The ultrasonographic dynamic heel-rise test of the Achilles tendon

Ciszkowska-Łysoń, Beata; Zdanowicz, Urszula; Śmigielski, Robert

doi:10.15557/jou.2021.0043

Fig. 1.

Technique: the initial stage of the dynamic assessment. The transducer is applied longitudinally above the calcaneal tuberosity, along the AT, allowing for direct evaluation of the presence of the tendon fibres’ resting tension, indicating a good function of the muscle-tendon unit, or blurred tendon structure with no fibrillar structure, which may indicate an impaired healing process

Fig. 2.

Ultrasound examination protocol. A. The transducer is applied along the AT, above the calcaneal tuberosity. The tendon tension is present at rest. B. An 18–5 MHz US image of a tendon at post-rupture remodelling phase (4.5 months postoperatively). A longitudinal plane, a linear arrangement of AT fibres [red short lines]; the image indicates the presence of resting tension. [red arrows mark the borders of the tendon]

Fig. 3.

Ultrasound examination protocol. A. The transducer is applied along the AT, above the calcaneal tuberosity. At rest, the tendon is undulated, there is no tension in the AT, which is visible on ultrasound as blurred tendon structure with no linear fibrillar arrangement of the fibres. An abnormal image. B. An 18–5 MHz US image of a tendon during the remodelling phase at 3 months after the surgery. Longitudinal plane, there is no linear arrangement of AT fibres; blurred tendon structure, hypoechoic zones are present within the tendon; the image indicates the absence of resting tension. [red arrows mark the borders of the tendon]

Fig. 4.

Technique: a US heel-rise test – the plantar flexion of the ankle with resistance applied against the foot imitating the classical heel-rise test; maximum active plantar flexion of the ankle, the diagnostician’s hand applies ground-like resistance to the foot, thereby forcing tension in the calf muscles. The transducer is placed longitudinally above the calcaneal tuberosity, along the Achilles tendon, which allows direct observation of the moving tendon. An ultrasound examination allows to directly assess the presence of tension of tendon fibres during active movement, indicating good function or tendon fibre undulation pointing to elongation during healing. In the case of elongation of a healing tendon, the ankle joint is not bent by the force of the triceps surae muscle, but by the strength of the other plantar flexors

Fig. 5.

Ultrasound examination protocol. A. The transducer is placed longitudinally above the calcaneal tuberosity, along the AT; active plantar flexion [curved arrow] of the ankle joint with the diagnostician’s hand applying ground-like foot resistance [straight arrow] as in the classical heel-rise test flexion. Evident tension of the AT. The heel-rise movement is made by the force of the triceps surae muscle with the tension of the AT. The image indicates a good function of a surgically treated AT. B. A longitudinal 18–5 MHz US image of the AT; evident fibrillar structure of the tendon fibres [red short lines]; good tendon tension; the image indicates a good function of the AT. [red arrows mark the borders of the tendon]

Fig. 6.

Ultrasound examination protocol. A. The transducer is placed longitudinally above the calcaneal tuberosity, along the AT; active maximum plantar flexion of the ankle joint [curved arrow] with the diagnostician’s hand applying ground-like foot resistance [straight arrow] as in the heel-rise test. No tension is seen in the AT, which is undulated. The heel-rise movement is performed not by the force of the triceps surae muscle, but with the strength of the other plantar flexors. The image indicates a dysfunction of the surgically treated AT, healing with elongation of the tendon. B. A longitudinal 18–5 MHz US image of the AT, the evident fibrillar structure, but the tendon fibres appear undulated in the dynamic imaging [the curved red lines indicate the wavy course of the fibres], indicating the lack of tension; the tendon is loose [red arrows mark the borders of the tendon]

Fig. 7.

The US heel-rise test, an examination 3 months after AT rupture reconstruction –– the longitudinal 18–5 MHz US images of the AT; on the left (A) a fibrillar structure of the tendon fibres is visible – the image indicates the presence of resting tension; on the right (B) – during active plantar flexion of the ankle with applied resistance, the fibres of the AT are linear, no waving of the fibres is observed. The image indicates a good function of the AT

Fig. 8.

The US heel-rise test, an examination 6 weeks after AT rupture reconstruction – the longitudinal 18–5 MHz US images of the AT; on the left (A) the fibrous structure of the tendon is not clearly visible, but there is no waviness of the tendon – the image indicates the presence of resting tension of AT; on the right (B) – during active plantar flexion of the ankle with resistance, wavy tendon fibres, and wavy surgical sutures are visible – indicating the lack of AT tension; the tendon is loose

Fig. 9.

The US heel-rise test, an examination 3 months after AT rupture reconstruction – the longitudinal 18–5 MHz US images of the AT; one the left (A) the fibrous structure of the tendon is not clearly visible, but there is no waviness of the tendon – the image does not show the resting tension of the tendon; on the right (B) – during active plantar flexion of the ankle with applied resistance, wavy tendon fibres, and wavy surgical sutures are visible – indicating the lack of AT tension; the tendon is loose