This month’s case is that of a 29-year-old male who presented to the London Foot and Ankle Centre in November of 2019. Whilst playing football in March 2019 he sustained a rupture of his left Achilles tendon and he attended A&E where an ultrasound was performed and a gap of 6mm detected. This was treated non-operatively in a plaster for four weeks followed by a boot for eight weeks.
In June 2019 everything seemed on course. He commenced physiotherapy. This was going as one would expect but in October whilst doing a physio exercise (this is seven months following the injury) he felt a tearing sensation in his calf.
He went back to the original surgeon and had an ultrasound and an MRI scan and these were reported as showing a 6cm gap between the tendon ends with intervening scar tissue.
LFAC 1st Consultation
When I saw him in November 2019 he was otherwise well but he was limping and had no strength in his calf and could not perform any sports. He had been offered an FHL tendon transfer and excision of the scar tissue and was seeking a second opinion.
On examination on the couch with his feet dependant there was an asymmetry with the left hind foot held at a neutral position i.e. the foot was at 90 degrees to the lower leg, whilst on the right side he had 20 degrees of plantar flexion. His calf squeeze test showed very little movement on the left whilst there was movement on the right.
At the consultation I only had the MRI scan to view without the reports and this was a poor quality MRI scan where I was unable to say whether what I was seeing was scar tissue or tendon. As is often the case when a patient has been seeing an unknown physio and an unknown orthopaedic surgeon I was not confident that he had been properly and accurately assessed. I suggested that he saw ‘one of my physios’ whom I trust. I also suggested that he have a further ultrasound performed and initially he was reluctant as he was a self-funding patient and had already spent a lot of money on this episode in his life.
Physiotherapist Reported Loss of Tension
He was duly seen by my physiotherapist who informed me that he was unable to help because there was loss of tension in the tendon and the patient came back to me to discuss this. I said at the time that until I had seen an ultrasound performed by a radiologist whom I trusted I was not able to advise him on the best way forward. He duly underwent the ultrasound on 6 January and the ultrasound report revealed that there was healing of two tears of his Achilles tendon, one at the mid Achilles which was the first tear and a second at the musculotendinous junction which was the tear that had occurred in October.
No Need for FHL Tendon Transfer
Both of these tendons had healed and the intervening tissue was in fact tendon, not scar tissue. I explained to him that there would almost certainly be no need for an FHL tendon transfer. This an operation to salvage the missed Achilles tendon rupture and results in about 70% of the normal strength of the calf and loss of flexion of the big toe. It also, whilst better than no tendon at all, is not compatible with high level sport.
On 27 January 2020 under general anaesthetic I made a posterior incision and found the tendon completely tethered to the deep fascia. I protected the sural nerve and freed up the tendon. It was obvious that this tendon was slack and I therefore carried out a Z-shortening of the tendon and then sutured it securely so that effectively it was 2cm shorter and in this new position the normal resting plantar flexion attitude of the foot was restored.
At two weeks the wound was well healed and he had the sutures removed and he commenced physiotherapy. At six weeks the attitude of the feet is symmetrical and he now can feel tension in the tender Achilles and the calf is building up. At this stage I am confident that the prognosis is very good indeed and I anticipate a full recovery.
This case highlights the statement that ‘It’s all in the history.’ When I saw him the question I had in my head was how could a 6mm gap become a 10cm gap when all his treatment had been appropriate. Often in busy clinics one does not sit back and think but when a history does not stack up one has to do this and think about alternative explanations for the radiology findings and the clinical story somewhat like the work of a detective.
The other conclusion or learning lesson from this is that there is a tendency for clinicians to believe that the radiology reports have been written in tablets of stone when they have not been. As a result of a misinterpretation of the MRI and ultrasound this gentleman came perilously close to having a radical operation which would have been unnecessary and would not have resulted in a very good outcome.
I would therefore advise anybody reading a radiology report always to do so with the question in one’s mind ‘Does this radiology report stack up with the history and examination findings’? Only this way will near miss episodes in the medical world be avoided.
LFAC Consultant Mark Davies (Founder)
Read about some other testimonials from patients who suffered Achilles Tendon issues here;
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