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Hi and thanks for your enquiry,
The normal Achilles tendon is comprised of linear collagen fibrils, represented by tightly packed parallel echogenic lines in the long axis plane sonographically. Separating the fibrils are hypoechoic, interfascicular layers that are comprised of a supporting matrix with tenocytes.
The Achilles tendon you identified songoraphically may represent a tendon which is reactive and/or in the early dysrepair stage of tendinopathy. There may be fusiform heterogeneous swelling of the mid-tendon when this occurs. Disorganisation in the orientation of the normal fascicular pattern of the tendon is usually seen sonographically. This can result in thickening of the hypoechoic interfascicular layers, representing mucoid degeneration and oedema. The echogenic foci that you noted, may represent a loss of continuity in the fibrillar alignment.
Sonographic tendon abnormalities are not always associated with patient-reported pain. Tendon degeneration can start long before the onset of symptoms, which you may have identified in the case you have described.
Thanks
The MSK SIG team