Claim against two London trusts for alleged delays in diagnosis and treatment of Achilles tendon rupture

Our client was engaged in a high activity class at her local gymnasium one evening when she jumped and landed on her right foot, experiencing immediate pain and discomfort in her ankle and the back of her calf.

Upon leaving the dance class, she struggled to walk as she had no control of her foot and she described feeling as if it had become detached from her leg. Not realising the severity of her injury, she returned home and kept her foot elevated that evening, taking analgesia to manage her pain.

As our client continued to struggle to weight bear and walk on the affected foot, she attended her local emergency department the following day. Our client’s ankle looked clearly swollen on visual inspection and an X-ray was performed due to a suspicion that she had sustained a fracture to her ankle. Following the X-ray, our client was discharged home with a ‘walking boot’. She was advised to keep her leg elevated and that she would be referred to a local ‘fracture clinic’ for further assessment.

Our client was subsequently invited to attend an appointment at her local fracture clinic some 11 days after sustaining her injury. The consultant reviewed the X-ray images previously taken and after a cursory examination of our client’s ankle, she was discharged from the clinic with a diagnosis of a sprain and was told to begin to mobilise on her affected foot.

Unfortunately, over the subsequent weeks, our client struggled to mobilise due to experiencing severe pain in her ankle/foot and a lack of control, as she was unable to pick her foot clear off the ground when walking. Some 11 weeks after sustaining the injury, our client was seen by a physiotherapist when a thorough examination of her lower leg was performed, which included a specialist test called a ‘Simmonds’ test’, also referred to as a ‘Thompson’s test’. The physiotherapist suspected that our client had an Achilles tendon rupture and an urgent referral was made to the orthopaedic team for further assessment, when the diagnosis was confirmed.

Upon receiving the diagnosis, our client was informed that unfortunately, because of the delayed diagnosis, surgery was the only option for treatment and that it would be ‘complex’ because the two ends of the tendon would have become retracted due to the long delay in carrying out the repair to the tendon.

Our client underwent surgery, and sustained a long wound to the back of her calf where the surgeons made the incision to repair the tendon. She experienced problems with wound infections after surgery which required antibiotic treatment. Unfortunately, despite undergoing surgery, our client has been left with a very poor outcome and ongoing symptoms which are likely to be permanent, including problems with walking for any prolonged distances and descending the stairs. Prior to sustaining her injury, she was very much a sports enthusiast, participating in marathons and outdoor sporting activities with her family. Unfortunately, due to the poor outcome in the recovery of the tendon after surgery, she has been unable to return to the majority of her much enjoyed recreational activities and hobbies.

She contacted Penningtons Manches Cooper as she was concerned about the significant delays in her diagnosis and treatment and felt that the initial assessments performed during the first two weeks after her injury were unsatisfactory, particularly as the physical examination of her injury was very cursory and was not to the same standard as performed by the physiotherapist subsequently. As part of the conduct of her legal claim, supportive expert evidence has been obtained and the case is currently proceeding down the court timetable.

Naomi Holland, senior associate in our clinical negligence team, comments: “This case illustrates some significant issues that we regularly see in the management of Achilles tendon injuries. As part of any assessment of the potential range of diagnoses for a patient, it is important that an appropriate history and examination is performed to rule out or confirm a particular diagnosis. In this case, our client feels let down in the care she received as the failings in her assessments during the crucial ‘window of opportunity’ (ie in the first two weeks of sustaining her injury) has meant that she has had to endure more invasive treatment, experience a difficult and prolonged recovery and face a poor outcome with life-long residual problems. It is hoped that by highlighting these issues, future occurrences might be avoided.”

What is an Achilles tendon rupture, and how is it diagnosed?

The Achilles tendon is a band of tissue that connects the muscle to a bone, and it runs down the back of the lower leg, linking the calf muscle to the heel bone. The Achilles tendon plays an important function in mobilising as it helps raise the heel off the ground.

A rupture occurs when a complete or partial tear arises if the tendon is stretched beyond capacity. Such injuries are commonly sustained in high activity sports, such as squash, tennis, netball and football.

A diagnosis is made by a medical professional eliciting a history from a patient of how the injury was sustained, as well as their initial and ongoing symptoms, and by undertaking a physical assessment.

The ‘typical’ signs and symptoms of an Achilles tendon injury include:

• sudden pain in the back of the ankle or calf, which can often be described by patients as though someone has kicked them at the back of the calf;
• a ‘popping’ or ‘snapping’ sensation at the time of sustaining the injury;
• swelling to the back of the leg between the heel and calf; and
• difficulty walking – particularly upstairs or uphill.

A key component of diagnosing a tendon rupture is ensuring that an appropriate physical examination is carried out of the calf and ankle by assessing the continuity of the tendon and whether a defect is present. The Simmonds-Thompson test is a term used to specifically assess suspected Achilles tendon ruptures and is performed by a clinician. During the test, the patient is asked to lie down or kneel on an examination bed with their feet hanging off the edge and the clinician will then examine both calf muscles and will squeeze/apply pressure along the vicinity of the tendon. If, upon examining the patient, there is no movement of the foot on the injured leg, but in comparison there is movement on the ‘uninjured side’, a diagnosis of an Achilles tendon rupture should usually be confirmed at this stage.

What are the treatment options for an Achilles tendon rupture?

It is generally recognised by orthopaedic surgeons that prompt diagnosis and treatment of an Achilles tendon rupture plays an important role in ensuring that a patient achieves an optimum recovery. If the injury is diagnosed within the first 10 days, but no more than 14 days after the injury is sustained, then a non-surgical option for treatment is available which will involve a plaster cast being placed on the injured ankle/leg with the foot held in a downwards (equinus) position. Over a six to eight week period the position of the foot is gradually changed to a more neutral position before the cast is removed. Physiotherapy treatment is then required to aid in the recovery of the tendon once the boot has been removed. With prompt action, a very good recovery of the function of the tendon is expected.

In addition, there is an option for surgical treatment which is performed under general anaesthetic. The surgeon will make an incision over the Achilles tendon and will repair the tendon with sutures, although in some cases a tendon graft may be required. After surgery, a plaster cast will need to be applied and will remain in place for several weeks, similarly to the non-surgical option as above. Surgery is generally recommended in patients with a delayed presentation of an Achilles tendon injury more than 14 days after the injury is sustained. The extent of the delay in the diagnosis and treatment does play a key role in a patient’s recovery from the injury and their ability to return to their pre-injury level of activities. The longer the delay, the poorer the outcome in the return of the function of the tendon.

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