DeShawn Freely: A 29-Year-Old Basketball Player With the Feeling He Had Been Shot in the Ankle

Learning Objectives

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Learn the common causes of ankle pain.
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Develop an understanding of the unique anatomy of the ankle joint.
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Develop an understanding of the anatomy of the Achilles tendon and gastrocnemius muscle.
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Understand the function of the Achilles tendon.
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Develop an understanding of the causes of Achilles tendon rupture.
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Develop an understanding of the various types of Achilles tendon pathology.
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Learn the clinical presentation of Achilles tendon rupture.
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Learn how to examine the Achilles tendon.
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Learn how to use physical examination to identify pathology of the Achilles tendon.
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Develop an understanding of the treatment options for Achilles tendon rupture.

DeShawn Freeley

DeShawn Freeley is a 29-year-old basketball player with the chief complaint of, “I feel like somebody shot me in the back of my ankle, and now I can barely walk.” I asked, “DeShawn, tell me exactly what happened.” He responded, “My wife keeps telling me it’s time to retire, but what am I going to do, sell insurance? I was going for a lay-up, and some kid with more muscle than brains came smashing into me when I was coming down. I made the basket, but he knocked me sideways, and I was really off balance when I landed. I landed really hard, and it sounded like somebody shot a gun. A second later I feel this unbelievable pain in the back of my ankle. Honestly, Doctor, for a second or two, I thought that I had actually been shot, but as soon as I got to my feet, I knew exactly what happened. I’ve seen it in other players before. I had a big bruise on the back of my ankle and the side of my foot. They helped me to the locker room, and I just sat there while the trainer put some ice on it—like that was going to help. Doctor, I felt like crying. I just sat there. And on top of it, we lost the game and our chance for the playoffs. I knew there was going to be a lot of ‘I told you so’ comments when Amy—that’s my wife—found out.” I broke in and asked, “DeShawn, had your ankle been bothering you before you injured it?” He shook his head and looked at me like I was stupid, and said, “Doc, have you ever played basketball for a living?” He then smiled and looked me up and down, and said, “I guess not. I may look like 10 miles of bad road, but I had another season or two in me. I’ve stayed in shape, stayed off the drugs, and tried to eat right.”

I asked DeShawn how he was sleeping, and he said that as long as he didn’t lie on his bad leg, it was lights out and sweet dreams. DeShawn denied any fever or chills associated with his pain. I asked if he had taken any antibiotics recently, and with an surprised look, DeShawn said, “Doc, are you a mind reader or something? About a month ago, we were on the road and I picked up a cough, and the team doctor put me on some Cipro. It put me right after a couple of days. I played through it. Like I said, I’m tough.” I asked, “Tell me about your walking.” He replied, “Doc, I can get around, but it’s almost impossible to walk stairs.”

On physical examination, DeShawn was afebrile. His respirations were 18, and his pulse was 64 and regular. His blood pressure was 148/90. His head, eyes, ears, nose, throat (HEENT) exam was normal, as was his cardiopulmonary examination. His thyroid was normal. His abdominal examination revealed no abnormal mass or organomegaly. There was a small right lower quadrant scar that DeShawn said was from having his appendix removed when he was in high school. There was no costovertebral angle (CVA) tenderness or peripheral edema. His low back examination was unremarkable. Visual inspection of the right ankle revealed a large area of ecchymosis over the lower calf and over the arch of his foot. I asked DeShawn to point with one finger to show me where it hurt the most. He pointed to the area just above the superior margin of the calcaneous. Before I could go on, he pointed to the bulge in his right calf and said, “Doc, let’s not worry about the pain. You need to get this tendon put back together.” I said to DeShawn, “I know exactly what it is and I know exactly what to do about it. So I got this! Let me make sure nothing else is going on, then together we will map out a plan.” He smiled weakly and said, “You’re the doctor.”

I then asked DeShawn to stand up and place both feet flat on the floor. I asked him to stand on his tiptoes. As expected, his toe raise test for Achilles tendon rupture was positive on the right ( Fig. 7.1A ). I then asked DeShawn to get back on the examination table and hang his legs over the edge. As expected, the Thompson squeeze test was positive (see Fig. 7.1B ). I had DeShawn roll over on his stomach and flex his knees to 90 degrees; not surprisingly, he was unable to plantarflex the affected lower extremity ( Fig. 7.2 ). He was tender over the distal Achilles tendon and a tendon defect was easily identifiable, as was the proximal bunching of the gastrocnemius muscle. Passive range of motion of the right ankle was normal. DeShawn’s left ankle examination was normal, as was examination of his other major joints. A careful neurologic examination of the upper and lower extremities revealed no evidence of peripheral or entrapment neuropathy, and the deep tendon reflexes were normal.

I told DeShawn that I was pretty sure that kid had got the better of him, and suspected he had ruptured his Achilles tendon. He was going to need surgery to repair it. I told him that I want to get some confirmatory testing to ascertain the condition of the proximal tendon so we could better go in and sew it all back together.

DeShawn slowly shook his head, and as a tear coursed down his cheek, he said, “You know, Doc, I had a pretty good run. I knew it wouldn’t be forever, but I thought I had a couple more seasons. Let’s get this fixed.” He was so down I decided to wait until after surgery to tell him about the role that the Cipro may have played in his tendon rupture.

Key Clinical Points—What’s Important and What’s Not

The History

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History of sudden onset of pain in the posterior ankle with an associated cosmetic deformity
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History of sudden, audible pop in the ankle at the time of the acute injury
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History of significant ecchymosis over the posterior ankle and arch of the foot
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No history of previous significant ankle injury
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No fever or chills
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Sleep disturbance

The Physical Examination

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Patient is afebrile
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Palpation of right ankle reveals tenderness over the Achilles tendon
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Presence of significant ecchymosis over the posterior ankle and arch of the affected foot
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Palpable defect in the Achilles tendon
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Normal passive range of motion of the right ankle
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Positive toe raise test for Achilles tendon rupture (see Fig. 7.1A )
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Positive Thompson squeeze test for Achilles tendon rupture (see Fig. 7.1B )
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Positive Matles test for Achilles tendon rupture (see Fig. 7.2 )

Other Findings of Note

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Normal HEENT examination
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Normal cardiovascular examination
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Normal pulmonary examination
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Normal abdominal examination with a well-healed appendectomy scar noted
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No peripheral edema
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Normal upper extremity neurologic examination, motor and sensory examination
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Examination of other joints was normal

What Tests Would You Like to Order?

The following tests were ordered:

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Plain radiographs of the ankle and foot
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Magnetic resonance imaging (MRI) of the right ankle to ascertain the condition of the distal Achilles tendon
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Ultrasound of the right ankle with special attention to the distal Achilles tendon