I reviewed this lady in her 40's in my ultrasound clinic 6 months post injury. She informed me that when landing from a jump, during an exercise session she heard a loud snapping sound and felt an immediate severe pain in her right Achilles area. She was unable to walk and was brought to an A&E department. She had an x-ray done which was negative. She was told that she had suffered an “Achilles Sprain” for which nothing could be done except wait for it to heal.
She subsequently carried on with her normal ADLs as best she could. She had been limping around for several months when seeing her GP who referred her to our department for further evaluation and management. In the mean time she had made some gradual improvements. She was now able to walk without a significant limp. She was however unable to run. As she was an active person who enjoyed running and working out in the gym this was not a great outcome. She did not suffer from any pain but felt that she was lacking power in the affected leg.
Clinical examination showed a thickened contour of the Achilles tendon at least twice the thickness of the non-affected side. She was unable to go on tiptoes on the affected side. She certainly could resist manual plantar flexion reasonably well. Palpation revealed noticeable interruptions in the normal smooth linear outline of the Achilles tendon when following from calcaneus towards MTJ. These irregularities were felt in the mid part of the tendon. Thompson or Simpsons test was sluggish. The finds were suggestive of an achilles rupture.
(See the video above for an overview of the ultrasound images)
Ultrasound revealed a grossly enlarged and abnormal tendon. The appearance was hypo-echogenic but with multiple hetero-genous areas throughout. In the long view moving from calcaneus in a cranial direction a very bulky tendon could be seen which had lost its tension and was displaced anteriorly (Figure 2) a very clear tendon stump could be seen demarcating the proximal torn end of the distal tendon.
Moving further cranial I could see no clear fibrillar echo-texture at all indicating that there was complete absence of tendon fibres (Figure 3) . It was interesting to note that a hypertrophic plantaris tendon could clearly be seen in this area. I guess the still intact plantaris muscle was attempting to compensate for the ruptured Achilles tendon. Moving further proximal after at least 5 cm some tendon strands again became visible Indicating the start of the proximal tendon stump (Figure 4).
I discussed my findings with this lady and referred her for an Orthopaedic opinion whilst still receiving physiotherapy treatment. She had recovered some power with physiotherapy but I warned her that high impact explosive activities would not be appropriate/possible. I was unsure as to the benefit of surgical intervention at this stage but felt that she still required a surgical opinion to at least discuss this option.
Of note, she had good power of plantarflexion, so isolated strength testing in supine does have its limitations for assessing the integrity of the achilles tendon.
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