Hi, I'm Chris Fulmer. I'm one of the faculty members for the Stanford O'Connor Sports Medicine Fellowship. In this case, we're approaching a patient who has a complaint of calf and ankle discomfort. For the video, I'll be focusing on examination of the Achilles tendon. So the first thing, if the patient's symptoms localize to the Achilles tendon itself, it's important to palpate the length of the tendon. The most common place to have Achilles tendinopathy is in the mid-substance or the more proximal position in the tendon itself, and oftentimes this is a late presentation or a chronic condition, and so you'll be able to palpate a fusiform-shaped swelling of the tendon. So on our model here, palpating the entire length of the tendon starting distally at the calcaneal attachment and palpating up proximally both just in that immediately kind of posterior aspect, but also palpating both the medial and lateral borders of the Achilles tendon and putting gentle pressure. This is a structure that even if it's healthy and normal, if you exert too much compression, it is tender. There are two varieties of Achilles tendinopathy. As I mentioned, the most common is mid-substance tendinopathy, but it can also occur in less common cases at the insertion of the Achilles tendon on the calcaneus. In that case, you'll have a tenderness directly to palpation at that insertion point, and most commonly it will be at that posterior lateral aspect of the calcaneus. If it's very chronic, oftentimes the patient will also have a bony deformity at that posterior lateral corner, which is called Haglund's deformity. Finally, in middle-aged patients, it's very important that if they come in complaining of Achilles area pain, not only to assess them for the more common Achilles tendinopathy, but also potentially for a partial rupture or a rupture of the Achilles tendon itself. If you have access to a point-of-care ultrasound, this is a distinction that can be made very easily just by using the in-the-office ultrasound to look at the tendon itself. If you don't have that or in addition to that, you can perform the Thompson test. I'm going to demonstrate two different ways that you can do that test today. The classic way of performing it is with the patient prone and the knee flexed to 90 degrees. The patient is very relaxed in this condition, and their foot is basically just under the forces of gravity. To perform the test, you place your hand over their calf muscle and exert a gentle squeeze. If the foot and ankle go into plantar flexion, you know their Achilles tendon is intact. Another way you can perform the Thompson test, especially if your patient has very limited mobility and they're unable to get up onto the exam table, is to make use of the chair in the exam room. You can have the patient rest their knee on the chair. This mimics the position of the lower leg as in the prone exam by exerting gentle compression on the calf muscle. You can see whether the ankle plantar flexes or not. If the ankle does not plantar flex with that compression, then that would be a positive Thompson test, indicative of an Achilles rupture.

2nd Edition, CASE 11

2nd Edition

Foot and Ankle

Achilles tendinopathy

examination techniques

Thompson test

Haglund's deformity

ultrasound diagnosis