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

 

 

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