Where is the achilles tendon located
Achilles Tendon Rupture
this week for Yemen five we're gonna
talk about Achilles tendon rupture
now the Achilles tendon is actually the
largest and the strongest tendon in the
body but despite that it can actually
rupture sometimes it's formed right
where the gastrocnemius and the soleus
end and then it inserts into the
calcaneus and the problem is it has this
weak spot it's about 2 to 6 centimeters
above the calcaneus and it's because it
has bad vasculature there and so it's
prone to rupture rate at that spot now
the classic patient you'll see come in
is about 30 to 50 year-old male they're
doing this occasional very strenuous
activity maybe not as conditioned as
they could be for that activity and so
they end up with rupture and they could
also have increased risk if they have
prior quinolone use if they're on
steroids either they've had them
injected to that area or if they're on
oral steroids and the way they get it is
if they have a dorsiflex foot that has
some kind of force to it and they'll say
they have a sudden pain it develops and
they might even hear a pop or feel it or
feel like they're kicked in the back of
the foot and they'll say that they
possibly can't even walk they definitely
can't run they can't stand up on their
toes they can't go up steps these are
all things they might describe to you if
they're coming in with this ankle pain
and some things you're gonna know Don
physical exam first off have them go
into prone position it's easiest to see
this and you'll notice it first off the
back of the ankle probably is going to
appear someone swollen possibly bruised
they lose the definition here so this is
the non injured side you can see that
there is a nice defined at Gilley's and
on the other side you lose that
definition one other thing to note is
that on the affected side they lose that
plantar flexion that the normal side has
when the patient is at rest now imaging
is not that helpful to us in the ER most
of this is gonna come from physical exam
and from their history but say we do get
an x-ray these are some findings so this
is the normal side here and this is the
ruptured side so on the normal side we
see that there's this fat pad here it's
called the keggers fat pad or pre
Achilles fat pad right there it's a
triangle
I mean it's normal finding and you'll
also see that there's this very
well-defined Achilles tendon on the
affected side you'll see that there is
loss of the pre Achilles fat pad it's
somewhat modeled it's not as clear
there's also a lot of soft tissue
swelling and that nice definition of the
Achilles tendon is lost again these are
things you might
see on x-ray here's one more example
again we had loss of the pre Keeley's
fat pad and a lot of soft tissue edema
ultrasound might actually be a little
bit more helpful to us you can see the
Achilles tendon on ultrasound and here's
two calcaneus you might see on a partial
tear that there's a fluid collection
some disruption of the tendon or if it's
a complete tear the anatomy is all
distorted then there's a big gap in the
tendon so we said that physical exam is
probably actually the most helpful
there's one more test we can do called
the Thompson test and in this test
you're gonna squeeze the calf while the
patient is prone on the table and
normally you should see that the foot
has some plantar flexion as you squeeze
the calf now if it's ruptured especially
if it's completely ruptured you'll not
see any foot movement here on this side
okay let's look at some examples you can
see what you think is the abnormal side
okay so here we're squeezing the calf
you see a little bit of movement here
you're squeezing the calf there's
potentially a little toe movement but
really no England movement let's compare
again definitely has plantar flexion
this side no plantar flexion all right
in one more example this is a little
more subtle so squeezing the calf all
right which side do you think is
abnormal all right let's switch to the
other side
so now we're going to do the patient's
left foot remember they're prone so it's
backwards squeezing the calf and there
you can see really no movement at all no
plantar flexion so in that case it was
the left foot that was had the rupture
okay so for treatment if you were
suspicious at all for a rupture or tear
you're gonna put them in a posterior
short leg splint with slight plantar
flexion the best way to do this is just
to look at how the patient's normal foot
is at rest and try to copy that on the
other side they should be
non-weight-bearing and make sure they
follow up with ortho give them some
crutches tell them to do the standard
pain control icing and elevation all
right so three two remember you should
be able to get most of this on your
history and exam they might complain if
a pop sudden pain in the back of the
ankle and they can't go off on their
toes for the Thompson test have them lay
prone and squeeze the calf there's no
movement you should be concerned for a
complete rupture and if you're concerned
for a tarry rupture put them in a
posterior splint with slight plantar
flexion and have them follow up with
ortho here's the references thanks for
joining us on am
