Background
The patient is 37 years old. Cohabitant. Works as a paramedic. Previously healthy. Comes to the emergency room for examination.
During a volleyball match, a jump triggered acute pain at the back of the left ankle (VAS 6), down toward the heel. The patient felt it like a kick to the calf and heard a pop when the pain occurred. It immediately became difficult to walk. The patient is now unable to bear weight on the left leg and feels weakness during plantar flexion.
Consultation video
Medical history
- Doctor
What happened?
- Patient
I played volleyball, and when I jumped I suddenly got really bad pain in the back of my left ankle, down towards the heel.
- Doctor
Did it happen suddenly right then?
- Patient
Yes, completely suddenly. It almost felt like someone kicked me in the back of the leg.
- Doctor
Did you hear or feel anything unusual when it happened?
- Patient
Yes, I heard a pop at the same time as the pain came.
- Doctor
Were you able to continue afterward?
- Patient
No. I had trouble walking immediately.
- Doctor
What is the biggest problem now?
- Patient
I cannot put proper weight on my left leg, and I feel weak when I try to press my foot down.
- Doctor
How painful is it now?
- Patient
About six out of ten.
Standard examination
Perform standard examination:
- 1 Inspection
- 2 Active movements
- 3 Passive movements
- 4 Isometric movements
- 5 Palpation
Tentative diagnosis
based on medical history and standard examination- Achilles tendon rupture.
Examination
Special tests to strengthen or weaken the likelihood of the tentative diagnosis.
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1. Inspection and loading
Doctor
I want to first see how you stand and walk.
Patient
Clearly offloading the left leg.
I can't get proper pressure on that leg.
Findings
- Problem with walking.
- Unable to bear normal load on the left leg.
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2. Palpation of the Achilles tendon
Doctor
I feel a bit at the back of the ankle and the calf. Tell me where it hurts.
Patient
Reacts with precise, recognizable pain on palpation along the Achilles tendon about five centimeters above its attachment on the calcaneus.
Yes, it hurts there.
It is located a little above the heel.
Findings
- Pain on palpation along the Achilles tendon approximately five centimeters above the tendon attachment on the calcaneus.
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3. Active plantarflexion
Doctor
Can you try to point your foot downward?
Patient
I try, but I can't do it well. There is clearly functional impairment, not just pain inhibition.
No, I can't do it properly.
Findings
- Problem with performing plantarflexion.
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4. Passive dorsiflexion and stretching of the Achilles tendon
Doctor
Now I will bend your foot slightly upwards. Let me know if it hurts.
Patient
Reports pain at the back of the calf when the forefoot is pushed upward and the Achilles tendon is stretched.
Yes, it hurts at the back of the calf.
Findings
- Pain at the back of the calf when the forefoot is pushed upward.
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5. Single-leg calf raise
Doctor
Can you try going up on your toes on your left leg?
Patient
Cannot perform the test on the left side. There is a clear loss of function.
No, that will not work.
Findings
- Cannot perform calf raise on one leg.
-
6. Isometric strength test in plantar flexion
Doctor
Press your foot down against my hand and hold back.
Patient
Trying, but shows clear weakness on the left side. This is interpreted as weakness, not just pain.
It is much weaker there.
Findings
- Weakness in isometric testing of plantar flexion.
-
7. Thompson test
Doctor
Now I am going to squeeze your calf. Just relax your foot.
Patient
Kneeling on the bench so that the calf muscles are well relaxed.
It feels strange, I don't get proper movement there.
Findings
- In Achilles tendon rupture, compression of the calf does not produce normal plantar flexion in the ankle. The test is positive.
Learning points
- 1 Classic medical history in Achilles tendon rupture with a sudden event, a pop, and the feeling of being kicked in the calf.
- 2 Functional tests like heel raise and isometric plantar flexion are important.
- 3 Local tenderness on palpation of the Achilles tendon and pain during stretching.
- 4 The Thompson test has clinical value in such a situation.