Unilateral leg oedema due to spontaneous Achilles tendon rupture
Unilateral leg oedema due to spontaneous Achilles tendon rupture
Athina Papadopoulou 1 2
Cornelius Kronlage 2
Manuel Kampmann 0 3
Joris Budweg 1
0 Division of Musculoskeletal Imaging, Department of Radiology, University of Basel and University Hospital Basel , Basel, CH , Switzerland
1 Medical Outpatient Clinic, University of Basel and University Hospital Basel , Basel, CH , Switzerland
2 Department of Neurology, University of Basel and University Hospital Basel , Basel, CH , Switzerland
3 Department of Radiology, Kantonsspital Aarau , Aarau, CH , Switzerland
This is a case of severe unilateral lower leg oedema in a 77-year-old man, due to a spontaneous, complete Achilles tendon rupture. What makes this case unusual is the absence of trauma in the patient's history. The correct diagnosis was made only after magnetic resonance imaging. However, a thorough clinical re-examination of the patient revealed an inability to stand and walk on toes and a palpable defect of the Achilles tendon, which was difficult to detect due to the marked oedema. This case reminds physicians that an Achilles tendon rupture can also occur without clear history of trauma and should be considered as a cause of unilateral lower leg oedema, especially in presence of pain. Moreover, it illustrates the crucial role of a thorough clinical examination (including standing and walking on toes) for the correct diagnosis, even when restricting factors such as oedema and pain are present.
Unilateral leg oedema is a common presenting symptom in the
emergency room and in medical outpatient settings. Differential
diagnoses include conditions causing venous or lymphatic stasis,
but musculoskeletal pathology is also a possible aetiology.
In the case reported here, a patient presenting with
unilateral leg oedema without any history of trauma was diagnosed
with complete Achilles tendon rupture. To our knowledge, no
similar cases have been published so far.
A 77-year-old patient presented in our Medical Outpatient
Clinic due to a persistent swelling of his left leg. The swelling
had begun ~6 weeks ago, without any obvious trigger and had
been gradually expanding from the toes towards the knee.
During the same time the patient had noticed pain at the calf
when walking; he reported a feeling ‘as though he was walking
on a metal bar’. He did not feel pain at rest; moreover he
reported no weakness of the leg and no sensory abnormalities.
The patient had normal body weight (BMI 24); his medical
history was remarkable for type 2 diabetes, treated with
metformin, vildagliptin and gliclazid, as well as coronary artery
disease treated with aspirin, metoprolol and simvastatin. He had
no history of arthritis and denied travelling or immobilization
before the onset of the symptoms. Moreover, he denied any
trauma and this was confirmed by his wife. He mentioned that
he had been working everyday in his garden by the time the
swelling and pain occurred. However, these daily gardening
activities were not unusual for him. Due to the pain while
walking, he was unable to go on with his gardening at the time
of presentation at our clinic.
The clinical examination revealed a severe, pitting oedema of
the left foot and lower leg (up to the level of the knee; Fig. 1) with
diffuse tenderness. There was no redness of the skin, but the left
lower leg was slightly warmer than the right. The Homans sign
was negative. The dorsalis pedis artery pulses were bilaterally
palpable; the posterior tibial artery pulse was not definitely
palpable on the left, possibly due to the marked oedema. There were
no signs of inguinal lymphadenopathy. Passive movements of the
left foot, especially the dorsal extension, were painful. The muscle
strength examination in lying position showed no weakness. The
sensory functions were intact besides a mild reduction in
vibration sense on both lower extremities, which was attributed,
together with bilaterally absent ankle jerk reflexes, to a mild
peripheral neuropathy, probably diabetic.
The patient’s walking ability was observed in the
examination room, a limping on the left was attributed to the reported
pain in the left leg, while walking. During this first clinical
examination a comprehensive assessment of standing and
walking was not performed.
D-dimer-testing was just above the age-adjusted cut-off
] (820 μg/l with age-adjusted normal values: <770 μg/l).
Based on the high probability of DVT in our patient according
to the clinical model proposed by Wells et al. [
] (score ≥ 2 due
to unilateral pitting oedema, difference in calf circumference
≥ 3 cm, no likely alternative diagnosis), we performed a venous
duplex ultrasonography which showed no signs of DVT.
However, it revealed diffuse subcutaneous fluid entrapment as
well as a small ruptured Baker’s cyst, which was not considered
a likely cause of the marked oedema. To further investigate the
soft tissues of the leg, we finally performed a magnetic
resonance imaging (MRI), which showed a complete acute to
subacute rupture of the left Achilles tendon (Fig. 2). Moreover, a
partial rupture of the soleus muscle with intramuscular
haematoma was seen (Fig. 3), with diffuse accompanying
muscle oedema in the posterior leg compartment.
A clinical re-examination of the patient revealed an inability
to stand or walk on his left toes, as well as a positive
Thompson test on the left. Moreover, we could palpate an
actual defect of the tendon, which was previously not noted,
probably due to the marked oedema.
Surgical therapy was chosen, mainly due to the severe impact
of the symptoms on everyday life. The repair of the Achilles tendon
rupture was augmented with a ‘turn down flap technique’ using
the plantaris-longus-tendon. The patient showed an excellent
recovery. The follow-up examination 8 months after the operation
showed a complete regression of the leg oedema (Fig. 4). Moreover,
the patient had no pain and could walk again on his toes.
In unilateral leg oedema differential diagnostic thinking is
related to the chronological development [
]. An acute
appearance (<72 h) has to be differentiated from a chronic
oedematous swelling. Deep vein thrombosis, ruptured Baker’s
cyst, muscular rupture and compartment syndrome are the
most frequent causes for an acute unilateral leg swelling. They
can all present with pain.
Common causes for a chronic unilateral swelling are:
chronic venous insufficiency, secondary lymphoedema, pelvic
tumour or lymphoma causing pressure on the veins and
complex regional pain syndrome (CRPS) [
]. Of these only the latter
is typically associated with pain.
In our case, the oedema was already 6-week old at the time
of the presentation. However, the patient could particularly
recall the time-period when the swelling first occurred, so that
an acute onset with persisting symptoms and delayed seeking
of medical care was possible.
The acute rupture of the Achilles tendon typically presents
with severe pain in the lower calf. Usually the cause is an
injury, as in running and sports like soccer [
However, there are cases of ‘atraumatic’ ruptures, with
various risk factors being discussed, such as obesity and
]. Neither these, nor other possible risk factors such as
use of fluoroquinolone antibiotics were present in our patient.
Diabetes was also considered a risk factor, but a recent
systematic review found no such association [
]. Since in our case, the
Achilles tendon rupture was accompanied by a rupture and
haematoma of the soleus muscle, the underlying cause must
have been an injury, which remained unnoticed by the patient.
The frequent crouching and kneeling during his gardening
activities could represent a form of consistent low-grade stress
on the tendon, which could have contributed to the rupture.
The diagnosis in our case was made by a 3T MRI, while a
previous ultrasound did not report any tendon abnormalities. In
general, the sensitivity of ultrasound for the detection of Achilles
tendon ruptures is high (between 80 and 100%) [
]. In our
particular case, the ultrasound may have been negative, due to the low
clinical suspicion of a tendon problem at the time (the indication
for the ultrasound was only to rule out a DVT).
To conclude, rupture of the Achilles tendon is a (rare) cause
of leg oedema, even without clear history of trauma. The
examination of standing and walking on the toes should be
performed in patients with unilateral painful lower leg oedema. In
suspicion of Achilles tendon rupture, ultrasound and—in our
case—MRI can confirm the diagnosis.
CONFLICT OF INTEREST STATEMENT
The authors report no conflicts of interest.
The authors report no targeted funding for this work.
The authors declare that no formal ethical approval was
needed for this work.
The case report contains no direct patient identifiers and no
relevant indirect identifiers (as specified in the journal policy).
The patient was however explicitly and adequately informed
by the corresponding author regarding the potential publication
of this case and the photographs submitted here and has given
1. Schouten HJ , Geersing GJ , Koek HL , Zuithoff NP , Janssen KJ , Douma RA , et al. Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis . Br Med J 2013 ; 346 : f2492 .
2. Wells PS , Hirsh J , Anderson DR , Lensing AW , Foster G , Kearon C , et al. Accuracy of clinical assessment of deep-vein thrombosis . Lancet 1995 ; 345 : 1326 - 30 .
3. Ely JW , Osheroff JA , Chambliss ML , Ebell MH . Approach to leg edema of unclear etiology . J Am Board Fam Med 2006 ; 19 : 148 - 60 .
4. Trayes K , Studdiford JS , Pickle S , Tully AS . Edema: diagnosis and management . Am Fam Physician 2013 ; 88 : 102 - 10 .
5. Holm C , Kjaer M , Eliasson P . Achilles tendon rupture-treatment and complications: a systematic review . Scand J Med Sci Sports 2015 ; 25 : e1 - 10 .
6. Claessen FM , de Vos RJ , Reijman M , Meuffels DE . Predictors of primary Achilles tendon ruptures . Sports Med 2014 ; 44 : 1241 - 59 .
7. Dams OC , Reininga IHF , Gielen JL , van den Akker -Scheek I , Zwerver J . Imaging modalities in the diagnosis and monitoring of Achilles tendon ruptures: a systematic review . Injury 2017 ; 48 : 2383 - 99 .