#MiniTeach: I Felt A Snap
"A 46-year-old lady attends ED complaining of pain in the right heel and calf."
She says that she’d been dancing all night at a party when she suddenly felt a snap at the back of her heel.
1. What might you expect to find on clinical examination and what test is being performed in this photo?
The attached image is Thompson-Simmonds test.
Squeezing the calf causes plantar flexion.
It is best not to document this in the notes as positive or negative as that can be confusing.
You might also find a palpable gap, bogginess, tenderness and the patient cannot stand on tip-toes.
Lack of these signs does not rule out a partial rupture, so have a high index of suspicion for this.
2. What kind of patient does this condition most commonly occur in and what factors might pre-dispose someone to develop this condition?
Usually men aged 30 – 50, who exercise intermittently.
It affects the left side more than the right as most people are right footed and ‘push off’ with their left.
Risk factors include: corticosteroid use, previous tendonitis, connective tissue disorders and Cushing’s.
There’s a possible link between quinolone antibiotics such as ciprofloxacin and an increased risk of rupture.
3. What is the differential diagnosis?
Tendonitis, Muscle tear, DVT, Fracture and Ankle joint disease.
4. Why is the ‘watershed zone’ at particular risk?
The watershed zone is the part of the Achilles tendon that lies 2-6cm from the calcaneal insertion.
The tendon is supplied with blood from the posterior tibial artery.
The supply is more tenuous in the watershed zone and it is at increased risk of injury as a result.
5. What is the management now in ED?
Analgesia, equinus plaster applied anteriorly.
(What’s equinus – the amount of plantar flexion you get when the foot is relaxed and under the influence of gravity).
Crutches, then Fracture Clinic.
6. What’s the evidence for operative versus non-operative management?
Operative management has a slightly lower re-rupture rate, but has the added complications of infection and general operative complications.
Other outcomes are the same for each group.
