Achilles Tendon Injuries Clinical Presentation

Updated: Sep 12, 2018
  • Author: Anthony J Saglimbeni, MD; Chief Editor: Dean H Hommer, MD  more...
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Presentation

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. [39]

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.

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