Calf pain diagnosis?

[Michael Shilton]

Hi Steve, this is a case of a woman in her 70’s who had a non traumatic onset of calf pain (points to her Achilles) whilst on a lengthy walk 3 weeks ago. The whole calf and ankle are swollen all round, her GP found no evidence of DVT. Her swelling reaches up to the knee and she is squishy around Bakers cyst area. I’d not seen a presentation quite like this and I was suspecting a ruptured Bakers cyst (although I’ve never seen one before)because of the lack of strenuous onset and degree of swelling. On scanning there appears to be a partial tear of The Achilles and some Retrocalcaneal bursitis. But there is loads of soft tissue oedema and I’m unsure what to make of the hypoechoic tracks that run above the Achilles then above the gastrocs? The bakers cyst was inconclusive in that I think I located it in transverse but couldn’t confirm it in long view. I guess it would be completely unlikely to rupture a cyst and tear a tendon at the same time so I’m left thinking can a Achilles tear cause all this oedema??
Mike

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[Stephen Bird]

Hi Mike,

the image at 12:38:44 with the colour box on it makes me suspicious of an Achilles rupture.

Certainly the Achilles is grossly abnormal,

When I read your text I was favouring a ruptured Bakers cyst that has emptied into the calf, however when I looked art your images I don’t think this explains the fluid deep to the Achilles and certainly the Achilles is damaged.

Like you I prefer one diagnosis to two so I am thinking the Achilles is the problem.

I would like to do a Thompson test and also look at the Achilles in long axis while doors and plantar flexing the ankle looking for paradoxical movement.

If they have had the leg elevated this could explain the proximal migration of the oedema.

Steve

[Michael Shilton]

Hi Steve, many thanks for the reply. Thomson test was negative but there was abnormal fibre movement with dorsi/plantar flexion leading me to think partial tear rather than rupture.I did record this test but I don’t think I can load it to this site. I wasn’t sure what to make of the reduced echogenic area above the Achilles and then the gastroc. If it’s not a blood vessel then could this be fluid and if I’ve understood you correctly it may have come from the Achilles being elevated? Thanks.

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[Stephen Bird]

Hi Mike,

Videos can certainly be uploaded as long as they are less than 9Mb.

You can also private email it to me or DropBox it and I can compress it and upload it for you.

The tubular looking fluid area is certainly the short saphenous vein and you have a nice short axis image of it to prove it.
But there is still some peri-tendon fluid which I suspect is haematoma from the injury and this is adding to the distal calf oedema.
I am not surprised that there is some paradoxical movement of these tendon ends and I am a little surprised the Thompson test did not suggest a rupture.

I would suggest it is at least a high grade partial tear and an MRI might be worthwhile for staging and management.

Nice case Mike.

Steve

[Michael Shilton]

Steve,
Many thanks for all your help on this case. I’ve uploaded the dynamic scan, hope it loads okay.
Mike

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[Stephen Bird]

Nice clip Mike,

This Achilles looks like a complete future to me that has slightly scarred up.

It is certainly a major injury and I doubt very much this tendon has any real strength left.

There is some paradoxical movement, however some of it looks like it has “glued up” a bit following the injury.

I would be suggesting an orthopaedic opinion for management with an MRI to confirm and quantitate your findings.

Nice work.

[Michael Shilton]

Thank you very much Steve, I’m super appreciative of your mentorship, I learn more all the time.
Mike

[Stephen Bird]

Always my pleasure Mike.

Steve.

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