Achilles Tendon Injection and Tenotomy

Other Names

Achilles percutaneous tenotomy
Percutaneous Achilles tendon release
Achilles tendon needling
Tendon fenestration of the Achilles
Achilles corticosteroid injection
Ultrasound-guided Achilles injection
Minimally invasive Achilles tenotomy
Achilles tendon debridement (percutaneous)
Achilles PRP injection
Percutaneous Achilles tendon intervention
Achilles Tendon Injection
Achilles Tendon Tenotomy

Background

Key Points

Needle: 25-27 gauge, 1-1.5 inche
Transducer: high frequency linear arrway

Anatomy of the Achilles Tendon

Longest, strongest tendon in the body; 12-15 cm in length, 6 mm in cross section
The tendon fuses from the distal tendininous components of the soleus and gastrocnemius muscles
It travels distally, inserting into the posterior surface of the calcaneus
Approximately 2-6 cm proximal to insertion is an area of relative hypovascularity^[3]
Paratenon: double layered connective tissue membrane^[4]
- Not a true sheath, no synovium
- Very vascular, provides blood supply to the tendon
Kagars fat pad separates the anterior Achilles tendon from the flexor hallucis longus
Retrocalcaneal Bursa lies anterior to the tendon, just proximal to the insertion on the calcaneus
The long, thin plantaris tendon is found along the medial border of the Achilles in 90% of individuals
The Sural Nerve and Saphenous Vein are found on the lateral aspect

Palpation Guidance vs Ultrasound Guidance

We strongly encourage the use of ultrasound to increase precision and safety of this procedure
Clinical outcomes of nonguided versus guided injection have not been described

Indications

Chronic Achilles Tendinopathy
Partial Achilles Tendon Rupture

Contraindications

Absolute
- Anaphylaxis to injectates
- Overlying cellulitis, skin lesion or systemic infection
Relative
- Can be treated with less invasive means
- Hyperglycemia or poorly controlled diabetes
- Lack of symptom improvement with previous injection

Procedure

Equipment

Sterile prep (i.e. chloraprep, chlorhexidine, iodine, etc)
Gloves
Needle: typically 21-25 gauge, 1.5 inch
Syringe: 5-10 mL
Gauze
Ethyl Chloride
Bandage
Injectate
- Local anesthetic
- Corticosteroid
Sterile probe cover

Ultrasound Findings

General considerations
- Visualize in both long axis and short axis
- Use high frequency linear transducer
- The tendon fibers curve as they approach the calcaneal insertion
- Be aware of the anisotropy that can occur
Common pathologic findings
- Hypoechogenicity
- Thickening
- Heterogenous echotexture
- Loss of fibrillar pattern
- Neovascularization entering the tendon from the ventral surface
- Tears within the proximal two-thirds of the tendon
Partial tear
- Disruption of the dorsal surface of the tendon with high power color Doppler flow near the disruption^[5]
Complete rupture
- Appear as focal defects in the tendon
- Paratenon is often intact
- Increased acoustic shadowing at the ends of the tear
Tendinopathy
- Often seen at the distal tendon
- Enthesophyes are common at the calcaneal insertion
- Often associated with retrocalcaneal bursitis^[6]

Midbody Achilles Tendinopathy: Short axis, In Plane

Patient Position
- Prone
- Foot hanging off table
Transducer Position
- Short axis to tendon
Needle Approach/ Orientation
- In plane
- Medial to lateral
Target
- Region of hypoechoic-heterogenous echotexture, thickening, neo-vessels, and/or anechoic tears within midbody Achilles tendon
Pearls & Pitfalls
- Consider pre-injection of anesthetic to improve pain control for patient

Midbody Achilles Tendinopathy: Short axis, Out of Plane

Patient Position
- Prone
- Foot hanging off table
Transducer Position
- Short axis to tendon
Needle Approach/ Orientation
- Out of plane
- Proximal to distal/ distal to proximal
Target
- Region of hypoechoic-heterogenous echotexture, thickening, neo-vessels, and/or anechoic tears within midbody Achilles tendon
Pearls & Pitfalls
- Consider pre-injection of anesthetic to improve pain control for patient

Insertional Achilles Tendinopathy: Long axis, In Plane

Patient Position
- Prone
- Foot hanging off table
Transducer Position
- Long axis to tendon
Needle Approach/ Orientation
- In plane
- Proximal to distal
Target
- Region of calcification, hypoechoic-heterogenous echotexture, thickening, and/or anechoic tears at the Achilles tendon insertion into the calcaneus
Pearls & Pitfalls
- Consider pre-injection of anesthetic to improve pain control for patient
- Calcifications/enthesophyte may require larger needle and barbotage

Insertional Achilles Tendinopathy: Short axis, In Plane

Patient Position
- Prone
- Foot hanging off table
Transducer Position
- Long axis to tendon
Needle Approach/ Orientation
- Out of plane
- Proximal to distal
Target
- Region of calcification, hypoechoic-heterogenous echotexture, thickening, and/or anechoic tears at the Achilles tendon insertion into the calcaneus
Pearls & Pitfalls
- Consider pre-injection of anesthetic to improve pain control for patient
- Calcifications/enthesophyte may require larger needle and barbotage

Aftercare

Motor exam should be intact
No major restrictions in most cases
Can augment with ice, NSAIDS
Can consider Ankle Compression Sleeve after

Complications

Infection
Damage to surrounding tissue

References

↑ ^1.0 ^1.1 ^1.2 ^1.3 ^1.4 ^1.5 ^1.6 ^1.7 Malanga, Gerard A., and Kenneth R. Mautner. " Atlas of ultrasound-guided musculoskeletal injections." (No Title) (2014)
↑ Case courtesy of Maulik S Patel, Radiopaedia.org, rID: 17567
↑ Bianchi, Stefano, and Carlo Martinoli. "Ankle." Ultrasound of the musculoskeletal system. Berlin, Heidelberg: Springer Berlin Heidelberg, 2007. 189-331.
↑ Pierre-Jerome, Claude, Valeria Moncayo, and Michael R. Terk. "MRI of the Achilles tendon: a comprehensive review of the anatomy, biomechanics, and imaging of overuse tendinopathies." Acta radiologica 51.4 (2010): 438-454.
↑ Alfredson, Håkan, and Lars Öhberg. "Sclerosing injections to areas of neo-vascularisation reduce pain in chronic Achilles tendinopathy: a double-blind randomised controlled trial." Knee Surgery, Sports Traumatology, Arthroscopy 13.4 (2005): 338-344.
↑ Gibbon, Wayne W., J. Robert Cooper, and Graham S. Radcliffe. "Distribution of sonographically detected tendon abnormalities in patients with a clinical diagnosis of chronic Achilles tendinosis." Journal of clinical ultrasound 28.2 (2000): 61-66.

Created by:

John Kiel on 25 November 2025 16:40:49

Authors:

John Kiel

Last edited:

25 November 2025 18:03:32

Category:

Procedures

[Malanga-1] 1.0 ^1.1 ^1.2 ^1.3 ^1.4 ^1.5 ^1.6 ^1.7 Malanga, Gerard A., and Kenneth R. Mautner. " Atlas of ultrasound-guided musculoskeletal injections." (No Title) (2014)

[2] Case courtesy of Maulik S Patel, Radiopaedia.org, rID: 17567

[3] Bianchi, Stefano, and Carlo Martinoli. "Ankle." Ultrasound of the musculoskeletal system. Berlin, Heidelberg: Springer Berlin Heidelberg, 2007. 189-331.

[4] Pierre-Jerome, Claude, Valeria Moncayo, and Michael R. Terk. "MRI of the Achilles tendon: a comprehensive review of the anatomy, biomechanics, and imaging of overuse tendinopathies." Acta radiologica 51.4 (2010): 438-454.

[5] Alfredson, Håkan, and Lars Öhberg. "Sclerosing injections to areas of neo-vascularisation reduce pain in chronic Achilles tendinopathy: a double-blind randomised controlled trial." Knee Surgery, Sports Traumatology, Arthroscopy 13.4 (2005): 338-344.

[6] Gibbon, Wayne W., J. Robert Cooper, and Graham S. Radcliffe. "Distribution of sonographically detected tendon abnormalities in patients with a clinical diagnosis of chronic Achilles tendinosis." Journal of clinical ultrasound 28.2 (2000): 61-66.

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