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Pathology associated with the Achilles tendon is a common problem, particularly at the site of insertion. A better understanding of the anatomy in this area would assist in developing and fine-tuning treatment options. A cadaveric examination was conducted using 60 human lower extremities (40 cadavers) to determine the location for the terminal insertion site of the Achilles tendon on the posterior aspect of the calcaneus. The average age of the specimens was 67.8 years (range, 43-98 years). Three different investigators examined each specimen, and a consensus as to the site of termination of the Achilles tendon was made. Upon inspection, 55% (22/40) of the limbs had the Achilles tendon inserting on the superior 1/3 aspect of the calcaneus, 40% (16/40) of the limbs inserted on the middle 1/3, and 5% (2/40) of the limbs inserted on the inferior 1/3. The distribution of the insertion was statistically different from random (P = .000371). Further, 8% (3/40) of the specimens revealed a partially contiguous relationship between the Achilles tendon and the plantar fascia. This correlated with the younger specimens (P < .0001). This study provides a better understanding of the anatomical relationship between the Achilles tendon, the calcaneus, and the plantar fascia.
The insertional location of the Achilles tendon traditionally has been thought to be on the superior aspect of the calcaneus. This is based on descriptions and illustrations in anatomical textbooks. Our study is a digital magnetic resonance imaging (MRI) examination of the insertional location of the Achilles tendon in 69 subjects, 12 to 40 years of age. A midsagittal slice of the ankle was used to identify the most distal insertional location of the Achilles tendon on the posterior aspect of the calcaneus. The superior and inferior margins of the posterior aspect of the calcaneus were measured and the Achilles tendon insertion was calculated as a percentage of the total length of the posterior aspect of the calcaneus. Our results revealed that there is a statistically significant difference in the insertional location as related to age. Additionally, there is a statistically significant proximal migration (0.63%) of the insertional location with each advancing year. Based on our results, it appears that there is an inaccurate depiction in the anatomical literature, which may necessitate a change in the approach to pathologic conditions associated with the Achilles tendon.
Anatomy of the Achilles tendon and plantar fascia in relation to the calcaneus in various age groups.
Snow SW, Bohne WH, DiCarlo E, Chang VK.
Hospital for Special Surgery, New York, New York 10021, USA.
Ten adult cadaver feet, three neonatal feet, and the feet of two fetuses were dissected to investigate whether an anatomical continuity exists between the fibers of the Achilles tendon and the plantar fascia. Histologic sections of the feet were done in three age groups: neonate, persons in their mid-20s, and the elderly. As the foot ages, there appears to be continued diminution of the number of fibers connecting the Achilles tendon and plantar fascia. The neonate has a thick continuation of fibers, while the middle-aged foot has only superficial periosteal fibers that continue from tendon to fascia. The elderly feet show simply an insertion of fibers of both structures into the calcaneus with periosteum in between.
PMID: 7550955 [PubMed - indexed for MEDLINE]
MeSH Terms, SubstancesMeSH Terms:Achilles Tendon/anatomy & histology*Achilles Tendon/embryologyAdipose Tissue/anatomy & histologyAdultAgedAging/pathology*Calcaneus/anatomy & histology*Calcaneus/embryologyCollagenFascia/anatomy & histology*Fascia/embryologyFoot/anatomy & histology*Foot/embryologyHumansInfant, NewbornMiddle AgedPeriosteum/anatomy & histologySubstances:Collagen
LinkOut - more resources
PS Dr. Bohne is a very smart and experienced orthopedic surgeon
Sincerely Steve Levitz
There is a great video around which shows the fascia to achilles connection through discection. They also show how there a single soft tissue connection from the plantar fascia up the posterior leg to the back which ends on the eye brows I think.
Ill see if I can find it when I get back to Sweden. or maybe someone else can post it up.
I'm surprised at the 55% superior number.
I would have guessed much less. My surgical experience tells me most insert in the middle.
It would be interesting to further break this down as to foot type and overall shape variations of the posterior surface.
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA