The results are in

MRI-3T LEFT ANKLE NON CONTRAST

HISTORY: M25.672 Left ankle stiffness M25.572 Left ankle pain

TECHNIQUE: MR imaging of the left ankle was performed without IV contrast on a 3.0 Tesla high-field wide-bore magnet.

COMPARISON: None

FINDINGS:

TENDONS/MUSCLES: There is moderate Achilles tendinosis with a high-grade tear at the myotendinous junction. There is no full-thickness discontinuity however fibers there is marked laxity of torn fibers at the myotendinous junction. Additionally, there is a second site of interstitial and superficial tearing comprising 30-40 percent of the total tendon surface area along the course of the distal tendon spanning a length of 4 cm up to the calcaneal insertion site. There is no muscle atrophy or intramuscular edema.

LIGAMENTS: The syndesmotic, deltoid and lateral collateral ligament complex is intact.

BONES AND CARTILAGE: The talar dome and tibial plafond are intact. There is no evidence of tarsal coalition. The cartilage of the tibiotalar, subtalar, calcaneocuboid and talonavicular joints is preserved.

JOINT FLUID: There is a physiologic amount of joint fluid. No loose bodies are identified.

PLANTAR FASCIA: Intact.

NERVES: Unremarkable.

TARSAL TUNNEL: No masses.

SINUS TARSI: Fat signal within the sinus tarsi is preserved.

SUBCUTANEOUS TISSUES: There is mild subcutaneous edema laterally and posteriorly about the ankle.

IMPRESSION:

High-grade tear of the Achilles tendon at the myotendinous junction with markedly lax fibers but no full-thickness discontinuity. There is a separate site of partial-thickness tearing along the distal aspect of the tendon.

ICD 10 –
Achilles Tear, S86.012A

Signed by:  MD
Signed Date: 7/9/2018 2:17 PM EDT