CASE

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):

Why ultrasound?

• 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)

CASE OUTCOME

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

Anatomy:

• Largest tendon in the body

• Formed by the soleus, medial gastrocnemius, and lateral gastrocnemius tendons

• Blood supply from the posterior tibial artery

Epidemiology:

• Incidence: 18:100,000 per year

• Demographics:

  • Men > Women

  • Ages 30-40 most common

  • Most often secondary to overuse and/or mechanical overload

• Risk factors:

  • Intermittent athletes, “weekend warrior”

  • Older age

  • Fluoroquinolone use

  • Local steroid injection

Mechanism:

• Sudden forced plantar flexion

• Violent dorsiflexion in a plantar flexed foot

Symptoms:

• Patient may report a “pop” or describe a feeling like being kicked in the leg

• Weakness and difficulty walking, especially with plantar flexion

• Heel pain

• 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

Imaging:

• 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.

• Nonoperative

  • 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

    • Improved strength

    • 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.

REFERENCES:

1. Karadsheh M. Achilles Tendon Rupture. Orthobullets [Internet]. Available from http://www.orthobullets.com/foot-and-ankle/7021/achilles-tendon-rupture. Accessed June 2017.

2. Egol KA, Koval KJ, Zuckerman, JD. Handbook of Fractures, 5th ed. Wolters Kluwer Health, 2015. 490-493 p.

3. 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.

4. 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.

5.  Tintinalli JE. Achilles Tendon Rupture, Chapter 272. Emergency Medicine: A Comprehensive Study Guide, 7th ed. New York: McGraw-Hill, 2011. 1867 p.