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.
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.
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.
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