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PostPosted: 26 Aug 2018 21:35 
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A 50 year old accountant was playing squash with a colleague when he developed sudden pain in the left ankle. He thought he had hurt his ankle. Although he was unable to continue the game he was able to limp home. He then noted a swollen ankle the next day. He applied ice and took ibuprofen.

Although he continued to have pain at the back of his ankle he did not see his GP (Dr N) immediately. As the swelling and aching continued he saw his GP a month later. His GP took his history and found some swelling at the ankle. There was no tenderness but she noted an antalgic gait. His ankle movements were full. She diagnosed a sprained ankle and advised him rest and elevation.

Two months later as the pain and swelling persisted he went to the accident and emergency department. He wondered if he had sustained a fracture. The doctor in the hospital noted swelling over the Achilles tendon and a weak response to Simmond’s test.
When reviewed at the fracture clinic the following day the doctor considered the Simmond’s test to be normal but noted that the patient was unable to stand on tiptoe. An ultrasound scan however confirmed a complete tear with a significant gap at the Achilles tendon. The tendon appeared to have healed in an elongated position.

As his present problem was affecting his ability to run and play sports he made a claim against the first doctor. He alleged failure by the doctor to diagnose a ruptured tendon which resulted in delayed treatment that subsequently resulted in his poor recovery.

Outcome

The medical protection Society fighting the case denied liability, arguing that it was reasonable for Dr N for diagnosing a sprained ankle based on the history and clinical examination. MPS also indicated that the Simmonds test done at the fracture clinic was normal. On this basis the claim was discontinued.

Learning points
 Achilles tendon rupture is often seen in sports such as squash, tennis, running etc. It can also happen when you miss a step and land awkwardly
 Prompt diagnosis is essential. Any delay in treatment often results in poor outcome. The patient is left with a limp and difficulty in running.
 Delayed diagnosis often leads to more complicated surgery.
 Both negative and positive findings should be clearly recorded when you examine the patient.
 Achilles tendon rupture is often missed by nonspecialists in 20% of cases .

My Take on this case:
1. Patient delayed treatment himself by seeing a doctor a month after injury
2. The family doctor who saw him did not perform the "Simmonds Test". A weak test even at 1 month should have indicated a possible injury to Achilles tendon.
3. With the patient prone and the feet (and ankle) hanging free from the edge of the couch, squeezing the calf muscle will normally produce plantar flexion when the achilles tendon is intact. If there is no movement of the foot (plantar flexion) the Simmonds test should be considered as positive.
4. When seen immediately a torn achilles tendon can be treated conservatively by immobilising the ankle in equines by a plaster cast for 6 weeks. A delay of more that 2 weeks will require surgery to bring the torn tendon together.
5. He was seen at the A&E dept. 3 months after the injury. We should expect the Simmond's test to be weakly positive even otherwise, plantar flexion power would be considerably less compared to the opposite side.

Based on a Report in MPS casebook June 2018


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