1
Rebecca Aspden, HMS III
Gillian Lieberman, MD
Achilles Tendon RuptureAchilles 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.
www.medicalmultimediagroup.com
3
Rebecca Aspden, HMS III
Gillian Lieberman, MD
Types of Achilles Tendon Types of Achilles Tendon
InjuryInjury
z 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.
z Tendinosis
– Intrasubstance degeneration of tendon itself.
z 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?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 patientOur 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
DiagnosisDiagnosis
• Look for:
– Palpable gap in tendon
– Positive Thompson test
– Difficulty standing on toes
– Tenderness
UpToDate
Diagnosis of Achilles Tendon rupture can almost
always be made clinically.
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Rebecca Aspden, HMS III
Gillian Lieberman, MD
Imaging OptionsImaging Options
z Plain films are not very helpful.
z In questionable cases ultrasound can provide
definitive diagnosis (particularly good in
differentiating partial from complete rupture).
z 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 AchillesPlain film of torn Achilles
PACS, BIDMC
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Rebecca Aspden, HMS III
Gillian Lieberman, MD
Longitudinal sonogram showing Longitudinal sonogram showing
partialpartial--thicknessthickness teartear
Hartgerink et al.
Tendon is markedly thickened and hypoechoic.
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Rebecca Aspden, HMS III
Gillian Lieberman, MD
Longitudinal sonogram showing Longitudinal sonogram showing
fullfull--thicknessthickness teartear
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 MRITendons 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 NORMAL -- axialaxial
Proton density T2
PACS, BIDMC PACS, BIDMC
Achilles tendon
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Rebecca Aspden, HMS III
Gillian Lieberman, MD
NORMAL NORMAL -- sagittalsagittal
Proton density T2
PACS, BIDMC PACS, BIDMC
Achilles tendon
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Rebecca Aspden, HMS III
Gillian Lieberman, MD
Tendons on MRITendons 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 DEGENERATED -- axialaxial
Proton density T2
PACS, BIDMC PACS, BIDMC
slightly increased signal
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Rebecca Aspden, HMS III
Gillian Lieberman, MD
DEGENERATED DEGENERATED -- sagittalsagittal
Proton density T2
PACS, BIDMC PACS, BIDMC
thickened tendon
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Rebecca Aspden, HMS III
Gillian Lieberman, MD
Tendons on MRITendons on MRI
Proton
Density
T2
Normal DARK DARK
Degenerated
(tendinosis)
BRIGHT DARK
Torn BRIGHT BRIGHT
18
Rebecca Aspden, HMS III
Gillian Lieberman, MD
TEAR TEAR -- axialaxial
Proton density T2
PACS, BIDMC PACS, BIDMC
intact plantaris tendon
tear
19
Rebecca Aspden, HMS III
Gillian Lieberman, MD
TEAR TEAR -- sagittalsagittal
Proton density T2
PACS, BIDMC PACS, BIDMC
avulsed piece of bone
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Rebecca Aspden, HMS III
Gillian Lieberman, MD
PACS
Proton Density Images
PACS, BIDMC
PACS, BIDMC
PACS, BIDMC
Normal
Degenerated
Torn
Summary - sagittal
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Rebecca Aspden, HMS III
Gillian Lieberman, MD
Proton Density Images
PACS, BIDMC
PACS, BIDMC
PACS, BIDMC
Normal
Degenerated
Torn
Summary - axial
22
Rebecca Aspden, HMS III
Gillian Lieberman, MD
Treatment for Achilles tendon ruptureTreatment for Achilles tendon rupture
z Surgery followed by early mobilization has
had better results than just immobilizing
tendon with cast for 8 weeks.
z Active rehabilitation phase after surgery is 6
months long.
zMost patients can return to pre-injury
activity including sports.
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Rebecca Aspden, HMS III
Gillian Lieberman, MD
ConclusionConclusion
•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.
www.home.zonnet.nl
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Rebecca Aspden, HMS III
Gillian Lieberman, MD
ReferencesReferences
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
AcknowledgementsAcknowledgements
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.
Achilles Tendon Rupture
Slide Number 2
Types of Achilles Tendon Injury
Who gets tears?
Our patient
Diagnosis
Imaging Options
Plain film of torn Achilles
Longitudinal sonogram showing partial-thickness tear
Longitudinal sonogram showing full-thickness tear
Tendons on MRI
NORMAL - axial
NORMAL - sagittal
Tendons on MRI
DEGENERATED - axial
DEGENERATED - sagittal
Tendons on MRI
TEAR - axial
TEAR - sagittal
Slide Number 20
Slide Number 21
Treatment for Achilles tendon rupture
Conclusion
References
Acknowledgements