Achilles tendon complex: The anatomy of its insertional footprint on the calcaneus and clinical implications

Mahan, Jared; Damodar, Dhanur; Trapana, Evan J.; Barnhill, Spencer; Nuño, Ane Ugarte; Smyth, Niall A.; Aiyer, Amiethab; Jose, Jean

doi:10.1016/j.jor.2019.06.008

Cited by 25 publications

(23 citation statements)

References 21 publications

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“…In general, for surgical reconstruction it has to be considered that the Achilles tendon is formed by the confluence of the tendons of the soleus and both gastrocnemius muscles. These subtendons intertwine and twist towards their distal insertion and have a specific arrangement in the midportion and the insertion of the calcaneus [ 5 , 17 ]. Based on the anatomic region within the tendon, partial ruptures might be assigned to the specific subtendon, which might lead to an isolated partial hypotrophy of the gastrocsoleus muscle complex with reduced voluntary electromyography activity [ 17 ].…”

Section: Resultsmentioning

confidence: 99%

“…These subtendons intertwine and twist towards their distal insertion and have a specific arrangement in the midportion and the insertion of the calcaneus [ 5 , 17 ]. Based on the anatomic region within the tendon, partial ruptures might be assigned to the specific subtendon, which might lead to an isolated partial hypotrophy of the gastrocsoleus muscle complex with reduced voluntary electromyography activity [ 17 ]. Partial tears mostly occur in the posterior mid-tendon 3–4 cm above the superior calcaneus, whereas a further study demonstrated that intratendinous tears are mostly anterior and medial, which mostly present fibers of the soleus and lateral gastrocnemius components [ 8 , 18 , 19 ].…”

Section: Resultsmentioning

confidence: 99%

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Partial Achilles Tendon Rupture—A Neglected Entity: A Narrative Literature Review on Diagnostics and Treatment Options

Gatz

Spang

Alfredson

2020

JCM

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Partial ruptures in the Achilles tendon are rather uncommon and are often misinterpreted as aggravated Achilles tendinopathy, and not always considered as a differential diagnosis. The aim of this literature review was to characterize typical symptoms, to provide an overview of available diagnosis and treatment options, and to give reference points for future research. There were few studies and sparse knowledge of scientific value, making it difficult to give evidence-based recommendations. Based on the few studies and the authors’ clinical experience, a diagnosis should be based on a patient’s history with a typical sharp onset of pain and inability to fully load the tendon. Previous intratendinous cortisone injections might be present. Clinical findings are a localized tender region in the tendon and often weakness during heel raises. Ultrasound and Doppler examinations show a region with an irregular and bulging superficial tendon line, often together with localized high blood flow. Magnetic resonance Imaging (MRI) shows a hyperintense signal in the tendon on T1 and T2-weighted sequences. First-line therapy should be a conservative approach using a 2 cm heel lift for the first 6 weeks and avoiding tendon stretching (for 12 weeks). This is followed by a reduced heel lift of 1 cm and progressive tendon loading at weeks 7–12. After 12 weeks, the heel lift can be removed if pain-free, and the patient can gradually start eccentric exercises lowering the heel below floor level and gradually returning to previous sport level. If conservative management has a poor effect, surgical exploration and the excision of the partial rupture and suturing is required. Augmentation procedures or anchor applications might be useful for partial ruptures in the Achilles insertion, but this depends on the size and exact location. After surgery, the 12 to 14-week rehabilitation program used in conservative management can be recommended before the patient’s return to full tendon loading activities.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Partial Achilles Tendon Rupture—A Neglected Entity: A Narrative Literature Review on Diagnostics and Treatment Options

Gatz

Spang

Alfredson

2020

JCM

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“…No large-scale MRI studies such as this have been previously reported. We studied the Achilles tendon between the lower outline of the soleus muscle belly to the level of the calcaneal tuber, which includes the zone where tendinopathy and ruptures most often occur 2 , 8 , 22 . Active tracking of the subtendons from the myotendinous junction, distal to the calcaneus, showed the same twisted structure of the Achilles tendon as revealed previously 5 , 10 , 17 , 18 , 20 , 23 .…”

Section: Discussionmentioning

confidence: 99%

“…retrocalcaneal bursitis or Haglund deformity. This area is also quite sensitive to partial injuries causing isolated laxity of the tendon 22 . The largely uniform structure of the Achilles tendon is only apparent because the nonuniform function of the Achilles tendon occurs during movement and exercise 23 and internal tendon tears are longitudinal in direction 24 .…”

Section: Side and Gender Value S-mgc S-lgc S-solmentioning

confidence: 99%

Distribution of the subtendons in the midportion of the Achilles tendon revealed in vivo on MRI

Szaro

Ramirez

Borkmann

et al. 2020

Sci Rep

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The aim of the study was to check if the subtendons of the Achilles tendon can be identified in vivo on MRI in the midportion of the tendon. The relation of the plantaris tendon to the Achilles tendon was also examined. A retrospective study of 200 MRI of ankle joints including the Achilles tendon was conducted. Statistical analysis of the correlation between the possibility of identifying the subtendons and the side, gender, presence of the central soleus tendon and plantaris tendon variation was performed. The inter-observer agreement between two reviewers in their evaluation of the subtendons was assessed using kappa statistics. The subtendon from the lateral head of the gastrocnemius muscle was identified in 65% (k = 0.63) and was located in the anterior part of the Achilles tendon. The subtendon from the soleus muscle was recognized in 12% (k = 0.75) comprising anterior part of the tendon. In 6% the subtendon from the medial head of the gastrocnemius muscle was identified (k = 0.58). The central soleus tendon was identified in 85% of cases. Statistical analysis shows the weak correlation of the presence of the central soleus tendon and the possibility of identifying the subtendon from the soleus muscle. The plantaris tendon was directly related to the insertion of the Achilles tendon in 42.5%. Identification of the subtendons of the Achilles tendon on MRI is challenging, and most often it is only possible to find the subtendon of the lateral head of the gastrocnemius muscle.

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“…Since the recognition and reporting of subtendons, there has been a surge in tendon and subtendon research, including imaging (Handsfield et al, 2017 ; Clark and Franz, 2020 ), computational modeling (Handsfield et al, 2017 ; Shim et al, 2018 ), anatomical dissection (Pekala et al, 2017 ; Mahan et al, 2020 ), and experimental approaches (Finni et al, 2018 ; Maas et al, 2020 ). Structurally, the subtendons display an internal torsion or twisting, which can be seen by the naked eye by observing the trajectory of collagen fascicles within the Achilles (White, 1943 ; van Gils et al, 1996 ).…”

Section: Introductionmentioning

confidence: 99%

Achilles Subtendon Structure and Behavior as Evidenced From Tendon Imaging and Computational Modeling

Handsfield

Greiner

Madl

et al. 2020

Front. Sports Act. Living

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The Achilles tendon is the largest and strongest tendon in the human body and is essential for storing elastic energy and positioning the foot for walking and running. Recent research into Achilles tendon anatomy and mechanics has revealed the importance of the Achilles subtendons, which are unique and semi-independent structures arising from each of the three muscular heads of the triceps surae. Of particular importance is the ability for the subtendons to slide, the role that this has in healthy tendons, and the alteration of this property in aging and disease. In this work, we discuss technical approaches that have led to the current understanding of Achilles subtendons, particularly imaging and computational modeling. We introduce a 3D geometrical model of the Achilles subtendons, built from dual-echo UTE MRI. We revisit and discuss computational models of Achilles subtendon twisting suggesting that optimal twist reduces both rupture loads and stress concentrations by distributing stresses. Second harmonic generation imaging shows collagenous subtendons within a rabbit Achilles tendon; a clear absence of signal between the subtendons indicates an inter-subtendon region on the order of 30 μm in our rabbit animal model. Entry of wheat germ agglutinin in both the inter-fascicular and the inter-subtendon regions suggests a glycoprotein-containing inter-subtendon matrix which may facilitate low friction sliding of the subtendons in healthy mammals. Lastly, we present a new computational model coupled with human exercise trials to demonstrate the magnitude of Achilles subtendon sliding which occurs during rehabilitation exercises for Achilles tendinopathy, and shows that specific exercise can maximize subtendon sliding and interface strains, without maximizing subtendon strains. This work demonstrates the value of imaging and computational modeling for probing tendon structure-function relationships and may serve to inform and develop treatments for Achilles tendinopathy.

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Achilles tendon complex: The anatomy of its insertional footprint on the calcaneus and clinical implications

Cited by 25 publications

References 21 publications

Partial Achilles Tendon Rupture—A Neglected Entity: A Narrative Literature Review on Diagnostics and Treatment Options

Partial Achilles Tendon Rupture—A Neglected Entity: A Narrative Literature Review on Diagnostics and Treatment Options

Distribution of the subtendons in the midportion of the Achilles tendon revealed in vivo on MRI

Achilles Subtendon Structure and Behavior as Evidenced From Tendon Imaging and Computational Modeling

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