Skip to main content

Advertisement

SpringerLink
Log in

Achilles tendon: functional anatomy and novel emerging models of imaging classification

  • Original Paper
  • Published:
International Orthopaedics Aims and scope Submit manuscript

Abstract

Purpose

Ideally, a classification should have some prognostic value, and should therefore include precise information upon extent and location of the Achilles tendon disorders. We propose a new imaging and anatomical system to classify Achilles tendon disorders at imaging using US and MRI.

Approach

We consider the non-insertional region as the tendon mid-portion, and distinguish the insertional component into a pre-insertion site, located about two centimetres above the calcaneum, and a calcaneal insertion, where the tendon is attached to the bone. On sagittal scans, we introduced a new classification which considers two main portions: “musculotendinous” and “insertional”. In the context of the muscolotendinous portion, it is possible to find muscle fibres proximally, and the free tendon distally. This latter is made up of proximal, middle and distal portions. We also propose a 5 grade Doppler classification system to quantify blood flow, in which Grades I and II are respectively characterised by the presence of one and two vessels within the tendon; in Grades III, IV and V, the neovascularisation respectively involves less than 50 %, from 50 to 90 %, and more than 90 % of the tendon tissue. These proposed systems will require validation and possible modification to be applied to different tendons.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8

Similar content being viewed by others

References

  1. Ahmed IM, Lagopoulos M, McConnell P, Soames RW, Sefton GK (1998) Blood supply of the Achilles tendon. J Orthop Res 16:591–596

    Article  PubMed  CAS  Google Scholar 

  2. Apaydin N, Bozkurt M, Loukas M, Vefali H, Tubbs RS, Esmer AF (2009) Relationships of the sural nerve with the calcaneal tendon: an anatomical study with surgical and clinical implications. Surg Radiol Anat 31(10):775–780

    Article  PubMed  Google Scholar 

  3. Astrom M, Gentz CF, Nilsson P, Rausing A, Sjoberg S, Westlin N (1996) Imaging in chronic achilles tendinopathy: a comparison of ultrasonography, magnetic resonance imaging and surgical findings in 27 histologically verified cases. Skeletal Radiol 25:615–620

    Article  PubMed  CAS  Google Scholar 

  4. Astrom M, Rausing A (1995) Chronic Achilles tendinopathy. A survey of surgical and histopathologic findings. Clin Orthop Relat Res 316:151–164

    PubMed  Google Scholar 

  5. Benjamin M, McGonagle D (2001) The anatomical basis for disease localisation in seronegative spondyloarthropathy at entheses and related sites. J Anat 199:503–526

    Article  PubMed  CAS  Google Scholar 

  6. Booth FW (1977) Time course of muscular atrophy during immobilization of hindlimbs in rats. J Appl Physiol 43:656–661

    PubMed  CAS  Google Scholar 

  7. Bottger BA, Schweitzer ME, El-Noueam KI, Desai M (1998) MR imaging of the normal and abnormal retrocalcaneal bursae. AJR Am J Roentgenol 170:1239–1241

    Article  PubMed  CAS  Google Scholar 

  8. Carden DG, Noble J, Chalmers J, Lunn P, Ellis J (1987) Rupture of the calcaneal tendon. The early and late management. J Bone Joint Surg Br 69:416–420

    PubMed  CAS  Google Scholar 

  9. Chan O, O’Dowd D, Padhiar N et al (2008) High volume image guided injections in chronic Achilles tendinopathy. Disabil Rehabil 30:1697–1708

    Article  PubMed  Google Scholar 

  10. Chen TM, Rozen WM, Pan WR, Ashton MW, Richardson MD, Taylor GI (2009) The arterial anatomy of the Achilles tendon: anatomical study and clinical implications. Clin Anat 22:377–385

    Article  PubMed  Google Scholar 

  11. Clain MR, Baxter DE (1992) Achilles tendinitis. Foot Ankle 13:482–487

    Article  PubMed  CAS  Google Scholar 

  12. Cook JL, Khan KM, Kiss ZS, Coleman BD, Griffiths L (2001) Asymptomatic hypoechoic regions on patellar tendon ultrasound: a 4-year clinical and ultrasound followup of 46 tendons. Scand J Med Sci Sports 11:321–327

    Article  PubMed  CAS  Google Scholar 

  13. Cook JL, Khan KM, Kiss ZS, Purdam CR, Griffiths L (2000) Prospective imaging study of asymptomatic patellar tendinopathy in elite junior basketball players. J Ultrasound Med 19:473–479

    PubMed  CAS  Google Scholar 

  14. Doral MN, Alam M, Bozkurt M et al (2010) Functional anatomy of the Achilles tendon. Knee Surg Sports Traumatol Arthrosc 18:638–643

    Article  PubMed  Google Scholar 

  15. Erickson SJ, Prost RW, Timins ME (1993) The “magic angle” effect: background physics and clinical relevance. Radiology 188:23–25

    PubMed  CAS  Google Scholar 

  16. Fahlstrom M, Jonsson P, Lorentzon R, Alfredson H (2003) Chronic Achilles tendon pain treated with eccentric calf-muscle training. Knee Surg Sports Traumatol Arthrosc 11:327–333

    Article  PubMed  Google Scholar 

  17. Fugl-Meyer AR, Nordin G, Sjostrom M, Wahlby L (1979) Achilles tendon injury. 5. A model of isokinetic strength training using biofeedback. Scand J Rehabil Med 11:37–44

    PubMed  CAS  Google Scholar 

  18. Garrett WE, Califf JC, Bassett FH (1984) Histochemical correlates of hamstring injuries. Am J Sports Med 12:98–103

    Article  PubMed  Google Scholar 

  19. Grumbine NA, Santoro JP (1990) The tendo Achillis as it relates to rearfoot position. A new classification for evaluation of calcaneal stance position. Clin Podiatr Med Surg 7:203–216

    PubMed  CAS  Google Scholar 

  20. Hastad K, Larsson LG, Lindholm A (1959) Clearance of radiosodium after local deposit in the Achilles tendon. Acta Chir Scand 116:251–255

    PubMed  CAS  Google Scholar 

  21. Khan KM, Cook JL, Kiss ZS et al (1997) Patellar tendon ultrasonography and jumper’s knee in female basketball players: a longitudinal study. Clin J Sport Med 7:199–206

    Article  PubMed  CAS  Google Scholar 

  22. Khan KM, Forster BB, Robinson J et al (2003) Are ultrasound and magnetic resonance imaging of value in assessment of Achilles tendon disorders? A two year prospective study. Br J Sports Med 37:149–153

    Article  PubMed  CAS  Google Scholar 

  23. Lagergren C, Lindholm A (1959) Vascular distribution in the Achilles tendon; an angiographic and microangiographic study. Acta Chir Scand 116:491–495

    PubMed  CAS  Google Scholar 

  24. Lento PH, Primack S (2008) Advances and utility of diagnostic ultrasound in musculoskeletal medicine. Curr Rev Musculoskelet Med 1:24–31

    Article  PubMed  Google Scholar 

  25. Maffulli N (1999) Rupture of the Achilles tendon. J Bone Joint Surg Am 81:1019–1036

    PubMed  CAS  Google Scholar 

  26. Maffulli N (2005) Augmented repair of acute Achilles tendon ruptures using gastrocnemius-soleus fascia. Int Orthop 29:134

    Article  PubMed  Google Scholar 

  27. Maffulli N, Khan KM, Puddu G (1998) Overuse tendon conditions: time to change a confusing terminology. Arthroscopy 14:840–843

    Article  PubMed  CAS  Google Scholar 

  28. Maffulli N, Regine R, Angelillo M, Capasso G, Filice S (1987) Ultrasound diagnosis of Achilles tendon pathology in runners. Br J Sports Med 21:158–162

    Article  PubMed  CAS  Google Scholar 

  29. Maffulli N, Spiezia F, Longo UG, Denaro V (2012) Z-shortening of healed, elongated Achilles tendon rupture. Int Orthop 36:2087–2093

    Article  PubMed  Google Scholar 

  30. Maffulli N, Waterston SW, Squair J, Reaper J, Douglas AS (1999) Changing incidence of Achilles tendon rupture in Scotland: a 15-year study. Clin J Sport Med 9:157–160

    Article  PubMed  CAS  Google Scholar 

  31. Millar AP (1979) Strains of the posterior calf musculature (“tennis leg”). Am J Sports Med 7:172–174

    Article  PubMed  CAS  Google Scholar 

  32. Moller A, Astron M, Westlin N (1996) Increasing incidence of Achilles tendon rupture. Acta Orthop Scand 67:479–481

    Article  PubMed  CAS  Google Scholar 

  33. Movin T, Gad A, Reinholt FP, Rolf C (1997) Tendon pathology in long-standing achillodynia. Biopsy findings in 40 patients. Acta Orthop Scand 68:170–175

    Article  PubMed  CAS  Google Scholar 

  34. O’Brien M (2005) The anatomy of the Achilles tendon. Foot Ankle Clin 10:225–238

    Article  PubMed  Google Scholar 

  35. Ohberg L, Lorentzon R, Alfredson H (2001) Neovascularisation in Achilles tendons with painful tendinosis but not in normal tendons: an ultrasonographic investigation. Knee Surg Sports Traumatol Arthrosc 9:233–238

    Article  PubMed  CAS  Google Scholar 

  36. Paavola M, Paakkala T, Kannus P, Jarvinen M (1998) Ultrasonography in the differential diagnosis of Achilles tendon injuries and related disorders. A comparison between pre-operative ultrasonography and surgical findings. Acta Radiol 39:612–619

    Article  PubMed  CAS  Google Scholar 

  37. Patel S, Fessell DP, Jacobson JA, Hayes CW, van Holsbeeck MT (2002) Artifacts, anatomic variants, and pitfalls in sonography of the foot and ankle. AJR Am J Roentgenol 178:1247–1254

    Article  PubMed  Google Scholar 

  38. Sandelin J, Kiviluoto O, Santavirta S, Honkanen R (1985) Outcome of sports injuries treated in a casualty department. Br J Sports Med 19:103–106

    Article  PubMed  CAS  Google Scholar 

  39. Scheller AD, Kasser JR, Quigley TB (1980) Tendon injuries about the ankle. Orthop Clin North Am 11:801–811

    PubMed  CAS  Google Scholar 

  40. Schweitzer ME, Karasick D (2000) MR imaging of disorders of the Achilles tendon. AJR Am J Roentgenol 175:613–625

    Article  PubMed  CAS  Google Scholar 

  41. Seebacher JR, Inglis AE, Marshall JL, Warren RF (1982) The structure of the posterolateral aspect of the knee. J Bone Joint Surg Am 64:536–541

    PubMed  CAS  Google Scholar 

  42. Soma CA, Mandelbaum BR (1994) Achilles tendon disorders. Clin Sports Med 13:811–823

    PubMed  CAS  Google Scholar 

  43. Tol JL, Spiezia F, Maffulli N (2012) Neovascularisation in Achilles tendinopathy: have we been chasing a red herring? Knee Surg Sports Traumatol Arthrosc 20:1891–1894

    Article  PubMed  Google Scholar 

  44. van Dijk CN, van Sterkenburg MN, Wiegerinck JI, Karlsson J, Maffulli N (2011) Terminology for Achilles tendon related disorders. Knee Surg Sports Traumatol Arthrosc 19:835–841

    Article  PubMed  Google Scholar 

  45. Watanabe Y, Moriya H, Takahashi K et al (1993) Functional anatomy of the posterolateral structures of the knee. Arthroscopy 9:57–62

    Article  PubMed  CAS  Google Scholar 

  46. Weinberg EP, Adams MJ, Hollenberg GM (1998) Color Doppler sonography of patellar tendinosis. AJR Am J Roentgenol 171:743–744

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Orthopaedic and Trauma Surgery, Campus Biomedico University of Rome, Via Alvaro del Portillo, Rome, Italy

    Angelo Del Buono

  2. Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, England, UK

    Otto Chan & Nicola Maffulli

Authors
  1. Angelo Del Buono
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Otto Chan
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Nicola Maffulli
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Nicola Maffulli.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Del Buono, A., Chan, O. & Maffulli, N. Achilles tendon: functional anatomy and novel emerging models of imaging classification. International Orthopaedics (SICOT) 37, 715–721 (2013). https://doi.org/10.1007/s00264-012-1743-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00264-012-1743-y

Keywords

Search

Navigation