When was the last time you met a patient with a ruptured Achilles?
I’m hoping not too frequently in your world, as it’s pretty catastrophic for patients when it does happen.
I suspect, however, that occasionally some cases may pass by unrecognised, or are mislabelled as being partially torn.
How good are we at clinically spotting complete Achilles ruptures?
What does the literature say?
A systematic review by Michael Reiman et al. The Utility of Clinical Measures for the Diagnosis of Achilles Tendon Injuries: A Systematic Review With Meta-Analysis (J Athl Train. 2014 Nov-Dec; 49(6): 820–829.) says. “The calf-squeeze test has the strongest diagnostic properties of all measures investigated, with a +LR of 13.71 and a −LR of 0.04, giving it the ability to rule in or rule out an Achilles tendon tear to a large and almost conclusive degree.”
In the Br J Gen Pract. 2015 Dec; 65(641): 668–669, we’re reassured that:“Clinicians will never be falsely reassured by these history and examination findings if they remember to assess for Achilles tendon rupture specifically with the Simmonds’ calf squeeze test.”
I’m gonna beg to differ and Here’s why…
Recently, I had a delightful patient come to see, and alongside me in clinic was one of my favourite, most clinically talented, physiotherapy colleagues.
We assessed the patient together, and after the consultation I sent the patient for some imaging – an MRI scan on this occasion, as there was lot of calf bruising and posterior ankle pain. I could equally have chosen a dynamic ultrasound scan assessment.
I’ll admit that I felt a little conflicted, because my gut was telling me ‘this patient has definitely ruptured their Achilles’, but in conversing with my colleague, there was talk about avoidance behaviour because the patient could manage to just about get onto tip toe. This made me think – geez– am I really falling into the trap of over-investigating things?
Here’s the thing….. I’ve been caught out many, many years ago by a falsely reassuring squeeze test.
Our recent patient had reassuring signs on a squeeze test. The patient could also just about get onto tip-toe, too.
Their angle of dangle, however, was not quite symmetrical, and the patient though they had been kicked in the back of the leg.
The MRI showed the following: A very big gap in the Achilles.
In my book, even a whiff of a dodgy angle-of-dangle combined with a story of “I was utterly convinced I’d been kicked/shot in the back of the leg”, means they’re getting some MSK imaging done. (Sorry, Mr Health Insurer).
Potentially subjecting a patient to living with a debilitating and lengthened calf-complex, as a result of hoping all is well (on the basis of a falsely-reassuring squeeze test) is not want we want to do as clinicians.
So, I’m going to continue to listen to my gut, when it comes to Achilles injuries, and order that scan. Just in case.
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