Endgames Case Report

A case of sudden ankle pain

BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e4420 (Published 24 July 2012) Cite this as: BMJ 2012;345:e4420
  1. Dominic Yue, foundation year 21,
  2. Jasmine Ho, foundation year 22,
  3. Nawfal Al-Hadithy, core trainee year 22
  1. 1Royal Free Hospital, London NW3 2QG, UK
  2. 2Lister Hospital, Stevenage, SG1 4AB, UK
  1. Correspondence to: D Yue domyue{at}doctors.org.uk

A 55 year old man presented with a sudden onset sharp pain in his right lower calf. It occurred while he was lunging forward in a game of tennis, and he had to stop playing. The initial pain, described as “like a hammer blow,” subsided, and on admission to hospital his only symptom was discomfort around the posterior aspect of his right ankle. He was able to weight bear and mobilise with some difficulty. He had no other injuries, had not previously experienced trauma to the area, and was fit and well apart from taking allopurinol for gout. There was no family medical history of note. He is a non-smoker and drank alcohol occasionally.

On examination, the right lower calf area was swollen and mildly tender. A depression was palpable along the Achilles tendon about 3 cm proximal to the site of tendon insertion at the calcaneus. He was neurovascularly intact and the range of movement was unaffected. The Simmonds-Thompson test was positive. Routine blood tests were unremarkable and a radiograph of the ankle showed no evidence of bony injuries.


  • 1 What is the most likely diagnosis?

  • 2 What are the risk factors for this condition?

  • 3 What would you expect to find on physical examination?

  • 4 What further investigations would you do?

  • 5 How would you manage this patient?


1 What is the most likely diagnosis?

Short answer

Spontaneous rupture of the Achilles tendon.

Long answer

The Achilles tendon, also known as the tendocalcaneus, is formed from the fibres of the soleus and gastrocnemius muscles and inserts into the calcaneus. Despite being the largest and strongest tendon in the body, it is the most commonly ruptured tendon in the lower limbs and comprises around 20% of all large tendon ruptures.1 2 Spontaneous rupture has an incidence of 0.02% in the general population.

It most commonly occurs in active people, …

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