Stephen Bird

Hi Mike,

I don’t really put any importance on vascularity when assessing an Achilles tear so if there was increased flow or not I would not think any differently.

The anatomy of the soleus muscle is complex!

In simple terms think of the Achilles as being a common tendon for 3 muscles (medial gastroc, lateral gastric, soleus).

The soleus muscle has the most distal extension and you see it deep to the proximal achilles long after the medial and lateral gastrocs have made their insertion / contribution.

The muscle you see deep to gastric and deep to the Kagers fat pad is FHL.

Once the 3 muscles have finished and you have a pure collagen tendon it rotated about 90 degrees before inserting on the calcaneum.

Please take a peek at the new tennis leg injury webinar on the website where I go into some interesting detail.

In the new images you have provided I agree the muscle deep to Achilles is soleus.

The soleus deep to the Achilles never looks like collagen, but rather muscle as it integrates with the Achilles. The soleus muscle should not get closer than 25mm from the calcaneum or it is considered a low lying soleus.

The Achilles looks grossly abnormal and I would recommend an MRI as this case is so complicated.
There are areas of myxoid degeneration and in some images there are echogenic areas which I have seen with CPPD infiltration of the achilles.

I haven’t really changed my thoughts from my previous reply.

Again, the importance of long axis dynamic assessment is paramount for me when I am working through a case such as this.

Off for an MRI !


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