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 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?
- Muscle tear
- 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.