30-year-old patient with right-sided mid-portion Achilles tendon pain. Clinically, there is a palpable local thickening of the Achilles tendon with tenderness on palpation. Ultrasound examination was performed of the right Achilles tendon, flexor hallucis longus tendon, talocrural joint, retrocalcaneal bursa, and calf muscles.
Ultrasound examination of the right Achilles tendon demonstrates moderate to severe degenerative mid-portion tendinopathy. The abnormality is localized predominantly to the medial 40% of the Achilles tendon.
The affected tendon region is clinically palpable as a local thickening and corresponds with the area of tenderness. Doppler examination demonstrates moderate to marked neovascularization within the tendinopathic region, supporting active chronic tendinopathic change.
There are no ultrasound signs of a partial or complete Achilles tendon rupture.
The Achilles tendon insertion has a normal anatomical appearance. The calcaneus and retrocalcaneal bursa also appear normal, without signs of insertional tendinopathy, calcaneal abnormality, or retrocalcaneal bursitis.
The remaining scanned structures, including the flexor hallucis longus tendon, talocrural joint region, and calf muscles, show no abnormalities.
1. Final diagnosis
Findings are consistent with moderate to severe right mid-portion Achilles tendinopathy, predominantly involving the medial 40% of the tendon, with clear Doppler neovascularization. No partial or complete Achilles tendon rupture is present.
2. Differential diagnosis
The differential diagnosis includes chronic degenerative mid-portion Achilles tendinopathy, focal intratendinous degeneration, paratenon-related pain, and less likely partial Achilles tendon tear. The absence of a discrete fiber defect or tendon discontinuity argues against rupture. There are no findings of insertional Achilles tendinopathy, retrocalcaneal bursitis, or calcaneal pathology.
3. Teaching points
Mid-portion Achilles tendinopathy typically occurs proximal to the calcaneal insertion and should be distinguished from insertional Achilles pathology. Doppler neovascularization may support active tendinopathic change, especially when it correlates with focal pain and palpable thickening. Ultrasound is useful for localizing the abnormal tendon region and excluding partial or complete rupture.
4. Injury/disease information
Mid-portion Achilles tendinopathy is a chronic degenerative tendon disorder characterized by tendon thickening, altered fibrillar structure, and sometimes increased Doppler signal. Symptoms often include localized pain, stiffness, tenderness, and reduced tolerance to loading. In this case, the pathology is medial rather than diffuse, while the tendon insertion, calcaneus, and retrocalcaneal bursa remain normal.
Marc is founder of, and trainer at, SonoSkills. SonoSkills is an organization dedicated to MSK ultrasound education. He's also an MSK Sonographer at EchoConsult in Roermond, the Netherlands.
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