A 46 year old lady attends ED complaining of pain at 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.

Image 1

Image 1

1. What might you expect to find on clinical examination and what test is being performed in Image 1?
  • 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
  • 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 and 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.

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