0:00

Well, here's a 68-year-old man

0:01

with hindfoot pain.

0:03

It is not a secret that the Achilles looks awful.

0:07

Although, with hindfoot pain, you always

0:09

have to go through the typical inspection

0:13

protocol of posterior tibiotalar impingement

0:18

syndrome, talocalcaneal impingement syndrome.

0:21

You want to be on your guard and look out for

0:24

any abnormalities of the medial tendon group.

0:28

Especially the flexor hallucis, as

0:30

it makes its way around the back

0:33

of the talocalcaneal articulation.

0:37

It's nice to just check the

0:38

Kager's space for any inflammation.

0:41

Um, you want to evaluate the posterior aspect

0:44

of the retinaculum, sometimes posterior OCDs,

0:47

or posterior stress fractures can play into

0:51

the theme of potential Achilles injuries.

0:53

Probably the one.

0:55

Other major abnormality that, uh, has

0:58

to go through your laundry list or

1:00

your checklist is plantar fasciitis.

1:03

Especially if you don't get a

1:03

good history from the clinician.

1:05

But most clinicians will tell you that

1:07

it's plantar hindfoot pain as opposed to

1:09

pain back in this region near the Achilles.

1:13

So the Achilles tendon connects

1:15

the gastrocnemius and the soleus.

1:17

Gastroc superficial.

1:19

Soleus is deep to the calcaneal

1:23

tuberosity on the heel bone.

1:25

But it's not just a connection.

1:27

You gotta, you gotta think a little more deeply.

1:29

So, the connection is a

1:30

footprint from here to here.

1:32

I mean, look at that footprint.

1:34

It has length.

1:36

So you could injure the

1:36

footprint here, or here, or here.

1:38

And it could be underneath, and it could be

1:41

completely and totally hidden from view with a

1:44

rim rent so that there's actually an extension or

1:48

an erosion into the bone that communicates with

1:51

the tear underneath, much like we see a rim rent.

1:54

In the shoulder, the tendon tends to have

1:57

a little bit of a spindly configuration

2:00

and then tapers and flattens out mightily.

2:03

As it gets to the back of the calcaneus, and

2:08

this spreading out of the tendon makes it

2:11

thinner down below, than it is up above. The

2:16

overall narrowest point of the tendon is probably

2:19

found about four centimeters above this locus.

2:22

In the normal individual, but

2:23

this is not a normal individual.

2:25

And that four-centimeter position denotes a

2:28

place where there is less vascular supply.

2:31

And it's considered somewhat of a watershed

2:34

zone and an area of potential weakening.

2:37

But that's, that's really not all there is.

2:40

Remember that the, the gastroc

2:42

and the Achilles are going to kind

2:43

of come together from both sides.

2:45

Now in the anatomy section, I went

2:47

through how that arrangement is made

2:50

and how there is some spiraling or

2:52

twisting or torsioning of these muscles.

2:55

I'm not going to review it right now.

2:57

But as they come together, I am

2:59

going to use my pen for a minute.

3:00

Let's see if I can get it working.

3:02

Um, those, those two sets of

3:04

muscles are going to come together.

3:06

The gastrocnemius and we'll

3:08

make the soleus kind of red.

3:10

And they come together and

3:11

they're going to form a tendon.

3:13

But there are basically two

3:15

components, two major bundles.

3:17

And there are times when these bundles,

3:20

even down in the watershed region,

3:23

may just split into, into two sides.

3:26

So you may have a tear, if we're looking axially

3:29

at the tendon, you may have a tear right down

3:31

the center between where those bundles coalesce.

3:34

And that's an area of potential

3:36

weakening, especially higher up.

3:39

And some people might refer to that,

3:41

go one end to the other end, front

3:43

to back, as a type of split tear.

3:46

On the other hand, I've seen a laminar

3:48

tear as well, and more than one.

3:51

So this would be our Achilles in cross

3:53

section, in the axial projection, and the

3:55

tear will run this way, from side to side.

3:59

It can be very thin, it can thicken

4:01

up, it can even appear as a cyst.

4:04

Now, if it goes to one surface, it's

4:06

still considered a laminar tear.

4:08

If it goes to both surfaces, we would

4:10

consider this a horizontal split tear.

4:13

If it goes to both surfaces this

4:15

way, it's a vertical split tear.

4:18

If it only goes to one or no

4:20

surfaces, one surface, it's a

4:23

delamination tear or a laminar tear.

4:25

If it goes to neither surface, in other words,

4:28

if it looks something like this, we would call

4:30

it an interstitial laminar or delamination tear.

4:35

So, let's keep going.

4:37

We are not done yet with describing

4:40

and assessing Achilles abnormalities.

4:42

Because these abnormalities, while

4:44

classically occurring in this hypovascular

4:48

watershed zone, they could also

4:50

occur at the myotendinous junction.

4:52

In which case, you would have to look up

4:54

higher and check out the soleus and the

4:56

gastrocnemius to make sure they're not torn.

5:00

You also are going to want to make, on your

5:02

checklist, an assessment of the plantaris.

5:06

Because sometimes, the plantaris which

5:08

travels with the Achilles, may be

5:11

used to augment the Achilles repair.

5:15

On your checklist, you're going to

5:16

want to describe the integrity of the

5:20

remaining Achilles that's not torn.

5:23

Because you may need to graft other tissues.

5:26

Not just use the plantaris for augmentation.

5:29

You may have to find fasciolata or some

5:32

other tendon-like material to graft in here.

5:34

Because the tendon is just too sick.

5:37

And that is the job of the imager.

5:39

So how long is our tear?

5:41

What's the epicenter of it?

5:43

Is there a gap?

5:44

If there is a gap, how big is the gap?

5:48

And as you make your way away from that gap,

5:51

what are the status of those torn edges?

5:54

Are they clean?

5:55

Do they look like the ragged edges of a mop?

6:00

No, we're not done yet.

6:02

We also then have to very carefully

6:04

inspect the footplate or footprint.

6:06

To see if there are concealed tears.

6:08

To see if this is peeled off the back.

6:11

Now generally, the gastroc fibers, which are

6:14

deeper, tend to have more of an insertion

6:17

on the footprint higher and deeper.

6:20

The soleofibers tend to be more

6:23

superficial, as you would expect.

6:25

Sorry, I've got that backwards.

6:26

The soleofibers will be higher and deeper.

6:30

And the gastrocnemius fibers will

6:34

be more superficial, and they'll

6:35

go a little bit more distal.

6:38

So, you know, even, even somebody

6:39

that's been doing this a long time

6:41

can change it up a little bit.

6:42

It's nice for you to see that.

6:44

So the gastrocnemius fibers account

6:46

for a lot of this portion of the

6:47

footprint, the sole fibers right here.

6:50

This portion of the footprint

6:52

and the footprint has length.

6:53

Now, under the footprint, we're

6:55

gonna assess the quality of the bone.

6:57

Is the bone smooth?

6:58

If it's irregular, do we have

7:00

erosions as part of a rim rent?

7:03

And do we have a posterosuperior medial spur,

7:07

especially medial known as a pump bump.

7:10

Or a Haglund deformity.

7:13

Now that, that is really my complete

7:15

assessment, checklist for Achilles injuries

7:18

with one other exception that isn't an injury.

7:21

If I've got massive Achilles involvement,

7:24

a huge Achilles, and it's beyond its normal

7:27

size which should be about 8 millimeters

7:29

from A to P, and the front of it in the axial

7:31

projection should be flat or concave backwards,

7:36

and the patient is not in a lot of pain,

7:38

then I start worrying about gout in a male,

7:41

CPPD, some type of collagen vascular disease.

7:44

Thank you very much.

7:45

Amyloid, chondrocalcinosis, or other.

7:48

Some type of infiltrative process.

7:51

Now, if it's bright on T1, or slightly hyperintense

7:54

on T1, I worry about a xanthoma,

7:57

critical diagnosis to make, because

7:59

then we've got to check the patient's

8:01

cholesterol, triglycerides, LDL, HDL, etc.

8:05

Now, I will give you as part of the search

8:07

pattern that I'll look at the rest of the foot,

8:09

and there are some areas of arthrosis in the

8:11

midfoot region, but I'm focusing on my search

8:14

pattern and thought process for hindfoot

8:17

discomfort, pain, and Achilles abnormalities.

8:21

Let's turn our attention now.

8:23

Uh, we've seen this very long tear.

8:25

We can measure it from top to bottom.

8:26

We can tell where it starts, where it stops.

8:30

But it's also a little strange that we

8:31

have some low signal intensity around it.

8:34

Posteriorly and anteriorly.

8:37

And it's still pretty straight.

8:39

So something is at least

8:42

holding it in this position.

8:44

So let's go axial.

8:48

And that is the plantaris.

8:50

And what is this round structure

8:54

that's holding it in place?

8:56

That, my friends, is the peritenon.

8:59

You have tenosynovial sheaths

9:02

in the hands and in the feet.

9:04

For instance, the posterior tibial tendon

9:06

has a tenosynovial sheath, not the Achilles.

9:10

It has a thick fibroelastic membrane

9:13

around the outside called peritenon.

9:15

There is no synovium.

9:17

And so, this is a tear within the peritenon.

9:21

Is it a full thickness tear?

9:23

You bet.

9:24

But it's with peritenon preservation.

9:27

There's a condition very similar to this called

9:30

Baseball Pitcher Hockey Goalie Syndrome where

9:33

you tear and avulse the adductor in its sheath

9:37

in those types of athletes and they have what's

9:42

known clinically as a subtype of sports hernia.

9:45

So this happens elsewhere in the body, but it's

9:48

a bit confusing if you have not seen it before.

9:50

There is our plantaris.

9:52

Unfortunately, this patient has a big one.

9:54

It blends with the rest of the tendon.

9:56

As we go down, you'll see it separate.

9:58

See if I can get it to separate off.

10:00

There it goes off to the side.

10:02

Now it's making its way in.

10:04

And we've got a tremendous amount of

10:07

high signal intensity in the sheath.

10:09

Now, we've got three sequences here.

10:11

T1, anatomic.

10:11

T1, anatomic.

10:12

T1, anatomic.

10:13

Pretty good at picking up a tear of

10:15

this conspicuity size and volume.

10:19

This tendon is probably a centimeter and

10:21

a half, much bigger than the 8 millimeters

10:24

that we allow, and it's convex forward.

10:26

The T2, what's that for?

10:28

That's for activity and chronicity.

10:30

So we have a very active area of the

10:33

tear that has a big hole in it that's

10:35

filled with inflammatory tissue.

10:37

What about this tissue right here?

10:39

That tissue is awfully irregular and gray.

10:42

Is that a tear?

10:42

You bet it is.

10:44

It's a tear with some fibers flopping around

10:47

in there, concealed by fibrous tissue.

10:50

Black.

10:51

Tendon.

10:52

Black.

10:53

Hemocytin.

10:53

Black.

10:54

Blood.

10:55

Black.

10:56

It's all black.

10:57

So it's telling you that a portion

10:59

of this tear exhibits chronicity.

11:02

Now a lot of times, even with chronicity, unless

11:05

it's really, really chronic, the PD spur will show

11:09

those Gray areas that are dark here, bright here.

11:13

But not in this case.

11:14

In this case, we go from gray to dark to dark.

11:18

So part of the tear is really, really

11:21

chronic and really, really fibrosed.

11:24

If we go to the cystic, fluid-like

11:27

area, that part is bright on everything.

11:30

So, what we've learned here is that we've got a

11:34

very chronically diseased Achilles pre-existing.

11:38

And then on top of that, we've An active

11:41

tear with a big hole and a very sick

11:44

tendon for a very long length without a

11:47

pump bump, without a Hagelin deformity.

11:51

And then finally, if you want to get one

11:52

more look at it in terms of overall length,

11:54

you can throw up the coronal, which is my

11:57

least favored nation, uh, configuration.

12:00

But sometimes I will use it to look

12:02

at the relationship between the

12:04

Achilles and its insertion on the bone.

12:07

And this looks pretty good,

12:08

this stride appearance.

12:10

Is, is okay.

12:11

There's just a tiny bit of inflammation,

12:14

but otherwise it's, it's pretty close

12:15

to normal for a patient of this age.

12:18

And then we also can get the, the

12:20

full, uh, deployment of the length

12:23

of this tear, uh, which is long.

12:26

It's about seven to eight centimeters.

12:28

So that concludes, really, our

12:30

discussion of assessment of the Achilles.

12:33

It's one of the strongest tendons in the body.

12:36

It's one of the longest tendon Uh, tendons

12:38

in the body, although the plantaris, uh,

12:41

probably is a bit longer, and, um, most

12:44

patients that have Achilles disease, uh, have

12:47

pre-existing disease, as this patient does.

12:50

Now, in the past, we would always sew them.

12:52

Uh, today, we now know, especially in

12:54

older patients, if we don't have a lot of

12:56

retraction, then they can be treated surgically

12:59

in a cast, and they can heal on their own.

13:01

The ones that are most nasty, that usually

13:03

require surgery, are the ones with the big bumps.

13:06

Especially in athletes that produce

13:07

bursitis and partial tears, you have to

13:10

take the tendon off, you have to saw off

13:12

the bump, and then reattach the tendon.

13:14

And the convalescence for this is anywhere

13:16

from 6 months to about a year and a half.

13:21

Um, other treatments that have been recommended,

13:23

especially if there's tendinosis without

13:25

a focal tear, PRP injection, platelet

13:28

rich plasma, works really, really well.

13:31

And you can take it one step further than this.

13:33

You can actually take stem cells out of the ilium.

13:36

You go right underneath the cortex of the

13:38

ilium to get the best stem cells, so multiple

13:41

punctures, and then you put the stem cells

13:43

directly into the locus of discomfort, and that

13:46

is another technique that is now gaining traction.

13:49

So, hopefully, I've given

13:51

you something to think about.

13:52

Not only the MR diagnosis of Achilles disease,

13:55

but it's so common, hopefully none of you

13:57

have it, a little bit about the treatment.