Practice Easily Missed

Acute Achilles tendon rupture

BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4722 (Published 22 October 2015) Cite this as: BMJ 2015;351:h4722
  1. Dishan Singh, consultant orthopaedic surgeon
  1. 1Foot and Ankle Unit, Royal National Orthopaedic Hospital, Stanmore, UK
  1. dishan.singh{at}rnoh.nhs.uk

What you need to know

  • Patients with an Achilles tendon rupture often report feeling a blow to the heel and sometimes an audible snap while playing sports or running

  • Patients may still be able to walk on tiptoes and plantarflex against resistance because the other ankle plantarflexors are intact

  • The Simmonds’ triad of altered angle of declination (the foot of the injured leg rests in a more dorsiflexed position than the other side when the patient lies prone), palpable gap, and lack of plantarflexion on calf squeeze test will detect a rupture in nearly all cases

  • Imaging is rarely necessary

While playing tennis, a healthy 35 year old man felt as though he had been hit on the back of the lower leg by his opponent’s racquet. He couldn’t keep playing but could walk. He presents the next day with mild bruising, swelling, and weakness while walking. He can walk on tip toes but Simmonds’ triad (calf squeeze, altered angle of declination, and palpable gap) confirms the diagnosis of a ruptured Achilles tendon.

What is an Achilles tendon rupture?

A rupture of the Achilles tendon (fig 1) is a disruption in the conjoined tendon of the gastrocnemius and soleus muscles, usually about 2-6 cm proximal to the tendon insertion into the calcaneus.1 Risk factors include increasing age, Achilles tendonopathy, systemic corticosteroids, previous steroid injections into or around the Achilles tendon, and use of quinolone antibiotics.1 2

Fig 1 On opening the paratenon at surgery, the two ends of a complete transverse rupture of the Achilles tendon, with an intervening gap (arrow), are seen. The plantaris tendon is intact (arrowhead)

How common is acute Achilles tendon rupture?

  • An acute rupture is commonly seen in squash, tennis, football, running, and other sports that require repetitive abrupt jumping or bursts of sprinting2

  • Injury may also occur from a fall or missing a step or a deep laceration …

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