Achilles Tendon Rupture - Clinical Skills - Dr Gill

hello and welcome back to the channel you've joined me Dr james Gil for a blended clinical skills video we're going to be looking at the Achilles tendon rupture and how we examine that injury in the clinic with the Thompson test to start I think it'll be worthwhile to have a quick look at the Achilles tendon structure and how the Achilles tendon damage occurs now personally I think the Achilles tendon is probably my favorite tendon yes I'm a doctor i can say that i have a favorite tendon and not crazy for me to say it but the point is there's a lot here to learn i think probably one of the reasons is that it's the longest and the strongest tendon in the whole human body it allows us to be these bipedal creatures that can run and jump and heck walk upright the point is that the Achilles tendon in many ways allows us to be human so before we get much further into that let's discuss that here let's highlight some of the anatomy so we're all on the same page now with regard to the calf muscle we've got two main calf muscles gastromis and celius muscles yes there is a third muscle in some people the plantarus muscle but this is actually absent in between 10 and 20% of people side note I actually find the concept of vestigial muscles to be quite fascinating in the hand there's the vestigial palarus longus tendon when you put your thumb and index finger together you can see the palarus longus here just on the ulna side of FCR flex carpet radiialis it's interesting enough that I have only one in one wrist but not the other i'm not sure if that means half of me is evolved and the other half isn't but feel free to make your own jokes in the comment okay so returning to the main focus the Achilles tendon the Achilles is actually formed with a blending of gastronmus and cleasus muscle with this elastic tissue of the tendon connecting to the insertion on the calccanous or the heelbone so given that the Achilles tendon we've highlighted is both the longest and the strongest tendon in the body the question's got to be what can result in it being damaged well I tell let's give you some numbers if you're a weekend warrior then we're looking at an incidence of about 25 ruptures per 100,000 people per year if you're less interested in your failide game or your squash score then your incidents drop considerably to about seven per 100,000 but in both cases once you're in your 30s you're in the danger group for clarification we can split Achilles ruptures into two based upon time we've got acute ruptures those that follow a sudden injury essentially acute overload and then we've got chronic tendon ruptures which is something that occurs about four to six weeks after the original injury which is thought of overload of the tendon the way I think about chronic Achilles tendon injury is that the damage has already happened so you've maybe got a an overstress maybe you've got lots of micro tears but ultimately they're not able to heal fast enough for the straw that breaks the camel's back that one day weeks after your original innocuous level of overload suddenly the tendon can't hold it together anymore and bang there it goes so we've got the two main types of Achilles tendon rupture the acute and the chronic one happens bang straight away and the other gives away over time more of a long-term issue but in terms of triggers essentially it's the same for both we're looking at overload injuries anything that puts a huge amount of stress on the tendon so for example squash you know those acute changes in direction football certainly basketball can do it again it's all about anything that's got that explosive activity really however it's always a however in medicine there are also longerterm factors that can put a thumb on the scale and increase your risk of an Achilles tendon rupture occurring now frankly it's kind of what you'd think anything putting increased strain on the tendon so two big risk factors are the natural aging process which is why we see middle-aged individuals who are trying to keep themselves fit expose themselves to that active load are more at risk similarly obesity which you know a group of people that might want to be associated getting fitter are more likely to walk into an issue similarly you could get into an issue just because of what you're doing in training if you've got poor biomechanics so you're not running efficiently or your walking isn't great this again can increase strain on the attendant over time now there is something from our perspective as doctors that we can do to increase the risk and that's giving medications steroids for example they're a known cause of connective tissue damage which is why we give a lot of caution when we're doing steroid injections and knee but there's also other specific medications like floricquinolones such as cyproflux and antibiotic although we do appreciate that the risk of cypro causing tendon damage isn't quite as alarming as we previously thought it's still a risk factor and something we need to make sure we warn our patients about if they're given the course of these antibiotics crucially we'd say that they shouldn't overexert themselves in the following few weeks not days after having had this medication so fine we understand what an Achilles tendon rupture is now we want to now think about how our Achilles patient is going to come in sorry let me reframe that because some smart Alex's going to say the coming of our ambulance what I mean by that is how will they present so the patient is going to say they've suddenly crucial bit had severe pain in the calf or ankle and often it'll say that they felt like they've been shot or struck in the back of the leg they might even comment that there was an association of a loud bang in reality it's probably they felt the bang but it's the kind of thing that you would assume that you've heard not knowing that you've ruptured your tendon now because of where the tendons tend to rupture there's probably going to be swelling around the heel because most commonly we're looking at the distal part of the tendon which tears then we'll observe the patient walking and we'll see if they've got an impaired gate this is going to be particularly noticeable in the sense that there'll be an asymmetry to the gate because on the injured leg they're now going to have a decreased plantar flexion which is the main action done by the Achilles tendon so that's going to mean a reduced ability to push off their injured leg when walking now when we physically assess the patient we're going to find that they've got an inability to raise their heel off the floor kind of makes sense if you can't push down if you can't plan to flex the foot so given the main focus of the test for an Achilles tendon rupture the Thompson test it's all about count what movement can we get on the foot it kind of makes sense so when we're assessing a patient's ankle and calf we might find a classical step in the tendon where we can press with our thumb or our fingers and feel this the tendon is literally not connected anymore but then we're still going to do the uh the squeezing part of the Thompson test if we've got a rupture we squeeze the calf we're not going to see any plantar flexion because well they're not connected anymore now I mentioned you might be able to feel a step or a tear in the killilles but that's not just an academic point this tear or step is actually very important because how we're going to classify the degree of injury particularly so as um there's one type of Achilles tear where 50% of the tendon is actually intact we've only torn part of it it might still present with you know the same pain and possibly the tearing noise but again the whole thing hasn't torn as a result you're not going to get the same clear step and initially you're probably going to have to rely more on the clinical history and other parts of the examination because the Thompson test there is probably going to be negative however when we assess the power at the ankle or the gate we're probably going to see a difference there particularly a weakness to plant flexion it'll still be positive as in they'll still be able to move the foot but it'll just be weaker compared to the other one now this type of tendon tear a grade one Achilles rupture is really important because it's largely going to be treated conservatively after all for all the other grades of tendon tears we need to get the surgeons involved so for the grade one we want to recognize it and get the physiootherapists involved as soon as we can and hopefully that'll mean that we can get healing of the tendon and hopefully it'll mean that it won't progress to a grade two later on potentially which would again involve the surgeons so I've mentioned type two there here we've now got a full gap but it's under 3 cm in size which hopefully will mean it can be repaired without difficulty as we increase the level of damage we've got a type three Achilles tenant tear and that's where the gap is now growing we've now got a 3 to 6 cm gap and here we're probably going to have to crank up things a little bit more as the surgeons are probably going to need to include a graft in the repair then finally we've got the type four defect this is kind of got a little bit of a projorative name to it because it's often described as a neglect rupture and the reason for that is it's arguably more difficult to treat because the muscles involved have been ignored and they've actually contracted up so it's no longer a case of simply pulling the two seed ends together and stitching it up making a good anastmosis we've now got to facilitate a much larger operation potentially with you know the much larger graft crucially than if they'd been treated earlier as a result of this retraction this gap is going to be greater than 6 cm and you know we're not talking about a small tear here you know six cmters of movement of a tissue is a large issue and that's going to put more weight on the grafting because we need to make sure that the graft is strong enough to cover and with that the recovery is much more difficult for the patient and realistically the likelihood of a full return to functionalities before the injury is much less there's no such thing as never there are fantastic surgeons and amazing physiootherapists but this grade four injury where we're assuming an element of delay if we're not going to use the word neglect delay um before they get seen might mean that it's much more difficult to get back to that same level of functionality now when it comes to formally assessing the Achilles tendon whilst we might be pretty confident we know what's going on from what the patient said in their history the testing that's the thing that's going to confirm our diagnosis to that end the Thompson test is probably the most important part of our clinical examination um kit here it's a very specific and sensitive test sufficiently so that with a positive clinical examination you're only going to miss about 4% of patients you know that's a very good test yes you're still going to request future imaging such as ultrasound to confirm the grade of the tear but the majority of clinical diagnosis can be made clinically now that is still very very important because if we're able to make the diagnosis quickly and accurately then it reduces greatly the possibility of having a grade four rupture where part of the problem is the muscle has retracted so being able to accurately diagnose your patient with an Achilles tendon rupture is very very crucial so to that end once we've diagnosed the rupture if we're dealing with a grade one we want to go for conservative treatment so immobilize the foot initially and then send the patient to the physio if it's worse than grade one as mentioned we need to get the surgeons involved and then we're going to return the patient to the physiotherapist couch with immobilization as well as I've said the crucial thing with Achilles tendon tears is timing hence why it's important to understand and make sure that you're confident in delivering the Thompson test because it's going to give us the answer so quickly the longer there's a delay in starting care the greater uh the probability we're not going to be able to help the patient return to full functionality now what that means is going to differ from case to case it might mean that the strength of the muscles never returns to where they were it might mean that the repair was difficult thus there's going to be an increased risk of repeat tendon rupture or repeat repair rupture than there would have been otherwise now as I'm just a GP and not a physio I can't speak to the specific rehabilitation options but that said I do still understand that the physio is going to be key in all aspects of an Achilles tendon rupture yes the surgeons might put the patient back together but that is not enough we're still talking months of specific physio to get the patient moving again get that patient hopefully able to do what they want now it's important to highlight with that that there's going to be a range of different uh approaches to rehabilitation and whichever physio approach is taken the aim however is always going to be the same to help the patient return to their desired level of activity with the understanding that we're probably looking about six months of care needed to do so now when I say return to their desired levels of activity we need to understand that that's not just going back six month six weeks later and carrying on with six months of physio care we need to make sure that their return is gradually that word gradually is very important if a patient rushes back they're going to significantly increase the risk of rerupture potentially the operation anastmosis and that's going to make further repair and rehab much more difficult the second time around well I think at this point it's probably a good idea for us to get close and actually show you the Thompson test in action given that that's going to be the main um uh test that you're going to be doing to diagnose your Achilles tendon rupture so in terms of doing the Thompson test um we're going to feel along the Achilles tendon to see if we can feel any um steps and things like that then we're going to slightly planter flex the foot and I'm going to squeeze at the same time and as we can see doing so squeezes the uh tendon and the foot moves so if I squeeze here again we get that excellent move by having both legs at the same position I can check for again steps again slightly planter flex in the foot and squeezing again so I can do squeezing squeezing squeezing squeezing and as we can see there's slightly less movement here on the right than there is on the left so if we're doing the Thompson test one leg at a time we can have the patient stabilize themselves on the floor with one leg um on a a bench the weight going through that leg at 90° so I'm going to press along the Achilles tendon seeing if I can feel any steps which I can't then I'm going to slightly dorsif flex the foot and squeeze so there we have it the Thompson test and how to assess an Achilles tendon rupture hopefully this has been a useful video for yourself if there's other areas that you'd like us to look at please put it in the comments and we'll see if we can get round to that if you could help me out by um subscribing to the channel it certainly shows YouTube that we're here and also gives you a notification when we've got the next one up take care and we'll see you in the next one cheerio