Makindo Medical Notes

🦶 Achilles tendon ruptures are classically described as a sudden "snap" or "kick" at the back of the ankle, often during sport. 🚫 Risk factors include fluoroquinolones, corticosteroid injections, diabetes, and increasing age. 🔎 The Thompson calf squeeze test is the hallmark diagnostic sign. ⚖️ Non-surgical treatment carries a higher re-rupture risk, while surgery reduces recurrence but increases wound complications.

📖 About Achilles Tendon Injury

• Despite being the strongest tendon in the body, the Achilles is prone to rupture under sudden eccentric load (jumping, sprinting).
• Often termed the “weekend warrior injury”, it typically affects middle-aged recreational athletes.

⚠️ Aetiology & Risk Factors

• Repetitive sporting stress or sudden acceleration/deceleration.
• Degenerative thinning with age, worsened by diabetes or arthritis.
• Medication-related: fluoroquinolones (e.g. ciprofloxacin), repeated corticosteroid injections.
• Other: obesity, poor conditioning, and systemic inflammatory disease.

🩺 Clinical Features

• Sudden sharp "snap" or "kick" sensation in the heel/ankle, sometimes audible.
• Weakness in plantarflexion; patients may walk flat-footed but cannot run or stand on tiptoe on the injured side.
• Palpable gap along tendon course.
• Thompson test: calf squeeze fails to cause plantar flexion (positive test).
• Partial ruptures: more subtle, may still allow limited tiptoe standing with both feet.

🔍 Investigations

• Ultrasound: First-line, dynamic, identifies site and extent of rupture.
• MRI: Reserved for equivocal cases or surgical planning.

💊 Management

• Non-surgical: Rest, ice, compression, elevation (RICE), functional bracing/boot in plantarflexion; suitable for partial tears or less active patients.
• Surgical repair: End-to-end tendon suturing; preferred in complete tears and active individuals. Allows faster rehab but carries wound/DVT risk.
• Rehabilitation: Physiotherapy essential for both strategies. Gradual strengthening, stretching, and proprioception training. Return to sport may take 6–12 months.

⚡ Complications

• Re-rupture (higher with conservative treatment).
• Wound healing problems, infection, adhesions (surgery).
• Chronic calf weakness or muscle atrophy.
• DVT risk with immobilisation.

🩺 Case 1 — Sudden Sports Injury

A 34-year-old man felt a sudden "pop" in the back of his ankle while playing football, followed by severe pain and difficulty walking. On exam: swelling over the Achilles tendon, positive Thompson’s test (no plantarflexion on calf squeeze), and inability to stand on tiptoe. Management: 🏥 Immobilisation in plantarflexion (cast or functional brace), early orthopaedic referral. Surgical repair often offered to young/active patients. Physiotherapy essential for rehab. Avoid: ❌ Missing the diagnosis by assuming it is 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 pain and weakness in the left ankle after stepping off a curb. Exam: palpable gap in the Achilles tendon, weak plantarflexion, and difficulty walking. Management: 💊 Non-surgical management with functional bracing may be appropriate given comorbidities; analgesia and physiotherapy. Surgical repair if fit and active. Avoid: ❌ Continuing steroids or fluoroquinolones without review (increase rupture risk); avoid prolonged immobilisation without venous thromboembolism prophylaxis.