Achilles Tendon – Ultrasound Imaging

Achilles tendonois or Tendinitis?
There’s a huge amount of information on the ‘net about Achilles Tendonitis but you need to know for sure whether you have got inflamation (which is “-itis”) or the longer lasting, harder to treat “tendinosis”; these two conditions feel pretty similar but they’re managed very differently. You need an expert!!

When patients present with any Achilles tendon complaint, David usually completes his usual physiotherapy assessment with a dynamic ultrasound scan, comparing the affected tendon with the ‘normal’ one.
In tendinosis the tendon feels thickened and tender to palpation, and loses some of its pliability; an ultrasound scan shows this thickening very clearly, especially when compared with the unaffected side. The condition is one of tendon overgrowth
(In ladies, the Achilles tendon is usually 3mm to 4mm thick; in males, it is usually 4mm to 5mm. This can double in tendonosis.)

This longitudinal scan shows a significantly enlarged achilles tendon in the right frame, with a more normal sized tendon on the left

This transverse scan shows a significantly enlarged achilles tendon in the right frame, with a more normal sized tendon on the left

However, when tendonitis is present, much less enlargement occurs because the condition is one of inflammation; the edges of the tendon can appear darker (hypo-echoic)

(Occasionally, we may see irregularities in the tendon structure, in which case we refer back to the GP for formal scanning and reporting. If there is no tear, we can proceed with vigorous remedial exercise protocols.)

Repeat scans:
We will often repeat a scan during a course of treatment, in order to compare record any changes. Since our clinical records are digital, we can embed a detailed image of each scan into the patients notes.

As tendonitis settles, responding to rest, ice, stretching and a gradual return to exercise, the ‘darkness’ (hypo-echoicity) reduces.
In tendonosis, the patients respond well to a graded exercise scheme called “eccentric exercises”; they begin to report less pain & stiffness early in the mornings and less discomfort on exercise. However, on rescanning, we often find that the tendon size has not reduced- occasionally, it has enlarged further.
This is thought to be because the condition is not an inflammatory one, but one of overgrowth. Patients can be disappointed when the tendon still seems to be thick and lumpy but we can reassure them that it is a normal part of the condition.
What is really great is that 80% of patients with this chronic problem respond very well to our treatment protocol, returning to normal daily activity and sport (even when they’ve had problems for many months).

David is not a qualified sonographer. However like many physiotherapists in musculo-skeletal practice, he has received basic training in the use of ultrasound imaging equipment and uses it to confirm his assessment findings and measure progress in recovery from certain injuries.