Intratendinous tears of the Achilles tendon - a new pathology? Analysis of a large 4 year cohort. Poster No.: C-1680 Congress: ECR 2014 Type: Scientific Exhibit Authors: S. Morton, T. Parkes, O. Chan, P. Malliaras, J. King, T. Crisp, N. Maffulli, D. Morrissey; London/UK Keywords: DOI: Tissue characterisation, Diagnostic procedure, Ultrasound, Musculoskeletal soft tissue 10.1594/ecr2014/C-1680 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 6
Aims and objectives The aim was to describe the presence of an additional pathology of the Achilles tendon: the intratendinous tear (ITT). This includes describing symptoms, ultrasound findings and co-presenting pathology for an ITT. Methods and materials Ultrasound (US) images and reports of Achilles tendons scanned for presumed Achilles tendinopathy between July 2008 and September 2012 were reviewed and characteristics noted. All US scanning of the Achilles tendons was carried out by one specialist MSK consultant radiologist (OC) at a specialist MSK centre using the same ultrasound scanner throughout (Elegra; Siemens, Erlangen Germany). A 13 MHz transducer was used along with power Doppler imaging. The radiologist was not blinded to the side of the symptoms. The subjects were positioned sitting with their hips flexed and externally rotated, their knees in 90 flexion and their ankles in a neutral position. Longitudinal and transverse static and video images were obtained. The shape of the Achilles tendon was recorded as either parallel or spindle shaped. The antero-posterior tendon diameter was measured at the thickest point. [1] Neovascularisation was graded using the Modified Ohberg scale, known to be weakly related to the clinical severity of Achilles tendinopathy. [2,3] The combination of the tendon diameter and neovascularisation was used for the sonographic diagnosis of Achilles tendinopathy. The pathologies recorded were: no pathology present on US, mid-tendon Achilles tendinopathy, insertional tendinopathy, partial tear ± tendinopathy, full tear/tendon rupture and intratendinous tear ± tendinopathy. An intratendinous tear was defined as: a clearly visualised echo-poor area on ultrasound situated centrally in the tendon or extending to the periphery, but not through the periphery of the tendon, with a positive ultrasound provocation test. If an intratendinous tear was observed descriptive data for the tear was recorded, including position in the tendon, shape of tear, size and direction of the tear and neovascularisation pattern at the ITT. Descriptive statistics were used to analyse the difference between pathological subgroups; images were described qualitatively. Results Page 2 of 6
5% (29 males, 8 females) of 740 patients were found to have an intratendinous tear (ITT). Only one bilateral ITT was reported. Patients typically presented with a history of sudden onset localised pain, with the ability to train but not reach maximal loading. The average age at presentation was 36.3 years for an ITT (range 20-64), with this being significantly lower than the mid-tendon tendinopathy pathology sub-group (8.48 years; p<0.01); the no pathology sub-group (5.81 years; p<0.05) and the full Achilles tear sub-group (11.74 years; p<0.01). 92% of subjects with an ITT had concurrent Achilles tendinopathy but had had no response to eccentric treatment (suggesting different management is required). Elite sports men were more highly represented in the ITT group than the mid-tendon tendinopathy group (86.2% ITT v 13.8% mid-tendon tendionpathy; p<0.01). The ultrasound images showed that 76% of ITTs were in the longitudinal direction. 59% of ITTs were oval in shape and 41% were linear. Images for this section: Fig. 1: Linear intratendinous tear on ultrasound Page 3 of 6
Fig. 2: Distal insertional oval intratendinous tear on ultrasound Page 4 of 6
Fig. 3: Figure 3: Power Doppler US of a linear ITT showing abnormal blood vessel supply to that area, which also corresponds to the area of maximum pain. Page 5 of 6
Conclusion Intratendinous tears should be actively searched for in patients with Achilles pathology, especially in elite male athletes with a history of high-impact related pain. A strong association with the presence of Achilles tendinopathy was observed, although it was not always present. Prospective research is warranted concerning the diagnosis and management of Achilles intratendinous tears. Personal information For any questions or additional information please contact Dr Dylan Morrissey: d.morrissey@qmul.ac.uk References 1. Fredberg U, Bolvig L, Andersen NT, et al. Ultrasonography in evaluation of Achilles and patella tendon thickness. Ultraschall Med 2008;29:60-65. 2. Ohberg L, Lorentzon R, Alfredson H. Neovascularisation in Achilles tendons with painful tendinosis but not in normal tendons: an ultrasonographic investigation. Knee Surg Sports Traumatol Arthrosc 2001;9:233-38. 3. Peers KHE, Brys PPM, Lysens RJJ. Correlation between power Doppler ultrasonography and clinical severity in Achilles tendinopathy. Int Orthop 2003;27:180-83. Page 6 of 6