ABSTRACT
Achilles tendinopathy is a common overuse injury in patients engaged in athletic activities.
Tendon degeneration is often accompanied by paratendinitis. Radiologists are frequently
asked to use imaging techniques to evaluate patients with problems at or around the
Achilles tendon. The main imaging modalities used in the assessment of Achilles tendon
disorders are plain radiography, ultrasound, and magnetic resonance imaging. In recent
years, ultrasound has also been used to guide minimally invasive local treatments
for Achilles tendinopathy, which may prevent the need for surgery if conservative
treatments have failed. In this article, we review the imaging features of Achilles
tendinopathy and consider the relative strengths and weaknesses of the various imaging
techniques. The role of imaging in directing patient management is also discussed,
with particular focus on ultrasound-guided treatments.
KEYWORDS
Achilles - tendinopathy - paratendinitis - ultrasound - MRI - treatment
REFERENCES
- 1
Kvist M.
Achilles tendon injuries in athletes.
Sports Med.
1994;
18(3)
173-201
- 2
Järvinen T A, Kannus P, Paavola M, Järvinen T L, Józsa L, Järvinen M.
Achilles tendon injuries.
Curr Opin Rheumatol.
2001;
13(2)
150-155
- 3
Werd M B.
Achilles tendon sports injuries: a review of classification and treatment.
J Am Podiatr Med Assoc.
2007;
97(1)
37-48
- 4
Maffulli N, Khan K M, Puddu G.
Overuse tendon conditions: time to change a confusing terminology.
Arthroscopy.
1998;
14(8)
840-843
- 5
el Hawary R, Stanish W D, Curwin S L.
Rehabilitation of tendon injuries in sport.
Sports Med.
1997;
24(5)
347-358
- 6
Bleakney R R, White L M.
Imaging of the Achilles tendon.
Foot Ankle Clin.
2005;
10(2)
239-254
- 7
Spina A A.
The plantaris muscle: anatomy, injury, imaging, and treatment.
J Can Chiropr Assoc.
2007;
51(3)
158-165
- 8
Simpson S L, Hertzog M S, Barja R H.
The plantaris tendon graft: an ultrasound study.
J Hand Surg Am.
1991;
16(4)
708-711
- 9
Cheung Y, Rosenberg Z S.
MR imaging of the accessory muscles around the ankle.
Magn Reson Imaging Clin N Am.
2001;
9(3)
465-473, x
- 10
Bianchi S, Martinoli C, Gaignot C, De Gautard R, Meyer J M.
Ultrasound of the ankle: anatomy of the tendons, bursae, and ligaments.
Semin Musculoskelet Radiol.
2005;
9(3)
243-259
- 11
Bottger B A, Schweitzer M E, El-Noueam K I, Desai M.
MR imaging of the normal and abnormal retrocalcaneal bursae.
AJR Am J Roentgenol.
1998;
170(5)
1239-1241
- 12
Carr A J, Norris S H.
The blood supply of the calcaneal tendon.
J Bone Joint Surg Br.
1989;
71(1)
100-101
- 13
Ahmed I M, Lagopoulos M, McConnell P, Soames R W, Sefton G K.
Blood supply of the Achilles tendon.
J Orthop Res.
1998;
16(5)
591-596
- 14
Hennessy M S, Molloy A P, Sturdee S W.
Noninsertional Achilles tendinopathy.
Foot Ankle Clin.
2007;
12(4)
617-641, vi–vii
- 15
James S L, Bates B T, Osternig L R.
Injuries to runners.
Am J Sports Med.
1978;
6(2)
40-50
- 16
Paavola M, Kannus P, Järvinen T A, Khan K, Józsa L, Järvinen M.
Achilles tendinopathy.
J Bone Joint Surg Am.
2002;
84-A(11)
2062-2076
- 17
Movin T, Gad A, Reinholt F P, Rolf C.
Tendon pathology in long-standing achillodynia. Biopsy findings in 40 patients.
Acta Orthop Scand.
1997;
68(2)
170-175
- 18
Khan K M, Cook J L.
Overuse tendon injuries: where does the pain come from?.
Sports Med Arthrosc Rev.
2000;
8
17-31
- 19
Öhberg L, Lorentzon R, Alfredson H.
Neovascularisation in Achilles tendons with painful tendinosis but not in normal tendons:
an ultrasonographic investigation.
Knee Surg Sports Traumatol Arthrosc.
2001;
9(4)
233-238
- 20
Bude R O, Adler R S, Bassett D R.
Diagnosis of Achilles tendon xanthoma in patients with heterozygous familial hypercholesterolemia:
MR vs sonography.
AJR Am J Roentgenol.
1994;
162(4)
913-917
- 21
Myerson M S, McGarvey W.
Disorders of the Achilles tendon insertion and Achilles tendinitis.
Instr Course Lect.
1999;
48
211-218
- 22
Pavlov H, Heneghan M A, Hersh A, Goldman A B, Vigorita V.
The Haglund syndrome: initial and differential diagnosis.
Radiology.
1982;
144(1)
83-88
- 23
Tan S C, Chan O.
Achilles and patellar tendinopathy: current understanding of pathophysiology and management.
Disabil Rehabil.
2008;
30(20–22)
1608-1615
- 24
Daftary A, Adler R S.
Sonographic evaluation and ultrasound-guided therapy of the Achilles tendon.
Ultrasound Q.
2009;
25(3)
103-110
- 25
Kainberger F M, Engel A, Barton P, Huebsch P, Neuhold A, Salomonowitz E.
Injury of the Achilles tendon: diagnosis with sonography.
AJR Am J Roentgenol.
1990;
155(5)
1031-1036
- 26
Mitchell A W, Lee J C, Healy J C.
The use of ultrasound in the assessment and treatment of Achilles tendinosis.
J Bone Joint Surg Br.
2009;
91(11)
1405-1409
- 27
Paavola M, Järvinen T A.
Paratendinopathy.
Foot Ankle Clin.
2005;
10(2)
279-292
- 28
Drakonaki E E, Allen G M, Wilson D J.
Real-time ultrasound elastography of the normal Achilles tendon: reproducibility and
pattern description.
Clin Radiol.
2009;
64(12)
1196-1202
- 29
Sconfienza L M, Silvestri E, Cimmino M A.
Sonoelastography in the evaluation of painful Achilles tendon in amateur athletes.
Clin Exp Rheumatol.
2010;
28(3)
373-378
- 30
Khan K M, Forster B B, Robinson J et al..
Are ultrasound and magnetic resonance imaging of value in assessment of Achilles tendon
disorders? A two year prospective study.
Br J Sports Med.
2003;
37(2)
149-153
- 31
Schweitzer M E, Karasick D.
MR imaging of disorders of the Achilles tendon.
AJR Am J Roentgenol.
2000;
175(3)
613-625
- 32
Robson M D, Benjamin M, Gishen P, Bydder G M.
Magnetic resonance imaging of the Achilles tendon using ultrashort TE (UTE) pulse
sequences.
Clin Radiol.
2004;
59(8)
727-735
- 33
Karjalainen P T, Soila K, Aronen H J et al..
MR imaging of overuse injuries of the Achilles tendon.
AJR Am J Roentgenol.
2000;
175(1)
251-260
- 34
Oatridge A, Herlihy A, Thomas R W et al..
Magic angle imaging of the achilles tendon in patients with chronic tendonopathy.
Clin Radiol.
2003;
58(5)
384-388
- 35
Marshall H, Howarth C, Larkman D J, Herlihy A H, Oatridge A, Bydder G M.
Contrast-enhanced magic-angle MR imaging of the Achilles tendon.
AJR Am J Roentgenol.
2002;
179(1)
187-192
- 36
Solan M, Davies M.
Management of insertional tendinopathy of the Achilles tendon.
Foot Ankle Clin.
2007;
12(4)
597-615, vi
- 37
Paavola M, Kannus P, Orava S, Pasanen M, Järvinen M.
Surgical treatment for chronic Achilles tendinopathy: a prospective seven month follow
up study.
Br J Sports Med.
2002;
36(3)
178-182
- 38
Alfredson H, Cook J.
A treatment algorithm for managing Achilles tendinopathy: new treatment options.
Br J Sports Med.
2007;
41(4)
211-216
- 39
Fahlström M, Jonsson P, Lorentzon R, Alfredson H.
Chronic Achilles tendon pain treated with eccentric calf-muscle training.
Knee Surg Sports Traumatol Arthrosc.
2003;
11(5)
327-333
- 40
Öhberg L, Lorentzon R, Alfredson H.
Eccentric training in patients with chronic Achilles tendinosis: normalised tendon
structure and decreased thickness at follow up.
Br J Sports Med.
2004;
38(1)
8-11, discussion 11
- 41
Paoloni J A, Appleyard R C, Nelson J, Murrell G A.
Topical glyceryl trinitrate treatment of chronic noninsertional achilles tendinopathy.
A randomized, double-blind, placebo-controlled trial.
J Bone Joint Surg Am.
2004;
86-A(5)
916-922
- 42
Aström M, Westlin N.
No effect of piroxicam on achilles tendinopathy. A randomized study of 70 patients.
Acta Orthop Scand.
1992;
63(6)
631-634
- 43
Tsai W C, Hsu C C, Chou S W, Chung C Y, Chen J, Pang J H.
Effects of celecoxib on migration, proliferation and collagen expression of tendon
cells.
Connect Tissue Res.
2007;
48(1)
46-51
- 44
Rompe J D, Nafe B, Furia J P, Maffulli N.
Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy
of the main body of tendo Achillis: a randomized controlled trial.
Am J Sports Med.
2007;
35(3)
374-383
- 45
Speed C A.
Injection therapies for soft-tissue lesions.
Best Pract Res Clin Rheumatol.
2007;
21(2)
333-347
- 46
Fredberg U, Bolvig L, Pfeiffer-Jensen M, Clemmensen D, Jakobsen B W, Stengaard-Pedersen K.
Ultrasonography as a tool for diagnosis, guidance of local steroid injection and,
together with pressure algometry, monitoring of the treatment of athletes with chronic
jumper's knee and Achilles tendinitis: a randomized, double-blind, placebo-controlled
study.
Scand J Rheumatol.
2004;
33(2)
94-101
- 47
Fredberg U, Ostgaard R.
Effect of ultrasound-guided, peritendinous injections of adalimumab and anakinra in
chronic Achilles tendinopathy: a pilot study.
Scand J Med Sci Sports.
2009;
19(3)
338-344
- 48
Alfredson H, Öhberg L.
Sclerosing injections to areas of neo-vascularisation reduce pain in chronic Achilles
tendinopathy: a double-blind randomised controlled trial.
Knee Surg Sports Traumatol Arthrosc.
2005;
13(4)
338-344
- 49
Öhberg L, Alfredson H.
Sclerosing therapy in chronic Achilles tendon insertional pain—results of a pilot
study.
Knee Surg Sports Traumatol Arthrosc.
2003;
11(5)
339-343
- 50
Lind B, Öhberg L, Alfredson H.
Sclerosing polidocanol injections in mid-portion Achilles tendinosis: remaining good
clinical results and decreased tendon thickness at 2-year follow-up.
Knee Surg Sports Traumatol Arthrosc.
2006;
14(12)
1327-1332
- 51
Willberg L, Sunding K, Öhberg L, Forssblad M, Fahlström M, Alfredson H.
Sclerosing injections to treat midportion Achilles tendinosis: a randomised controlled
study evaluating two different concentrations of Polidocanol.
Knee Surg Sports Traumatol Arthrosc.
2008;
16(9)
859-864
- 52
Boesen M I, Torp-Pedersen S, Koenig M J et al..
Ultrasound guided electrocoagulation in patients with chronic non-insertional Achilles
tendinopathy: a pilot study.
Br J Sports Med.
2006;
40(9)
761-766
- 53
Chan O, O'Dowd D, Padhiar N et al..
High volume image guided injections in chronic Achilles tendinopathy.
Disabil Rehabil.
2008;
30(20-22)
1697-1708
- 54
Sharma P, Maffulli N.
Tendon injury and tendinopathy: healing and repair.
J Bone Joint Surg Am.
2005;
87(1)
187-202
- 55
Maxwell N J, Ryan M B, Taunton J E, Gillies J H, Wong A D.
Sonographically guided intratendinous injection of hyperosmolar dextrose to treat
chronic tendinosis of the Achilles tendon: a pilot study.
AJR Am J Roentgenol.
2007;
189(4)
W215-220
- 56
James S L, Ali K, Pocock C et al..
Ultrasound guided dry needling and autologous blood injection for patellar tendinosis.
Br J Sports Med.
2007;
41(8)
518-521; discussion 522
- 57
Edwards S G, Calandruccio J H.
Autologous blood injections for refractory lateral epicondylitis.
J Hand Surg Am.
2003;
28(2)
272-278
- 58
Testa V, Capasso G M, Benazzo F, Maffulli N.
Management of Achilles tendinopathy by ultrasound-guided percutaneous tenotomy.
Med Sci Sports Exerc.
2002;
34(4)
573-580
- 59
McLauchlan G J, Handoll H H.
Interventions for treating acute and chronic Achilles tendinitis.
Cochrane Database Syst Rev.
2001;
2(2)
CD000232
- 60
Brown R, Orchard J, Kinchington M, Hooper A, Nalder G.
Aprotinin in the management of Achilles tendinopathy: a randomised controlled trial.
Br J Sports Med.
2006;
40(3)
275-279
- 61
Nelen G, Martens M, Burssens A.
Surgical treatment of chronic Achilles tendinitis.
Am J Sports Med.
1989;
17(6)
754-759
- 62
Rolf C, Movin T.
Etiology, histopathology, and outcome of surgery in achillodynia.
Foot Ankle Int.
1997;
18(9)
565-569
- 63
Kvist H, Kvist M.
The operative treatment of chronic calcaneal paratenonitis.
J Bone Joint Surg Br.
1980;
62(3)
353-357
- 64
Clancy Jr W G, Neidhart D, Brand R L.
Achilles tendonitis in runners: a report of five cases.
Am J Sports Med.
1976;
4(2)
46-57
- 65
Alfredson H, Ohberg L, Forsgren S.
Is vasculo-neural ingrowth the cause of pain in chronic Achilles tendinosis? An investigation
using ultrasonography and colour Doppler, immunohistochemistry, and diagnostic injections.
Knee Surg Sports Traumatol Arthrosc.
2003;
11(5)
334-338
- 66
Andersson G, Danielson P, Alfredson H, Forsgren S.
Nerve-related characteristics of ventral paratendinous tissue in chronic Achilles
tendinosis.
Knee Surg Sports Traumatol Arthrosc.
2007;
15(10)
1272-1279
- 67
Den Hartog B D.
Flexor hallucis longus transfer for chronic Achilles tendonosis.
Foot Ankle Int.
2003;
24(3)
233-237
- 68
Schepsis A A, Leach R E.
Surgical management of Achilles tendinitis.
Am J Sports Med.
1987;
15(4)
308-315
- 69
Vora A M, Myerson M S, Oliva F, Maffulli N.
Tendinopathy of the main body of the Achilles tendon.
Foot Ankle Clin.
2005;
10(2)
293-308
- 70
Paavola M, Kannus P, Orava S, Pasanen M, Järvinen M.
Surgical treatment for chronic Achilles tendinopathy: a prospective seven month follow
up study.
Br J Sports Med.
2002;
36(3)
178-182
- 71
Maffulli N, Binfield P M, Moore D, King J B.
Surgical decompression of chronic central core lesions of the Achilles tendon.
Am J Sports Med.
1999;
27(6)
747-752
- 72
Paavola M, Orava S, Leppilahti J, Kannus P, Järvinen M.
Chronic Achilles tendon overuse injury: complications after surgical treatment. An
analysis of 432 consecutive patients.
Am J Sports Med.
2000;
28(1)
77-82
- 73
Steenstra F, van Dijk C N.
Achilles tendoscopy.
Foot Ankle Clin.
2006;
11(2)
429-438, viii
- 74
Thermann H, Benetos I S, Panelli C, Gavriilidis I, Feil S.
Endoscopic treatment of chronic mid-portion Achilles tendinopathy: novel technique
with short-term results.
Knee Surg Sports Traumatol Arthrosc.
2009;
17(10)
1264-1269
- 75
Maquirriain J, Ayerza M, Costa-Paz M, Muscolo D L.
Endoscopic surgery in chronic achilles tendinopathies: a preliminary report.
Arthroscopy.
2002;
18(3)
298-303
- 76
Vega J, Cabestany J M, Golanó P, Pérez-Carro L.
Endoscopic treatment for chronic Achilles tendinopathy.
Foot Ankle Surg.
2008;
14(4)
204-210
Justin C. LeeM.R.C.S. F.R.C.R.
Department of Radiology, Chelsea and Westminster Hospital
369 Fulham Road, London SW10 9NH, UK
Email: Justin.Lee@chelwest.nhs.uk
