Case 1 is a 54-year-old female who experienced right ankle pain after an injury, leading to the clinical suspicion of Achilles tendon rupture, and was evaluated by radiograph and MRI after 1 week.
Case 2 is a 62-year-old male who reported calf pain, raising concerns for deep vein thrombosis, further evaluated with ultrasound. He noted a trivial trauma occurred 10 days prior.
In Case 1, the lateral ankle radiograph revealed increased soft tissue thickness around the Achilles tendon with small calcification (Figure 1). MRI indicated significant disruption (95%) of the distal 5.5 cm of the tendon, cystic areas, and signs of haemorrhage (Figures 2a, 2b, 3a, 3b, and 4). Extensive oedema in the posterior lower leg muscles led to a screening of the leg that identified a 2.8 x 1.6 x 5.4 cm collection in the intermuscular fascial plane, causing indentation on the soleus. The plantaris tendon was partially torn, while the soleus and medial gastrocnemius exhibited grade 1 strain without fibre discontinuity (Figures 5a and 5b).
In Case 2, the ultrasound showed a bulky distal 6.0 cm Achilles tendon with altered echotexture, multiple calcific foci, and a high-grade partial thickness tear (Figures 6a, 6b, and 6c). An anechoic collection measuring 3.3 x 1.2 x 8.6 cm was observed in the intermuscular fascial plane, between the gastrocnemius and soleus muscles, with no increased vascularity noted on the Doppler study (Figures 7a and 7b).
Both patients had co-existent high-grade near full-thickness tears involving the distal Achilles tendon and showing features of background calcific tendinitis and tennis leg.
Ultrasound is an inexpensive and widely available diagnostic tool for accurately diagnosing both tennis leg and Achilles rupture. Although MR imaging is not mandatory for diagnosis, it is more sensitive, subtle findings can be picked up, and provides greater detail of information.
Tennis leg is most often a sports-associated injury incurred during an extension of the knee and forced dorsiflexion of the ankle [1]. In a study conducted by Delgado et al. [1], patients diagnosed to have tennis leg had the following spectrum of imaging findings: partial rupture of the medial head of the gastrocnemius (66.7%), collection between the medial head of the gastrocnemius and soleus without muscle injury (21.3%), plantaris tendon rupture (1.4%), partial rupture of the soleus (0.7%). Rohilla et al. suggested that injury to any muscle in the posterior superficial compartment, including the gastrocnemius, soleus, or plantaris, can cause comparable symptoms, commonly known as “tennis leg”. However, the extent of these symptoms can vary in severity. When the plantaris muscle or tendon is ruptured in isolation, the symptoms are typically milder than those associated with a rupture or strain of the gastrocnemius or soleus muscles, leading to a quicker recovery in terms of mobility [2].
Conservative management with RICE (rest, ice application, compression of the affected part, and elevation), analgesics and physiotherapy are recommended. USG-guided steroid/analgesic injections, as well as evacuation of haematoma, may be done in cases complicated by compartment syndrome [3].
Achilles tendon ruptures in older patients may occur at sites of chronic degeneration during routine activities [4].
Both our patients had the rare association of calcific Achilles tendinopathy with high-grade tear along with features of tennis leg. They were managed conservatively as one patient had no significant functional impairment on follow-up, and the other was a poorly controlled diabetic and, hence, surgical Achilles repair was deferred.
Achilles rupture with tennis leg
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1. X-ray shows: a localized area of increased density at the distal Achilles tendon, suggesting a calcific lesion; partial discontinuity of the Achilles tendon and soft tissue swelling.
2. MRI (T1, T2 weighted images, and fat suppression sequences) shows:
- Significant disruption of soft tissue signals near the distal attachment of the Achilles tendon, with abnormal tendon signal and a high-signal tear line, consistent with signs of a near full-thickness high-grade tear.
- Speckled or clumped areas of mixed high and low signals, suggesting calcific lesions and peritendinous inflammatory changes.
- Abnormal fluid signal or partial fiber tear between the medial head of the gastrocnemius and the soleus muscle, consistent with the imaging appearance of “tennis leg.”
3. Ultrasound shows: irregular hypoechoic or anechoic areas within the Achilles tendon, with obvious swelling and partial discontinuity of tendon fibers, as well as local calcific echo spots; additionally, an anechoic fluid area is seen between the medial head of the gastrocnemius and the soleus muscle, matching the muscle/tendon tear seen in “tennis leg.”
Taking into account the patient’s history of trauma, possible age-related or chronic degenerative factors, imaging findings, and clinical symptoms, the most likely diagnosis is: “A high-grade near full-thickness tear of the distal Achilles tendon with concomitant calcific Achilles tendinopathy, accompanied by medial head gastrocnemius and soleus injury (‘tennis leg’).”
This report is based on available imaging studies and clinical information for comprehensive reference. It does not replace an in-person consultation or professional medical advice. Specific treatment plans must be determined by a specialist after evaluating the patient’s actual condition.
Achilles rupture with tennis leg
