Achilles Tendon Rupture

A common sporting injury, especially in disciplines that require stop start sprints or rapid changes of direction

 A photograph demonstrating a ruptured Achilles tendon laid open during surgery.

 

Achilles tendon ruptures are not uncommon within the ED. And are likely to present around now as a people return to sport after a long winter break, but neglect to ease back into the season and adequately stretch.

 

  • More common in men aged 30-40
  • More common amongst amateur/episodic athletes
  •  7:100,000 of the general population
  • 12:100,000 in competitive athletes.

 

History

 

Normally reported as patient pushing off as to sprint (rapid plantar-flexing foot) and sudden pain to posterior of ankle region. Often described as a blow to the back of the ankle may be accompanied by a snap or crack sound.

 

A common story is the patient is playing five-a-side, sprints forward from stood to meet the ball, has the sensation of being kicked to back of the ankle but on turning there is no-one there.

 

  • Maybe preceded by a history of aching or dull pain to the area
  • Patient will have immediate significant pain, and reduced weight-bearing.
  • This will reduce to a dull aching pain.
  • May try to continue with sport/activity and may have some success in this
  • It is not uncommon to have a delayed presentation.
  • Will be unable to toe raise or plantar-flex the foot, such as to climb stairs.

 

Examination

 

 

  • Normally weight-bearing but with an altered gait
  • Useful to examine patient with them in knelt position and their feet unsupported (such as over the edge of a couch or chair)
  • Maybe some swelling, but often not grossly swollen
  • Some increased resting dorsi-flexion to affected side compared to normal (but only in described examination position)
  • Tender to Achilles and distal calf regions
  • Maybe a palpable gape to the Achilles / Achilles ill defined and not palpable compared to other side
  • Calf squeeze (commonly known as Simmonds test) will produce no plantar-flexion in rupture – compare both sides to locate the best location to produce flexion.
  • Active plantar-flex of will be poor with very poor strength
  • Passive dorsi-flex maybe increased

 

Treatment

 

  • Below knee anterior slab in Equineous position (foot plantar-flexed).
  • Non Weight Bearing crutches or other walking aid.
  • VTE prophylaxis assessment
  • Fracture clinic Follow Up

 

If you consider it unlikely there is a rupture.

 

  • Weight bearing gently +/- crutches
  • Rest, Ice, Elevate
  • Gentle limited weight-bearing – to avoid loaded plantar-flexion
  • Lower Limb ED physio review

 

  • Very simple sprains and more chronic presentations should seek GP review.

 

Furrther reading

www.bmj.com/content/346/bmj.f1262

patient.info/doctor/achilles-tendinopathy-and-rupture

www.orthobullets.com/foot-and-ankle/7021/achilles-tendon-rupture

 

 

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