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Remote Fellowship – Foot & Ankle Fundamentals – 11/2/2020

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Achilles Tendinopathy 

Case Discussion

Achilles tendinopathy is considered chronic intratendinous degeneration of the tendon which may be complicated by tendon tearing.  Achilles tendinopathy is the most prevalent of the ankle tendon tendinopathies, with a higher male predilection, most commonly presenting between 30-50 years of age.

Intrinsic and extrinsic factors are involved in etiology. Intrinsic factors (including tendon hypovascularity and metabolic disorders) and extrinsic factors (such as excessive repetitive micro-trauma or overloading) contribute to tendinopathy, tendon degeneration and micro-tearing. Well-recognized predisposing factors include gout, diabetes mellitus, and systemic inflammatory diseases (e.g., rheumatoid arthritis, peritendinous steroid injection, and quinolone antibiotic therapy such as ciprofloxacin).

MRI signs of Achilles tendinopathy include: increased tendon diameter in the sagittal and axial planes, increased intratendinous signal on T1 weighted images and to a lesser extent T2 weighted images, a thickened paratenon, the presence of peritendinous fluid, and edema of Kager’s triangle.

Characteristics of achilles injuries should include: length, width, depth, high or low footprint, position relative to the superior calcaneus, bursitis, cppd, kager’s space, bundle (medial or lateral), muscular hypertrophy or atrophy, periostitis, and the presence or absence of haglund.

Treatment may require surgical intervention with debridement of adhesions and degenerative tendon, followed by decompression of the tendon.

Key Images

Moderate-severe insertional Achilles tendinopathy and enthesopathy with a developing undersurface insertional partial tear in a 72-year-old man complaining of pain and swelling in the Achilles area for 9 months.

A. Sagittal T2 FSE image shows thickening and increased signal of the achilles tendon at the insertion indicative of insertional tendinopathy and enthesopathy (yellow arrow). Hyperintense signal in the dorsal calcaneus (blue arrow) and calcaneal tuberosity (green arrow) signify associated stress osseous edema. There is high signal reactive edema throughout the dorsal calcaneal enthesophyte (red arrow). Prominent soft tissue thickening and increased signal of the adjacent retrocalcaneal bursa (white arrow) is consistent with a degree of reactive bursitis.
B. Sagittal T1 FSE image shows insertional tendinopathy (yellow arrow). A prominent hypointense area at the dorsal calcaneus (red arrow) is consistent with enthesophyte-related erosion.
C. Axial PD fat saturated image shows the prominent dorsal calcaneal enthesophyte with high signal reactive edema (red arrow). Associated stress osseous edema is seen in the calcaneal tuberosity (green arrow).
D. Sagittal T2 FSE image shows a small developing undersurface insertional tear of the achilles tendon (red arrows).


  1. Schweitzer ME, Karasick D. MR imaging of disorders of the Achilles tendon. American Journal of Roentgenology 2000; 175:613-625