Anatomy Msk · Year 1 · from Anatomy Msk
Case 2: Achilles Tendon Rupture
Clinical Image
Source: Wikimedia Commons - Achilles Tendon Rupture - CC BY-SA 3.0
Case Presentation
A 42-year-old man presents with acute left ankle pain after playing basketball. He was running and suddenly pushed off to sprint when he felt like he was "kicked in the back of the ankle." He heard a pop and immediately fell to the ground. He was unable to continue playing and has difficulty walking. He denies any prior Achilles problems but notes he had been taking ciprofloxacin for a urinary tract infection last week. Physical examination reveals swelling and ecchymosis over the posterior heel and distal leg. A palpable gap is present 4-6 cm proximal to the calcaneal insertion of the Achilles tendon. He has weakness of active plantarflexion but some movement is preserved (due to intact plantaris and toe flexors). Thompson test is positive - squeezing the calf while the patient is prone with feet hanging off the examination table does not produce passive plantarflexion of the foot. Simmonds squeeze test also positive. Ultrasound confirms complete Achilles tendon rupture at the watershed zone 4 cm proximal to insertion. After discussing options, he elects for operative repair given his active lifestyle. He undergoes primary surgical repair and is placed in a walking boot for 12 weeks with gradual rehabilitation.
Key Learning Points
- The Achilles tendon is the strongest tendon in the body, formed by the gastrocnemius and soleus
- Rupture typically occurs 2-6 cm proximal to insertion (watershed zone of relative hypovascularity)
- Mechanism: forceful push-off, sudden dorsiflexion, or direct trauma; often in middle-aged "weekend warriors"
- Risk factors: fluoroquinolone antibiotics, corticosteroid injections, chronic tendinopathy
- Thompson test (calf squeeze test): no plantarflexion with calf squeeze indicates complete rupture