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MR Imaging of Disorders of the Achilles Tendon
T he Achilles tendon is among the
most frequently injured tendons of
the body with a variety of types of
traumatic and overuse conditions affecting it.
These conditions are common, often come to
clinical attention, and are frequently imaged.
The pathophysiology of Achilles disorders is
complex, and the nomenclature is irregularly
applied; this leads to miscommunication be-
tween clinicians and radiologists and inconsis-
tencies in the literature. Therefore, we review
the anatomy, MR imaging findings, and patho-
logic findings in an attempt to develop a sys-
tematic nomenclature.
Gross Anatomy
The Achilles tendon originates in the mid
leg and is formed by the junction of the two
heads of the gastrocnemius muscles and the
soleus muscle [1, 2]. The bulk of the Achilles
is formed from the gastrocnemius muscle. The
larger medial head originates almost entirely
from just proximal to the medial femoral
condyle, and the smaller lateral head arises
from both the posterior and lateral surfaces of
the lateral femoral condyle. At the junction of
the proximal and mid calf, the two heads of the
gastrocnemius muscles and their tendons ap-
proximate midline. The gastrocnemius tendon
origin is gradual, occurring over approxi-
mately 34 cm. The fibers of the medial head
originate slightly lower than those of the lat-
eral head. The Achilles tendon is not formed
until the soleus muscle inserts onto the gas-
Received May 3, 1999; accepted after revision February 24, 2000.
1
Both authors: Department of Radiology, Thomas Jefferson University Hospital, 111 S. 11th St., 3390 Gibbon, Philadelphia, PA 19107. Address correspondence to M. E. Schweitzer.
AJR 2000;175:613625 0361803X/00/1753613 American Roentgen Ray Society
AJR:175, September 2000
trocnemius tendon, approximately 34 cm
more distally [2].
The plantaris muscle originates from the
lateral meniscus and the lateral femoral epi-
condyle in close association with the lateral
head of the gastrocnemius muscle. The plan-
taris tendon then crosses obliquely between
the soleus and gastrocnemius muscles and
continues just medial to the Achilles. Various
plantaris insertions are seen, but most fibers
insert on the medial aspect of the superior cal-
caneal tuberosity or 1 cm anterior and medial
to the Achilles on the calcaneus, a distinct in-
sertion point separate from that of the Achil-
les. The Achillesplantaris complex is termed
the tricepssurae complex [3].
The Achilles tendon is enclosed almost
completely within a paratendon. This paraten-
don has both visceral and parietal layers [4].
The paratendon is analogous to synovium in
that it provides nutrition for the tendon, but
because the Achilles tendon does not change
its axis of motion, there is no need for the lu-
brication function of synovium.
Two layers of filmy fibrous tissue with
fine internal mesotendal blood vessels make
up the paratendon [5]. The interwoven fibers
of the paratendon allow it to stretch up to
several centimeters in length with tendon
movement and provide some degree of ten-
don gliding [4].
Mesotendal vascular anastomoses pro-
vide tendon nourishment. However, 26 cm
proximal to the calcaneal insertion, this
Review
Mark E. Schweitzer 1 and David Karasick
blood supply is diminished [6]. This region
of decreased vascularity is the usual region
of Achilles rupture [7]. Proximal tears are
uncommon because of the nutrition provided
by the muscular branches from the gastroc-
nemius [8]. Distal tears are uncommon be-
cause the blood supply from the periosteal
vessels is near the calcaneal insertion.
As the Achilles tendon descends, the fi-
bers rotate laterally approximately 90.
Therefore, the gastrocnemius fibers insert
laterally onto the posterior calcaneus,
whereas the soleus fibers insert medially [9].
The insertion site of the Achilles onto the
calcaneus is an enthesis and is intimately re-
lated to the only true anatomic bursa in the
ankle, the retrocalcaneal bursa [10].
The retrocalcaneal bursa is horseshoe-
shaped, filled with synovial fluid, and sur-
rounded anteriorly by Kagers fat pad. The
function of the retrocalcaneal bursa is to pro-
tect the distal Achilles tendon from frictional
wear against the posterior calcaneus [11]. Pos-
terior to the tendon lies an acquired bursa,
termed the retro-Achilles. The enthesis itself
is fibrocartilage directly intermeshing into the
marrow of the calcaneus [10]. This direct
meshing of tendon fibrils into marrow pro-
vides significant strength at the enthesis and
makes it a rare site of tendon failure.
Tendon Ultrastructure
Approximately 15 cm in length, the Achilles
is the strongest, largest, and thickest tendon in
613

the human body. The Achilles is made of fasci-
cles, with an interfascicular membrane separat-
ing the fascicles into bundles. Each bundle of
fascicles is roughly shaped like a quarter of a
pie. On a microstructural level, the fascicles are
made of fibroblasts, which have a sinusoidal
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structure. This sinusoidal structure allows the
Achilles to stretch considerably before tendon
rupture. The fibroblasts are made of fibrils, the
fibrils are made of microfibrils, and the mi-
crofibrils are made of tropocollagen [12]. The
fibrils normally have an undulating pattern.
This undulation decreases with aging, which
leads to a decrease in the Achilles elasticity
[13]. In addition, the average diameter, density,
and cellularity of the collagen fibrils also de-
crease with aging. The combination of cellular
changes, ultrastructural changes, and a tenuous
blood supply predisposes the aged Achilles to
degeneration and injury.
Functional Anatomy
The gastrocnemius, soleus, and plantaris
muscles act to flex the foot [14]. The gastroc-
nemius is also a knee flexor. The gastrocne-
mius muscle is active in walking, jumping,
and running, and therefore it is composed
predominantly of type II fibers [15]. Because
the soleus muscle has more of a stabilization
Fig. 1.41-year-old man with normal tendon.
A, Sagittal T2-weighted MR image (TR/TE, 6000/70) shows normal parallel anterior and posterior margins of ten-
don (open arrows ). Note normal volume of fat in Kagers fat pad anterior to tendon (solid arrows ) and insertion
of soleus muscle onto tendon.
B, Axial T1-weighted MR image (500/20) shows normal concave anterior margins of tendon (arrow ). Kagers fat
pad can be seen anterior to tendon.
614
Schweitzer and Karasick
effect on the foot for standing, it consists pri-
marily of type I fibers [16]. Consequently,
muscle fiber atrophy of the soleus occurs
more rapidly than does that of the gastrocne-
mius [17], making the soleus muscle a more
sensitive indicator of atrophy as a result of
complete tears or denervation.
Normal MR Appearance
The normal average thickness of the
Achilles tendon is 6 mm. The Achilles ten-
don is thicker in tall patients, in men, and in
the elderly [18]. Achilles size is also directly
related to lean body mass and is somewhat
related to total body mass.
On sagittal images, the anterior and poste-
rior margins of the Achilles tendon should be
parallel below the soleus insertion (Fig. 1).
On axial images, the anterior margin of the
Achilles is concave for most of its course.
Somewhat proximally, just above the soleus
insertion, the margin may be straight or con-
vex; at the soleus insertion, the margin is typ-
ically convex and may be focally bulbous.
On coronal images, both sides of the Achilles
are fairly straight and the tendon widens as it
extends distally at the lesion.
The normal retrocalcaneal bursa is visible
on MR imaging but should measure less than
A B
patients, with a mean age of 36 years, as com-
before the onset of adolescence [25]. Of all the
6 mm superior to inferior, 3 mm medial to
lateral, and 2 mm anterior to posterior [19].
Subcutaneous fat should be seen between the
Achilles and the skin. Focal absence of fat
may represent a skin callus, a blister (if it has
high signal on T2-weighted images and bows
the skin out), or retro-Achilles bursitis (if it
has high signal and is without mass effect on
the skin). Fat should also be normally seen
anterior to the tendon in Kagers fat pad. Oc-
casionally, vessels within Kagers fat pad can
mimic edema, although their tubular mor-
phology should allow differentiation.
The Achilles tendon is usually dark on all
imaging sequences. However, the normal fas-
cicular anatomy of the Achilles tendon may be
visible as a single line and can mimic an inter-
stitial tear [20]. This fascicular signal is usually
not present or fades on T2-weighted images.
Small punctate areas of high signal, seen dis-
tally in the Achilles tendon on axial images, are
interfascicular membranes (Figs. 2 and 3).
Lastly, some fraction of distal internal signal
may represent the magic angle artifact. This
phenomenon occurs in the Achilles tendon even
though it does not grossly change its axis, be-
cause the fibers twist internally. This artifact is
not present on T2-weighted images [21].
Epidemiology
True rupture of the Achilles tendon was
first described by Ambroise Pare in 1575 and
first reported in the medical literature in
1633. Achilles tendon rupture was a rarely
reported injury until the 1950s [22]. Before
1929, fewer than 70 cases were reported in
the world literature. During the 1970s, the re-
ported incidence increased by up to 50% a
year in developed countries [23].
Achilles tendon tears are most common in
developed countries, but the prevalence var-
ies among developed countries. The highest
rates are seen in Germany, Austria, Sweden,
Denmark, and Switzerland. Lower rates oc-
cur in France, Spain, the United Kingdom,
and the United States [23]. However, some
industrialized nations, such as The Nether-
lands, Japan, and Korea, have an extremely
low incidence of Achilles tears, and in the
third world, the incidence of Achilles tears is
even lower [24]. Currently, the incidence in
industrialized nations is approximately seven
cases per 100,000 inhabitants per year [24].
Achilles tendon rupture occurs in younger
pared with ruptures of other tendons, but Achil-
les rupture almost never occurs in patients
tendons in the foot and ankle, the Achilles ten-
AJR:175, September 2000

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Fig. 2.37-year-old woman with normal fascicles
of Achilles tendon. Axial proton densityweighted
MR image (TR/TE, 4000/40) shows normal fascicu-
lar anatomy. Fascicles appear as intratendon sig-
nal (arrows ) in Achilles tendon.
don is the only one for which disorders have a
male predominance [26]. Achilles tendon dis-
orders are also more common on the left than
on the right side for unknown reasons [27]. Be-
cause Achilles tendon disorders are activity-re-
lated disorders, incidence peaks during the
summer [28].
A significant relationship between leisure
athletic activities and tendon injuries exists
[27]. The sedentary lifestyle of modern white-
collar workers results in decreased blood flow
and nutrition to the Achilles tendon [29]. This
situation is compounded by the effects of aging
on the vascular supply. Recreational physical
activities that intermittently stress the ischemic
Achilles tendon, without giving it time to
adapt, may lead to spontaneous Achilles ten-
don rupture [29].
AJR:175, September 2000
MR Imaging of the Achilles Tendon
Fig. 3.45-year-old man with normal fascicles and peri-
tendonitis. Axial T2-weighted MR image (TR/TE, 6000/78)
with fat suppression shows barbed-wire appearance of
fascicles (curved arrow ). Also note partially circumferen-
tial high signal (straight arrow ) consistent with small de-
gree of peritendonitis.
The specific causative activity varies among
countries according to the popularity of sport-
ing events in the country involved. In the
United States, running sports, particularly those
that involve pivot motion, are the most com-
mon causative sport, with jogging as the lead-
ing cause of Achilles disorders [28]. However,
in Germany, soccer is the leading cause [27].
MR Imaging and Pathologic Anatomy
Achilles tendonosis is a preferable term to
Achilles tendonitis because this disorder is
manifested as intratendinous degeneration
without a significant inflammatory response
[18]. The Achilles tendon is protected against
inflammatory processes because no true syn-
ovial sheath is present. However, because of
A B
the intimate association between the distal
Achilles tendon and the retrocalcaneal bursa,
the Achilles tendon is secondarily affected by
inflammatory processes involving the retrocal-
caneal bursa [10]. In addition, involvement of
the Achilles paratendon has been noted to be
reasonably frequent in systemic inflammatory
diseases, such as rheumatoid arthritis [30]. This
manifestation of rheumatoid arthritis has not
been widely recognized previously because
this inflammation, similar to that of many wrist
tendons, is often clinically occult [31].
Most imaging findings represent the
pathologic processes of tendon degeneration
and repair [32]. Grossly, the degenerated ten-
don appears nodular and yellow and loses its
usual glistening luster, often appearing
edematous or fibrillated [33].
On a microscopic level, four predominant
types of tendon degeneration are seen includ-
ing fibromatosis or hypoxic, lipoid, osseous or
calcific, and myxoid [34]. Although only the
former two frequently lead to macroscopic
tears, all pathologic changes may be the result
of microscopic tears [35]. These microscopic
tears evolve and coalesce to form the spectrum
of Achilles disorders that is seen on imaging. It
is the coalescence of these microtears that leads
to the development of focal mycoid regions and
interstitial tears along the long axis of the ten-
don. Therefore, tears on a microscopic level be-
gin the cascade of tendon disorders, and tears
on a macroscopic level end it [35].
Fibromatous degeneration is also termed
hypoxic degenerative tendonopathy and is
the most frequently seen degenerative finding
in ruptured Achilles tendons [36]. These hy-
poxic changes are likely caused by ischemia
because of the relative hypovascularity of the
critical zone of the Achilles tendon [37]. This
hypovascularity results in anoxic injury to
tenocytes and collagen fibers [34]. Hypoxic
Fig. 4.60-year-old man with hy-
poxic degeneration.
A and B, Sagittal T1-weighted (A) (TR/
TE, 500/10) and sagittal short tau in-
version recovery (B) (6000/40; inver-
sion time, 150 msec) MR images show
bulbous thickening (solid straight
arrows ) of Achilles tendon and that
anterior and posterior margins of
Achilles tendon are no longer parallel.
No internal signal can be seen. Note
normal volume of retrocalcaneal
bursa fluid (solid curved arrow ). Inci-
dentally noted is cartilaginous calca-
neal navicular coalition (open arrow ).
615
 Schweitzer and Karasick
Fig. 5.48-year-old man with hypoxic degeneration. Ax-
ial T2-weighted fat-suppressed MR image (TR/TE, 6000/
80) shows extensive thickening of Achilles tendon with
loss of normal concave anterior margin (arrows ).
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6 7
A B
616
degenerative tendonopathy leads to a thick-
ened dysmorphic Achilles tendon [36] (Figs. 4
and 5). This type of degeneration usually oc-
curs after multiple symptomatic episodes [37]
and usually lacks internal signal on MR imag-
ing. A similar MR appearance can be seen in
rheumatoid arthritis (Fig. 6) and gout (Fig. 7)
and after tendon repair.
The second most common type of degen-
eration is mucoid. Most patients with mu-
coid degeneration also have some degree of
hypoxic degeneration [33]. This is the most
common degeneration to occur asymptom-
atically. In mucoid degeneration, large mu-
coid patches and vacuoles are seen between
the thinned degenerated tendon fibers [35].
Interrupted signal on T2-weighted images is
the best marker for mucoid deposits (Figs.
810). Grossly, these tendons appear en-
larged, and enlargement may also be seen
Fig. 6.55-year-old woman with
rheumatoid arthritis. Sagittal T1-
weighted MR image (TR/TE, 500/20)
shows markedly thickened Achilles
tendon (white arrows ) caused by
rheumatoid arthritis. Also, note find-
ings consistent with retrocalcaneal
bursitis (straight black arrow ) and
with subtalar joint disease (curved
black arrow ). Erosion of calcaneus
can be seen as well.
Fig. 7.50-year-old man with gout.
Sagittal T1-weighted MR image (TR/
TE, 500/12) shows thickening of
Achilles tendon (straight arrows )
representing gouty infiltration. Gouty
infiltration of anterior tibialis tendon
(curved arrow ) can also be seen.
Fig. 8.55-year-old woman with mucoid degenera-
tion.
A and B, Sagittal T1-weighted (TR/TE, 500/20) and
sagittal short tau inversion recovery (6000/70) MR im-
ages show thickened Achilles tendon with internal
signal (arrows ). This signal was nonlinear and inter-
rupted on T2-weighted image (not shown).
AJR:175, September 2000
 MR Imaging of the Achilles Tendon
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Fig. 9.58-year-old woman with mucoid degen-
eration. Sagittal F-short tau inversion recovery
image (TR/TE, 4000/48; inversion time, 150 msec)
shows irregular longitudinal mucoid deposit in
Achilles tendon (arrows).
Fig. 10.48-year-old man with mucoid degeneration. Axial Fig. 11.56-year-old man with ossified Achilles. T1-
T2-weighted fat-suppressed MR image (TR/TE, 6000/80) weighted MR image (TR/TE, 500/12) shows bone frag-
shows thickened Achilles tendon (arrows ) with multifocal ments (arrow ) with trabeculae inside Achilles tendon.
speckled appearance consistent with mucoid degeneration.

on MR imaging. It is the coalescence of quently than tendon calcification and is rela- The first symptomatic stage of Achilles dis-
vacuoles and lacunae that is the beginning tively more common than in other tendons in orders is paratendonitis, which is often mistak-
of an interstitial tear. Patients with mucoid the body [42]. Therefore, not only is ossifica- enly termed tendonitis [44] (Figs. 3 and 12).
degeneration may have a tear at first clinical tion distinct from calcification because of the This stage is analogous to synovitis in sheathed
presentation because earlier episodes were presence of cortical bone and trabeculae, but it tendons. On T2-weighted MR sequences, para-
asymptomatic. may represent a different degenerative path- tendonitis appears as partially circumferential
Tenolipomatosis is the most age-dependent way than calcification. high signal around the Achilles tendon. Fat sup-
type of tendon degeneration. Tenolipomatosis
occurs with fatty deposits between normal
tenocytes [38]. Because the tenocytes are nor-
mal, lipoid degeneration does not seem to af-
fect the structural properties of the Achilles
[39] and does not predispose the tendon to tear
[40]. This disorder, like hypoxic degeneration,
is often clinically silent and is related to, but
distinct from, tendinous xanthoma. Xantho-
mas are the result of lipomatosis seen in inher-
ited metabolic diseases such as type 2 and type
3 hyperlipoproteinemias and cerebrotendinous
xanthomatosis [41]. Although severe forms of
these metabolic disorders are rare, one diagnos-
tic criterion for familial hyperlipoproteinemia
is focal thickening of the Achilles tendon on
imaging [42]. Xanthomas can mimic hypoxic
Achilles tendonitis or various rheumatologic
conditions, with diffuse tendon thickening and,
often, quite subtle internal signal.
Calcifying tendonopathy is rare in the
Achilles tendon, seen in only 3% of ruptured Fig. 12.47-year-old male runner with peritendonitis. Fig. 13.45-year-old man with acute Achilles ten-
tendons [43]. This dystrophic calcification Axial T2-weighted fat-suppressed MR image (TR/TE, donitis. Fat-suppressed MR image (TR/TE, 6000/80)
may progress to Achilles ossification [41] 4000/78) shows thin rim of partially circumferential shows edema in fat anterior to Achilles tendon
high signal (arrows ), which represents mild periten- (arrows ).
(Fig. 11). On a macroscopic level in the donitis. Background mucoid degeneration within ten-
Achilles, tendon ossification occurs more fre- don and intratendon signal can be seen.

AJR:175, September 2000 617


pression is usually necessary to visualize this
high signal. The high signal is not as bright as
synovial fluid because the paratendon is not
made of a synovial membrane. The external
margins of the signal are typically slightly ill
defined, and the high signal predominates
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posteriorly and extends medially up to three
quarters around the tendon. In isolated paraten-
donitis, the tendon itself is normal. True acute
tendonitis is an infrequent entity and is an even
less frequent entity to be imaged. Most clinical
cases of tendonitis are either paratendonitis or an
exacerbation of hypoxic tendonosis. True ten-
donitis, if imaged, occasionally appears as edema
not only in the paratendon but also in Kagers fat
pad anterior to the Achilles tendon [45] (Fig. 13).
The spectrum of tears ranges from mi-
crotears to interstitial tears (parallel to the
14
16
618
Schweitzer and Karasick
long axis of the Achilles), to partial tears, and
eventually to complete tears [46]. This abrupt
demarcation between tears and nontears is
misleading because there is a junctional entity,
mucoid degeneration [35]. In mucoid degen-
eration, the vacuoles may coalesce into an in-
terstitial tear [36]; also, in tendonosis perhaps
the inciting event is a microtear [47]. Lastly,
many cases of tendonosis are treated identi-
cally to cases of interstitial tears with dbride-
ment of the degenerative center of the tendon
and oversewing of the preserved peripheral
aspects of the tendon [48].
Almost all tears, interstitial (Figs. 14 and
15), partial (Figs. 16 and 17), or complete
(Figs. 18 and 19) show high signal on T2-
weighted imaging [49]. Tendon-end retraction
can also be seen occasionally in acute tears
17
[50]. Because one of the treatments for an
Achilles tendon tear is casting in plantar flexion,
sagittal images can be obtained after casting. If
the tendon edges are not opposed in this posi-
tion, the treatment will be unsuccessful [48].
Achilles tendon tears can also occur
abruptly without a definite history of overuse
[45]. In some patients, MR images show evi-
dence of mucoid (silent) degeneration but not
of interstitial tear, and in a smaller number of
these patients, MR images show chronic ten-
donosis related to hypoxic degeneration [51]
or no evidence of degeneration at all.
With chronic Achilles tendon tears not only
are the tendon edges retracted from each other,
but there is ongoing atrophy of the Achilles ten-
don fibers and, to a greater and more mechani-
cally important degree, of muscle [52]. Muscle
Fig. 14.45-year-old man with inter-
stitial tear. Sagittal short tau inver-
sion recovery image (TR/TE, 4000/48;
inversion time, 150 msec) shows
multiple longitudinal lines (arrows )
inside thickened Achilles tendon
consistent with interstitial tear.
Fig. 15.58-year-old male runner with
interstitial tear. Sagittal short tau inver-
sion recovery image (TR/TE, 4000/48;
inversion time, 150 msec) shows longi-
tudinal area (arrowheads ) inside distal
Achilles tendon consistent with inser-
tional interstitial tear. Small amount of
reactive marrow edema (straight
arrow ) is seen in calcaneus as well as
excessive retrocalcaneal bursitis
(curved arrow ).
15
Fig. 16.58-year-old woman with partial Achilles tendon
tear. Sagittal T2-weighted MR image (TR/TE, 6000/80)
shows partial posterior Achilles tendon tear (black
arrow ). Longitudinal interstitial tear (white arrows ) and
evidence of underlying hypoxic degeneration with thick-
ened tendon can also be seen.
Fig. 17.25-year-old male runner with partial Achilles
tendon tear. Axial T1-weighted fat-suppressed MR im-
age (TR/TE, 500/10) obtained after IV administration of
gadolinium shows focal enhancement in medial par-
tial Achilles tendon tear (arrow ).
AJR:175, September 2000
 MR Imaging of the Achilles Tendon

atrophy can be classified either as acute or sub-
acute and potentially reversible or as remote and
irreversible [53]. Acute atrophy manifests as dif-
fuse edema throughout the muscle belly [54]
(Fig. 20). A patient with acute atrophy has the
best prognosis after surgery. Irreversible atrophy
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quently have microscopic tears. We describe
some commonly used clinical terms and their
meanings in an attempt to develop a systematic
nomenclature (Table 1).
Associated Osseous Injuries and
This enthesophyte usually maintains normal
marrow signal on MR images. Occasionally,
these enthesophytes show evidence of marrow
edema on MR imaging (Fig. 21). In this situa-
tion, the enthesophyte may be acutely symp-
tomatic. These edematous spurs are the types of

appears as a fatty infiltrated or fatty marbled Abnormalities enthesophytes that respond best to focal surgical
muscle [55]. A small muscle may have under- The most common associated osseous abnor- resection. Rarely, an enthesophyte can also cause
gone either reversible or irreversible atrophy [56]. mality in Achilles disorders is an enthesophyte at pain as the spur grows past the protective margin
In disorders of the Achilles, atrophy occurs the insertion of the Achilles into the calcaneus. of the retrocalcaneal bursa.
first in the soleus because of the predominance
of slow-twitch fibers. Because the soleus mus-
cle is part of the Achilles tendon, soleus atrophy TABLE 1 Clinical, Histologic, and MR Imaging Finding in Achilles Disorders
can be thought of as a predictor of a dysfunc- Clinical Findings Histologic Findings MR Imaging Findings
tional myotendinous unit. Therefore, when im-
aging the Achilles tendon, sagittal images Tendonitis Paratendonitis Partially circumferential high signal
should include at least 3 cm of the distal soleus Acute tendonitis Paratendonitis Partially circumferential high signal
belly to reveal whether soleus fatty infiltration is Hypoxic degeneration Thick black tendon
present. Occasionally, gastrocnemius muscle at- Rarely true tendonitis Edema of Kagers fat pad
rophy can be seen, but atropy of this muscle is Insertional tendonitis Microscopic tear Multiple thin distal longitudinal lines on
rare even in remote Achilles tendon tears. T2-weighted images
Ca++ and ossification Intratendon ossification
Enthesopathy Posterior calcaneal enthesophytes
Nomenclature Chronic tendonitis or Hypoxic degeneration Thickened tendon with flat or convex
One difficulty in interpreting images of tendonosis anterior margin and little internal signal
Achilles tendon disorders is the inconsistent Silent tendonitis Mucoid degeneration Intratendon signal that becomes more focal
use of nomenclature in imaging and clinical ar- on T2-weighted images but has
ticles. Clinically, there is an abrupt demarcation interrupted appearance on sagittal
between tendon disorders in which the tendon images
is overtly torn versus those in which it is not Spontaneous Achilles tear Interstitial tears (coalescent Longitudinal
[57]. This demarcation, although useful in tri- mucoid vacuoles) Noninterrupted high signal on T2-weighted
images
aging patients for surgery, is arbitrary and inac-
curate. Mucoid degeneration can mimic a tear Chronic tear Hypoxic degeneration and tear Horizontal disruption with a thickened
tendon
clinically, and silent Achilles disorders fre-

Fig. 18.58-year-old woman with sponta-
neous Achilles tendon tear. Sagittal T2-
weighted MR image (TR/TE, 7000/90) shows
complete Achilles tendon tear (arrows ) in
typical location: 5 cm from its insertion. Gap
is approximately 1 cm.
Fig. 19.50-year-old man with spontaneous Achilles tendon
tear. Sagittal short tau inversion recovery image (TR/TE, 4000/48;
inversion time, 150 msec) shows completely avulsed Achilles
tendon (arrow ) with significant gap because proximal fibers
have been retracted. Fluid can be seen within gap.
Fig. 20.45-year-old man with acute Achilles tendon
tear and atrophy. Axial short tau inversion recovery
image (TR/TE, 6000/58; inversion time, 150 msec)
shows evidence of edema within soleus muscle
(arrows ), which is consistent with acute atrophy.

AJR:175, September 2000 619


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A B
Tendon ossification predominates distally in
the tendon, appearing as focal fatty marrow. This
calcification is related to insertional enthesopa-
thy [58]. However, true Achilles enthesopathy
occurs at the edge of rather than within the ten-
don. This dystrophic ossification may have the
appearance of a broken enthesophyte, although
enthesophytes are not related to the Achilles dis-
orders. Distal ossification appearing as a broken
enthesophyte is thought to be the result of partial
insertion tears [59]. Whether ossification also in-
creases the risk of Achilles tears or is merely the
result of prior partial tears is unclear. Although
proximal ossification may present as a mass,
most patients provide a history of repetitive run-
ning-related tendonitis [60].
Somewhat more common than proximal os-
sification is marrow edema around the entheso-
phyte in response to inflammatory retrocalcaneal
bursitis or as a degenerative cystic phenomenon
[61] (Fig. 22). The marrow edema caused by
retrocalcaneal bursitis is seen at the calcaneal
margin of an enlarged bursa. The degenerative
edema is often cystic or has a cyst within it, is
620
Schweitzer and Karasick
A B
located at the inferiormost aspect of the Achilles
insertion, and is well defined.
In addition, calcaneal edema can also be a
response to altered mechanics [62]. This reac-
tive marrow edema, although seen in several
ankle tendon disorders, is less commonly re-
lated to Achilles disorders (Fig. 23). If present,
this calcaneal response to altered mechanics is
seen anterior to the Achilles insertion.
An associated osseous injury to the calcaneus
occurs in Achilles disorders as well [63]. This
microavulsion injury is similar to changes seen in
the elbow with epicondylitis or in the knee with
medial collateral ligament tears [58, 64], but this
injury may occur in Achilles disorders other than
tears. It is often difficult to differentiate the types
of calcaneal marrow edema (Fig. 23).
Another consideration in the differential
diagnosis of calcaneal marrow edema is
stress fracture [65]. Typically, stress fractures
occur several millimeters anterior to the pos-
terior aspect of the calcaneus, do not occur
posterior at the Achilles insertion, and are
vertically oriented.
Fig. 21.48-year-old man with
symptomatic spur.
A and B, Sagittal T1-weighted (TR/
TE, 600/12) (A) and short tau inver-
sion recovery (TR/TE, 6000/40; inver-
sion time, 150 msec) (B) MR images
show subtle edema in posterior cal-
caneal spur (arrows ).
Fig. 22.49-year-old man with de-
generative cyst.
A and B, Sagittal T1-weighted (TR/TE,
600/12) (A) and short tau inversion re-
covery (6000/40; inversion time, 150
msec) (B) MR images show degenera-
tive cyst at posterior calcaneus (ar-
rows) adjacent to thickened Achilles
tendon insertion. Small amount of reac-
tive edema can be seen around cyst.
Fig. 23.60-year-old man with acute Achilles ten-
donitis clinically. Sagittal short tau inversion recovery
image (TR/TE, 4500/48; inversion time, 150 msec)
shows edema (curved arrows ) in Kagers fat pad an-
terior to Achilles tendon, which is consistent with
acute Achilles tendonitis. Extensive reactive marrow
edema (straight arrows ) can also be seen.
One final differential diagnosis to consider is
residual red marrow. Residual red marrow may
be bright, closely mimicking marrow edema,
AJR:175, September 2000
 MR Imaging of the Achilles Tendon

on fat-suppressed T2-weighted or short tau in-
version recovery images [66]. Residual red
marrow in the calcaneus occurs in children and
adolescents but rarely persists in adults. Resid-
ual red marrow has a typical location superi-
orlyjust posterior to the posterior facet of the
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Atypical Achilles Tears
Although most Achilles tears occur 26
cm from the insertion, Achilles tears can be
seen in two other locations: distally and
proximally. Distal tears occur as a result ei-
ther of severe end-stage pump-bump, with
high percentage of fast-twitch fibers [56],
which is the reason the gastrocnemius is af-
fected but the soleus is not.
On axial images, myotendinous junction
tears are manifested as focal fluid at the muscu-
lotendinous junction of the Achilles tendon.

calcaneusand does not closely approach the
Achilles insertion. Most important, this entity
is usually multifocal in the foot. If necessary,
in-phase and out-of-phase imaging can confirm
the diagnosis of red marrow.
Insertional Tendonitis
Insertional Achilles tendonitis is an impor-
tant subtype of injury that is common in run-
ners and frequently leads to the development
of an enthesophyte. Insertional Achilles ten-
donitis may be the only true form of acute
Achilles tendonitis. On MR imaging, the
Achilles is thickened distally with vaguely
seen ill-defined longitudinal high signal (Figs.
2426). This signal may be fairly intense and
can mimic a partial tear, albeit fairly distally.
attritional tendon tearing caused by shoe fric-
tion, or of inappropriately treated or severe
insertional tendonitis.
More common than an insertional tear, a
proximal Achilles tear is, in reality, a musculo-
tendinous junction injury. This strain injury is
listed in the differential diagnosis for tennis
leg [67]. Proximal Achilles tears typically in-
volve the medial head of the gastrocnemius, are
twice as common in males as in females, usu-
ally involve the dominant leg, and occur in pa-
tients ranging in age from 23 to 57 years [68]
(Figs. 2729). The most common risk factor is
participation in sports such as football, tennis,
and squash [69]. Like all muscle strain injuries,
the muscles at highest risk are those that cross
two joints, function eccentrically, and have a
Fluid follows the distal margins of the muscle
belly. On coronal images, tears have a U ap-
pearance because the fluid dissects down along
the fascial plane of a distal muscle belly of the
gastrocnemius. The tear may be complete with
focal absence of the tendon at a specific level
or, more commonly, the tear is partial. Incom-
plete tear or edema from muscle strain occurs
focally in the center of the muscle.
Adjacent edema can be seen in the muscle
as a component of the strain injury or as a
manifestation of acute atrophy. Although the
medial head of the gastrocnemius is usually
involved, the resulting atrophy can affect
both heads because they act in concert [69].
In these circumstances, whether an adja-
cent hematoma (Fig. 29) is present should be

Fig. 24.50-year-old male runner

with insertional tendonitis.
A and B, Sagittal short tau inversion re-
covery (TR/TE, 6000/48; inversion time,
150 msec) (A) and axial T2-weighted
fat-suppressed (TR/TE, 7000/80) (B)
MR images show slightly thickened
distal Achilles tendon with distal inser-
tional signal (open arrow, A; short ar-
row, B) that is relatively high signal on
fat suppressed image. Excessive ret-
rocalcaneal bursitis (solid arrow, A)
and peritendonitis (long arrows, B)
can also be seen.

A B
Fig. 25.60-year-old woman with insertional tendoni-
tis. Sagittal short tau inversion recovery image (TR/TE,
4000/52; inversion time, 150 msec) shows internal sig-
nal linearly oriented in Achilles tendon (arrow ). If this
finding were in more proximal location, it would be
consistent with tear, but at insertion tendonitis often
mimics partial tears on MR imaging.

Fig. 26.48-year-old male runner with distal tendoni-

tis. Axial fast spin-echo MR image (TR/TE, 6000/80)
shows extensive retrocalcaneal bursitis (solid arrow )
with linear thick signal within Achilles tendon (open
arrow ) representing insertional tendonitis.
25 26

AJR:175, September 2000 621

 Schweitzer and Karasick
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Fig. 27.38-year-old woman with medial gastrocnemius tear. Fig. 28.47-year-old man Fig. 29.53-year-old woman with proximal Achilles tear. Axial fast spin-
Axial fast spin-echo MR image (TR/TE, 6000/85) shows com- with partial proximal echo MR image (TR/TE, 6000/70) shows partial tear (curved arrow ) of me-
plete tear of medial gastrocnemius myotendinous junction Achilles tear. Sagittal short dial head of gastrocnemius with associated hematoma (straight arrows ).
filled with fluid (arrows ). tau inversion recovery Clinically, this finding is often termed proximal Achilles tear.
image (TR/TE, 6000/40; in-
version time, 150 msec)
shows edema (arrows) at
myotendinous junction of
medial head of gastroc-
nemius with U-shaped
dissecting fluid.

Fig. 30.49-year-old woman with
plantaris tendon tear. Sagittal short
tau inversion recovery image (TR/
TE, 6000/78; inversion time, 150
msec) shows edema anterior to
gastrocnemius caused by plantaris
tear (arrows ).
Fig. 31.58-year-old man with plantaris tendon tear. Axial fast spin-echo MR
image (TR/TE, 7000/85) shows retracted plantaris filled with fluid (arrows ) be-
tween gastrocnemius (G) and soleus (S) muscles.
Fig. 32.55-year-old man with plantaris tendon
tear. Sagittal short tau inversion recovery im-
age (TR/TE, 7000/55; inversion time, 150 msec)
shows line of fluid (arrows ) just between gas-
trocnemius and soleus muscles.

622 AJR:175, September 2000

 MR Imaging of the Achilles Tendon

Fig. 33.53-year-old woman with

Haglunds disease.
A and B, Sagittal T1-weighted (A) and
sagittal T2-weighted fat-suppressed
short tau inversion recovery (B) MR
images (TR/TE, 600/12) show soft-tis-
sue signal displacing fat posterior to
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thickened Achilles tendon consistent

with retro-Achilles bursitis (open ar-
row, B). Ill-defined fluid can be seen in
retrocalcaneal bursa, which is consis-
tent with retrocalcaneal bursitis
(curved arrows ). Edema in enlarged
tuberosity (straight arrows ) is seen as
well. All these findings are suggestive
of Haglunds disease.

A B

noted. A hematoma is a frequent sequela of Fig. 34.48-year-old woman with

muscle injury. Clinically, hematomas are
evacuated [70]. Complete myotendinous
junction tears are also treated surgically, but
partial proximal myelotendinous junction
tears are treated conservatively [68].
Plantar Muscle Injury
The symptoms of a ruptured plantaris tendon
have been described with specific sports (e.g.,
tennis leg). The tendon can tear when force-
fully contracted, resulting in the patient feeling
a pop in the calf [71]. Sudden dorsiflexion of
the ankle with the knee in extension has been
implicated as the mechanism for this injury. The
symptoms consist of calf pain followed by me-
dial swelling. Clinically, this condition needs to
be differentiated from Achilles tendon injuries
and medial gastrocnemius muscle injuries.
Clinically, the torn plantaris is considered a less
severe injury than gastrocnemius muscle tears
and is conservatively treated with ice, rest, and
antiinflammatory medications [72].
On T2-weighted MR imaging, plantaris in-
jury shows high signal cephalad to the location
of typical gastrocnemius injury. The fluid tends
to dissect medially and proximally to the bulk
of the soleus muscle (Figs. 3032).
Haglunds Disease
Haglunds disease is frequently associated
with pump-style shoes. More important than
the shoe style is the presence of a stiff-heel
counter, which compresses the retro-Achilles
bursa against the posterior lateral calcaneal
prominence [73]. The calcaneal tuberosity may
focally enlarge in response to chronic irritation
Haglunds disease. Sagittal short tau
inversion recovery image (TR/TE,
6000/48; inversion time, 150 msec)
shows edema in calcaneal tuberos-
ity (arrow ) and enlarged tuberosity.
In addition, Achilles tendon is chron-
ically thickened without evidence of
internal signal. Hypertrophy of cal-
caneal tubercle is shown its projec-
tion above parallel pitch lines
(dashed lines).
[74]. This enlargement further irritates the retro- level of the posterior lip of the subtalar articu-
Achilles bursa and the Achilles tendon, which lar facet. In Haglunds disease, a portion of
increases the irritation that causes further enlarge- the tuberosity is seen above the upper pitch
ment of the tuberosity. This results in a cycle of line [76] (Fig. 34).
injury, response to injury, and reinjury [75].
In patients with Haglunds disease, MR
images reveal excessive fluid in the retrocal- Conclusion
caneal bursa, fluid in the retro-Achilles MR imaging can provide important infor-
bursa, and an enlarged calcaneal tuberosity mation about the pathologic state of the
(Figs. 33 and 34). Achilles tendon, and these imaging findings
The diagnosis of an enlarged calcaneal tu- can provide information that is useful in pa-
berosity (or of a bursal projection) is made by tient treatment.
drawing parallel pitch lines on the upper and
lower aspects on the calcaneus on sagittal im-
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