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Review
MR Imaging of Disorders of the Achilles Tendon
Mark E. Schweitzer 1 and David Karasick

T he Achilles tendon is among the


most frequently injured tendons of
the body with a variety of types of
traumatic and overuse conditions affecting it.
trocnemius tendon, approximately 34 cm
more distally [2].
The plantaris muscle originates from the
lateral meniscus and the lateral femoral epi-
blood supply is diminished [6]. This region
of decreased vascularity is the usual region
of Achilles rupture [7]. Proximal tears are
uncommon because of the nutrition provided
These conditions are common, often come to condyle in close association with the lateral by the muscular branches from the gastroc-
clinical attention, and are frequently imaged. head of the gastrocnemius muscle. The plan- nemius [8]. Distal tears are uncommon be-
The pathophysiology of Achilles disorders is taris tendon then crosses obliquely between cause the blood supply from the periosteal
complex, and the nomenclature is irregularly the soleus and gastrocnemius muscles and vessels is near the calcaneal insertion.
applied; this leads to miscommunication be- continues just medial to the Achilles. Various As the Achilles tendon descends, the fi-
tween clinicians and radiologists and inconsis- plantaris insertions are seen, but most fibers bers rotate laterally approximately 90.
tencies in the literature. Therefore, we review insert on the medial aspect of the superior cal- Therefore, the gastrocnemius fibers insert
the anatomy, MR imaging findings, and patho- caneal tuberosity or 1 cm anterior and medial laterally onto the posterior calcaneus,
logic findings in an attempt to develop a sys- to the Achilles on the calcaneus, a distinct in- whereas the soleus fibers insert medially [9].
tematic nomenclature. sertion point separate from that of the Achil- The insertion site of the Achilles onto the
les. The Achillesplantaris complex is termed calcaneus is an enthesis and is intimately re-
Gross Anatomy the tricepssurae complex [3]. lated to the only true anatomic bursa in the
The Achilles tendon originates in the mid The Achilles tendon is enclosed almost ankle, the retrocalcaneal bursa [10].
leg and is formed by the junction of the two completely within a paratendon. This paraten- The retrocalcaneal bursa is horseshoe-
heads of the gastrocnemius muscles and the don has both visceral and parietal layers [4]. shaped, filled with synovial fluid, and sur-
soleus muscle [1, 2]. The bulk of the Achilles The paratendon is analogous to synovium in rounded anteriorly by Kagers fat pad. The
is formed from the gastrocnemius muscle. The that it provides nutrition for the tendon, but function of the retrocalcaneal bursa is to pro-
larger medial head originates almost entirely because the Achilles tendon does not change tect the distal Achilles tendon from frictional
from just proximal to the medial femoral its axis of motion, there is no need for the lu- wear against the posterior calcaneus [11]. Pos-
condyle, and the smaller lateral head arises brication function of synovium. terior to the tendon lies an acquired bursa,
from both the posterior and lateral surfaces of Two layers of filmy fibrous tissue with termed the retro-Achilles. The enthesis itself
the lateral femoral condyle. At the junction of fine internal mesotendal blood vessels make is fibrocartilage directly intermeshing into the
the proximal and mid calf, the two heads of the up the paratendon [5]. The interwoven fibers marrow of the calcaneus [10]. This direct
gastrocnemius muscles and their tendons ap- of the paratendon allow it to stretch up to meshing of tendon fibrils into marrow pro-
proximate midline. The gastrocnemius tendon several centimeters in length with tendon vides significant strength at the enthesis and
origin is gradual, occurring over approxi- movement and provide some degree of ten- makes it a rare site of tendon failure.
mately 34 cm. The fibers of the medial head don gliding [4].
originate slightly lower than those of the lat- Mesotendal vascular anastomoses pro- Tendon Ultrastructure
eral head. The Achilles tendon is not formed vide tendon nourishment. However, 26 cm Approximately 15 cm in length, the Achilles
until the soleus muscle inserts onto the gas- proximal to the calcaneal insertion, this is the strongest, largest, and thickest tendon in

Received May 3, 1999; accepted after revision February 24, 2000.


1
Both authors: Department of Radiology, Thomas Jefferson University Hospital, 111 S. 11th St., 3390 Gibbon, Philadelphia, PA 19107. Address correspondence to M. E. Schweitzer.
AJR 2000;175:613625 0361803X/00/1753613 American Roentgen Ray Society

AJR:175, September 2000 613


Schweitzer and Karasick

the human body. The Achilles is made of fasci- effect on the foot for standing, it consists pri- 6 mm superior to inferior, 3 mm medial to
cles, with an interfascicular membrane separat- marily of type I fibers [16]. Consequently, lateral, and 2 mm anterior to posterior [19].
ing the fascicles into bundles. Each bundle of muscle fiber atrophy of the soleus occurs Subcutaneous fat should be seen between the
fascicles is roughly shaped like a quarter of a more rapidly than does that of the gastrocne- Achilles and the skin. Focal absence of fat
pie. On a microstructural level, the fascicles are mius [17], making the soleus muscle a more may represent a skin callus, a blister (if it has
made of fibroblasts, which have a sinusoidal sensitive indicator of atrophy as a result of high signal on T2-weighted images and bows
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structure. This sinusoidal structure allows the complete tears or denervation. the skin out), or retro-Achilles bursitis (if it
Achilles to stretch considerably before tendon has high signal and is without mass effect on
rupture. The fibroblasts are made of fibrils, the the skin). Fat should also be normally seen
Normal MR Appearance
fibrils are made of microfibrils, and the mi- anterior to the tendon in Kagers fat pad. Oc-
crofibrils are made of tropocollagen [12]. The The normal average thickness of the casionally, vessels within Kagers fat pad can
fibrils normally have an undulating pattern. Achilles tendon is 6 mm. The Achilles ten- mimic edema, although their tubular mor-
This undulation decreases with aging, which don is thicker in tall patients, in men, and in phology should allow differentiation.
leads to a decrease in the Achilles elasticity the elderly [18]. Achilles size is also directly The Achilles tendon is usually dark on all
[13]. In addition, the average diameter, density, related to lean body mass and is somewhat imaging sequences. However, the normal fas-
and cellularity of the collagen fibrils also de- related to total body mass. cicular anatomy of the Achilles tendon may be
crease with aging. The combination of cellular On sagittal images, the anterior and poste- visible as a single line and can mimic an inter-
changes, ultrastructural changes, and a tenuous rior margins of the Achilles tendon should be stitial tear [20]. This fascicular signal is usually
blood supply predisposes the aged Achilles to parallel below the soleus insertion (Fig. 1). not present or fades on T2-weighted images.
degeneration and injury. On axial images, the anterior margin of the Small punctate areas of high signal, seen dis-
Achilles is concave for most of its course. tally in the Achilles tendon on axial images, are
Somewhat proximally, just above the soleus interfascicular membranes (Figs. 2 and 3).
Functional Anatomy insertion, the margin may be straight or con- Lastly, some fraction of distal internal signal
The gastrocnemius, soleus, and plantaris vex; at the soleus insertion, the margin is typ- may represent the magic angle artifact. This
muscles act to flex the foot [14]. The gastroc- ically convex and may be focally bulbous. phenomenon occurs in the Achilles tendon even
nemius is also a knee flexor. The gastrocne- On coronal images, both sides of the Achilles though it does not grossly change its axis, be-
mius muscle is active in walking, jumping, are fairly straight and the tendon widens as it cause the fibers twist internally. This artifact is
and running, and therefore it is composed extends distally at the lesion. not present on T2-weighted images [21].
predominantly of type II fibers [15]. Because The normal retrocalcaneal bursa is visible
the soleus muscle has more of a stabilization on MR imaging but should measure less than Epidemiology
True rupture of the Achilles tendon was
first described by Ambroise Pare in 1575 and
first reported in the medical literature in
1633. Achilles tendon rupture was a rarely
reported injury until the 1950s [22]. Before
1929, fewer than 70 cases were reported in
the world literature. During the 1970s, the re-
ported incidence increased by up to 50% a
year in developed countries [23].
Achilles tendon tears are most common in
developed countries, but the prevalence var-
ies among developed countries. The highest
rates are seen in Germany, Austria, Sweden,
Denmark, and Switzerland. Lower rates oc-
cur in France, Spain, the United Kingdom,
and the United States [23]. However, some
industrialized nations, such as The Nether-
lands, Japan, and Korea, have an extremely
low incidence of Achilles tears, and in the
third world, the incidence of Achilles tears is
even lower [24]. Currently, the incidence in
industrialized nations is approximately seven
cases per 100,000 inhabitants per year [24].
A B Achilles tendon rupture occurs in younger
Fig. 1.41-year-old man with normal tendon. patients, with a mean age of 36 years, as com-
A, Sagittal T2-weighted MR image (TR/TE, 6000/70) shows normal parallel anterior and posterior margins of ten- pared with ruptures of other tendons, but Achil-
don (open arrows ). Note normal volume of fat in Kagers fat pad anterior to tendon (solid arrows ) and insertion
les rupture almost never occurs in patients
of soleus muscle onto tendon.
B, Axial T1-weighted MR image (500/20) shows normal concave anterior margins of tendon (arrow ). Kagers fat before the onset of adolescence [25]. Of all the
pad can be seen anterior to tendon. tendons in the foot and ankle, the Achilles ten-

614 AJR:175, September 2000


MR Imaging of the Achilles Tendon

the intimate association between the distal


Achilles tendon and the retrocalcaneal bursa,
the Achilles tendon is secondarily affected by
inflammatory processes involving the retrocal-
caneal bursa [10]. In addition, involvement of
the Achilles paratendon has been noted to be
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reasonably frequent in systemic inflammatory


diseases, such as rheumatoid arthritis [30]. This
manifestation of rheumatoid arthritis has not
been widely recognized previously because
this inflammation, similar to that of many wrist
tendons, is often clinically occult [31].
Most imaging findings represent the
pathologic processes of tendon degeneration
and repair [32]. Grossly, the degenerated ten-
don appears nodular and yellow and loses its
usual glistening luster, often appearing
edematous or fibrillated [33].
Fig. 2.37-year-old woman with normal fascicles Fig. 3.45-year-old man with normal fascicles and peri- On a microscopic level, four predominant
of Achilles tendon. Axial proton densityweighted tendonitis. Axial T2-weighted MR image (TR/TE, 6000/78) types of tendon degeneration are seen includ-
MR image (TR/TE, 4000/40) shows normal fascicu- with fat suppression shows barbed-wire appearance of
lar anatomy. Fascicles appear as intratendon sig- fascicles (curved arrow ). Also note partially circumferen- ing fibromatosis or hypoxic, lipoid, osseous or
nal (arrows ) in Achilles tendon. tial high signal (straight arrow ) consistent with small de- calcific, and myxoid [34]. Although only the
gree of peritendonitis. former two frequently lead to macroscopic
tears, all pathologic changes may be the result
don is the only one for which disorders have a The specific causative activity varies among of microscopic tears [35]. These microscopic
male predominance [26]. Achilles tendon dis- countries according to the popularity of sport- tears evolve and coalesce to form the spectrum
orders are also more common on the left than ing events in the country involved. In the of Achilles disorders that is seen on imaging. It
on the right side for unknown reasons [27]. Be- United States, running sports, particularly those is the coalescence of these microtears that leads
cause Achilles tendon disorders are activity-re- that involve pivot motion, are the most com- to the development of focal mycoid regions and
lated disorders, incidence peaks during the mon causative sport, with jogging as the lead- interstitial tears along the long axis of the ten-
summer [28]. ing cause of Achilles disorders [28]. However, don. Therefore, tears on a microscopic level be-
A significant relationship between leisure in Germany, soccer is the leading cause [27]. gin the cascade of tendon disorders, and tears
athletic activities and tendon injuries exists on a macroscopic level end it [35].
[27]. The sedentary lifestyle of modern white- Fibromatous degeneration is also termed
collar workers results in decreased blood flow MR Imaging and Pathologic Anatomy hypoxic degenerative tendonopathy and is
and nutrition to the Achilles tendon [29]. This Achilles tendonosis is a preferable term to the most frequently seen degenerative finding
situation is compounded by the effects of aging Achilles tendonitis because this disorder is in ruptured Achilles tendons [36]. These hy-
on the vascular supply. Recreational physical manifested as intratendinous degeneration poxic changes are likely caused by ischemia
activities that intermittently stress the ischemic without a significant inflammatory response because of the relative hypovascularity of the
Achilles tendon, without giving it time to [18]. The Achilles tendon is protected against critical zone of the Achilles tendon [37]. This
adapt, may lead to spontaneous Achilles ten- inflammatory processes because no true syn- hypovascularity results in anoxic injury to
don rupture [29]. ovial sheath is present. However, because of tenocytes and collagen fibers [34]. Hypoxic

Fig. 4.60-year-old man with hy-


poxic degeneration.
A and B, Sagittal T1-weighted (A) (TR/
TE, 500/10) and sagittal short tau in-
version recovery (B) (6000/40; inver-
sion time, 150 msec) MR images show
bulbous thickening (solid straight
arrows ) of Achilles tendon and that
anterior and posterior margins of
Achilles tendon are no longer parallel.
No internal signal can be seen. Note
normal volume of retrocalcaneal
bursa fluid (solid curved arrow ). Inci-
dentally noted is cartilaginous calca-
neal navicular coalition (open arrow ).
A B

AJR:175, September 2000 615


Schweitzer and Karasick

Fig. 5.48-year-old man with hypoxic degeneration. Ax- degenerative tendonopathy leads to a thick-
ial T2-weighted fat-suppressed MR image (TR/TE, 6000/ ened dysmorphic Achilles tendon [36] (Figs. 4
80) shows extensive thickening of Achilles tendon with
loss of normal concave anterior margin (arrows ). and 5). This type of degeneration usually oc-
curs after multiple symptomatic episodes [37]
and usually lacks internal signal on MR imag-
ing. A similar MR appearance can be seen in
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rheumatoid arthritis (Fig. 6) and gout (Fig. 7)


and after tendon repair.
The second most common type of degen-
eration is mucoid. Most patients with mu-
coid degeneration also have some degree of
hypoxic degeneration [33]. This is the most
common degeneration to occur asymptom-
atically. In mucoid degeneration, large mu-
coid patches and vacuoles are seen between
the thinned degenerated tendon fibers [35].
Interrupted signal on T2-weighted images is
the best marker for mucoid deposits (Figs.
810). Grossly, these tendons appear en-
larged, and enlargement may also be seen
Fig. 6.55-year-old woman with
rheumatoid arthritis. Sagittal T1-
weighted MR image (TR/TE, 500/20)
shows markedly thickened Achilles
tendon (white arrows ) caused by
rheumatoid arthritis. Also, note find-
ings consistent with retrocalcaneal
bursitis (straight black arrow ) and
with subtalar joint disease (curved
black arrow ). Erosion of calcaneus
can be seen as well.

Fig. 7.50-year-old man with gout.


Sagittal T1-weighted MR image (TR/
TE, 500/12) shows thickening of
Achilles tendon (straight arrows )
representing gouty infiltration. Gouty
infiltration of anterior tibialis tendon
(curved arrow ) can also be seen.
6 7

Fig. 8.55-year-old woman with mucoid degenera-


tion.
A and B, Sagittal T1-weighted (TR/TE, 500/20) and
sagittal short tau inversion recovery (6000/70) MR im-
ages show thickened Achilles tendon with internal
signal (arrows ). This signal was nonlinear and inter-
rupted on T2-weighted image (not shown).
A B
616 AJR:175, September 2000
MR Imaging of the Achilles Tendon
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Fig. 9.58-year-old woman with mucoid degen- Fig. 10.48-year-old man with mucoid degeneration. Axial Fig. 11.56-year-old man with ossified Achilles. T1-
eration. Sagittal F-short tau inversion recovery T2-weighted fat-suppressed MR image (TR/TE, 6000/80) weighted MR image (TR/TE, 500/12) shows bone frag-
image (TR/TE, 4000/48; inversion time, 150 msec) shows thickened Achilles tendon (arrows ) with multifocal ments (arrow ) with trabeculae inside Achilles tendon.
shows irregular longitudinal mucoid deposit in speckled appearance consistent with mucoid degeneration.
Achilles tendon (arrows).

on MR imaging. It is the coalescence of quently than tendon calcification and is rela- The first symptomatic stage of Achilles dis-
vacuoles and lacunae that is the beginning tively more common than in other tendons in orders is paratendonitis, which is often mistak-
of an interstitial tear. Patients with mucoid the body [42]. Therefore, not only is ossifica- enly termed tendonitis [44] (Figs. 3 and 12).
degeneration may have a tear at first clinical tion distinct from calcification because of the This stage is analogous to synovitis in sheathed
presentation because earlier episodes were presence of cortical bone and trabeculae, but it tendons. On T2-weighted MR sequences, para-
asymptomatic. may represent a different degenerative path- tendonitis appears as partially circumferential
Tenolipomatosis is the most age-dependent way than calcification. high signal around the Achilles tendon. Fat sup-
type of tendon degeneration. Tenolipomatosis
occurs with fatty deposits between normal
tenocytes [38]. Because the tenocytes are nor-
mal, lipoid degeneration does not seem to af-
fect the structural properties of the Achilles
[39] and does not predispose the tendon to tear
[40]. This disorder, like hypoxic degeneration,
is often clinically silent and is related to, but
distinct from, tendinous xanthoma. Xantho-
mas are the result of lipomatosis seen in inher-
ited metabolic diseases such as type 2 and type
3 hyperlipoproteinemias and cerebrotendinous
xanthomatosis [41]. Although severe forms of
these metabolic disorders are rare, one diagnos-
tic criterion for familial hyperlipoproteinemia
is focal thickening of the Achilles tendon on
imaging [42]. Xanthomas can mimic hypoxic
Achilles tendonitis or various rheumatologic
conditions, with diffuse tendon thickening and,
often, quite subtle internal signal.
Calcifying tendonopathy is rare in the
Achilles tendon, seen in only 3% of ruptured Fig. 12.47-year-old male runner with peritendonitis. Fig. 13.45-year-old man with acute Achilles ten-
tendons [43]. This dystrophic calcification Axial T2-weighted fat-suppressed MR image (TR/TE, donitis. Fat-suppressed MR image (TR/TE, 6000/80)
may progress to Achilles ossification [41] 4000/78) shows thin rim of partially circumferential shows edema in fat anterior to Achilles tendon
high signal (arrows ), which represents mild periten- (arrows ).
(Fig. 11). On a macroscopic level in the donitis. Background mucoid degeneration within ten-
Achilles, tendon ossification occurs more fre- don and intratendon signal can be seen.

AJR:175, September 2000 617


Schweitzer and Karasick

pression is usually necessary to visualize this long axis of the Achilles), to partial tears, and [50]. Because one of the treatments for an
high signal. The high signal is not as bright as eventually to complete tears [46]. This abrupt Achilles tendon tear is casting in plantar flexion,
synovial fluid because the paratendon is not demarcation between tears and nontears is sagittal images can be obtained after casting. If
made of a synovial membrane. The external misleading because there is a junctional entity, the tendon edges are not opposed in this posi-
margins of the signal are typically slightly ill mucoid degeneration [35]. In mucoid degen- tion, the treatment will be unsuccessful [48].
defined, and the high signal predominates eration, the vacuoles may coalesce into an in- Achilles tendon tears can also occur
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posteriorly and extends medially up to three terstitial tear [36]; also, in tendonosis perhaps abruptly without a definite history of overuse
quarters around the tendon. In isolated paraten- the inciting event is a microtear [47]. Lastly, [45]. In some patients, MR images show evi-
donitis, the tendon itself is normal. True acute many cases of tendonosis are treated identi- dence of mucoid (silent) degeneration but not
tendonitis is an infrequent entity and is an even cally to cases of interstitial tears with dbride- of interstitial tear, and in a smaller number of
less frequent entity to be imaged. Most clinical ment of the degenerative center of the tendon these patients, MR images show chronic ten-
cases of tendonitis are either paratendonitis or an and oversewing of the preserved peripheral donosis related to hypoxic degeneration [51]
exacerbation of hypoxic tendonosis. True ten- aspects of the tendon [48]. or no evidence of degeneration at all.
donitis, if imaged, occasionally appears as edema Almost all tears, interstitial (Figs. 14 and With chronic Achilles tendon tears not only
not only in the paratendon but also in Kagers fat 15), partial (Figs. 16 and 17), or complete are the tendon edges retracted from each other,
pad anterior to the Achilles tendon [45] (Fig. 13). (Figs. 18 and 19) show high signal on T2- but there is ongoing atrophy of the Achilles ten-
The spectrum of tears ranges from mi- weighted imaging [49]. Tendon-end retraction don fibers and, to a greater and more mechani-
crotears to interstitial tears (parallel to the can also be seen occasionally in acute tears cally important degree, of muscle [52]. Muscle

Fig. 14.45-year-old man with inter-


stitial tear. Sagittal short tau inver-
sion recovery image (TR/TE, 4000/48;
inversion time, 150 msec) shows
multiple longitudinal lines (arrows )
inside thickened Achilles tendon
consistent with interstitial tear.

Fig. 15.58-year-old male runner with


interstitial tear. Sagittal short tau inver-
sion recovery image (TR/TE, 4000/48;
inversion time, 150 msec) shows longi-
tudinal area (arrowheads ) inside distal
Achilles tendon consistent with inser-
tional interstitial tear. Small amount of
reactive marrow edema (straight
arrow ) is seen in calcaneus as well as
excessive retrocalcaneal bursitis
(curved arrow ).
14 15

Fig. 16.58-year-old woman with partial Achilles tendon


tear. Sagittal T2-weighted MR image (TR/TE, 6000/80)
shows partial posterior Achilles tendon tear (black
arrow ). Longitudinal interstitial tear (white arrows ) and
evidence of underlying hypoxic degeneration with thick-
ened tendon can also be seen.

Fig. 17.25-year-old male runner with partial Achilles


tendon tear. Axial T1-weighted fat-suppressed MR im-
age (TR/TE, 500/10) obtained after IV administration of
gadolinium shows focal enhancement in medial par-
tial Achilles tendon tear (arrow ).
16 17
618 AJR:175, September 2000
MR Imaging of the Achilles Tendon

atrophy can be classified either as acute or sub- quently have microscopic tears. We describe This enthesophyte usually maintains normal
acute and potentially reversible or as remote and some commonly used clinical terms and their marrow signal on MR images. Occasionally,
irreversible [53]. Acute atrophy manifests as dif- meanings in an attempt to develop a systematic these enthesophytes show evidence of marrow
fuse edema throughout the muscle belly [54] nomenclature (Table 1). edema on MR imaging (Fig. 21). In this situa-
(Fig. 20). A patient with acute atrophy has the tion, the enthesophyte may be acutely symp-
best prognosis after surgery. Irreversible atrophy Associated Osseous Injuries and tomatic. These edematous spurs are the types of
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appears as a fatty infiltrated or fatty marbled Abnormalities enthesophytes that respond best to focal surgical
muscle [55]. A small muscle may have under- The most common associated osseous abnor- resection. Rarely, an enthesophyte can also cause
gone either reversible or irreversible atrophy [56]. mality in Achilles disorders is an enthesophyte at pain as the spur grows past the protective margin
In disorders of the Achilles, atrophy occurs the insertion of the Achilles into the calcaneus. of the retrocalcaneal bursa.
first in the soleus because of the predominance
of slow-twitch fibers. Because the soleus mus-
cle is part of the Achilles tendon, soleus atrophy TABLE 1 Clinical, Histologic, and MR Imaging Finding in Achilles Disorders
can be thought of as a predictor of a dysfunc- Clinical Findings Histologic Findings MR Imaging Findings
tional myotendinous unit. Therefore, when im-
aging the Achilles tendon, sagittal images Tendonitis Paratendonitis Partially circumferential high signal
should include at least 3 cm of the distal soleus Acute tendonitis Paratendonitis Partially circumferential high signal
belly to reveal whether soleus fatty infiltration is Hypoxic degeneration Thick black tendon
present. Occasionally, gastrocnemius muscle at- Rarely true tendonitis Edema of Kagers fat pad
rophy can be seen, but atropy of this muscle is Insertional tendonitis Microscopic tear Multiple thin distal longitudinal lines on
rare even in remote Achilles tendon tears. T2-weighted images
Ca++ and ossification Intratendon ossification
Enthesopathy Posterior calcaneal enthesophytes
Nomenclature Chronic tendonitis or Hypoxic degeneration Thickened tendon with flat or convex
One difficulty in interpreting images of tendonosis anterior margin and little internal signal
Achilles tendon disorders is the inconsistent Silent tendonitis Mucoid degeneration Intratendon signal that becomes more focal
use of nomenclature in imaging and clinical ar- on T2-weighted images but has
ticles. Clinically, there is an abrupt demarcation interrupted appearance on sagittal
between tendon disorders in which the tendon images
is overtly torn versus those in which it is not Spontaneous Achilles tear Interstitial tears (coalescent Longitudinal
[57]. This demarcation, although useful in tri- mucoid vacuoles) Noninterrupted high signal on T2-weighted
images
aging patients for surgery, is arbitrary and inac-
curate. Mucoid degeneration can mimic a tear Chronic tear Hypoxic degeneration and tear Horizontal disruption with a thickened
tendon
clinically, and silent Achilles disorders fre-

Fig. 18.58-year-old woman with sponta- Fig. 19.50-year-old man with spontaneous Achilles tendon Fig. 20.45-year-old man with acute Achilles tendon
neous Achilles tendon tear. Sagittal T2- tear. Sagittal short tau inversion recovery image (TR/TE, 4000/48; tear and atrophy. Axial short tau inversion recovery
weighted MR image (TR/TE, 7000/90) shows inversion time, 150 msec) shows completely avulsed Achilles image (TR/TE, 6000/58; inversion time, 150 msec)
complete Achilles tendon tear (arrows ) in tendon (arrow ) with significant gap because proximal fibers shows evidence of edema within soleus muscle
typical location: 5 cm from its insertion. Gap have been retracted. Fluid can be seen within gap. (arrows ), which is consistent with acute atrophy.
is approximately 1 cm.

AJR:175, September 2000 619


Schweitzer and Karasick

Fig. 21.48-year-old man with


symptomatic spur.
A and B, Sagittal T1-weighted (TR/
TE, 600/12) (A) and short tau inver-
sion recovery (TR/TE, 6000/40; inver-
sion time, 150 msec) (B) MR images
show subtle edema in posterior cal-
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caneal spur (arrows ).

A B

Fig. 22.49-year-old man with de-


generative cyst.
A and B, Sagittal T1-weighted (TR/TE,
600/12) (A) and short tau inversion re-
covery (6000/40; inversion time, 150
msec) (B) MR images show degenera-
tive cyst at posterior calcaneus (ar-
rows) adjacent to thickened Achilles
tendon insertion. Small amount of reac-
tive edema can be seen around cyst.
A B

Tendon ossification predominates distally in located at the inferiormost aspect of the Achilles
the tendon, appearing as focal fatty marrow. This insertion, and is well defined.
calcification is related to insertional enthesopa- In addition, calcaneal edema can also be a
thy [58]. However, true Achilles enthesopathy response to altered mechanics [62]. This reac-
occurs at the edge of rather than within the ten- tive marrow edema, although seen in several
don. This dystrophic ossification may have the ankle tendon disorders, is less commonly re-
appearance of a broken enthesophyte, although lated to Achilles disorders (Fig. 23). If present,
enthesophytes are not related to the Achilles dis- this calcaneal response to altered mechanics is
orders. Distal ossification appearing as a broken seen anterior to the Achilles insertion.
enthesophyte is thought to be the result of partial An associated osseous injury to the calcaneus
insertion tears [59]. Whether ossification also in- occurs in Achilles disorders as well [63]. This
creases the risk of Achilles tears or is merely the microavulsion injury is similar to changes seen in
result of prior partial tears is unclear. Although the elbow with epicondylitis or in the knee with
proximal ossification may present as a mass, medial collateral ligament tears [58, 64], but this
most patients provide a history of repetitive run- injury may occur in Achilles disorders other than Fig. 23.60-year-old man with acute Achilles ten-
ning-related tendonitis [60]. tears. It is often difficult to differentiate the types donitis clinically. Sagittal short tau inversion recovery
Somewhat more common than proximal os- of calcaneal marrow edema (Fig. 23). image (TR/TE, 4500/48; inversion time, 150 msec)
shows edema (curved arrows ) in Kagers fat pad an-
sification is marrow edema around the entheso- Another consideration in the differential terior to Achilles tendon, which is consistent with
phyte in response to inflammatory retrocalcaneal diagnosis of calcaneal marrow edema is acute Achilles tendonitis. Extensive reactive marrow
bursitis or as a degenerative cystic phenomenon stress fracture [65]. Typically, stress fractures edema (straight arrows ) can also be seen.
[61] (Fig. 22). The marrow edema caused by occur several millimeters anterior to the pos-
retrocalcaneal bursitis is seen at the calcaneal terior aspect of the calcaneus, do not occur One final differential diagnosis to consider is
margin of an enlarged bursa. The degenerative posterior at the Achilles insertion, and are residual red marrow. Residual red marrow may
edema is often cystic or has a cyst within it, is vertically oriented. be bright, closely mimicking marrow edema,

620 AJR:175, September 2000


MR Imaging of the Achilles Tendon

on fat-suppressed T2-weighted or short tau in- Atypical Achilles Tears high percentage of fast-twitch fibers [56],
version recovery images [66]. Residual red Although most Achilles tears occur 26 which is the reason the gastrocnemius is af-
marrow in the calcaneus occurs in children and cm from the insertion, Achilles tears can be fected but the soleus is not.
adolescents but rarely persists in adults. Resid- seen in two other locations: distally and On axial images, myotendinous junction
ual red marrow has a typical location superi- proximally. Distal tears occur as a result ei- tears are manifested as focal fluid at the muscu-
orlyjust posterior to the posterior facet of the ther of severe end-stage pump-bump, with lotendinous junction of the Achilles tendon.
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calcaneusand does not closely approach the attritional tendon tearing caused by shoe fric- Fluid follows the distal margins of the muscle
Achilles insertion. Most important, this entity tion, or of inappropriately treated or severe belly. On coronal images, tears have a U ap-
is usually multifocal in the foot. If necessary, insertional tendonitis. pearance because the fluid dissects down along
in-phase and out-of-phase imaging can confirm More common than an insertional tear, a the fascial plane of a distal muscle belly of the
the diagnosis of red marrow. proximal Achilles tear is, in reality, a musculo- gastrocnemius. The tear may be complete with
tendinous junction injury. This strain injury is focal absence of the tendon at a specific level
Insertional Tendonitis listed in the differential diagnosis for tennis or, more commonly, the tear is partial. Incom-
Insertional Achilles tendonitis is an impor- leg [67]. Proximal Achilles tears typically in- plete tear or edema from muscle strain occurs
tant subtype of injury that is common in run- volve the medial head of the gastrocnemius, are focally in the center of the muscle.
ners and frequently leads to the development twice as common in males as in females, usu- Adjacent edema can be seen in the muscle
of an enthesophyte. Insertional Achilles ten- ally involve the dominant leg, and occur in pa- as a component of the strain injury or as a
donitis may be the only true form of acute tients ranging in age from 23 to 57 years [68] manifestation of acute atrophy. Although the
Achilles tendonitis. On MR imaging, the (Figs. 2729). The most common risk factor is medial head of the gastrocnemius is usually
Achilles is thickened distally with vaguely participation in sports such as football, tennis, involved, the resulting atrophy can affect
seen ill-defined longitudinal high signal (Figs. and squash [69]. Like all muscle strain injuries, both heads because they act in concert [69].
2426). This signal may be fairly intense and the muscles at highest risk are those that cross In these circumstances, whether an adja-
can mimic a partial tear, albeit fairly distally. two joints, function eccentrically, and have a cent hematoma (Fig. 29) is present should be

Fig. 24.50-year-old male runner


with insertional tendonitis.
A and B, Sagittal short tau inversion re-
covery (TR/TE, 6000/48; inversion time,
150 msec) (A) and axial T2-weighted
fat-suppressed (TR/TE, 7000/80) (B)
MR images show slightly thickened
distal Achilles tendon with distal inser-
tional signal (open arrow, A; short ar-
row, B) that is relatively high signal on
fat suppressed image. Excessive ret-
rocalcaneal bursitis (solid arrow, A)
and peritendonitis (long arrows, B)
can also be seen.

A B
Fig. 25.60-year-old woman with insertional tendoni-
tis. Sagittal short tau inversion recovery image (TR/TE,
4000/52; inversion time, 150 msec) shows internal sig-
nal linearly oriented in Achilles tendon (arrow ). If this
finding were in more proximal location, it would be
consistent with tear, but at insertion tendonitis often
mimics partial tears on MR imaging.

Fig. 26.48-year-old male runner with distal tendoni-


tis. Axial fast spin-echo MR image (TR/TE, 6000/80)
shows extensive retrocalcaneal bursitis (solid arrow )
with linear thick signal within Achilles tendon (open
arrow ) representing insertional tendonitis.
25 26

AJR:175, September 2000 621


Schweitzer and Karasick
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Fig. 27.38-year-old woman with medial gastrocnemius tear. Fig. 28.47-year-old man Fig. 29.53-year-old woman with proximal Achilles tear. Axial fast spin-
Axial fast spin-echo MR image (TR/TE, 6000/85) shows com- with partial proximal echo MR image (TR/TE, 6000/70) shows partial tear (curved arrow ) of me-
plete tear of medial gastrocnemius myotendinous junction Achilles tear. Sagittal short dial head of gastrocnemius with associated hematoma (straight arrows ).
filled with fluid (arrows ). tau inversion recovery Clinically, this finding is often termed proximal Achilles tear.
image (TR/TE, 6000/40; in-
version time, 150 msec)
shows edema (arrows) at
myotendinous junction of
medial head of gastroc-
nemius with U-shaped
dissecting fluid.

Fig. 30.49-year-old woman with Fig. 31.58-year-old man with plantaris tendon tear. Axial fast spin-echo MR Fig. 32.55-year-old man with plantaris tendon
plantaris tendon tear. Sagittal short image (TR/TE, 7000/85) shows retracted plantaris filled with fluid (arrows ) be- tear. Sagittal short tau inversion recovery im-
tau inversion recovery image (TR/ tween gastrocnemius (G) and soleus (S) muscles. age (TR/TE, 7000/55; inversion time, 150 msec)
TE, 6000/78; inversion time, 150 shows line of fluid (arrows ) just between gas-
msec) shows edema anterior to trocnemius and soleus muscles.
gastrocnemius caused by plantaris
tear (arrows ).

622 AJR:175, September 2000


MR Imaging of the Achilles Tendon

Fig. 33.53-year-old woman with


Haglunds disease.
A and B, Sagittal T1-weighted (A) and
sagittal T2-weighted fat-suppressed
short tau inversion recovery (B) MR
images (TR/TE, 600/12) show soft-tis-
sue signal displacing fat posterior to
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thickened Achilles tendon consistent


with retro-Achilles bursitis (open ar-
row, B). Ill-defined fluid can be seen in
retrocalcaneal bursa, which is consis-
tent with retrocalcaneal bursitis
(curved arrows ). Edema in enlarged
tuberosity (straight arrows ) is seen as
well. All these findings are suggestive
of Haglunds disease.

A B

noted. A hematoma is a frequent sequela of Fig. 34.48-year-old woman with


muscle injury. Clinically, hematomas are Haglunds disease. Sagittal short tau
inversion recovery image (TR/TE,
evacuated [70]. Complete myotendinous 6000/48; inversion time, 150 msec)
junction tears are also treated surgically, but shows edema in calcaneal tuberos-
partial proximal myelotendinous junction ity (arrow ) and enlarged tuberosity.
In addition, Achilles tendon is chron-
tears are treated conservatively [68]. ically thickened without evidence of
internal signal. Hypertrophy of cal-
caneal tubercle is shown its projec-
Plantar Muscle Injury tion above parallel pitch lines
(dashed lines).
The symptoms of a ruptured plantaris tendon
have been described with specific sports (e.g.,
tennis leg). The tendon can tear when force-
fully contracted, resulting in the patient feeling
a pop in the calf [71]. Sudden dorsiflexion of
the ankle with the knee in extension has been
implicated as the mechanism for this injury. The
symptoms consist of calf pain followed by me-
dial swelling. Clinically, this condition needs to
be differentiated from Achilles tendon injuries
and medial gastrocnemius muscle injuries.
Clinically, the torn plantaris is considered a less
severe injury than gastrocnemius muscle tears [74]. This enlargement further irritates the retro- level of the posterior lip of the subtalar articu-
and is conservatively treated with ice, rest, and Achilles bursa and the Achilles tendon, which lar facet. In Haglunds disease, a portion of
antiinflammatory medications [72]. increases the irritation that causes further enlarge- the tuberosity is seen above the upper pitch
On T2-weighted MR imaging, plantaris in- ment of the tuberosity. This results in a cycle of line [76] (Fig. 34).
jury shows high signal cephalad to the location injury, response to injury, and reinjury [75].
of typical gastrocnemius injury. The fluid tends In patients with Haglunds disease, MR
to dissect medially and proximally to the bulk images reveal excessive fluid in the retrocal- Conclusion
of the soleus muscle (Figs. 3032). caneal bursa, fluid in the retro-Achilles MR imaging can provide important infor-
bursa, and an enlarged calcaneal tuberosity mation about the pathologic state of the
(Figs. 33 and 34). Achilles tendon, and these imaging findings
Haglunds Disease The diagnosis of an enlarged calcaneal tu- can provide information that is useful in pa-
Haglunds disease is frequently associated berosity (or of a bursal projection) is made by tient treatment.
with pump-style shoes. More important than drawing parallel pitch lines on the upper and
the shoe style is the presence of a stiff-heel lower aspects on the calcaneus on sagittal im-
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626
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AJR:175, September 2000