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Home , Achilles tendon, Achilles tendon rupture, Soft tissue, Strain (injury)

J Am Board Fam Pract: first published as 10.3122/15572625-13-5-371 on 1 September 2000. Downloaded from BRIEF REPORTS Achilles Rupture: A Challenging Diagnosis

jocelyn R. Gravlee, MD, Robert L. Hatch, MD, MPH, and Anthony M. Galea, MD

Since the 1950s the incidence of spontaneous com­ both passively and against resistance. 'When the plete rupture of the has risen tendon was palpated, it was unclear whether there steadily, possibly as a result of increased sedentary was a gap in the tendon; however, several lumps of lifestyles and intermittent participation in recre­ fibrous tissue were felt approximately 5 cm above ational sports. 1 Today the Achilles tendon is the the tendon insertion. The Thompson squeeze second most frequently ruptured tendon,2 and no test showed a considerable decrease in plantar flex­ other tendon suffers complete rupture more often.3 ion of the left compared with the right. Up to 25% of all cases are misdiagnosed,4-6 with reflex on the left was absent, but there were no serious consequences for the patient. Family phy­ other neurologic deficits. The patient had no sicians must be able to recognize acute Achilles rise when walking and seemed to lack the normal tendon ruptures to initiate expedient treatment and rocking motion in the heel during his gait. He was referral. The overwhelming majority of cases can unable to lift up completely on his toes. Findings be diagnosed using only findings from the history from the examination were normal. and . The following case illus­ A sonogram was ordered, which showed a com­ trates common pitfalls encountered when evaluat­ plete tear of the left Achilles tendon 3 to 4 em ing Achilles tendon . above the insertion with a small amount of fluid and fatty herniation in the gap between the tom ends.

Case Report copyright. An otherwise healthy 60-year-old man complained Discussion of increasing swelling and in his left foot and The increased incidence of and numbness and burning on the plantar sur­ is distributed unequally in the population. In find­ face of his left heel. The patient had fallen down his ings consistent with other studies, Jozsa et a!' re­ basement stairs 4 months earlier and initially port that the mean age for patients with Achilles sought treatment from an orthopedic surgeon for tendon rupture is 35.2 years and that the incidence pain in his left calf, foot, and ankle. A partial tear of is four times greater among men than women. the Achilles tendon was diagnosed by sonography, They also found that 62.3% of Achilles tendon http://www.jabfm.org/ and the patient was advised that the would ruptures occur in professional and white-collar heal on its own. Four months later the patient came workers.7 Achilles tendon ruptures often occur in to us complaining of worsening gait, now requiring sports requiring abrupt, repetitive jumping or a cane, and unbearable pain in his left foot, ankle, bursts of sprinting. Ball sports, such as soccer, bas­ and heel. ketball, and tennis, and fast-twitch sports, such as

On physical examination, the patient had pitting gymnastics and track and field, are associated with on 24 September 2021 by guest. Protected (2 +) from his left foot to mid calf. Pain was a higher incidence of rupture.7 Achilles tendon elicited on palpation of the Achilles tendon to mid­ ruptures can also occur after falling from a height, calf. He had good plantar flexion and dorsiflexion, after being struck directly on the tendon, after a misstep, or after sudden movements, such as push­ ing off or dorsiflexion of the foot. 8 Submitted, revised, 28 July 1999. Patients with acute ruptures generally relate a From the Department of Community Health and Family classic history. They typically describe the precip­ aRG, RLH), College of Medicine, University of Florida, Gainesville, and the Institute of Sports Medicine itating incident as feeling like they had been hit or and Human Performance (AMG), Toronto, Canada. Ad­ kicked on the back of the leg or heel, and they dress reprint requests to Robert Hatch, MD, MPH, Depart­ ment of Community Health and Family Medicine, PO Box sometimes report hearing a popping or snapping 9 100222, Gainesville, FL 32610. sound as they faU to the ground.2• The immediate

Achilles Tendon Rupture 371 J Am Board Fam Pract: first published as 10.3122/15572625-13-5-371 on 1 September 2000. Downloaded from pain can soon resolve, leaving only residual calf The examiner might tend to regard the injury as tenderness.9 \Vhile palpating the area, the physi­ trivial if the patient does not complain of much cian might feel a gap or interruption in the conti­ pain. One study, however, reported that roughly nuity of the tendon, and the patient can have in­ one third of patients with complete Achilles tendon creased dorsiflexion on passive range of motion and ruptures did not complain of pain.ll 8 weakness in plantar flexion of the ankle. ,10 These The practicing physician can best avoid these findings are more likely in the acute phase, al­ misconceptions and improve the diagnosis of Achil­ though they can be present in chronic ruptures. les tendon ruptures by performing an appropriate Patients with old ruptures might also have a calca­ clinical examination. Several clinical tests for Achil­ neus gait,10 characterized by a lack of push-off at les tendon ruptures have been developed, but only the end of the stance phase as a result of the dys­ three will be described here. These tests have the function of the gastrocnemius and soleus muscles. advantage of being inexpensive, noninvasive, and The diagnosis of Achilles tendon ruptures is effective when used in combination. Other well­ difficult even for the experienced physician. The known tests, including the Copeland sphygmoma­ includes acute Achilles ten­ nometer test12 and the O'Brien needle test,13 are don peritendinitis, tennis leg (medial gastrocne­ excluded from this discussion because of the dis­ mius tear), calf muscle or rupture, posterior comfort they cause to patients. tibialis syndrome, injuries, fracture, Palpation: It is important to position the patient posterior tibialis tendon injuries, and peroneal in­ so that both Achilles can be observed from juries.9 According to Josza et at,7 missed ruptures behind. Achilles tendon ruptures can often be di­ are most often diagnosed as ankle . There agnosed by simply palpating the tendon along its are several widely held fallacies that likely contrib­ entire length. Maffulli3 reports a sensitivity of only ute to the high rate of missed diagnosis. 0.73, however, which reflects the decreasing effec­ Fallacy 1. The patient walked into the examination tiveness of this test with older ruptures. room and therefore could not have ruptured the Achilles 8 Calf squeeze (Thompson) test: This test requires copyright. tendon. The Achilles tendon is the major plantar positioning the patient in the prone position with flexor of the foot, which is the basis of this common the feet hanging off the table, or with the misconception. Weakness of plantar flexion, how­ flexed and the feet hanging over the end of a chair. ' ever, can be masked by the force of gravity and the As the examiner squeezes the patient's calf muscle, activity of the posterior tibial, peroneal, and plantar muscles.10 Particularly in the case of old ruptures, it plantar flexion of the ankle should occur if the is possible that patients with complete tears could Achilles tendon is intact. The test is positive if the walk. foot remains in the neutral position or if there is Fallacy 2. The patient could flex the plantar muscle minimal plantar flexion of the ankle compared with http://www.jabfm.org/ 3 passively and against resistance and therefore could not the unaffected side. Maffulli reports a sensitivity of have ruptured the Achilles tendon. This misconcep­ 0.96 for this test. False negative results, however, tion overlooks the other muscles that act as flexors are more likely in older injuries, where organiza­ at the ankle, as discussed above. tion of a hematoma can cause some reconstitution 3 Fallacy 3. The Achilles tendon must be intact because of the tendon. lO no gap was felt on palpation. Surrounding swelling Knee flexion (}.fatles) test: In this test, the pa­ on 24 September 2021 by guest. Protected can disguise the gap in acute ruptures.IO In ruptures tient is asked to actively flex the knee through 90 more than 4 weeks old, hematomas produced by degrees while in the prone position. The examiner tendon ruptures can organize and contribute to observes the feet and throughout the move­ reconstitution of the tendon, thus obliterating the ment. With an intact tendon, the foot should dis­ gap.3 play slight plantar flexion; rupture is probable if the Fallacy 4. An Achilles tendon rupture is unlikely foot falls into the neutral position or the movement because the patient did not have increased dorsiflexion results in dorsiflexion. Maffulli reports a sensitivity with passive range ofmotion. This clinical finding can of 0.88. Unlike the Thompson test, the Matles test be masked by pain in acute ruptures. should be positive even in older ruptures, because Fallacy 5. The patient has no pain in the Achilles the tendon will lengthen with hematoma formation tendon, so an Achilles tendon rupture is improbable. and tendon reconstitution. 3

372 JABFP September-October 2000 Vol. 13 No.5 J Am Board Fam Pract: first published as 10.3122/15572625-13-5-371 on 1 September 2000. Downloaded from A positive finding in two of the three tests is nation can substantially improve the diagnosis of good evidence of an Achilles tendon rupture.3 If the Achilles tendon ruptures. The Thompson and diagnosis is still in question, sonography or mag­ Matles tests, along with palpation of the tendon, netic resonance imaging (MRI) is warranted. These are simple, inexpensive means to arrive at the cor­ studies, as do any other, have their disadvantages. rect diagnosis in most cases. The consequences of Sonography is operator dependent. It can be hard overlooking this injury can be severe: chronic pain to differentiate a partial tear from a complete tear and swelling, poor gait, and inability to return to using imaging.9 A complete tear might sporting activities. Early diagnosis and referral are be mistaken for a partial tear if the intact plantaris essential for a full and successful recovery. l4 tendon (which rarely, if ever, tears ) or an orga­ nized hematoma is mistaken for a partially intact References Achilles tendon. Based on this limitation of sonog­ 1. Kvist M. Achilles tendon injuries in athletes. Sports raphy, it is unclear whether the patient described Med 1994;18:173-201. above actually had a partial tear when he was first 2. Ballas MT, Tytko J, Mannarino F. Commonly seen by the orthopedic surgeon. The tear might missed orthopedic problems. Am Fam Physician have been complete and the physician misled by the 1998;57:267-74. sonographic interpretation. Although MRI is non­ 3. Maffulli N. The clinical diagnosis of subcutaneous invasive and has superior contrast, it is tear of the Achilles tendon. A prospective study in costly, time consuming, and not always readily 174 patients. Am J Sports Med 1998;26:266-70. 0, available. 4. Arner Lindholm A. Subcutaneous rupture of the Achilles tendon. Acta Chir Scand 1959;239(Suppl): The goal of treatment is to restore normal 1-51. length and tension of the Achilles tendon. IS This 5. Lawrence GH, Cave EF, O'Connor H. Injury to the goal can be achieved by either surgical or nonsur­ Achilles tendon. AmJ Surg 1955;89:795-802. gical means, and no one method is ideal for all 6. Beskin JL, Sanders RA, Hunter SC, Hughston JC. 15 cases. Landvater and Renstrom recommend sur­ Surgical repair of Achilles tendon ruptures. Am J gery for patients who are young and athletic and in Sports Med 1987;15:1-8. copyright. all cases where there has been a delay of more than 7. Jozsa L, Kvist M, Balint BJ, et al. The role of rec­ 1 week in diagnosis and treatment. assures reational sport activity in Achilles tendon rupture. A the correct apposition of the tendon ends, thus clinical, pathoanatotnical, and sociological study of 292 cases. AmJ Sports Med 1989;17:338-43. allowing patients to regain full strength, endurance, 8. Thompson TC, Doherty JH. Spontaneous rupture power, and an early return to athletic activities. of tendon of Achilles: a new clinical diagnostic test. Nonathletes or low-end recreational athletes whose J Trauma 1962;2:126-9. tendon rupture has been diagnosed early (less than 9. LeppilahtiJ, Orava S. Total Achilles tendon rupture. 48 hours) may undergo conservative treatment with A review. Sports Med 1998;25:79-100. http://www.jabfm.org/ a short leg cast for 8 weeks (first 4 weeks in maxi­ 10. Matles AL. Rupture of the tendo Achilles: another mum plantar flexion). They then should have 2 diagnostic sign. Bull HospJoint Dis 1975;36:48-51. months of supervised . Patients 11. Christensen lB. Rupture of the Achilles tendon. should be advised that there is a longer recovery Analysis of 57 cases. Acta Chir Scand 1953-1954; period and a higher incidence of re-rupture with 106:50-60. 15 12. Copeland SA. Rupture of the Achilles tendon: a new conservative management. Because of the perma­ on 24 September 2021 by guest. Protected clinical test. Ann R ColI Surg EngI1990;72:270-1. nent disability that can result from mismanagement of the injury, Achilles tendon ruptures are best 13. O'Brien T. The needle test for complete rupture of the Achilles tendon. J Surg Am 1984;66: referred to an orthopedic surgeon. 1099-101. \Vhen evaluating a patient with a swollen, ten­ 14. Simmonds FA. The diagnosis of the ruptured Achil­ der ankle, physicians must be particularly alert for les tendon. The Practitioner 1957;179:56-8. an Achilles tendon rupture, or the diagnosis might 15. Landvater SJ, Renstrom PA. Complete Achilles ten­ be missed. A thorough history and clinical exami- don ruptures. Clin Sports Med 1992;11:741-58.

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