Achilles Tendon rupture

Related Subjects: |Sprained Ankle |Achilles Tendon rupture

🦶 Achilles tendon rupture typically presents as a sudden “snap” or sensation of being kicked at the back of the ankle, most often during sporting activity. 🚫 Key risk factors: fluoroquinolones, corticosteroid injections, diabetes mellitus, obesity, and increasing age. 🔎 Hallmark sign: a positive Thompson calf squeeze test (absence of plantarflexion). ⚖️ Management trade-off: conservative treatment has a higher re‑rupture rate, whereas surgery lowers recurrence but increases wound and thrombotic risk.

📖 About Achilles Tendon Injury

• The Achilles is the strongest tendon in the human body, yet is vulnerable to rupture during sudden eccentric loading (e.g. jumping or sprinting).
• Often referred to as the “weekend warrior injury”, it most commonly affects middle‑aged recreational athletes.

⚠️ Aetiology & Risk Factors

• Sudden acceleration or deceleration during sport.
• Age‑related degenerative changes, exacerbated by diabetes or inflammatory arthritis.
• Medication‑associated: fluoroquinolones (e.g. ciprofloxacin) and repeated corticosteroid injections.
• Additional risks: obesity, poor conditioning, and systemic inflammatory disease.

🩺 Clinical Features

• Sudden sharp pain, audible “snap” or sensation of being kicked in the posterior ankle or calf.
• Weak plantarflexion — patients may still walk, but often cannot run, push off, or stand on tiptoe on the affected side.
• A palpable gap along the Achilles tendon, usually best felt 2–6 cm proximal to the calcaneal insertion.
• Simmonds' triad suggests Achilles tendon rupture:
  • 🕳️ Palpable gap in the Achilles tendon.
  • 🦶 Increased passive ankle dorsiflexion compared with the other side.
  • ❌ Positive calf squeeze / Thompson test — squeezing the calf fails to produce normal plantarflexion.
• Thompson / Simmonds calf squeeze test: with the patient prone and feet hanging over the couch edge, squeezing the calf should cause plantarflexion. Little or no plantarflexion suggests rupture.
• Matles test: with the patient prone and knees flexed to 90°, the affected foot rests in a more dorsiflexed position than the normal side, rather than maintaining slight plantarflexion.
• Bruising, swelling and tenderness may occur around the posterior ankle or calf.
• Partial ruptures can present subtly and may still allow some plantarflexion or limited bilateral tiptoe standing.

📌 Clinical pearl: Ability to walk does not exclude Achilles rupture because other flexor tendons can still produce some plantarflexion. The most useful bedside clues are a palpable tendon gap, a positive calf squeeze test, and the Matles test.

🔍 Investigations

• Ultrasound: first‑line investigation; dynamic and readily identifies rupture location and severity.
• MRI: reserved for indeterminate cases or pre‑operative planning.

💊 Management

• Non‑surgical: functional bracing or boot immobilisation in plantarflexion; appropriate for partial tears or less physically active patients.
• Surgical repair: end‑to‑end tendon suturing; preferred in complete ruptures and younger, active individuals. Enables earlier rehabilitation but carries wound and DVT risk.
• Rehabilitation: physiotherapy is essential for all patients. Gradual strengthening, stretching, and proprioceptive training; return to sport typically takes 6–12 months.

⚡ Complications

• Re‑rupture (higher with conservative management).
• Wound complications, infection, or adhesions following surgery.
• Chronic calf weakness or muscle atrophy.
• Venous thromboembolism related to immobilisation.

🩺 Case 1 – Sudden Sports Injury

A 34‑year‑old man experiences a sudden “pop” in the posterior ankle while playing football, followed by pain and difficulty walking. Examination reveals swelling, a positive Thompson’s test, and inability to stand on tiptoe.
Management: 🏥 Immobilisation in plantarflexion (cast or functional brace), urgent orthopaedic referral. Surgical repair often advised for young, active patients. Early physiotherapy is essential.
Avoid: ❌ Misdiagnosis as a simple ankle sprain; avoid weight‑bearing until stabilised.

🩺 Case 2 – Older Patient on Steroids

A 65‑year‑old man on long‑term prednisolone for COPD presents with sudden ankle pain after stepping off a curb. Examination reveals a palpable tendon gap and weak plantarflexion.
Management: 💊 Non‑surgical functional bracing may be appropriate given comorbidities, with analgesia and physiotherapy. Consider surgery if functionally independent and fit.
Avoid: ❌ Unreviewed continuation of steroids or fluoroquinolones; prolonged immobilisation without VTE prophylaxis.