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 Table of Contents  
IMAGES IN ACADEMIC MEDICINE: REPUBLICATION
Year : 2017  |  Volume : 3  |  Issue : 3  |  Page : 205-207

Diagnosis of Achilles tendon rupture with ultrasound in the emergency department setting


1 Department of Emergency Medicine, The Ohio State University Medical Center, Columbus, Ohio, USA
2 OPUS 12 Foundation, Columbus, Ohio, USA

Date of Web Publication21-Apr-2017

Correspondence Address:
David P Bahner
Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, Ohio 43210
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJAM.IJAM_16_17

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  Abstract 


The authors describe a case of a middle-aged male with ruptured Achilles tendon sustained while jumping. Bedside ultrasound was instrumental in making the diagnosis.
The following core competencies are addressed in this article: Medical knowledge, Patient care.
Reprinted with permission from: Peck J, Gustafson KE, Bahner DP. Bedside sonography primer: diagnosis of Achilles tendon rupture with ultrasound in the emergency department. OPUS 12 Scientist 2011;5(2):17-18.

Keywords: Achilles tendon rupture, bedside sonography, diagnostic imaging


How to cite this article:
Peck J, Gustafson KE, Bahner DP. Diagnosis of Achilles tendon rupture with ultrasound in the emergency department setting. Int J Acad Med 2017;3, Suppl S1:205-7

How to cite this URL:
Peck J, Gustafson KE, Bahner DP. Diagnosis of Achilles tendon rupture with ultrasound in the emergency department setting. Int J Acad Med [serial online] 2017 [cited 2019 Sep 23];3, Suppl S1:205-7. Available from: http://www.ijam-web.org/text.asp?2017/3/3/205/204947




  Introduction and Case Report Top


A 59-year-old male patient presented to the emergency department (ED). He complained of feeling a “snap” in his left ankle the day before presenting to the ED. He had been playing with his grandchildren and was jumping on one leg when he heard the snap and felt immediate pain in the left Achilles area. The pain was followed by swelling of his left ankle. An ankle X-ray was read as: “(a) No acute fracture or dislocation; (b) Thickened and ill-defined Achilles tendon likely related to Achilles tendon rupture; (c) post-traumatic changes to deltoid and tibiotalar ligaments (d) Diffuse soft tissue swelling.” [Figure 1]. Posterior ankle ultrasound was performed at the bedside, which demonstrated the rupture of the left Achilles tendon [Figure 2],[Figure 3],[Figure 4]. Contralateral Achilles tendon ultrasound was performed to obtain a view of a normal Achilles tendon [Figure 5].
Figure 1: Left ankle X-ray

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Figure 2: Left Achilles longitudinal view with disruption of the tendon fibers

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Figure 3: Left Achilles longitudinal view with rupture of the tendon fibers. Edema can be visualized between the proximal and distal stumps of the tendon

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Figure 4: Left Achilles proximal to rupture. Measurement of Achilles; tendon width in blue with values in the lower right corner of the image

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Figure 5: Right Achilles tendon, which is intact. Measurement of Achilles tendon is shown in blue

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  Discussion Top


To evaluate the Achilles tendon, the patient should lie prone to allow complete examination of the calf and ankle. The tendon is first evaluated longitudinally, in a sagittal plane. The transducer is then rotated 90 degrees and the tendon is evaluated in the transverse plane.[1]

The Achilles tendon is apt to injury in the region 2-6 cm proximal to the calcaneus insertion due to a relative decrease in vascularity to that area. Partial thickness tears can appear as an area of hypo- or anecho-genecity within the tendon disrupting the fibers. Full thickness tears have completely disrupted tendon fibers and can have tendon retraction. The tendon stumps are often tapered. It is important to keep in mind that an intact plantaris tendon can simulate the fibers of an intact Achilles tendon. In addition, dynamic imaging is an important key to the full examination of the tendon. With palpation of the calf muscles or passive movement of the foot, tendon retraction can make identification of the Achilles tendon stumps easier.[1]

Achilles tendon rupture evaluated with lateral radiographs shows soft tissue swelling and an Achilles tendon tear is suggested when the Kager's triangle is disrupted.[2] While evaluating partial Achilles tendon ruptures, in 1990, Kalebo found that soft tissue radiography only showed localized swelling and that ultrasound was a better method for detection of ruptures.[3] In the same study, Kalebo found that ultrasound was more accurate than computed tomography in identification of partial Achilles tendon ruptures.[3] Magnetic resonance imaging (MRI) accurately images Achilles tendon pathology.[4],[5]

Advantages to ultrasound imaging include direct correlation of image findings with patient symptoms, dynamic imaging, wide availability of ultrasound equipment, lower cost than MRI, and speed of examination. Disadvantages of ultrasound imaging include operator dependence, unfamiliarity with scanning technique, and limitation to imaging only structures superficial to the bony cortex.[6] An additional asset of ultrasound is that it can visualize the entire Achilles tendon, from the muscle body to the calcaneal insertion.

X-ray evaluation of tendons is limited, and MRI is costly and time-consuming. For many patients with suspected tendon injury, ultrasound may be a fast and cost-effective method of evaluation.


  Conclusion Top


In this case, the patient was referred to an orthopedic surgeon. The decision was made for operative repair of the Achilles tendon. Approximately 7 months after the surgical repair, the Achilles tendon was reported to be doing well. In summary, we provided a compelling argument for the utility of ultrasound in diagnosing Achilles' tendon in the emergency setting

Acknowledgment

Justifications for re-publishing this scholarly content include: (a) The phasing out of the original publication after a formal merger of OPUS 12 Scientist with the International Journal of Academic Medicine and (b) Wider dissemination of the research outcome(s) and the associated scientific knowledge.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jacobson, JA. Fundamentals of Musculoskeletal Ultrasound. Vol. 284. Philadelphia: Saunders, Elsevier; 2007. p. 308-18.  Back to cited text no. 1
    
2.
Cetti R, Andersen I. Roentgenographic diagnoses of ruptured Achilles tendons. Clin Orthop Relat Res 1993;286:215-21.  Back to cited text no. 2
    
3.
Kälebo P, Goksör LA, Swärd L, Peterson L. Soft-tissue radiography, computed tomography, and ultrasonography of partial Achilles tendon ruptures. Acta Radiol 1990;31:565-70.  Back to cited text no. 3
    
4.
Astrom M, Gentz CF, Nilsson P, Rausing A, Sjoberg S, Westlin N. Imaging in chronic Achilles tendinopathy: A comparison of ultrasonography, magnetic resonance imaging and surgical findings in 27 histologically verified cases. Skeletal Radiol 1996;25:615-20.  Back to cited text no. 4
    
5.
Keene JS, Lash EG, Fisher DR, De Smet AA. Magnetic resonance imaging of Achilles tendon ruptures. Am J Sports Med 1989;17:333-7.  Back to cited text no. 5
    
6.
Fessell DP, Van Holsbeeck MT. Foot and ankle sonography. Radiol Clin North Am 1999;37:831-58.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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