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70 Intratendinous Tears Of The Achilles Tendon – A New Pathology? Analysis Of A Large 4 Year Cohort
  1. Sarah Morton1,
  2. Otto Chan2,
  3. Mel Pritchard2,
  4. Tina Parkes1,
  5. Peter Malliaras1,
  6. Nicola Maffulli2,
  7. Tom Crisp1,2,
  8. Nat Padhiar1,2,
  9. John King1,2,
  10. Dylan Morrissey1,2
  1. 1Centre for Sports and Exercise Medicine, William Harvey Research Institute, Queen Mary University of London, Mile End Hospital, Bancroft Road, London, E1 4DG, UK
  2. 2BMI London Independent Hospital, 1 Beaumont Square, Stepney Green, London, E1 4NL, UK

Abstract

Introduction The two main intra-tendinous pathologies reported are Achilles tendinopathy and Achilles rupture.1 Recent observations at one specialist sports medicine centre suggests an additional pathology should be considered in the list of differentials for Achillodynia: the intratendinous tear (ITT). This study therefore aims to report the findings of intratendinous tears diagnosed over a four-year period including ultrasound (US) findings, clinical symptoms and its relationships to other Achilles pathologies.

Methods The US reports and images of all patients who attended for Achilles tendon US scans for presumed Achilles tendinopathy (AT) between July 2008 and September 2012 were reviewed. All US scanning had been carried out by one specialist MSK consultant radiologist using the same US scanner throughout. Subjects were categorised into six groups based on US findings: no pathology, mid-tendon AT, insertional AT, partial tears, Achilles rupture and ITT. An ITT was defined as a clearly visualised echopoor area on US situated centrally in the tendon or extending to, but not through, the tendon periphery, with pain on palpation and no clinical findings consistent with Achilles rupture. Descriptive statistics were used to analyse differences between pathological sub-groups and images described qualitatively.

Results 5% (29 males, 8 females) of 740 patients had an ITT. Patients typically presented with a history of sudden onset localised pain and the ability to train but not reach maximal loading. Average age was 36.3 years (range 20–64), significantly lower than mid-tendon tendinopathy (8.48 years; p < 0.01); no pathology (5.81 years; p < 0.05) and full tear (11.74 years; p < 0.01). 92% had concurrent Achilles tendinopathy. Elite sports men were more highly represented in the ITT than mid-tendon tendinopathy groups (86.2% ITT group v 13.8% mid-tendon AT group; p < 0.01). 59% were oval tears and 41% were linear tears – see Figure 1 and 2 for images.

Abstract 70 Figure 1

A small 82 mm linear intratendinous tear (left) and large 156 mm linear intratendinous tear (right) within the tendon without disruption of the overall tendon shape

Abstract 70 Figure 2

A small 76 mm oval intratendinous tear (left) and large oval intratendinous tear (right)

Discussion ITTs should be actively searched for in patients with Achilles pathology, especially in elite male athletes with a history of high-impact pain. The diagnosis can be made based on a combination of clinical suspicion and characteristic US findings. There was a strong, but incomplete, association with mid-tendon tendinopathic presentation. Prospective research is warranted concerning diagnosis and management.

Reference Asplund, Best. BMJ. 2013;346:f1262

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