the

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

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