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Squash and a squeeze

01 September 2012

Forty-seven-year old shop assistant Mr U had noticed a persistent pain in his heel for several months, which deteriorated suddenly whilst playing his weekly game of squash. It took him two weeks before he attended his local Emergency Department, where he was x-rayed and diagnosed with a bony spur on his calcaneus. He was advised to rest and to follow-up with his own GP if it did not resolve.

For the next three months, the symptoms continued and Mr U saw his GP Dr V on several occasions to have his leg examined. He distinctly recalled two separate episodes of acute heel pain when he was playing squash, which he felt had precipitated his ongoing symptoms. No weakness or immobility was noted, and the pain appeared to be isolated to the heel only. Reassured by the normal x-ray and unremarkable examination, Dr V recommended further conservative treatment.

Unfortunately, Mr U’s heel pain did not resolve and he reattended a few weeks later complaining of swelling and erythema of the calf on the affected side. A definitive diagnosis was not obtained, and over the course of several weeks he was investigated for DVT on two occasions and commenced on antibiotics for suspected cellulitis.

Three months after the initial event, symptoms remained much the same and Dr V sent Mr U to see an orthopaedic consultant in clinic. The orthopaedic surgeon made a clinical diagnosis of an Achilles tendon rupture, which was then confirmed with a soft tissue ultrasound. Mr U required surgical repair of his injury and made a very slow recovery with various complications. He made a claim against Dr V for the delay in diagnosis.

The case was complex since it was considered that it was not a case of sudden rupture of the Achilles, with the more recognisable associated signs, and it would have been very difficult for the GP to make an early diagnosis, especially as the patient did not present immediately following injury. It was further complicated by the fact that there was no mention at all of a calf squeeze test having been performed, so it was difficult to judge at what point the tendon finally snapped. Expert evidence was sympathetic to the unusual presentation of the case, but felt that there were weaknesses in the case because there was no documentation of the squeeze test. The case was therefore settled for a moderate sum.

Learning points

  • No matter how careful you are and how much effort you take on dealing with your patients in an appropriate manner, things sometimes do go wrong. Most doctors will have at least one claim against them during their practising lives.
  • Documenting consultations thoroughly is essential. Keep records of any specific test or examination carried out – “whatever is not written has not happened” is a good safety motto.
  • The calf squeeze test is used to examine the integrity of the Achilles tendon. The patient lies prone with the foot extended beyond the edge of the examination couch. The examiner squeezes the calf and watches the foot for mild plantarflexion in a normal exam. Lack of ankle movement can indicate rupture of the Achilles tendon. A useful link to a reminder about the squeeze test can be found here.