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Ankle & Foot
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Achilles tendon
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Tennis Leg
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The Achilles tendon is formed from the gastrocnemius and soles muscle. The principle contribution comes from the medial and lateral heads of gastrocnemius with a tendon forming on their dorsal aspect and uniting in mid calf to form the Achilles tendon which runs along the dorsal aspect of the soleus muscle. The central tendon of the soleus muscle eventually joins on the anterior aspect of the gastric tendon, and the combined tendon continues to its insertion on the posterosuperior aspect of the os calcis. Prior to its insertion, the Achilles tendon is separated from the underlying bone by the pre-Achilles bursa and a fibrocartilagenous enthesis. It is separated from the posterior tibia and flexor hallucis muscle bellies by a triangle of fat called Kagers Fat Triangle. Achilles tendinopathy is a common cause of posterior calf pain. It occurs as an overuse syndrome. The aetiology is unclear with many factors contributing including foot mal-alignment, particularly hyper-pronation. Various stages of disease are described. In the earlier stages tendon enlargement may be present without symptoms. As the pathology progresses posterior pain particularly on exertion develops. Two distinct types are present termed insertional and non-insertional. The commonest of these is non-insertional tendinopathy which typically involves the proximal two thirds of the tendon. Insertional tendinopathy will be described in a later section. The imaging appearances of non-insertional Achilles tendinopathy includes tendon enlargement with loss of its normal internal structure. In later stages, delimitation tears or splits occur which may ultimately predispose to tendon rupture Achilles Tendinopathy -|>
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On T1 weighted images there is loss of the normal low signal tendon structure with enlargement particularly in its AP diameter. Under normal circumstances the tendon measures 5-6mm in this plane. On T2 weighted images, areas of focal or linear increased signal indicating focal degeneration, partial tear or tendon splits may be found. On ultrasound, the fusiform tendon swelling is also easily identified. There is loss of the normal reflective echo structure. Focal degeneration and partial tears can be identified as areas of focal loss of reflectivity. In addition, ultrasound combined with Doppler imaging demonstrates areas of angioneogenesis. Chronic tendon degeneration perhaps related to hypoxia serve as a stimuli for new vessel formation. New vessels are distributed in a haphazard fashion and are often blind ending. There is some correlation with symptoms probably as a consequence of aberrant nerve growth that accompanies vascular ingrowth. Insertional Achilles tendinopathy involves the distal one third of the tendon. Whilst this may be mechanical in aetiology, sometimes the consequence of bony overgrowth of the posterosuperior margin of the oscalcis, a condition termed Haglund’s syndrome, other cases are associated with inflammatory arthropathy.
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Rupture of the Achilles tendon is a common event. The condition most commonly occurs in the 30 – 50 age group and is frequently associated with racquet sports such as badminton, squash and tennis. It has been argued that unaccustomed exercise without warming up can predispose but it is likely that there is a significant contribution from underlying Achilles tendinopathy. Patients classically complain of a sudden and acute event where they get a sensation of being kicked in the back of the ankle. An audible popping may also be described. There is a loss of plantar flexion and ability to stand on the toes. Clinically a palpable defect may also be felt. The Achilles tendon tends to rupture in one of three locations. The commonest is in the central third involving the tendinous portion between 4 and 7cm above its insertion. The second commonest is a rupture that occurs at the musculotendinous junction often in or around the level of soleal incorporation. The least common injury occurs with the tendon insertion where an avulsion may occur. Avulsion of the tendon needs to be distinguished from an insufficiency fracture of the os calcis which, as a consequence of tendon retraction, may also similate Achilles rupture.
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