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Acute Achilles tendon rupture — MSRA MCQ

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HardAnkle and FootAcute Achilles tendon ruptureMSRA

A 49-year-old man attends an urgent treatment centre 3 hours after feeling a sudden painful “kick” to the back of his left ankle while pushing off to sprint during tennis. He stopped immediately but was able to walk with a limp. He has swelling and bruising 4 cm proximal to the calcaneal insertion. He cannot perform a single-leg heel raise on the left. Calf-squeeze testing produces no plantarflexion of the affected foot, compared with normal plantarflexion on the right. There is a palpable tendon discontinuity. There is no bony tenderness over either malleolus, the navicular or the base of the fifth metatarsal, and he can take four steps. Distal pulses, sensation and capillary refill are normal. He has no previous VTE, active cancer, bleeding history, renal impairment or anticoagulant use. What is the most appropriate management today?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: B — Arrange same-day emergency or orthopaedic assessment for immobilisation in equinus, with VTE risk assessment and fracture-clinic follow-up

Explanation lettering: B = shown as A · E = shown as B · D = shown as C · C = shown as D · A = shown as E

This is an acute Achilles tendon rupture: the sudden push-off mechanism, loss of single-leg heel raise, palpable tendon gap and absent plantarflexion on calf squeeze are concordant clinical features. The ability to walk does not exclude rupture, because patients may retain some function through other plantarflexors. The priority is prompt immobilisation with the ankle in equinus (plantarflexion), which apposes the ruptured tendon ends, and urgent orthopaedic/trauma pathway assessment. Lower-limb immobilisation also requires formal assessment of both VTE and bleeding risk before discharge; pharmacological prophylaxis is considered where VTE risk outweighs bleeding risk. A is attractive because ultrasound can define tendon pathology, but it must not delay immediate protective positioning and referral when the clinical diagnosis is clear. B is inappropriate because Ottawa ankle-rule findings do not support radiography, and a neutral boot does not provide the required initial tendon-protective position. C confuses acute rupture with DVT: the mechanism and positive calf-squeeze test are diagnostic of tendon disruption, with no DVT-focused presentation. D risks tendon elongation and poorer functional outcome because active loading is not appropriate before initial immobilisation and specialist-directed rehabilitation.

Reference: Clinical Guideline: Fracture Management—ED, Foot and Ankle Trauma (Reviewed April 2022) — https://www.rightdecisions.scot.nhs.uk/media/1yfnbnvu/139-fracture-management-ed-gri-v8.pdf NICE NG89: Venous thromboembolism in over 16s—reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism (2018; updated 2019) — https://www.nice.org.uk/guidance/ng89/resources/%20venous-thromboembolism-in-over-16s-reducing-the-riskof-hospitalacquired-deep-vein-thrombosis-or-pulmonaryembolism-pdf-1837703092165 NICE QS201: VTE risk assessment for people with lower-limb immobilisation (2021) — https://www.nice.org.uk/guidance/qs201/chapter/quality-statement-2-venous-thromboembolism-risk-assessment-for-people-with-lower-limb