Achilles Tendon Injuries Workup: Approach Considerations, Imaging Studies

Sections

Workup

Approach Considerations

Laboratory studies usually are not necessary in evaluating and diagnosing an Achilles tendon rupture or injury, although evaluation may help to rule out some of the other possibilities in the differential diagnosis. These laboratory tests, all of which are normal in Achilles tendinosis, include the following:

Complete blood count (CBC) with differential
Coagulopathy panel
Erythrocyte sedimentation rate
Arthritis panel

Imaging studies can aid in the diagnosis and evaluation of Achilles tendon pathology, but typically they are not needed. Like laboratory studies, however, they can be helpful in evaluating possibilities in the differential diagnosis and should be ordered as clinically indicated.

Plain radiography

Radiography may reveal tendon calcifications in tendinosis or spurs at the calcaneal insertion site, but neither is diagnostic for Achilles tendinosis.

Radiographs are more useful for ruling out other injuries than for ruling in Achilles tendon ruptures. The bones appear normal in patients with a ruptured Achilles tendon, although soft tissue swelling may be evident.^[55]

Radiographs of the tibia and fibula often are indicated when the patient’s history shows trauma that may have resulted in fracture of these long bones. Radiographs of the knee and ankle may help to discover findings of degenerative or inflammatory arthropathies.

Ultrasonography

Ultrasonography of the leg and thigh can help to evaluate the possibility of deep venous thrombosis and also can be used to rule out a Baker cyst. Moreover, in experienced hands, ultrasonography can identify a ruptured Achilles tendon or the signs of tendinosis.

Unlike magnetic resonance imaging (MRI), ultrasonography cannot distinguish a partial tear from tendinosis.

In a small study, De Zordo et al concluded that, in terms of revealing the characteristics of Achilles tendinosis, the ultrasonographic technique known as sonoelastography was comparable to clinical examination and ultrasonography only in the identification of distinct softening of the Achilles tendon. However, very early changes in tissue elasticity in Achilles tendinosis may cause mild softening, which should be assessed in follow-up studies.^[56]

MRI

MRI can facilitate definitive diagnosis of a disrupted tendon. This is especially useful when considering the possibility of partial disruption of the Achilles tendon. Partial disruption often is undetectable clinically and may be misdiagnosed as simple Achilles tendinosis; however, partial Achilles disruption often responds to surgical intervention. Imaging the knee can confirm a Baker cyst, as well as the probable underlying pathology causing the Baker cyst.^[57]

MRI can also distinguish between paratenonitis, tendinosis, and bursitis.^[55]In paratenonitis, MRI can reveal fluid in and around the tendon, while in chronic paratenonitis, the paratenon may be seen as thickened and fibrotic.

In tendinosis, increased MRI signal is evident in the tendon and degenerative changes, and partial tears may occasionally be seen. Keep in mind that these MRI findings may also be present in asymptomatic individuals.

Treatment & Management

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Anthony J Saglimbeni, MD President, South Bay Sports and Preventive Medicine Associates; Private Practice; Team Internist, San Francisco Giants; Team Internist, West Valley College; Team Physician, Bellarmine College Prep; Team Physician, Presentation High School; Team Physician, Santa Clara University; Consultant, University of San Francisco, Academy of Art University, Skyline College, Foothill College, De Anza College

Anthony J Saglimbeni, MD is a member of the following medical societies: California Medical Association, Santa Clara County Medical Association, Monterey County Medical Society

Disclosure: Received ownership interest from South Bay Sports and Preventive Medicine Associates, Inc for board membership.

Coauthor(s)

Christian J Fulmer, DO Private Practice in Sports and Family Medicine; Team Physician, Valley Christian High School

Christian J Fulmer, DO is a member of the following medical societies: American Academy of Family Physicians, American Academy of Osteopathy, American Medical Society for Sports Medicine, American Osteopathic Association

Disclosure: Nothing to disclose.

Chief Editor

Dean H Hommer, MD Chief Medical Officer, William Beaumont Army Medical Center

Dean H Hommer, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Healthcare Executives, American Association for Physician Leadership, American Society of Regional Anesthesia and Pain Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Michael T Andary, MD, MS Professor, Residency Program Director, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine

Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Association of Academic Physiatrists

Disclosure: Allergan Honoraria Speaking and teaching

Edward Behn, MBBS, MRCS

Disclosure: Nothing to disclose.

David T Bernhardt, MD Director of Adolescent and Sports Medicine Fellowship, Associate Professor, Department of Pediatrics/Ortho and Rehab, Division of Sports Medicine, University of Wisconsin School of Medicine and Public Health

David T Bernhardt, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Sports Medicine, and American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Jason H Calhoun, MD, FACS Department Chief, Musculoskeletal Sciences, Spectrum Health Medical Group

Jason H Calhoun, MD, FACS, is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Diabetes Association, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Missouri State Medical Association, Musculoskeletal Infection Society, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, and Texas Orthopaedic Association

Disclosure: Biocomposite Grant/research funds Other

James K DeOrio, MD Associate Professor of Orthopedic Surgery, Duke University School of Medicine

James K DeOrio, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Foot and Ankle Society

Disclosure: Merete Royalty Other; SBi Royalty Other; BioPro Royalty Other; Acumed, LLC Honoraria Speaking and teaching; Wright Medical Technology, Inc Honoraria Speaking and teaching; SBI Honoraria Speaking and teaching; Integra Speaking and teaching; Datatrace Publishing Honoraria Speaking and teaching; Exactech, Inc Honoraria Speaking and teaching; Tornier Honoraria Speaking and teaching

Kevin J Eerkes, MD Clinical Assistant Professor, Department of Medicine, New York University School of Medicine; Medical Team Physician, New York University Athletics

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Laura M Gottschlich, DO Assistant Professor of Family and Community Medicine and Orthopedic Surgery, Medical College of Wisconsin; Consulting Staff, Family Medicine Residency Program, All Saints Hospital, Wheaton Franciscan Healthcare

Laura M Gottschlich, DO is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Association, American Medical Society for Sports Medicine, and American Osteopathic Association

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Richard Hargrove, MBBS, FRCS(Ire), FRCS Consulting Staff, Hip and Hip Revision Arthroplasty, Frimley Park Hospital

Richard Hargrove, MBBS, FRCS(Ire), FRCS is a member of the following medical societies: Royal College of Surgeons of England and Royal Society of Medicine

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Sherwin SW Ho, MD Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, and Herodicus Society

Disclosure: Biomet, Inc. Consulting fee Consulting; Smith and Nephew Grant/research funds Fellowship funding; DJ Ortho Grant/research funds Course funding; Athletico Physical Therapy Grant/research funds Course, research funding

Shepard R Hurwitz, MD Executive Director, American Board of Orthopaedic Surgery

Shepard R Hurwitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for the Advancement of Science, American College of Rheumatology, American College of Sports Medicine, American College of Surgeons, American Diabetes Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Association for the Advancement of Automotive Medicine, Eastern Orthopaedic Association, Orthopaedic Research Society, Orthopaedic Trauma Association, and Southern Orthopaedic Association

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Brian A Jacobs, MD, FACSM Consulting Staff, Private Practice, Family Medicine of South Bend; Team Physician, Marian High School

Brian A Jacobs, MD, FACSM is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, and American Medical Society for Sports Medicine

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David Y Lin, MD Fellow, Department of Orthopedic Surgery, Section of Pediatrics, University of Tennessee Campbell Clinic

David Y Lin, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

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Henry Marano, MD Director, Department of Orthopedic Surgery, Associate Professor, St Joseph's Hospital, Albert Einstein College of Medicine

Henry Marano is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, and Medical Society of the State of New York

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Chris McLean, MBBS, MRCS(Glasg), AFRCS(Ire) Specialist Registrar, Departments of Orthopedic and Trauma Surgery, Frimley Park Hospital, UK

Chris McLean, MBBS, MRCS(Glasg), AFRCS(Ire) is a member of the following medical societies: British Medical Association

Disclosure: Nothing to disclose.

Evan Schwartz, MD Director of Orthopedic Surgery, New York Medical College; Assistant Professor, St John's Queens Hospital, Department of Surgery, Albert Einstein School of Medicine

Evan Schwartz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Society for Sports Medicine

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Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

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Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM President and Director, Georgia Pain Physicians, PC; Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, Emory University School of Medicine

Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, American Medical Association, International Association for the Study of Pain, and Texas Medical Association

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