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Achilles Tendon Injuries Clinical Presentation

  • Author: Anthony J Saglimbeni, MD; Chief Editor: Consuelo T Lorenzo, MD  more...
 
Updated: Jun 03, 2014
 

History

Patients with an Achilles tendon rupture frequently present with complaints of a sudden snap in the lower calf associated with acute, severe pain. The patient reports feeling like he or she has been shot, kicked, or cut in the back of the leg, which may result in an inability to ambulate further. In some cases, the patient can ambulate with a limp but is unable to run, climb stairs, or stand on his or her toes. (A very strong athlete usually is able to overcome the gait abnormality of an Achilles tendon rupture by using other plantar flexors to ambulate normally.)

Patient history in Achilles tendon rupture may also include any of the following:

  • Chronic, recurrent calf or Achilles tendon ̶ area pain
  • Previous rupture of the affected tendon
  • Loss of plantar flexion power in the foot
  • Swelling of the calf
  • Recent increase in physical activity/training volume
  • Recent use of fluoroquinolones, corticosteroids, or corticosteroid injections

Family history is a possible risk factor for Achilles tendon disorders. According to a study by Kraemer et al, individuals with a positive family history of Achilles tendinosis have a 5-fold greater risk for such injuries.[38]

Patient history in Achilles tendinosis may also include the following:

  • Paratenonitis: Localized/burning pain during or following activity occurs; as the disease progresses, onset of pain may occur earlier during activity, with decreased activity level, or even at rest.
  • Tendinosis: Usually, this injury is an asymptomatic, noninflammatory, degenerative disease process (mucoid degeneration); the patient may complain of a sensation of fullness or a nodule in the back of the leg
  • Paratenonitis with tendinosis: Activity-related pain and diffuse swelling of the tendon sheath with nodularity is present
Next

Physical Examination

With the patient in a prone position and his or her feet off the table, palpate the entire gastrocsoleus complex for tenderness, nodules, swelling, warmth, atrophy, and tendon defects, and note whether ecchymosis is present. Localization of the tenderness should be differentiated between musculotendinous (tennis leg), intrasubstance (Achilles tendon injury), and insertional (eg, Haglund deformity, pump bump).

Nodules should be palpated for tenderness, boundaries, mobility, and size. Calf atrophy, determined by comparison of calf circumference on the affected side with that on the contralateral side, may provide information as to the chronicity of the disease process (acute vs chronic). Gaps, or areas of tendon discontinuity, are often signs of partial or complete tendon rupture.

A patient with Achilles tendon rupture will be unable to stand on his or her toes on the affected side. Upon presentation, however, the individual may be able to weakly plantar flex his or her ankle due to the intact peroneal muscles, posterior tibialis tendon, or flexor hallucis tendons; therefore, misdiagnosis or delay in treatment may occur because the condition is believed to be just a strain.

Ascertain active and passive ROM and strength of the knee, ankle, and subtalar joints. Patients with overuse Achilles tendon injuries typically have decreased motion and strength in the ankle and/or subtalar joints.

Note the resting alignment and motion of the forefoot and ankle. Forefoot and heel varus, pronated feet, cavus feet, and tibia vara are known predisposing risk factors for Achilles tendinosis.

Clinical tests for Achilles tendon rupture

These include the following:

  • Hyperdorsiflexion sign: With the patient prone and knees flexed to 90°, maximal passive dorsiflexion of both feet may reveal excessive dorsiflexion of the affected leg
  • Thompson test: With the patient prone, squeezing the calf of the extended leg may demonstrate no passive plantar flexion of the foot if its Achilles tendon is ruptured
  • O’Brien needle test: Insert a needle 10 cm proximal to the calcaneal insertion of the Achilles tendon; with passive dorsiflexion of the foot, the hub of the needle will tilt rostrally when the Achilles tendon is intact.

Tendinosis

Tendinosis is often pain free. Typically, the only sign of the condition may be a palpable intratendinous nodule that accompanies the tendon as the ankle is placed through its range of motion (ROM). Occasionally, a thickening along the entire tendon may develop in chronic conditions.

Paratenonitis

Patients with paratenonitis typically present with warmth, swelling, and diffuse tenderness localized 2-6 cm proximal to the tendon's insertion. Crepitation may also be felt if paratenonitis presents acutely. As the condition becomes more chronic, symptoms may be provoked by decreased amounts of physical activity.

Paratenonitis with tendinosis

Paratenonitis with tendinosis is diagnosed in patients with activity-related pain, as well as swelling of the tendon sheath and tendon nodularity.

Previous
 
 
Contributor Information and Disclosures
Author

Anthony J Saglimbeni, MD President, South Bay Sports and Preventive Medicine Associates; Private Practice; Team Internist, San Francisco Giants; Team Internist, West Valley College; Team Physician, Bellarmine College Prep; Team Physician, Presentation High School; Team Physician, Santa Clara University; Consultant, University of San Francisco, Academy of Art University, Skyline College, Foothill College, De Anza College

Anthony J Saglimbeni, MD is a member of the following medical societies: California Medical Association, Santa Clara County Medical Association, Monterey County Medical Society

Disclosure: Received ownership interest from South Bay Sports and Preventive Medicine Associates, Inc for board membership.

Coauthor(s)

Christian J Fulmer, DO Private Practice in Sports and Family Medicine; Team Physician, Valley Christian High School

Christian J Fulmer, DO is a member of the following medical societies: American Academy of Family Physicians, American Academy of Osteopathy, American Medical Society for Sports Medicine, American Osteopathic Association

Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD Medical Director, Senior Products, Central North Region, Humana, Inc

Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Acknowledgements

Michael T Andary, MD, MS Professor, Residency Program Director, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine

Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Association of Academic Physiatrists

Disclosure: Allergan Honoraria Speaking and teaching

Edward Behn, MBBS, MRCS

Disclosure: Nothing to disclose.

David T Bernhardt, MD Director of Adolescent and Sports Medicine Fellowship, Associate Professor, Department of Pediatrics/Ortho and Rehab, Division of Sports Medicine, University of Wisconsin School of Medicine and Public Health

David T Bernhardt, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Sports Medicine, and American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Jason H Calhoun, MD, FACS Department Chief, Musculoskeletal Sciences, Spectrum Health Medical Group

Jason H Calhoun, MD, FACS, is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Diabetes Association, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Missouri State Medical Association, Musculoskeletal Infection Society, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, and Texas Orthopaedic Association

Disclosure: Biocomposite Grant/research funds Other

James K DeOrio, MD Associate Professor of Orthopedic Surgery, Duke University School of Medicine

James K DeOrio, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Foot and Ankle Society

Disclosure: Merete Royalty Other; SBi Royalty Other; BioPro Royalty Other; Acumed, LLC Honoraria Speaking and teaching; Wright Medical Technology, Inc Honoraria Speaking and teaching; SBI Honoraria Speaking and teaching; Integra Speaking and teaching; Datatrace Publishing Honoraria Speaking and teaching; Exactech, Inc Honoraria Speaking and teaching; Tornier Honoraria Speaking and teaching

Kevin J Eerkes, MD Clinical Assistant Professor, Department of Medicine, New York University School of Medicine; Medical Team Physician, New York University Athletics

Disclosure: Nothing to disclose.

Laura M Gottschlich, DO Assistant Professor of Family and Community Medicine, Medical College of Wisconsin; Consulting Staff, Family Medicine Residency Program, St Joseph Hospital, Wheaton Franciscan Healthcare

Laura M Gottschlich, DO is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Association, American Medical Society for Sports Medicine, and American Osteopathic Association

Disclosure: Nothing to disclose.

Richard Hargrove, MBBS, FRCS(Ire), FRCS Consulting Staff, Hip and Hip Revision Arthroplasty, Frimley Park Hospital

Richard Hargrove, MBBS, FRCS(Ire), FRCS is a member of the following medical societies: Royal College of Surgeons of England and Royal Society of Medicine

Disclosure: Nothing to disclose.

Sherwin SW Ho, MD Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, and Herodicus Society

Disclosure: Biomet, Inc. Consulting fee Consulting; Smith and Nephew Grant/research funds Fellowship funding; DJ Ortho Grant/research funds Course funding; Athletico Physical Therapy Grant/research funds Course, research funding

Shepard R Hurwitz, MD Executive Director, American Board of Orthopaedic Surgery

Shepard R Hurwitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for the Advancement of Science, American College of Rheumatology, American College of Sports Medicine, American College of Surgeons, American Diabetes Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Association for the Advancement of Automotive Medicine, Eastern Orthopaedic Association, Orthopaedic Research Society, Orthopaedic Trauma Association, and Southern Orthopaedic Association

Disclosure: Nothing to disclose.

Brian A Jacobs, MD, FACSM Consulting Staff, Private Practice, Family Medicine of South Bend; Team Physician, Marian High School

Brian A Jacobs, MD, FACSM is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, and American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

David Y Lin, MD Fellow, Department of Orthopedic Surgery, Section of Pediatrics, University of Tennessee Campbell Clinic

David Y Lin, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Henry Marano, MD Director, Department of Orthopedic Surgery, Associate Professor, St Joseph's Hospital, Albert Einstein College of Medicine

Henry Marano is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, and Medical Society of the State of New York

Disclosure: Nothing to disclose.

Chris McLean, MBBS, MRCS(Glasg), AFRCS(Ire) Specialist Registrar, Departments of Orthopedic and Trauma Surgery, Frimley Park Hospital, UK

Chris McLean, MBBS, MRCS(Glasg), AFRCS(Ire) is a member of the following medical societies: British Medical Association

Disclosure: Nothing to disclose.

Evan Schwartz, MD Director of Orthopedic Surgery, New York Medical College; Assistant Professor, St John's Queens Hospital, Department of Surgery, Albert Einstein School of Medicine

Evan Schwartz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Society for Sports Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM President and Director, Georgia Pain Physicians, PC; Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, Emory University School of Medicine

Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, American Medical Association, International Association for the Study of Pain, and Texas Medical Association

Disclosure: Nothing to disclose.

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