The Achilles (calcaneal) tendon is composed of the gastrocnemius-soleus complex tendons and is commonly injured or ruptured when athletes abruptly increase their activity, as seen in this patient. The most appropriate physical examination maneuver to test for complete rupture of the Achilles tendon is the Thompson test, which has a sensitivity of 96% and specificity of 93%. With the patient lying in the prone position, feet hanging off the table, the clinician should squeeze the patient's calf muscles and observe for the presence of plantar flexion of the foot. If plantar flexion is observed on calf squeeze, the test is negative and indicates normal function of the Achilles tendon.
Achilles tendinopathy without rupture requires no further imaging. Magnetic resonance imaging is the diagnostic modality of choice for Achilles tendon rupture and particularly useful in the setting of high clinical suspicion with a negative Thompson test or if partial tendon tears are suspected.
Many patients who suffer inversion ankle injuries have simple sprains and do not require radiographic evaluation. However, some patients will have fractures in the distal fibula and/or tibia. The Ottawa Ankle Rules were established to determine which patients should receive plain x-rays of the ankle. The Rules state that patients who have pain near the malleoli and either an inability to bear weight or bony tenderness at the malleoli should have plain films taken. This patient's severe pain and inability to bear weight would qualify, and therefore a standard 3-view x-ray series should be obtained.