Walking wounded

Paul is a man in his mid-40s who presents with pain, swelling and bruising around his left ankle. He experienced sudden onset of the pain while playing recreational soccer a few days ago.

This was severe enough to cause him to fall to the ground. However, he was able to bear weight on the leg immediately afterwards, albeit with considerable discomfort and a limp.

Initially he thought he simply had a bad ankle sprain, but the next day decided to seek medical advice.

Likely diagnosis?
Paul’s history is consistent with an Achilles tendon rupture. The main differential diagnoses are fracture or ligamentous injury.

When Paul is examined, the classic signs of Achilles tendon rupture are present, including localised bruising, a palpable gap along the heel cord, decreased plantarflexion power and a positive Thompson test.

Paul’s malleoli are not tender, indicating that an