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    • #46493
      Michael Shilton
      Participant

      HI Stephen. Would you mind helping me with this case please. 66 year old chap instant pain and noise in the Achilles area when playing walk football 8 weeks ago. Calf has swollen to 9cm larger than the other, really swollen! Thomson calf squeeze does illicit some plantar flexion but a lot less than the asymptomatic side. The fibres seem to disappear so looks like a rupture? Do you think I’ve found the stumps? Thanks Mike

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    • #46515
      Stephen Bird
      Keymaster

      Hi Mike,

      That is a messy Achilles tendon.

      I don’t think the measurements on the still images reflect the location of the stumps.

      The material between your callipers looks more like detensioned tendon so it may be a clue there is a complete rupture, however I am not convinced on the images it is where you have measured.

      I have never seen a gap this wide with a rupture.

      There is obvious extensive degenerative phase tendinosis.

      The question is “is there a complete rupture”

      If the Thompson test does not fail it may just be underlying extensive tendinosis and a partial tear from the acute event.

      I use long axis imaging with the patient prone to sort these out.

      While scanning in long axis gently plantar and dorsiflex the ankle joint and watch what the tendon does.

      If it is a partial tear or intact tendon it will move in synch,

      If it is a complete tear the stumps will move paradoxically, bumping into each other with plantar flextion and moving apart from each other with dorsiflexion.

      There is also considerable atrophy of the medial gastrocnemius muscle on your images.

      Looking at the images again I think the most likely diagnosis here is a complete or near complete tear quite proximally. A MTJ type tear.

      This would explain the volume of bleeding and haematoma which has swollen the calf so extensively.

      I also think I can see some disruption of the soleus component at the proximal end of the Achilles tendon.

      So I am betting on a complete or near complete proximal Achilles failure with an underlying chronic degenerative phase tendinosis involving the rest of the tendon.

      Long axis dynamic assessment will help here,

      Steve.

    • #46519
      Michael Shilton
      Participant

      Many thanks Steve, the patient was certainly reporting more tenderness proximally which supports your thoughts on MTJ.
      For my learning I’ve got a couple of questions.
      I’ve attached a few more long axis views and although there was some extra blood flow in the soft tissue oedema there was none in and around the Achilles which surprised me given the extent of the tear. Is this because of the 8 week passage of time do you think?
      Also I realise I’m not as secure as I thought with the anatomy/location of the soleus, when I see a long axis collagen pattern I thought that was Achilles but in this case it’s so thick can soleus appear like this too? Am I right in thinking soleus doesn’t have a a tendon as such of its own rather it attaches to the Achilles throughout its length? Thanks, Mike

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    • #46526
      Stephen Bird
      Keymaster

      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 !

      Steve

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