Achilles Tendon rupture

🦶 Achilles tendon rupture typically presents as a sudden “snap” or sensation of being kicked at the back of the ankle, most often during sporting activity. 🚫 Key risk factors: fluoroquinolones, corticosteroid injections, diabetes mellitus, obesity, and increasing age. 🔎 Hallmark sign: a positive Thompson calf squeeze test (absence of plantarflexion). ⚖️ Management trade-off: conservative treatment has a higher re‑rupture rate, whereas surgery lowers recurrence but increases wound and thrombotic risk.

📖 About Achilles Tendon Injury

• The Achilles is the strongest tendon in the human body, yet is vulnerable to rupture during sudden eccentric loading (e.g. jumping or sprinting).
• Often referred to as the “weekend warrior injury”, it most commonly affects middle‑aged recreational athletes.

⚠️ Aetiology & Risk Factors

• Sudden acceleration or deceleration during sport.
• Age‑related degenerative changes, exacerbated by diabetes or inflammatory arthritis.
• Medication‑associated: fluoroquinolones (e.g. ciprofloxacin) and repeated corticosteroid injections.
• Additional risks: obesity, poor conditioning, and systemic inflammatory disease.

🩺 Clinical Features

• Sudden sharp pain or audible “snap” in the posterior ankle or heel.
• Weak plantarflexion — patients may walk but cannot run or stand on tiptoe on the affected side.
• A palpable gap along the course of the tendon (best felt 2–6 cm proximal to insertion).
• Thompson test: squeezing the calf fails to produce plantarflexion.
• Partial ruptures may present subtly and still allow limited bilateral tiptoe standing.

🔍 Investigations

• Ultrasound: first‑line investigation; dynamic and readily identifies rupture location and severity.
• MRI: reserved for indeterminate cases or pre‑operative planning.

💊 Management

• Non‑surgical: functional bracing or boot immobilisation in plantarflexion; appropriate for partial tears or less physically active patients.
• Surgical repair: end‑to‑end tendon suturing; preferred in complete ruptures and younger, active individuals. Enables earlier rehabilitation but carries wound and DVT risk.
• Rehabilitation: physiotherapy is essential for all patients. Gradual strengthening, stretching, and proprioceptive training; return to sport typically takes 6–12 months.

⚡ Complications

• Re‑rupture (higher with conservative management).
• Wound complications, infection, or adhesions following surgery.
• Chronic calf weakness or muscle atrophy.
• Venous thromboembolism related to immobilisation.

🩺 Case 1 – Sudden Sports Injury

A 34‑year‑old man experiences a sudden “pop” in the posterior ankle while playing football, followed by pain and difficulty walking. Examination reveals swelling, a positive Thompson’s test, and inability to stand on tiptoe.
Management: 🏥 Immobilisation in plantarflexion (cast or functional brace), urgent orthopaedic referral. Surgical repair often advised for young, active patients. Early physiotherapy is essential.
Avoid: ❌ Misdiagnosis as a simple ankle sprain; avoid weight‑bearing until stabilised.

🩺 Case 2 – Older Patient on Steroids

A 65‑year‑old man on long‑term prednisolone for COPD presents with sudden ankle pain after stepping off a curb. Examination reveals a palpable tendon gap and weak plantarflexion.
Management: 💊 Non‑surgical functional bracing may be appropriate given comorbidities, with analgesia and physiotherapy. Consider surgery if functionally independent and fit.
Avoid: ❌ Unreviewed continuation of steroids or fluoroquinolones; prolonged immobilisation without VTE prophylaxis.