Achilles Tendon Rupture

Rebecca Aspden, HMS III
Gillian Lieberman, MD
Achilles Tendon Rupture
Rebecca Aspden, Harvard Medical School Year III
Gillian Lieberman, MD
November 15, 2004
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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.
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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.
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Rebecca Aspden, HMS III
Gillian Lieberman, MD
• Look for:
Diagnosis
Diagnosis of Achilles Tendon rupture can almost
always be made clinically.
– Palpable gap in tendon
– Positive Thompson test
– Difficulty standing on toes
– Tenderness
UpToDate
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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
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Rebecca Aspden, HMS III
Gillian Lieberman, MD
Longitudinal sonogram showing
partial-thickness
partial thickness tear
Hartgerink et al.
Tendon is markedly thickened and hypoechoic.
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Rebecca Aspden, HMS III
Gillian Lieberman, MD
Longitudinal sonogram showing
full-thickness
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.
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Rebecca Aspden, HMS III
Gillian Lieberman, MD
Tendons on MRI
Proton
Density
T2
Normal DARK DARK
Degenerated
(tendinosis)
BRIGHT DARK
Torn BRIGHT BRIGHT
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Rebecca Aspden, HMS III
Gillian Lieberman, MD
NORMAL - axial
Proton density T2
PACS, BIDMC
Achilles tendon
PACS, BIDMC
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Rebecca Aspden, HMS III
Gillian Lieberman, MD
NORMAL - sagittal
Proton density T2
PACS, BIDMC
Achilles tendon
PACS, BIDMC
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Rebecca Aspden, HMS III
Gillian Lieberman, MD
Tendons on MRI
Proton
Density
T2
Normal DARK DARK
Degenerated
(tendinosis)
BRIGHT DARK
Torn BRIGHT BRIGHT
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Rebecca Aspden, HMS III
Gillian Lieberman, MD
DEGENERATED - axial
Proton density T2
slightly increased signal
PACS, BIDMC PACS, BIDMC
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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
T2
Normal DARK DARK
Degenerated
(tendinosis)
BRIGHT DARK
Torn BRIGHT BRIGHT
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Rebecca Aspden, HMS III
Gillian Lieberman, MD
TEAR - axial
Proton density T2
tear
PACS, BIDMC PACS, BIDMC
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intact plantaris tendon

Rebecca Aspden, HMS III
Gillian Lieberman, MD
TEAR - sagittal
Proton density T2
PACS, BIDMC
avulsed piece of bone
PACS, BIDMC
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Normal
Rebecca Aspden, HMS III
Gillian Lieberman, MD
Summary - sagittal
Degenerated
PACS
PACS, BIDMC
PACS, BIDMC
Torn
Proton Density Images
PACS, BIDMC
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Normal
Rebecca Aspden, HMS III
Gillian Lieberman, MD
Summary - axial
Degenerated
PACS, BIDMC
PACS, BIDMC
Torn
Proton Density Images
PACS, BIDMC
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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
•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.
Conclusion
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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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