J Am Board Fam Pract: first published as 10.3122/15572625-13-5-371 on 1 September 2000. Downloaded from BRIEF REPORTS Achilles Tendon 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 Achilles tendon 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 calf 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 foot compared with the right. Ankle 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 heel 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 knee examination were normal. and physical examination. 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 injuries. 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 pain in his left foot and The increased incidence of Achilles tendon rupture leg 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 injury 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 edema (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 Medicine 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 differential diagnosis 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 strain or rupture, posterior comfort they cause to patients. tibialis stress syndrome, ligament injuries, fracture, Palpation: It is important to position the patient posterior tibialis tendon injuries, and peroneal in­ so that both Achilles tendons 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 sprains. 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 knees 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 ankles 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.