Clinical Negligence

FAQs on tendon injury misdiagnosis and negligence claims

In recent years our specialist solicitors have supported many individuals in pursuing claims for negligent treatment of tendon injuries following a delayed diagnosis. Such delays often result in a worse outcome than would have been the case if the tendon injury had been treated within an acceptable timeframe.

The most common negligent tendon injuries we see relate to delayed diagnosis of Achilles tendon ruptures and of biceps tendon ruptures. Below is an overview of the symptoms, potential scenarios and issues associated with these types of cases and some frequently asked questions on tendon injury claims in general.

Achilles tendon ruptures

Rupture of the Achilles tendon is a common injury, with approximately 4,500 patients seeking medical help every year in the UK. An Achilles tendon injury that is diagnosed and treated early – either by immobilising the ankle in a rigid boot, or by surgery – tends to have a reasonably good outcome. Delays in treatment, however, can lead to pain and loss of function, to more extensive surgery and to ongoing disability.

Achilles tendon injuries are often associated with sports that involve repetitive, abrupt jumping, or bursts of sprinting, such as squash, tennis, football or running. The Achilles tendon is also susceptible to damage during a fall, for example, from accidentally missing a step when walking down stairs.

When Achilles tendon injuries occur, the injured person often presents to their GP, or in hospital to the A&E department or an orthopaedic surgeon, with a common history:

  • a sudden pain in the back of the leg, with an audible snap;
  • immediate pain;
  • a feeling that they have been hit or kicked directly in the calf;
  • a sense of weakness and lack of control of the foot.

A person may still be able to walk, stand on tip-toes and point their toes away from the leg, even against resistance, after an Achilles tendon rupture because other muscles and ligaments are intact. They may not be aware that they have injured their Achilles tendon.

How should diagnosis of an Achilles tendon rupture be made?

It is very important that medical professionals obtain a full history of how the injury happened and what the patient experienced and that they then perform appropriate examinations/tests in order to reach a diagnosis. This should involve:

  • taking a careful history of how the injury occurred, for example, whether it was while playing sport or as a result of a fall;
  • examining the ankle and the Achilles tendon;
  • checking for swelling and bruising;
  • feeling the Achilles tendon for a step-gap in the tendon.

Where an Achilles tendon rupture is suspected:

  • the patient should be asked to see whether they are able to stand on their tip-toes; and
  • a test of the Achilles tendon, known as a ‘Simmonds calf squeeze’ test, should be performed. This is best carried out with the patient lying face down on an examination table, with their leg over-hanging the end of the table; or kneeling on a chair with their foot hanging free over the edge. The doctor should gently squeeze the bulky part of the calf muscle. An uninjured Achilles tendon will move the foot into a plantar flexion, where the foot straightens. An injured Achilles tendon will not move because the calf muscle is no longer connected to the foot.

Occasionally, these tests can result in false results: some patients with a ruptured Achilles tendon are still able to stand on the tips of their toes (on both feet together – not on the injured limb alone); and the Simmonds test can result in some movement of the foot if the injury is not completely fresh and an element of healing has already occurred.

In such situations, where the history nevertheless suggests a ruptured Achilles tendon, even without conclusive test results the appropriate management is to assume the worst and to arrange imaging to confirm whether there is an injury, or alternatively, to immobilise the ankle and refer the patient to an orthopaedic surgeon for further investigation.

How should the tendon injury be treated?

A patient who has suffered an Achilles tendon rupture has two main treatment options:

  • if diagnosis is made within 10 days, then the patient will not need surgery. The foot is often placed into a fixed walking boot, with the foot in a downward facing position, so that the ruptured Achilles tendon can heal naturally. The patient will need to wear the fixed boot for around 9-12 weeks and can expect to achieve a 90-95% recovery by six to nine months after the injury;
  • if diagnosis is made after 10 days, but within six weeks of the injury, then the patient will usually be offered surgery, but again, so long as diagnosis and treatment occur within that time-frame, the patient usually achieves a 90-95% recovery.

What if there is a delay in diagnosis or treatment of the tendon injury?

In situations where patients present to medical professionals with a history suggestive of Achilles tendon rupture, but where the doctor does not take a careful history or does not perform appropriate examinations and the diagnosis/treatment is delayed by more than six weeks, then the only treatment option is surgery. The outcome of surgery six weeks or more after a tendon injury is not likely to be as good as surgery within the first six weeks.

Tendon retraction and the development of scar tissue (as a result of the body’s natural healing processes) make surgery more difficult after six weeks. A more complex procedure is usually then required, to try to lengthen the Achilles tendon or to reconstruct the tendon through a surgical technique. The prolonged retraction means there is often long-term muscle weakness and some pain. Functional recovery for these patients is typically around 70-80%, so less than for patients treated promptly.

Where there has been a delay in diagnosing or treating an Achilles tendon rupture, the patient may have a compensation claim for the greater loss of function and pain the negligence causes. While the level of damages awarded in Achilles tendon rupture claims will vary, some cases will result in significant settlements.

Biceps tendon ruptures

The biceps muscle is at the front of the upper arm and is the muscle which allows bending and rotation of the arm. The upper part of the biceps has two tendons, which attach it to the shoulder (the proximal biceps tendons). The lower part of the muscle has one tendon (known as the distal biceps tendon), which attaches the muscle to the elbow.

Ruptures can occur to the proximal or the distal biceps tendons. Biceps tendon tears can be partial or complete. As the terms suggest, whereas a partial tear damages the tissue without severing the tendon, a complete tear detaches the tendon from where it is attached to the bone.

In the case of a distal biceps tendon rupture, whereas timely surgical repair can result in excellent recovery of function and strength, delay in treatment can lead to a poor outcome.

How does a biceps tendon rupture happen?

Biceps tendon ruptures are most commonly caused by a sudden injury, or lifting a heavy object. When the elbow is made to straighten suddenly against resistance, the force can cause a rupture. These injuries are more common in men aged 30 years or older, particularly in athletes, bodybuilders and heavy manual labourers. Other risk factors include smoking and corticosteroid medication, both of which affect tendon strength. Proximal biceps tendon ruptures are more common than distal tendon ruptures.

What are the symptoms?

The classic sign of a biceps tendon rupture is feeling a sudden ‘pop’ at the level of the injury. Other symptoms may include:

  • acute pain, swelling and bruising of the upper arm (proximal biceps tendon rupture);
  • biceps muscle deformity, where the tendon has retracted (known as a ‘Popeye deformity’ because the muscle appears bunched up);
  • weakness on bending the elbow (flexion) and raising the forearm upwards (supination);
  • pain, bruising around the elbow and swelling of the antecubital fossa (distal biceps tendon rupture).

How is diagnosis made?

A detailed history may elicit characteristic signs of a biceps tendon rupture – including the feeling of a sudden ‘pop’ at the moment of rupture. An examination of the biceps muscle is likely to reveal a retracted muscle on the injured arm, as compared with the uninjured arm.

In the case of a distal biceps tendon rupture, a ‘hook test’ can be performed, which involves a clinician using their index finger to try to hook the lateral edge of the biceps tendon. If the tendon is intact or partially torn, the clinician will be able to insert their finger directly below the tendon and ‘hook’ it. If the tendon cannot be hooked, this indicates a complete rupture.

If a biceps tendon rupture is suspected following examination, this can then be confirmed on ultrasound.

Treatment

Non-surgical, conservative treatment can be an option for proximal biceps tendon ruptures and can achieve good results. For distal biceps tendon rupture, early surgical repair is key to recovering function and strength of the muscle – ideally within three weeks. With timely surgery, the tendon can be brought down and reattached, using bone anchors. This leads to a strong repair and function is immediately restored (although heavy lifting is to be avoided for six weeks after surgery). Physiotherapy is then recommended to improve range of movement and strength.

Following timely surgery to repair distal biceps tendon ruptures, strength in supination can return to 95% of normal, and biceps muscle power to 90-95% - in other words, a recovery of the vast majority of functional use of the arm.

Delay in treatment of biceps tendon ruptures

In the case of distal biceps tendon ruptures, if surgery is delayed, the tendon may prove more difficult to repair as it can become retracted. Once the opportunity for direct repair is lost, reconstruction using another tendon may be required – for example the nearby brachialis tendon. In some cases, a graft may be required.

Re-rupture is rare with primary surgical repair, but if an optimal technique cannot be used because of negligent delay, the risk of re-rupture increases.

What circumstances could give rise to a tendon injury compensation claim?

In most cases, the fact that a patient has suffered a tendon rupture is not something that could have been predicted or prevented. The issue that we see most often is medical professionals failing in their duty by not taking account of the patient’s history to suspect tendon rupture, not performing appropriate examinations, or not acting upon a suspected tendon rupture sufficiently early, any of which can delay treatment.

Scenarios that may give rise to a tendon injury negligence claim include the following actions or failures to act by GPs, A&E practitioners and orthopaedic surgeons:

  • failing to take a full history of the patient’s injury;
  • failing to recognise the relevance of the patient’s history and to suspect a tendon injury;
  • failing to perform an appropriate examination, including appropriate physical tests;
  • if the tests are negative, but the history is clinically suggestive of a ruptured tendon, then failing to arrange objective investigations, including for example, an ultrasound scan;
  • failing to make appropriate and timely referrals to the orthopaedic teams for further management;
  • failing to advise the patient of the available treatment options. This includes advising on the option of conservative management where appropriate, so the patient has the opportunity to avoid surgery if preferred;
  • making technical errors during surgery that go beyond the inherent risks of tendon repair or reconstruction and cause additional injury.

Can I make a claim for delayed diagnosis of my tendon rupture?

To succeed in a tendon injury negligence claim, it is necessary to prove two things:

  • Breach of duty (negligence) 
    That one or more of the medical staff providing care did so in a way that would not be supported by any responsible body of practitioners in those same circumstances; and
  • Causation - that the alleged negligence has caused damage
    This is often the more difficult and contentious part of medical negligence cases because it must be proved that, more likely than not, the patient would have had a better outcome had the delay or negligent failure not occurred. In situations where a patient has suffered a delay in their diagnosis, but has ultimately gone on to experience a good recovery, it can be quite difficult to show that the failings have made a material difference to either the nature and extent of the treatment required or the patient’s long-term prognosis.

How is a tendon injury negligence claim established?

Proving clinical negligence depends on independent medical expert evidence as to the standard of care provided and the impact that any failures have had. Experts will primarily base their assessment of the case on medical records and radiological imaging. The patient’s own evidence on the history of their injury, what they told the medical professionals about their injury, and what happened in terms of response, advice and treatment are also patently important in tendon rupture claims.

We obtain a full set of medical records from the patient’s GP and hospitals as well as witness evidence from the individual concerned. We then consider if there is likely to be a negligence claim to be pursued and instruct experts to give their opinion.

We usually require at least two experts in these cases – one who investigates the standard of care provided (eg a GP, or A&E practitioner) and one expert who addresses the likely course of events and outcome with proper care (often a consultant orthopaedic surgeon). If those experts are supportive of a tendon injury negligence claim, we will be able to allege negligence against the defendant doctor or NHS trust.

How long will a claim for delayed diagnosis of tendon rupture take?

Medical negligence claims do take time, partly because both sides rely on evidence from medical experts who have their own busy clinical practice and expert witness work, and partly also as a result of the complexity of the issues involved. 

Cases can also be complicated, depending on the factual history and the number of experts that are needed. For example, if a patient’s tendon rupture is missed in A&E, leading to a delay in diagnosis and treatment, then we will need to obtain evidence from an A&E expert to address the standard of care that was provided. If that expert is supportive, we then need to investigate causation with an expert orthopaedic surgeon, who will provide their opinion on whether the patient’s outcome is worse because of the delay and what the patient’s outcome would have been had the delay not occurred.

As the case progresses, further delays can be introduced if, for example, additional expert evidence is needed to assess any ongoing disability that gives rise to care needs or an inability to continue working to the extent the patient was able before the alleged negligence.

We progress everything as quickly as we can, but some cases can take several years to conclude. If negligence is admitted at an early stage in the claim, it is often possible to obtain an early payment of some damages (known as an ‘interim payment’) to fund treatment and support needs while the case is ongoing.

What are the time limits on making a tendon rupture compensation claim?

From the date of the negligence (ie the date when the diagnosis should have been made), patients have three years to bring a claim. Court proceedings must be issued by that three-year deadline (unless the claim settles before then). This is known as the ‘limitation period’. If the claim is not issued in time, then it is likely to fail because it will become ‘time-barred’. 

Sometimes the limitation period may start to run at a later date, where the patient did not become aware of possible negligence until later. This can often apply in tendon injury cases, when a patient attends their GP or the A&E department and is reassured that they have not suffered a rupture. Arguably the patient will only have knowledge that there has been potential negligence when they later receive their diagnosis of their injured tendon. In that scenario, the three-year period may only start to run at the time of diagnosis. We will always assess limitation and advise you of the earliest limitation date.

In cases where the patient is under the age of 18, the three-year time limit begins from the date of their 18th birthday.

The time limit does not apply to patients who do not have the mental capacity to litigate.

If a patient dies before concluding any claim, the three-year period may re-start from the date of their death if it has not already expired. There can be significant factual issues relevant to limitation so it is important to avoid unnecessary delay in seeking legal advice.

Why bring a compensation claim for delayed diagnosis of tendon rupture?

We always advise patients to think carefully before bringing a claim. Litigation is rarely straightforward, it is time-consuming and by its very nature involves focusing on poor care and a negative outcome. Cases involving delayed diagnosis of tendon ruptures give rise to difficult issues, such as how the negligence has affected prognosis. This can be hard emotionally and psychologically where pain and loss of function was potentially avoidable, particularly for those who are left with a chronic and permanent disability because of negligence.

It is therefore very important that anyone considering a tendon injury negligence claim knows what will be involved and makes an informed decision about whether or not to proceed.

On the positive side, those who do have a poor outcome as a result of tendon injury negligence may recover damages that can make a real difference to their quality of life. Examples of the areas where we can claim and recover compensation include:

  • compensation for lost earnings and loss of pension – this takes into account any absence from work because of the negligent delay in diagnosing the injury, resulting in lost earnings, and also includes considering whether the patient’s long-term working capacity has been limited by the negligence;
  • funds to pay for treatment that may improve the patient's condition - including surgery, if appropriate; physiotherapy; medication; and, if relevant, counselling/psychological therapy.
  • funds to pay for care or domestic assistance that has been needed because of the negligence or will be needed in the future;
  • funds to pay for home alterations required as a result of disabilities caused by the negligence;
  • funds to buy aids and equipment that could make life easier, for example, mobility aids; and
  • funds to cover additional travel, holiday and leisure costs.

Some recent examples of tendon rupture cases that we have settled for our clients can be found here:

Do I have to handle the tendon injury compensation claim myself?

We often find that, although patients may not feel up to managing a case day to day, they are keen to pursue it – either to deal with and get answers to their concerns or because they have suffered financially.

As medical negligence solicitors specialising in tendon injury cases, we take the lead in dealing with the claim on a day to day basis. We keep our clients involved with the case as much as they would like to be – some clients wish to be heavily involved, whereas some prefer a hands-off approach. This is something we can discuss with you at the outset.

If you or a family member are concerned about a delay in diagnosing a tendon rupture, and/or management of your injury, we would be happy to talk to you on a ‘no obligation’ basis to listen to the history and provide you with initial advice on the steps that may be available to you. 

Please call us on 0800 328 9545, email us at clinnegspecialist@penningtonslaw.com, or contact a member of our specialist orthopaedic clinical negligence team directly.

For details on funding a tendon injury negligence claim, please click here.


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