How to heal the heel

Author: Juan Pablo Nieto, MD

Peer-reviewer: Brandon Godfrey, MD

Final editor: Alex Tomesch, MD

45 year-old male and "weekend warrior" presents with sudden onset of posterior heel pain while playing basketball and also states he felt a 'pop'. He is tender at the distal posterior ankle and unable to fully plantarflex the foot. He has the following ultrasound findings. 

 

Image 1. Case courtesy of Dr Bruno Di Muzio, From the case rID: 11022

1. What is your diagnosis?

2. What is your management in the ED?

3. What is your disposition? Do you consult orthopedics emergently?

 

 

 

 

 

-- see below for answers --

 

 

 

 

 

What is your diagnosis?

This patient is diagnosed with an achilles tendon rupture. This injury is typically caused by pushing off suddenly with the forefoot while extending the knee. The tendon usually tears 2-6 cm proximal to its distal insertion where there is poor blood supply. [2]

• Pearl: Positive Thompson sign is diagnostic. Squeeze calf muscle and watch for plantarflexion, if absent, it is consistent with Achilles tendon rupture.

• Pearl: To avoid missing a calcaneal avulsion fracture which requires surgical treatment, obtain ankle radiographs and look for this fracture on the lateral view

 

Image 2. Case courtesy of Assoc Prof Frank Gaillard, from the case rID: 35974 [4]

2. What is your management in the ED?

If no other injuries are noted, a short-leg posterior splint in slight ankle plantarflexion should be applied and the patient made non-weightbearing. 

3. What is your disposition? Do you consult orthopedics emergently?

The patient can be discharged home with outpatient orthopedic follow up. 

 

• Pearl: The 2 definitive treatment options are casting vs surgical repair. Casting has a faster return to activity timeline and is usually recommended for older and less active patients. Surgical repair has a longer recovery time but its risk of tendon re-rupture is lower, 1-4% vs 10-30% with casting [5]. 

 

References:

1. Case courtesy of Dr Bruno Di Muzio, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/11022">rID: 11022</a>

2. Achar, S. A., & Taylor, K. S. (2020). The 5-minute sports Medicine Consult (3rd ed.). Wolters Kluwer. 

3. Achar, S. A., & Taylor, K. S. (2020). The 5-minute sports Medicine Consult (3rd ed.). Wolters Kluwer. 

4. Case courtesy of Assoc Prof Frank Gaillard, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/35974">rID: 35974</a>

5. Cetti R, Christensen SE, Ejsted R, et al. Operative versus nonoperative treatment of Achilles tendon rupture. A prospective randomized study and review of the literature. Am J Sports Med. 1993;21:791-799 [PMID:8291628]

For more reading about Achilles Tendon Ruptures follow the link to WikiSM here!

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