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MR Imaging of Overuse Injuries of the Achilles Tendon

¹ Department of Radiology, Helsinki University Central Hospital, Haartmaninkatu 4, FIN-00290, Helsinki, Finland.
² Department of Diagnostic Radiology, Mt. Sinai Medical Center, 4300 Alton Rd., Miami Beach, FL 33140.
³ Department of Clinical Radiology, University Hospital of Kuopio, P. O. Box 1777, FIN-70211, Kuopio, Finland.
⁴ Department of Orthopaedics and Traumatology, Helsinki University Central Hospital, Topeliuksenkatu 5, FIN-00260, Helsinki, Finland.
⁵ Helsinki University Central Hospital Diagnostics, P. O. Box 401, FIN-00290, Helsinki, Finland.
⁶ San Francisco MR Imaging Center, 3333 California St., Ste. 105, San Francisco, CA 94118.

View larger version (141K): [in a new window]   Fig. 1A. —23-year-old woman with long-standing pain in left Achilles tendon. Right asymptomatic Achilles tendon shows normal appearance on axial high-resolution T1-weighted spoiled gradient-echo MR image (TR/TE, 600/10).

View larger version (140K): [in a new window]   Fig. 1B. —23-year-old woman with long-standing pain in left Achilles tendon. MR image shows left leg with anterior convexity (arrow) and thickening of Achilles tendon as a sign of tendinosis. Note lack of intratendinous signal changes.

View larger version (97K): [in a new window]   Fig. 2. —33-year-old man with symptomatic Achilles tendinosis. Sagittal T1-weighted spin-echo MR image (TR/TE, 460/14) shows anterior bulging and thickening (arrow) of tendon as evidence of tendinosis.

View larger version (157K): [in a new window]   Fig. 3A. —Intratendinous lesion of painful Achilles tendon in 38-year-old man. Axial high-resolution T1-weighted spoiled gradient-echo MR image (TR/TE, 600/10) shows large intermediate-signal-intensity intratendinous lesion in thickened Achilles tendon. Note thickened paratenon (arrow) posterior to Achilles tendon.

View larger version (139K): [in a new window]   Fig. 4A. —39-year-old woman with long-standing Achilles tendon pain. Axial T1-weighted spoiled gradient-echo MR image (TR/TE, 600/10) shows large intratendinous lesion with radiating stripes to surface of tendon.

View larger version (116K): [in a new window]   Fig. 4B. —39-year-old woman with long-standing Achilles tendon pain. Corresponding fast short tau inversion recovery MR image (4700/30) shows lesion with high-signal-intensity center. Paratenon posterior to intratendinous lesion exhibits increased intensity, suggesting paratenonitis (arrow).

View larger version (116K): [in a new window]   Fig. 4D. —39-year-old woman with long-standing Achilles tendon pain. Proton density-weighted (C) and T2-weighted (D) MR images show intermediate- and high-signal-intensity center of lesion, respectively.

View larger version (83K): [in a new window]   Fig. 5. —Retrocalcaneal bursitis in 20-year-old woman. Sagittal fast short tau inversion recovery MR image shows enlargement of bursae caused by excessive fluid. Achilles tendon insertion to calcaneus has normal appearance.

View larger version (138K): [in a new window]   Fig. 3C. —Intratendinous lesion of painful Achilles tendon in 38-year-old man. Proton density-weighted (2100/20) (C) and T2-weighted spin-echo (2100/80) (D) MR images exhibit very mild intratendinous changes. Paratenon is poorly demarcated compared with high-resolution image in A.

View larger version (129K): [in a new window]   Fig. 3D. —Intratendinous lesion of painful Achilles tendon in 38-year-old man. Proton density-weighted (2100/20) (C) and T2-weighted spin-echo (2100/80) (D) MR images exhibit very mild intratendinous changes. Paratenon is poorly demarcated compared with high-resolution image in A.

View larger version (73K): [in a new window]   Fig. 6A. —22-year-old woman with clinical diagnosis of tendinosis of insertion of Achilles tendon. Sagittal fast short tau inversion recovery (STIR) MR image shows increased signal intensity (arrows) in calcaneal bone marrow as sign of reactive edema. Also, retrocalcaneal bursa and adjacent Kager's fat pad show increased signal intensity.

View larger version (162K): [in a new window]   Fig. 6B. —22-year-old woman with clinical diagnosis of tendinosis of insertion of Achilles tendon. On axial T1-weighted spoiled gradient-echo fast low-angle shot (FLASH) MR image, calcaneal bone marrow has normal appearance.

View larger version (117K): [in a new window]   Fig. 6C. —22-year-old woman with clinical diagnosis of tendinosis of insertion of Achilles tendon. Axial STIR MR image corresponding to B shows increased signal intensity in calcaneal bone marrow at insertion of Achilles tendon (arrow).

View larger version (162K): [in a new window]   Fig. 6D. —22-year-old woman with clinical diagnosis of tendinosis of insertion of Achilles tendon. Axial FLASH image at level of calcaneal corner shows anteriorly located intratendinous lesion (arrow).

View larger version (111K): [in a new window]   Fig. 6E. —22-year-old woman with clinical diagnosis of tendinosis of insertion of Achilles tendon. Axial STIR image, corresponding to D, shows retrocalcaneal bursitis (arrows) typically associated with other insertional findings.

View larger version (75K): [in a new window]   Fig. 7B. —Various patterns of peritendinitis on fast short tau inversion recovery MR images. 32-year-old woman with increased signal intensity in Kager's fat pad anterior to Achilles tendon, sign of anterior peritendinitis.

View larger version (100K): [in a new window]   Fig. 8A. —20-year-old man with anterior peritendinitis in Kager's fat pad. Sagittal T1-weighted spin-echo MR image shows abnormal low-signal-intensity strands in Kager's fat pad anterior to normal Achilles tendon.

View larger version (83K): [in a new window]   Fig. 8B. —20-year-old man with anterior peritendinitis in Kager's fat pad. Abnormal high-signal-intensity changes are seen on sagittal fast short tau inversion recovery MR image.

View larger version (99K): [in a new window]   Fig. 7C. —Various patterns of peritendinitis on fast short tau inversion recovery MR images. 20-year-old man with both anterior and posterior peritendinitis (posteriorly also called paratenonitis).

View larger version (107K): [in a new window]   Fig. 9B. —Various patterns of thickening of paratenon on high-resolution T1-weighted spoiled gradient-echo MR fast low-angle shot images. 24-year-old man with Achilles tendinosis shows moderately thickened paratenon (arrows) and thickened Achilles tendon.

View larger version (123K): [in a new window]   Fig. 9C. —Various patterns of thickening of paratenon on high-resolution T1-weighted spoiled gradient-echo MR fast low-angle shot images. 48-year-old man with long-standing achillodynia. Posterior paratenon (arrows) is severely thickened. Note also large intratendinous lesion extending to surface of abnormally thickened tendon indicating tendinosis.

View larger version (129K): [in a new window]   Fig. 3B. —Intratendinous lesion of painful Achilles tendon in 38-year-old man. Corresponding fast short tau inversion recovery MR image (4700/30) shows low signal intensity in lesion and moderately increased intensity in posterior paratenon (arrow).

View larger version (119K): [in a new window]   Fig. 4C. —39-year-old woman with long-standing Achilles tendon pain. Proton density-weighted (C) and T2-weighted (D) MR images show intermediate- and high-signal-intensity center of lesion, respectively.

View larger version (122K): [in a new window]   Fig. 3E. —Intratendinous lesion of painful Achilles tendon in 38-year-old man. Light photomicrograph of histopathology of intratendinous lesion shows weak collagen staining and derangement of tendon fibers. (van Gieson stain, x200)

View larger version (97K): [in a new window]   Fig. 4E. —39-year-old woman with long-standing Achilles tendon pain. Light photomicrograph of histopathology of lesion shows presence of rounded tenocyte nuclei (arrows) with some normal spindle-shaped nuclei in Achilles tendon tissue. (H and E, x400)

View larger version (121K): [in a new window]   Fig. 4F. —39-year-old woman with long-standing Achilles tendon pain. Light photomicrograph shows damaged Achilles tendon tissue with extensive capillary proliferation. Arrows indicate some single vessels. Note also high number and round morphology of tenocyte nuclei. (H and E, x400)

View larger version (80K): [in a new window]   Fig. 7A. —Various patterns of peritendinitis on fast short tau inversion recovery MR images. 25-year-old man with small intratendinous lesion (arrow) and increased signal intensity posteriorly as sign of associated paratenonitis.

View larger version (93K): [in a new window]   Fig. 9A. —Various patterns of thickening of paratenon on high-resolution T1-weighted spoiled gradient-echo MR fast low-angle shot images. 32-year-old asymptomatic male volunteer shows normal, intermediate-signal-intensity paratenon deep to low-signal-intensity chemical shift artifact between paratenon and subcutaneous fat.

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