0:00

This is a 51-year-old complaining

0:02

of Achilles pain for two weeks.

0:05

So when I hear Achilles, the first thing

0:07

I do is I pull down all my sagittals.

0:10

So that's what we're going to do.

0:13

Sagittal number one, sagittal number two.

0:17

I think I've only got two.

0:19

So let's pull down those first two.

0:22

And I can usually figure out in the

0:23

Achilles what's going on from just this.

0:27

Now there is another interesting finding here.

0:30

The patient's 51 and has

0:32

somehow escaped into adulthood.

0:35

with a fibrocartilaginous coalition.

0:40

Why is this a coalition as opposed

0:42

to just simply the Chopart joint?

0:47

And the answer is it's too broad.

0:50

In other words, the snout of the anterior

0:52

process of the calcaneus normally is pointed.

0:56

This one is rectangular.

0:59

And then you see the cartilaginous interface

1:03

between the anterior process and the navicular.

1:09

Now, some of these patients, we don't

1:10

have the resolution to tell, will have

1:13

deficiency of the bifurcate ligament

1:16

as part of a congenital abnormality.

1:19

Those that have such a deficiency will often have

1:22

More pronounced arthrosis of the Chopart joint.

1:26

So by inference, the fact that there is so

1:28

little arthritis of the Chopart joint, which

1:31

is the talonavicular and calcaneal cuboid

1:35

articulation tells you that you probably do

1:38

not have displaces or absence of the ligaments.

1:42

As you keep scrolling you see just

1:43

how irregular though that coalition

1:46

is there's some fragmentation.

1:48

On the navicular side of the articulation.

1:51

You also see a little swelling of the subtalar

1:55

lateral sinus Tarsi with the extensive retinaculum

2:00

and that is a side finding to the case.

2:03

Now let's turn our attention.

2:05

Back to the Achilles.

2:07

So get out your pen.

2:09

Let's go down the Achilles checklist.

2:12

First question.

2:14

Gender.

2:15

It's a man.

2:16

How do I ask that?

2:18

But women wear high heels.

2:20

They're more likely not exclusively, but

2:22

they're more likely to have a pump bump or a

2:24

Haglund deformity, which is found right here.

2:28

Posterior superior.

2:29

It looks like this,

2:32

but a piece of bone.

2:33

This patient doesn't have it.

2:35

What if it was a man?

2:38

In a man, in certain settings, I might

2:40

consider something like reactive arthritis,

2:44

formerly known as Reiter's syndrome.

2:47

I might also consider gout.

2:49

We had one last week, gouty

2:50

infiltration of the Achilles tendon.

2:54

So, that colors my judgment

2:56

and my differential diagnosis.

2:57

And I look at the age. This patient's 51.

3:03

So I'm not thinking about,

3:04

you know, congenital things.

3:06

I'm thinking about acquired things.

3:08

I'm thinking about overuse syndromes.

3:11

And the next thing I do is I look

3:13

at the shape of the calcaneus.

3:15

I look for that pump bumper Haglund deformity.

3:18

I check Kager's fat space.

3:20

These are all part of my Achilles checklist.

3:23

And there's a little bit of scarring there,

3:25

nothing too dramatic in Kager's fat space.

3:29

And then I look at the Achilles.

3:31

I first start out up high, I look at the size of

3:34

the muscles, I look at the myotendinous junction.

3:37

And by the way, I do this very quickly,

3:38

within a matter of 15 to 30 seconds.

3:41

Then I work my way down and I look for focal

3:44

architectural distortion of the fibers,

3:48

which are normally parallel fibers that are

3:50

hard to see unless the Achilles is inflamed.

3:52

Okay.

3:53

But they should run in parallel.

3:54

There should be no focal high signal

3:57

intensity defects, not even little ones.

4:01

And I really don't see any defects so far.

4:06

Now I do see something that is defect-like

4:08

right here that's more focal, but when I look at

4:12

the T1, it's got the signal intensity of bone.

4:16

So I've got some heterotopic bone that

4:20

is forming in the superficial Achilles.

4:24

And the next thing I do is

4:26

I look at the Achilles size.

4:28

I'll allow the Achilles to be

4:29

8 to 10 millimeters A to P.

4:32

This one's well under 8 millimeters.

4:35

Next on my checklist is the Supra Calcaneal Bursa.

4:41

And this one has a tiny amount of fluid,

4:43

nothing that I would even comment on.

4:44

It's too small to even bother with.

4:48

The next thing I do is I look

4:49

at the footplate or footprint.

4:52

This is the footprint of the Achilles.

4:54

It has a high attachment, a mid

4:56

attachment, and a low attachment.

5:00

There's the low attachment right here.

5:01

So you got to look all the way up and down and

5:03

make sure that the Achilles is not delaminated.

5:07

I look for concealed interstitial under surface

5:11

delaminations, which would occur right here, here.

5:18

here and they might or might not insert some

5:22

insight, some periosteitis or marrow swelling.

5:26

Now I don't have these little small

5:28

under surface concealed tears, but I

5:31

do have reactive bone marrow swelling

5:34

right there on the water-weighted image.

5:37

Hard to see on the T1, but it is there.

5:39

It's real.

5:40

It's not a coil artifact right there.

5:43

So that is an indicator that

5:45

the patient has periosteitis

5:48

from traction from the Achilles.

5:50

But if this was a man, and it is, I might

5:53

also consider the diagnosis of reactive

5:55

arthritis, formerly known as Reiter's syndrome.

6:00

The next thing I do is I look at the

6:02

peritenon, the outer covering of the Achilles.

6:06

Now I can't see the peritenon, but I want

6:09

to see fat circumscribing the Achilles.

6:12

And I don't see that in this locus right here.

6:17

Move it around a little bit.

6:20

Not seeing good fat right there.

6:22

Remember, that's where we saw that piece of bone.

6:25

I look at the superficial aspect of the Achilles.

6:28

So what do you call that?

6:30

A superficial tear or fraying of

6:32

the Achilles with heterotopic bone.

6:36

Now, let's say there was a tear.

6:38

Let's say there was a tear right here.

6:42

I would tell the clinician in my report

6:44

that the tear begins two centimeters

6:48

above the superior calcaneal protuberance.

6:51

The tear is two centimeters long.

6:54

The tear is not full depth.

6:57

And then I would go on to look at the

6:59

axial and I would decide off the axial.

7:04

What percent from side to side.

7:08

If there were a tear here, let's say

7:10

there was a tear that looked like this.

7:13

I would say there's a 25 percent tear

7:15

in the middle portion of the tendon.

7:19

I would also give a depth.

7:20

I would say less than 25, 25 to 50, or

7:23

greater than 50 percent depth or full depth.

7:29

And then I would also describe

7:30

whether it has involvement of the

7:32

lateral bundle or the medial bundle.

7:35

That is pretty much the

7:37

checklist for Achilles pathology.

7:39

I don't use the coronal all that much.

7:42

They did provide a heavily

7:44

water-weighted coronal sequence.

7:46

And sometimes you can see tears a

7:48

little better here than on the other

7:50

sequences, but most of the time not.

7:53

And you can see that the Achilles itself,

7:55

these wispy linear areas right here.

7:58

They're not normal.

8:00

They are a sign of intra-Achilles inflammation.

8:03

They're parallel to one another.

8:05

That's interstitial swelling between

8:08

the tendon fibrils of the Achilles.

8:10

So the diagnosis in this case would be

8:14

Achilles tendinopathy, chronic, um, but active

8:19

because of the swelling with heterotopic

8:22

bone and a superficial fraying-type tear.

8:25

Of the Achilles along its inferior footprint.

8:30

That would be number one.

8:31

Number two would be incidentally

8:33

noted fibrocartilaginous coalition of

8:37

the calcaneonavicular articulation.

8:39

And if you wanted to, in the body, the

8:41

report, you could throw in this, this

8:44

chronic erosion that is seen in the cuboid.

8:47

I do not use parallel pitch lines.

8:49

Now I understand to diagnose Hagelin deformity.

8:53

Here's what I do.

8:55

I draw.

8:56

I do use.

8:57

I don't ever draw a line.

8:58

I do very little measuring and drawing.

9:01

I will draw a line straight across the

9:03

calcaneus, the superior ridge of the calcaneus.

9:08

And if the superior calcaneal protuberance

9:11

projects more than 8 millimeters above that

9:13

line, I will call it a Hagelin deformity.

9:18

Again, I don't measure it.

9:19

I usually just look.

9:20

People that typically have a symptomatic

9:23

Hagelin deformity will have swelling around it.