A 23-year-old male fell and marathon runner, attended clinic with a 10-week history of
posterior left lower leg pain, which he injured, whilst out fell running. Prior to injury, the
man (Mr. K) was running his usual training regimen, in addition to having a physically
active job as a topographical surveyor. He is currently unable to train or perform certain
aspects of his work, as he feels as though he may have damaged his Achilles tendon
History of complaint: (*key findings)
Mr. K’s injury occurred 10 weeks previously during a regular training session in the
Peak District. He reports, he slipped several metres off a ridge, falling forwards with
his left foot wedged upwards and the left leg ‘forced backwards’ at the knee (i.e.
hyperextension at the knee and forced dorsiflexion to the left foot). The patient
reported simultaneous feelings of: sudden stretching; having been kicked hard*; and
an acute pain* to the back of the lower leg, below the level of the calf muscle but above
the ankle, with no audible sound on injury. A moderate amount of localised swelling*
and stiffness* but no bruising* was reported. Mr. K stated he felt the power* and
stability* to his left foot had been compromised post injury, but ‘the pain was not
terrible’ as he was still able to walk 3 hours downhill* before seeking medical attention
Following an initial x-ray and examination, no definable injury was determined. The
patient was advised to regularly apply ice, apply compression (supportive bandaging)
and to elevate (RICE) the effected limb for 2-3 weeks. He was thereafter following
improvement, directed to perform progressive load bearing (eccentric) exercises, and
to walk, as guided by the physiotherapist in weeks 3-6 post injury. This however
aggravated Mr Ks pain considerably. He was subsequently advised to reduce the
strain on the posterior compartment of the lower leg by off-loading with the use of an
aircast boot. Mr K continues to experience reduced dorsiflexion and pain on the
application of pressure to the posterior lower leg and is therefore unable to train and
perform sports as usual (Table 1),
Table 1. Usual Weekly Training Diary
Activities Frequency Duration
Running 4 times per week 2 hours
Gym 3 times per week 1 hour
Cycling 5 times per week ½ hour
Behaviour of present complaint:
A 9/10 VAS pain score at the time of injury, but the application of R.I.C.E. reduce the
swelling and pain to a minimum, with the additional combination of rest and gradual
loading of the tendon. Walking is not painful but there is tenderness or VAS 3/10 with
the application of direct pressure to the immediate area. The pain however improves
after twenty minutes on consumption of naproxen (Table 2).
Table 2. Aggravating and easing factors
Aggravating factors (VAS) Easing factors
Application of direct pressure to either the achilles midportion or the musculotendinous junction (3/10)
Taking naproxen reduces VAS from 3/10 to 2/10
The patient reports that since wearing the aircast boot he has developed right anterior hip ache/pain at the level
of the ASIS. P=2 This pain has remained low grade at 1/10 VAS
Wearing the aircast boot provided support to walk and promoted comfort to 0/10 VAS for left P=1 pain. (Table 2)
Past medical History:
The patient disclosed that his health is good with no cardiovascular, systemic,
endocrine, inflammatory or skeletal problems to note. He has never taken quinolone
antibiotics (with suspected correlation to tendon rupture) and regularly takes vitamin
supplements for their health benefits. Mr. K however endured an Anterior Cruciate
Ligament (ACL) rupture at the age of 18 years (also in the left leg), which resulted in
surgical repair. No residual pain or mobility problems from that injury were reported.
Figure 1. Body Chart Table 3. Initial symptom chart
The location of the pain was very specific to two areas: just proximal to the ankle where
the free tendon* is located and at musculotendon junction* of the gastrocnemius with
a VAS of 7/10 at time of injury only (Table 3). The patient complains of ankle instability*
however it has not collapsed or given way.
Symptom VAS Symbol
P2 also ache/
P2= (new hip pain)
Figure 2. demonstrates the current pain distribution experienced by the gentleman
over a 24-hour period. The aircast boot reduced the pain experienced in the left leg,
however on the application of pressure to the posterior leg, pain elevates to
approximately 3/10. Mr. K states that he is compensating heavily on his right leg whilst
wearing the aircast boot, this he feels is contributing to a recent experience of mild
right hip pain (VAS 1/10).
Figure 2. Pattern of pain over a 24-hour period
1. Achilles midportion tendon rupture.
2. Incomplete Achilles tendon rupture.
3. Achilles Tendon tear at the myotendinous junction
*Prior to physical evaluation a base line x-ray in A+E revealed no fracture.
0 0.5 1 1.5 2 2.5 3 3.5 Pain socre out of 10
Hourly distribution of pain at specified locations
24 Hour VAS Pain Chart
Left posterior leg pain Right hip pain
Examination findings- observational:
no evidence of upper body malalignment;
Slightly adducted legs with externally rotated patella alignment off the sagittal
left leg demonstrated a mild flexion (5°) at the knee due to elevation of aircast
boot and reduced weight bearing;
No swelling or ecchymosis located at the posterio-medial compartment or at
the level of the malleolus of the left lower leg. Atrophy of muscle bulk was
evident at the gastrocnemius of approximately 30-40%.
Both feet adducted with cavoid foot type.
An antalgic gait, with reduced dorsiflexion and stepping on the affected limb
was evident, with overcompensation on the right leg.
Table 4 below, shows the limitations of the patient’s lower limbs on testing.
Table 4: Functional Testing of the patient’s lower limbs
Tip toe test Able to perform, however reduced ability to plantarflex and load the forefoot due to lack of mechanical advantage Heel walking test unable to excessively dorsiflex
Double leg squat able to perform
Single leg squat unable to load and flex the left leg at the knee
Table 5 below demonstrates Mr. Ks clinical assessment findings.
Table 5: Clinical assessments and findings (on static palpation and passive loading/stress tests of both legs)
DF: 90° 90+10°
PF: 20° 25°
INV: 25° 25°
EVR: 10° 10°
No red flags noted
Left sagittal ankle ROM:
reduced dorsiflexion *by 10°
reduced plantarflexion *by 5°
Ankle Instability: Mild
Simmonds Triad (2) Tests for Achilles rupture:
Looking for the angle of declination at the
foot with the knee flexed to 90° (Matles test),
showing the foot drop into a more dorsiflexed
position due to loss of mechanical
advantage by the dysfunctional Achilles
tendon. This test was shown positive and
has a sensitivity of .88, and a specificity of
.92 (3) other authors second these findings
Feeling /palpation of the tendon for
gap/rupture. No discontinuities were noted
on palpation; however, the tendon was
painful, uneven and softer on the application
of pressure of the left tendon, than that of the
right. This test has been found to have a poor
sensitivity of .73 and a specificity of .82 (3).
Mobility of the gastrocnemius on squeeze
(Thompson) testing showed negative as
there was weak plantarflexion. This test has
a sensitivity of .96 and a specificity of .98 (3).
Table 5 (continued): Clinical assessments and findings (on static palpation and
passive loading/stress tests of both legs)
Talar tilt test (5):
The lower leg is held in one hand with the
calcaneus cupped in the other, then pressure is
applied to the lateral aspect of the talus. The talus
and calcaneus were assessed in relation to the
tibia and fibula and no pain or excessive mobility
Anterior drawer test (5):
The lower leg is firmly held at the anterior aspect
with the fore foot with the foot plantarflexed. The
other hand cups the calcaneus and it is drawn
anteriorly and vertically, at about a 60° angle from
its starting position. No pain or excessive
excursion was noted.
Both tests check the integrity of the talofibular and
the calcaneofibular ligaments, which appeared to
be intact and unremarkable. These tests are
however considered subjective to each
Pulses and sensation:
All neurovascular examinations were also
Following clinical assessment:
On palpation, no evidence of rupture was noted, the AT felt continuous but thickened.
Dorsiflex and plantarflex was possible at the ankle in both open and closed chain. A
reduction of sagittal motion identified at the affected ankle, with 10° less dorsiflexion
and 5° plantarflexion when compared to the contralateral ankle range of motion
(ROM). The Thompson test was negative, with plantarflexion of the affected foot
occurring when the gastrocnemius above was squeezed. Pain was only experienced
on the application of pressure to the affected limb at the midportion and at the
musculotendinous junction of the AT.
Mr. K had a 10-week history of a traumatic hyperextension of his left knee and ankle
after a fall from a height. Since the accident, the pain and swelling has improved
however, the reduced sagittal ROM at the ankle; Mr. Ks ability to weight bear, and his
poor level of mobility persist. Both subjective and objective findings are consistent with
an incomplete tear at the musculotendinous junction +/- incomplete rupture of the AT.
Hypothesis and prediction levels:
Tear at the musculotendinous junction (Grade II b/c) (90%)
Incomplete Achilles tendon rupture (10%)
Mr. Ks injury is mechanical given his reduced sagittal ROM and posterior leg pain,
consistent with his high impact hyperextension injury. Tearing at the muscle tendon
unit of the AT has been shown to result in localised bleeding and pain, with/ or without
paralysis (7). In Mr Ks case, no haematoma or neurological deficit was presented. Pain
and a loss of approximately 40% of muscle bulk was however a feature of his distally
affected gastrocnemius. A paucity of evidence has been noted on the diagnosis and
treatment of myotendinous rupture of the AT. Bianchi at al. (8) suggest that traumatic
partial tears are rare at musculotendinous junction (MTJ), however this location is
distinguished to be the weakest position of the muscle tendon and is extremely
vulnerable to overload.
Although uncommon, proximal AT tears are thought to involve the MTJ and the medial
head of the gastrocnemius (4). DeWall et al. (9) have examined the stiffness of the
tricepts surae from the Achilles tendon, and have found that the distal end of the
tendon to hold greater elastic properties than that of the proximal portion, propounding
vulnerability to injury. Acute atrophy of both the medial and the lateral heads of the
gastrocnemius have been noted as a strong indicator of injury at the MTJ, in addition
to the presence of oedema within the fibres of the muscles (10).
On clinical examination, continuity of Mr Ks bulky tendon was recognised on palpation.
On injury, the pain was sudden in onset, localised, and Mr. Ks ability to bear load was
compromised by his inability to reach optimal loading. These presentations are typical
of partial AT tear/ intratendinous tear (11) and must also be given due consideration.
It is argued that diagnosis of partial tears of the AT cannot be identified uniquely on
clinical examination but require imaging with high resolution ultrasound and colour
In this instance, it is thought that both hypothesis may closely coexist, given the
clinically identified injury to the distal end of the gastrocnemius muscles (MTJ) and the
tendon midportion pain and thickening on examination. Investigation reveal the extent
of injury and correlate with the presenting symptoms.
On the 5th week post injury Mr. K had an ultrasound and was subsequently advised to
immobilise the ankle due to findings which demonstrated ‘near complete rupture at the
level of the left AT with only a few remaining fibres seen’. The wear of an aircast
offloading boot was recommended and had been worn for 4 weeks by the gentleman’s
return to clinic. Image 1 below shows a Magnet Resonance Image (MRI) STIR (Short
T1 Inversion Recovery / fat suppressed) image at week 8 post injury.
Magnetic Resonance Image (MRI) -STIR, sagittal section of the left ankle.
Image 1. was reported (by a Senior Radiologist) showing a bruised thickened Achilles
tendon with a linear cleft or hypoechoic area (red arrow) at the level of the free tendon
which also reached the anterior surface of the tendon, suggestive of an midsubstance
rupture or partial tear. No gap was therefore evident on palpation. Anterior surface tear
of the tendon has been associated with pathological influences as this side of the
tendon is less loaded (12).
Table 6 (p12) demonstrates an MRI based scale of injury severity (1-4 grades) and
injury position (a, b or c). Based on this grading system, the tear in image 1 above
appears to be a possible grade 2 c as it extends into the tendon.
Table 6.: British athletics muscle injury classification (13)
MRI negative with positive symptoms (may be undetectable or referred
from another source)
Grade 1- Small tears <1cm with mild oedema (≤10% of the muscle and <5cm
longitudinal length within the muscle.
Grade 2- Moderate tear (fibre disruption >5cms); moderate oedema signal (e.g.
10-50% of muscle cross-sectional area or longitudinal length of 1
Grade 3- Extensive partial tear- fibre disruption of 5cms; extensive oedema signal
(e.g. >50% of muscle cross-sectional area or longitudinal oedema signal
Grade 4- Complete tear (rare in muscles)
Position of Injury
‘a’ - myofascial injury in the peripheral aspect of the muscle
‘b’ - an injury within the muscle belly, typically at the muscle-tendon junction
‘c’- An injury extending into the tendon (poor prognosis).
Partial tears are found mainly on the dorsal or skin side of the Achilles tendon, the side
of the tendon that takes the most tensile stress (14). A correlation has also been made
between partial tears and tendinopathic changes (thickened, irregular structure with
neovascular involvement) (15, 12). Mr. K has previously experienced an ACL rupture
at the age of 18, consideration of the possibility of histopathological tendinopathic
changes may merit further consideration.
MRI or Ultrasound?
It is argued that ultrasound should be the investigation of choice when identifying
incomplete tears of the achilles as the MRI is considered to lack specific subtleties
(14). Masci and Alfredson (12:49) in their study of partial Achilles tears discovered
common findings to aid with diagnosis, have been outlined below in Table 7.
Table 7. Specific ultrasound findings with colour doppler of partial Achilles
1. Thickening of the Achilles tendon midportion (>6mm)
2. Irregular and disrupted posterior (skin side) tendon fibres
3. Irregularity or disruption of the posterior tendon extending into the midportion
4. High blood flow in the region with tendon changes
At week 10 post injury further Ultrasound images were taken. The above conjoined
images (Image 2) have marked areas where midportion rupture is evident between
the Achilles free tendon and the musculotendon junction at the gastrocnemius.
Longitudinal view showing a thickened Achilles at the tendon midportion, with colour
doppler identified vascularisation within the tendon.
In the above image (3), there is evidence of moderate blood flow/hyperaemia in the
tendon area. A correlation between neovascularsation and pain has been identified
hence support for eccentric exercises and conservative treatment to reduce vascular
infiltration has been supported (16).
Transverse image of a partial tear of Achilles tendon with disruption to the fibres and
Ahmad et al. (17:1075) suggest the following rehabilitation for myotendinous Achilles
a removable achilles boot (Bledsoe Brace System) with 3 one-inch wedges
and to be non- weightbearing for 3 weeks.
An Achilles strengthening programme from weeks 3 with weights fitted into the
boot and the removal of one of the wedges.
A strengthening programme with a physiotherapist whilst fully weight bearing
and not wearing the boot.
Week 6 saw patients remove the boot at incremental stages with increased
activity depending on tolerance levels.
Weeks 6-12 saw patients return to work without constraint, dependent on their
levels of pain and functional progress.
Findings and management:
Practice appears to be varied in the UK and opinion based depending on the individual
(18). Maffuli (19) suggests that rates of healing and rerupture in the UK are comparable
between operative and conservative treatment. Maffulli advocates percutaneous
repair of tears at the musculotendinous junction to those who wish to return to sport
for better outcomes, as it has been shown that those who are conservatively managed,
were less likely to return to sport, and feel less confidence with their affected limb.
Conservative treatment is suggested in treating grade II injuries where muscle fibre
damage, swelling, pain and slight reduction in muscle strength is experienced (7).
Evidence provided by some authors has shown healing, reduced pain and improved
function with nonsurgical interventions in treating rupture in other areas of the body
(20, 21). Their treatment continuum consisted of immobilisation, rest and therapeutic
exercise or physiotherapy.
In the case of Mr. K, the findings suggest continuing with conservative management,
avoiding Achilles tendon eccentric loading extension for 3 months post injury as this
is associated with poor outcomes (14). The rehabilitation considered most effective in
cases of partial tendon tear would include: the use of heel lifts to ease the extension
on the tendon (and right hip area); and a modified activity level that would seek to
reduce tension on the midportion tear, promote healing, and a return to sport.
Given that the patient was Swiss, included here is the Swiss protocol for non-operative
treatment versus operative treatment (Ecker et al 2016) below in an algorithm format
(Appendix 1). Findings in this study saw that out of the non-operative individuals, 90%
had good-excellent outcomes.
Appendix 1. Swiss protocol for Achilles treatment
*Nonoperative treatment involved:
immobilisation foot in cast plantarflexed at 20° weightbearing on a 20° wedge
then fitted into a rehab rocker sole boot with adjustable posterior access.
low molecular weight heparin was also administered as prophylactic treatment
for deep vein thrombosis (DVT).
Acute rupture of Achilles tendon ≤ 48 hours after trauma ≤ 5mm approximation of stump
Start nonoperative treatment
Follow up after 10-14 days Assessment of resting plantar flexion
≤ 10° difference No resting plantarflexion > 10°
Continue with nonoperative treatment
Conversion to operative treatment
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