A 41 year-old male without significant past medical history presents to the emergency department after sudden onset right leg pain while playing soccer. The patient reports jumping for the ball, landing on his feet, and immediately feeling sharp pain in his right ankle. On exam, he has mild swelling to the posterior ankle overlying the Achilles tendon, and the area is tender to palpation. Plantarflexion is absent with calf squeeze, neurovascular exam is normal, and the remainder of patient’s exam is unremarkable. Bedside ultrasound is used to confirm the suspected diagnosis (Figure 1):
US is useful to determine complete vs. partial rupture
It is not necessary for diagnosis
Provocative Testing: The Thompson Test (Figure 2)
Lack of plantar flexion when calf is squeezed with patient in prone position (sensitivity 0.96; specificity 0.93)
The diagnosis of Achilles tendon rupture was made. The patient was evaluated by orthopedics in the ED. He was placed in a posterior splint in resting equinus and discharged with instructions for non-weight-bearing with crutches. Orthopedic follow-up in 7-10 days was advised.
OVERVIEW OF ACHILLES TENDON RUPTURES
Largest tendon in the body
Formed by the soleus, medial gastrocnemius, and lateral gastrocnemius tendons
Blood supply from the posterior tibial artery
Incidence: 18:100,000 per year
Men > Women
Ages 30-40 most common
Most often secondary to overuse and/or mechanical overload
Intermittent athletes, “weekend warrior”
Local steroid injection
Sudden forced plantar flexion
Violent dorsiflexion in a plantar flexed foot
Patient may report a “pop” or describe a feeling like being kicked in the leg
Weakness and difficulty walking, especially with plantar flexion
Patient usually cannot perform a single heel raise
The presence of at least two physical exam findings establishes the diagnosis:
Positive Thompson test
Palpable defect in the tendon
Decreased ankle plantar flexion strength and increased ankle dorsiflexion
Not necessary for diagnosis
MRI may be useful in cases of equivocal physical exam findings or chronic ruptures, but is not necessary in the ED setting
Ultrasound can help differentiate between complete and partial ruptures
Management: nonoperative vs. operative management is controversial.
For acute injury; patient/provider preference; elderly/frail patients
Splint or cast in resting equinus
Early range of motion exercises
Re-rupture rates similar to those of tendon repair with fewer complications
Operative: End-to-end Achilles tendon repair
For acute injury (<6weeks); patient/provider preference
Higher percentage of patients who return to sports
TAKE HOME POINTS
Achilles tendon rupture tends to occur in older men who participant in strenuous activities on an occasional basis
Often a clinical diagnosis. Imagining is generally unnecessary for diagnosis but may help differentiate between partial and complete tears.
Patients can be discharged in splint or cast in resting equinus with close orthopedic follow-up.
Management is controversial and may be surgical or nonoperative based on several factors.
Faculty Reviewer: Jeffrey P. Feden, M.D.
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Kadakia AR, Dekker RG, Ho BS. Acute Achilles Tendon Ruptures: An Update on Treatment. Journal of the American Academy of Orthopaedic Surgeons: January 2017;25(1): 23-31.
Chiodo CP, Glazebrook M, Bluman EM, et al. Diagnosis and Treatment of Acute Achilles Tendon Rupture. Journal of the American Academy of Orthopaedic Surgeons: August 2010; 18(8): 503-510.
Tintinalli JE. Achilles Tendon Rupture, Chapter 272. Emergency Medicine: A Comprehensive Study Guide, 7th ed. New York: McGraw-Hill, 2011. 1867 p.