Background
Anatomy
The Achilles tendon is a tendon on the back of the lower leg and the largest, thickest and strongest tendon in the body[1]. The Achilles tendon is a conjoint aponeurosis and connects the plantaris, gastrocnemius and the soleus muscles and is attached to the calcaneus[2]. Therefore the Achilles tendon is also known as calcaneus tendon or calf tendon. The Achilles tendon causes plantar flexion and is used during activities such as walking, jumping and other movements where plantar flexion is required. The Achilles tendon plays an important role in the biomechanics of the lower extremity and can withstand great forces[1].
A double-layered connective tissue membrane, called the paratenon, covers the Achilles tendon. It is vascularized
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The fibers withstand forces and stretch linear, if the foot is not pronated or supinated[4].
Figure 2 Gait cycle
Terminology
Achilles tendinopathy is a practical problem where pain-induced limitation in sports and related activities is reported; there is usually no restriction in normal daily activities[5].
‘Achilles Tendinopathy’ is a label for a clinical syndrome, characterized by a combination of pain, swelling and impaired performance[5][6].
Achilles tendinopathy is divided in the next 3 subjects:
- Insertional: the insertion site of the Achilles tendon is onto the calcaneal bone. Patients with IAT (insertional Achilles tendinopathy) complain about pain, stiffness and sometimes a (solid) swelling which can be visible at clinical examination.[6]
- Midportion: the midportion is located 2-6cm 1,3 from the insertion onto the calcaneus, this is also called the ‘main body of the Achilles tendon’. Patients present with a combination of pain and (diffuse or localized) swelling.[6]
- Paratenon: a thin membrane covers the Achilles tendon. Patients present with exercise-induced pain and local swelling around the midportion Achilles
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Clinical differentiation between the causes of the pain can be difficult but it is important because this will affect treatment and rehabilitation.[2]
Diagnostic imaging is a tool after medical history and physical examination took place. Therefore, diagnostic imaging is said to be a high specific tool to determine the origin of the symptoms. Treatment is not only based upon diagnostic imaging. The decision for next clinical steps is based upon a combination of medical history, physical examination and imaging. US is often performed in primary care physicians while (xero)radiography, CT and MRI is maintained for secondary care.[2][11]
Radiography is reserved for the evaluation of the bones. Bones contain calcium that absorbs the X-ray because of the high atomic number and soft tissues don’t. The X-ray shows tissues with a high atomic number as white and non-absorbed tissues give a black picture. Therefore, plain radiography can also demonstrate ossification or calcification in tendons[2]. Xeroradiography is a precursor of nowadays radiography where a photo was made on