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Musculoskeletal » Lower Extremity
Bilateral Achilles Tendinosis
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Author(s) :
Leandro Fernandez, MD
Presentation 75 year old male patient. The posterior region of distal segment of both legs were painful and swollen.
Caption: Tranversal view of posterior region, distal segment of right leg.
Description: The sonogram shows enlarged right Achilles tendon, with a heterogeneous internal echo pattern and multiple areas with calcifications.
Caption: Longitudinal view of R Achilles tendon. (Extended field-of-view)
Description: By using the extended field-of-view technique, the ultrasound shows an enlarged right Achilles tendon, very heterogeneous, with multiple internal calcifications, including in the insertional portion at the calcaneous. Hypoechoic areas alternate with hyperechoic ones, corresponding to edema and areas of degeneration with calcification.
Caption: Comparative right (Der.) and left (Izq.) transversal Achilles
Description: Both Achilles tendons are enlarged, right more than left. Both exhibit disruption of the normal echo pattern. The right tendon is more heterogeneous and exhibits extensive calcification.
Caption: Achilles tendon left, longitudinal view
Description: Although less affected than the right tendon, the left also exhibits enlargement, heterogeneous internal echo pattern and a few isolated areas of calcification.
Differential Diagnosis
  1. Bilateral Achilles Tendinosis
  2. Rupture of Achilles Tendon
Final Diagnosis Bilateral Achilles Tendinosis

Tendinosis is a chronic condition due to degenerative tendinopathy. It usually occurs in patients who are between 35 and 45, and who are not necessarily athletic. The Achilles tendon is swollen and thickened.

Ultrasonography is an excellent method for the diagnosis of acute and chronic Achilles tendon disorders. By using sonography it is possible to detect many conditions that affect this tendon such as peritendinous edema, bursitis, ruptures of the Achilles tendon, and calcified insertion of the tendon at the calcaneous.

B mode ultrasonographic findings in Achilles tendinosis may include:

  • enlargement (AP >6 mm) usually presenting as localized fusiform enlargement
  • disruption of the normal fibrillar striation pattern of the tendon
  • intratendinous hypoechoic areas due to chronic mucoid degeneration
  • extra-tendinous hypoechoic areas due to edema
  • focal calcifications

Color Doppler may show increased flow in the intra and extra-tendinous regions, depending on the grade of inflammation present; the higher the grade, the more Doppler signal can be observed.

Case References

Grechenig W et al. Ultrasound diagnosis of the Achilles tendon. Orthopade. 2002; 31(3):319-25

 Koenig MJ et al. Preliminary results of colour Doppler-guided intratendinous glucocorticoid injection for Achilles tendonitis in five patients. Scand J Med Sci Sports.  2004; 14(2):100-6 

Technical Details Philips iU22 ultrasound system with a L17-5 (17 to 5 Mhz) linear transducer.
Follow Up Ultrasound findings confirmed the initial clinical diagnosis of bilateral Achilles tendinosis. The patient was referred for shock-wave (orthotripsia) treatment and physical therapy.
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