Ortho Hors D'oeuvres (Answer):

To review, the patient is a 26 year-old male presenting with sudden onset atraumatic ankle pain.

Questions and Answers:

1) What is the likely diagnosis? What risk factors does the patient have and what are other serious risk factors for this injury?

This patient is likely to have a left-sided Achilles tendon rupture. As you can see in the below picture, the Achilles tendon is the distal insertion of both the gastrocnemius and soleus muscles and primarily responsible for plantar flexion of the foot. Tibialis posterior, peroneus longus, and peroneus brevis also cause plantar flexion of the foot, so preserved ability to “point toes” does not rule out Achilles tendon rupture.

In order to isolate the gastrocnemius and soleus muscles, the above physical exam technique is used. If the patients foot does not plantar flex with external compression onto the belly of the gastrocnemius or soleus, the patient has a positive “Thompson test;” this is pathognomonic for Achilles fracture with a sensitivity and specificity of 96 and 93 percent respectively.

Males are 4-5 times more likely than women to have rupture of the Achilles tendon. Other risk factors include steroid use, obesity, fluoroquinolone use, and cold weather.

2) What adjunctive test could be done to confirm the diagnosis?

As you can see in below clips, bedside ultrasound can be used to diagnosis Achilles tendon rupture. Surgeons often use ultrasound in order to assess for severity of rupture and need for operative repair in the case of the possible partial tendon rupture. For diagnosis of acute rupture, ultrasound has a sensitivity and specificity of 100 and 90 percent respectively.

In the above film, you can see the normal smooth appearance of the achilles tendon. Compare this directly to the abnormal appearance of the tendon below:

3) What is the management of this injury?

This is generally an operative injury, although not an orthopedic emergency. Patients with Achilles tendon ruptures should be referred to outpatient orthopedic evaluation within 1-2 days of their injury in order to discuss operative planning and management.

Appropriate management in the emergency department is key in the healing of this injury. The patient must be splinted in full equinus (full plantar flexion) in order to decrease strain on the Achilles tendon and allow the torn ends to come closer together in preparation for operative repair. Care must be taken to pad this splint significantly, as the patient is not in a position of comfort and may unintentionally resist the splint.

References:

Claessen FM, de Vos RJ, Reijman M, Meuffels DE. Predictors of primary Achilles tendon ruptures. Sports Med. 2014 Sep;44(9):1241-59.

Gulati V et al. Management of Achilles tendon injury: A current concepts systematic review. World J Orthop. 2015 May 18;6(4):380-6.

Holmes GB, Lin J. Etiologic factors associated with symptomatic achilles tendinopathy. Foot Ankle Int 2006; 27:952.

Maffulli N. The clinical diagnosis of subcutaneous tear of the Achilles tendon. A prospective study in 174 patients. Am J Sports Med 1998; 26:266.

Rockett MS, Waitches G, Sudakoff G, Brage M. Use of ultrasonography versus magnetic resonance imaging for tendon abnormalities around the ankle. Foot Ankle Int. 1998;19:604-612

Wilkins R, Bisson LJ. Operative versus nonoperative management of acute Achilles tendon ruptures: a quantitative systematic review of randomized controlled trials. Am J Sports Med 2012; 40:2154.

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