import { HighYieldBox, ExamCheatSheet, Tabs, Tab, ComparisonTable, VivaScenario, ContentSection, SpecialTestCard , MedicalImage} from '@/components/content' # Ankle Achilles Complex Examination The Achilles tendon examination is fundamental to ankle assessment. Examiners expect you to perform Thompson's test correctly for rupture, use the Silfverskiold test to differentiate gastrocnemius from soleus tightness, and recognize the clinical features of tendinopathy including the "painful arc sign." ## Quick Reference One-Pager ## Anatomy **Gastrocnemius:** - Two heads: Medial (from medial femoral condyle), Lateral (from lateral femoral condyle) - Crosses TWO joints (knee and ankle) - Tight when knee extended - Primary plantarflexor during running/jumping **Soleus:** - Deep to gastrocnemius - Origin: Posterior tibia and fibula - Crosses ONE joint (ankle only) - Primary postural muscle (standing) **Achilles Tendon:** - Formed by confluence of gastrocnemius and soleus - Longest and strongest tendon in body - Inserts on posterior calcaneal tuberosity - Blood supply: Poorest 2-6cm above insertion (watershed zone) **Clinical Importance of Dual Origin:** - Silfverskiold test differentiates gastrocnemius from soleus tightness - Knee extended: Both gastrocnemius and soleus tightness limit dorsiflexion - Knee flexed: Only soleus tightness limits dorsiflexion (gastrocnemius relaxed) ## Achilles Rupture Examination **Classic Presentation:** - Sudden onset, often during push-off activity - "Pop" or "snap" felt - Felt like "kicked in the back of the leg" - Unable to push off or walk normally - Age typically 30-50 years (recreational athletes) - May have prodromal Achilles symptoms (tendinopathy) ### Rupture Tests **Thompson's Test False Negatives:** A false negative (apparently normal Thompson's) can occur with: - Partial rupture (some fibers intact) - Intact plantaris tendon (rare) - Delayed examination with healing If clinical suspicion high despite equivocal Thompson's, obtain ultrasound or MRI. ### Additional Signs **Inspection:** - Swelling and bruising around Achilles - Loss of normal tendon contour - Increased passive dorsiflexion (asymmetric) **Palpation:** - Palpable gap in tendon (may be filled with hematoma/swelling) - Tenderness at rupture site (usually 2-6cm above insertion) **Note Location:** - Most ruptures occur 2-6cm above calcaneal insertion (watershed zone) - Insertional ruptures are less common ## Achilles Tendinopathy Examination **Midsubstance Tendinopathy (Non-insertional):** - 2-6cm above insertion - Most common in runners - Fusiform swelling - Painful arc sign positive **Insertional Tendinopathy:** - At calcaneal insertion - Associated with Haglund's deformity - Often bilateral - Older, less active patients ## Gastrocnemius/Soleus Tightness **Silfverskiold Test Interpretation:** | Finding | Knee Extended | Knee Flexed | Diagnosis | |---------|---------------|-------------|-----------| | Normal | Greater than 10° DF | Greater than 10° DF | No equinus | | Gastrocnemius tight | Less than 10° DF | Greater than 10° DF | Isolated gastrocnemius | | Soleus tight | Less than 10° DF | Less than 10° DF | Soleus or combined | **Clinical Relevance:** - Isolated gastrocnemius tightness → Gastrocnemius recession (Strayer/Baumann) - Combined tightness → Achilles lengthening (TAL) or gastrosoleus recession ## Differential Diagnosis ## Summary Presentation ## Acute vs Chronic Rupture ## Examiner Tips