Case study - An Achilles' heel

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Risk Management
Bulletin issue
February 2012
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MIGA’s Claims Committee has recently considered two cases of failure to diagnose tendoachilles ruptures in patients presenting with ankle or lower leg symptoms.

Both patients had clinical presentations suggestive of an ankle injury. The calf squeeze or Thompson’s test for an Achilles tendon rupture was not performed. This quick and simple test on the injured limb assesses whether normal plantar flexion compared to the unaffected side is present and may assist in the diagnosis of tendoachilles rupture.

The doctors on the Committee noted it is important for a treating doctor to consider this diagnosis and include the test in the initial and subsequent consultations. Should symptoms persist and the expected improvements for the diagnosed injury not occur, a diagnostic reappraisal with further imaging should be considered. This approach was lacking in the two cases under consideration and review of the initial diagnosis did not occur.

The patients concerned had also consulted other medical and physiotherapy practitioners, none of whom gave independent consideration to the initial diagnosis either, despite little improvement in the symptoms.

The delay in diagnosis meant there were limited treatment options and poor long term outcomes. The patients both required major tendoachilles reconstruction with tendon transplantation.



In another reported matter the Thompson’s test was performed at the initial presentation The result was normal but the doctor did not document he had undertaken the test. Subsequently, a diagnosis of tendoachilles injury was made. The patient’s complaint against the doctor for a delayed diagnosis of tendoachilles injury proved more difficult to defend as the patient asserted the test had not been performed.

Clinical management

A good history of the mechanism of the injury should be taken and documented. A history of ‘calf muscle tear’ or chronic tendonitis can precede an Achilles tendon rupture. A higher index of suspicion is appropriate in such cases as well in those patients who are 30 to 50 years old, male and in ’weekend warriors‘ who subject the calf to unaccustomed exercise.

Symptoms can include the sudden onset of pain in the lower calf on exertion, a limp, inability to run, climb or stand on toes, weakness or absence of active plantar flexion and calf swelling.

Clinical examination should include palpation of the tendon. The doctor is looking for swelling, tenderness or a defect with weakness or absence of plantar flexion on application of Thomson’s test. This test should be conducted with the patient either prone or kneeling with their feet hanging free over the end of the bed and by squeezing the affected calf. An absence of passive plantar flexion of the foot suggests rupture of the Achilles’ tendon.

Ultrasound can determine the presence of tendonitis and tendon rupture (incomplete or complete). Referral to an orthopaedic colleague is essential if there is any doubt about the diagnosis.

The issues

These cases highlight the importance of:

  • Considering tendoachilles injury in all cases of lower leg and ankle injury
  • The timely reconsideration of the diagnosis when recovery is prolonged or progress is not as expected
  • Documenting all clinical tests and examinations undertaken.

Risk management tips

Documentation is essential to the successful defence of allegations of failure to diagnose. It should include:

  • Presenting complaint, mechanism of the injury and signs and symptoms
  • All diagnostic tests and examinations conducted even when the results are normal or show no abnormalities
  • Clinical management and treatment plan
  • Timely and appropriate referral if in any doubt
  • Your discussion with the patient that includes the need to review the injury if symptoms are not resolving

By: Victoria Webster – Claims Solicitor

and Gareth Thomas – Clinical Risk Co-ordinator

with contribution from Dr Roger Sexton – GP and MIGA Board member and member of MIGA’s Claims Committee

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