Remember analgesia.Always assess and record the patient's ability to bear weight
History
- "Snap" at ankle / calf (textbook = painful, often not!)
- Reported at "push off" during sport
- Beware - may be the initial trigger (hidden) for "twisted" ankle
Ask about
- Steroid or Quinolone use
- Rheumatoid arthritis
- SLE
- Renal failure
- Hyperparathyroidism
- Hyperlipoproteinaemia
- Gout
Examination
- Cannot toe weight bear on that side
- Observe # foot may not rest in natural plantar-flexion
- Palpable step in Achilles Tendon
- Thompson test - lie prone and calf squeeze produces plantar flexion in normal individuals
- Matles test - lie prone, knees flexed 90°, gravity makes # side ankle more dorsiflexed
Differential
- Server's (calcaneal apophysitis) in teenagers
- Peroneal tendonopathy or dislocation
- Retrocalcaneal bursa, Os trigonum syndrome
- Ankle OA, Systemic arthritis (check other side)
- Sural neuroma (or referred pain from sacral roots)
s
Management
- Refer to on call orthopaedic team
- Operative repair is preferable to conservative management [Bestbets].(NNT=10, NNH=21 [Bandolier])
- If conservative Mx consider prophylactic anticoagulation (LMWH) particularly if high risk of VTE or prior DVT.[BestBets]
| Type | Consider |
|---|---|
| Type 1: <50% tear | Cast for 8 weeks |
| Type 2: defect < 3cm | Surgical anastimosis |
| Type 3: defect 3-6 cm | Anastimosis or graft |
| Type 4: defect >6cm (incl. delayed repairs) |
Tendon graft |
Thromboprophylaxis
In patients immobilised in leg casts:
- Consider prophylactic anticoagulation (Rivaroxaban or LMWH).[BestBets]
- CUH EM and Orthpaedic divisions have (Feb 2013) reviewed the literature (including the 2012 Oct CEM guideline). Prophylactic anticoagualtion is not required those pateints discharged in a splint but should be considered in all in PoP
- Achilles # patients in equinus PoP are particularly prone to VTE