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Delayed diagnosis of Achilles tendon rupture

19 July 2018
By Dr Anna Fox, GP

Mr E, a 50-year-old accountant, was playing squash with a colleague after work and hurt his left ankle. He couldn’t keep playing but he was able to walk, so he went home. The next day his ankle became quite swollen, so Mr E kept it on ice and took some ibuprofen.

He did not see a GP at the time because he was busy at work. He was still able to walk, although he had pain around the back of his ankle and heel. A month later, the swelling and aching around his ankle did not seem to be settling down, so he made an appointment with his GP, Dr N.

Dr N noted that his ankle had been very painful and swollen after the injury, although overall it was significantly better. She examined Mr E and found that his gait was antalgic. She documented mild swelling but no tenderness to the ankle, and noted that his ankle had full range of movement. She diagnosed a sprain and advised Mr E to rest the ankle, elevate it when he was sitting and to use a compression bandage in the daytime.

Mr E followed the advice but was getting very frustrated since his pain and swelling failed to improve. Two months later his pain worsened and he was finding it hard to fully weight bear.  He went to the Emergency Department (ED) to see if he needed an x-ray. He wondered if he could have broken a bone with the initial injury and that was why his symptoms were not settling down.

The ED doctor noticed a swelling over his Achilles tendon and a weak plantar response to a Simmond’s test. It was also noted that he was unable to stand on tiptoe.

A review by the fracture clinic the following day considered the Simmond’s calf squeeze test to be normal, but again noted Mr E’s inability to stand on tiptoes. A rupture of his Achilles tendon was suspected, and an ultrasound scan confirmed a complete tear with a significant gap.

Mr E’s tendon healed but in an elongated fashion, affecting his ability to run and play sports. He made a claim against his GP, Dr N, alleging failure to diagnose a ruptured Achilles tendon, thus delaying treatment and adversely affecting his recovery.
 
Outcome
In this case, based on the medical records and the assessment of the legal team, Medical Protection was able to serve a letter of response denying liability. In the letter of response it was argued that it was reasonable for Dr N to diagnose an ankle sprain based on the history and her clinical examination. The letter highlighted that as the Simmond’s test performed at the fracture clinic was normal, it therefore would likely have also been normal at the time of Dr N’s examination. The claim was discontinued by Mr E’s solicitors.
 
Learning points
  • Rupture of the Achilles tendon can be seen in sports such as squash, football and running, but can also occur as a result of missing a step when walking and a subsequent abrupt landing.
  • Prompt diagnosis of Achilles rupture is very important. A delay in treatment can lead to poorer outcomes, since a discontinuous or lengthened tendon can cause weak plantar flexion. The patient can be left with a limp and difficulty running, heel rising and stair climbing. More complicated surgery, with longer scars and higher risks of complications, may  be needed, and return to sports may not always be possible.1
  • Examination details, including negative findings, should be clearly documented.
  • Achilles tendon rupture can be missed by non-specialists in about 20% of cases. It can be missed for multiple reasons that clinicians should be mindful of.1,2
  • If in doubt regarding the diagnosis, further opinion should be sought.
References

  1. Singh D, Acute Achilles tendon rupture, BMJ 351: h4722 (2015)
  2. https://cks.nice.org.uk/achilles-tendinopathy
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