathies, we present two casesinvolving patients with insertional enthesopathy and tendini-tis of the Achilles.

Case Review 1

A 42-year-old female weighing 85 kg presented with heelpain, palpable swelling, tenderness and reddening of the rightheel. With a history of difficulty in walking over a 6-week pe-riod, the patient indicated that she had had no previous inves-tigation or treatment of her heel pain. Initial clinical

examination indicated Achilles tendonitis. Musculoskeletalultrasound was requested to confirm clinical diagnosis andinform further line of management.

Ultrasound scan reported chronic tendinopathy with inser-tional enthesopathy. The scan images showed the presence offocal hypoechoic area and thickening of the tendon just pro-ximal to the insertion (measuring 16 mm thick). There wasdiffuse disruption of fibrillar echo pattern and multiple focalcalcifications. Neovascularization on color Doppler interroga-tion was noted. On ultrasound, the tendon assumed a roundedappearance with loss of concave or flattened anterior contour.An area of marked decreased reflectivity was noted near thecalcaneal insertion suggesting focal tendon split. There wasno fluid in the retro-Achilles and pre-Achilles bursae, andthe paratenon appeared normal and intact. There was slightincrease in Kager’s fat pad echogenicity. No other calcanealabnormalities were noted (Figures 1–4).

Case Review 2

A 40-year-old female with swelling, pain and palpable ten-derness of the left heel presented for ultrasound scan. No his-tory of previous sporting activity or trauma was reported.

Figure 1. Transverse image showing thickened heteroechoic Achilles tendon

and calcifications near the insertion, measuring 16mm thick in anteroposte-

rior dimension.

Figure 3. Longitudinal view of Figure 2.

Before the scan, the patient did not have any previousradiological investigation or physiotherapy.

Ultrasound findings showed a diffuse hypoechoic, thick-ened Achilles tendon (about 5 cm from the insertion) measur-ing 13 mm thick. There was loss of fibrillar echo patternanteriorly. The tendon appeared rounded in shape with lossof concave or flattened anterior contour. Color Dopplershowed significant neovascularization. No definite focal splittear was seen, and there was no intratendon calcification.The insertion and myotendinous junction appeared intact.Normal appearance of the Kager’s fat pad, pre-Achilles andretro-Achilles bursae were reported (Figures 5–8).

Discussion

Chronic tendinopathy of the Achilles is a common overuseinjury that causes considerable distress with pain and

Figure 2. Transverse image of the Achilles tendon showing the presence of

focal hypoechoic areas and thickening of the Achilles tendon just proximal

to the insertion. Calcifications with acoustic shadowing and neovasculariza-

tion on power Doppler are noted.

134 E. Ehiwe et al./Journal of Medical Imaging and

disability [6]. Histology of the Achilles shows that tendinosisis a noninflammatory process resulting from a failed wound-healing cascade with evidence of disordered, haphazard heal-ing; intratendinous collagen degeneration; fiber disorientationand thinning; hypercellularity; scattered vascular ingrowth;and increased interfibrillar glycosaminoglycans [7]. Studieshave also shown that these areas of collagen degeneration cor-respond to the hypoechoic areas seen on sonography [8].

Although the etiology of Achilles tendinopathy is multifac-torial in origin, it is reported to be caused by repetitive strain,increased age, trauma, rheumatoid arthritis and hypercholes-terolemia [9]. Ultrasound is used to assess the heel areabecause it is a noninvasive, nonionizing, readily available,quick, safe and inexpensive imaging modality [10]. It alsohas the advantage of high resolution and color Doppler to as-sess vascularization of the Achilles tendon and other periten-dinous structuresdsubcutaneous tissues, Kager’s fat pad orpre-Achilles fat pad, bursae, calcaneal insertion, plantar fasciaand plantaris muscle. Other significant benefits of real-timesonography over other imaging modalities are that low kilo-voltage x-rays and xeroradiography can only outline the

Figure 4. Transverse image of the Achilles tendon shows flattened anterior

contour, with hypoechoic areas in the posterior part.

Radiation Sciences 41 (2010) 133-136

Figure 5. Longitudinal image of the Achilles tendon showing a fusiform-

shaped, hypoechoic, thickened Achilles tendon. Figure 7. Split-screen images of the Achilles tendon in longitudinal and trans-

verse sections. The heterogeneous appearance of the tendon is evident in the

images.

silhouette of the Achilles and indicate the level of fluid accu-mulation in surrounding tissue [11]. This level of informationis not sufficient to indicate fibrillar echo pattern or assess thepresence of capillary vascularization in the Achilles as reportedin the two cases discussed in this report.

Research has also shown that although magnetic resonanceimaging is excellent in soft-tissue contrast resolution of theAchilles and its adjacent bursae [12], and has the advantageof multiplanar capabilities to differentiate fluid collectionsin the heel from hematoma and other nonsanguinous collec-tions; it is limited, however, by inaccessibility, cost and claus-trophobia among patients who cannot tolerate the scanningprocedure. This is unlike ultrasound, which is readily avail-able, cheap, quick and safe to undertake [13].

The cases reviewed showed similar findings with areas ofreduced reflectivity in the tendons with diffuse disruption oftheir fibrillar echo pattern. This is quite different from thenormal sonographic outline of the normal tendon. The

Figure 6. Longitudinal image showing Achilles tendinopathy with neovascu-

larization on power Doppler.

E. Ehiwe et al./Journal of Medical Imaging and

tendons also showed thicknesses of 16 mm in Case 1 and13 mm in Case 2, respectively. These increases in the anteriorposterior plane diameter are 10 mm and 7 mm more than theaverage Achilles tendon dimension. The areas of decreased re-flectivity also noted near the calcaneal insertion indicatedmarked tendon degeneration and partial tear. This is sugges-tive of early signs of tendon rupture and focal split in the par-atendon sheath [14]. The presence of neovascularizationreported in both patients also indicated the presence of bloodcirculation, which would not be found in the normal tendonsheath.

Although tendon calcification is a rare finding in the nor-mal Achilles [15], it was reported in the patient discussed inCase 1. This ultrasound finding was indicative of the levelof chronicity [16] and degeneration of the Achilles [17] inthat patient. It also highlights the advantage of ultrasound

Figure 8. Image of the Achilles tendon showing flattened anterior contour in

the transverse view, with neovascularization. The tendon demonstrates

a heterogeneous echogenicity.

Radiation Sciences 41 (2010) 133-136 135

over other imaging modalities such as plain radiography andmagnetic resonance imaging or computed tomography scanimaging. This is vital in view of the fact that magnetic reso-nance imaging is the gold standard in estimating the degreeof tendon abnormalities [18] and differentiating among func-tional, morphologic and pathologic conditions [19].

Conclusion

The Achilles tendonitis and the peritendinous injuriesindicated on clinical examination were demonstrated usingultrasound. This helps to support the argument that real-time ultrasound is a veritable tool in demonstrating differenttypes of abnormalities of the Achilles tendon.

Acknowledgment

We thank Dr. D.S. Shetty, consultant radiologist, SpireHarpenden Hospital, England, for peer reviewing this article.

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