Case 40 A middle-aged man with an ankle injury

Paul was 45 years old when he saw Dr du Vivier about an injury to his right foot/ankle area which he had sustained playing badminton three days earlier. He had felt something go bang in his calf and thought his opponent had hit him. Dr du Vivier examined Paul, noted the history, recorded there was some slight calf swelling and ‘achilles tendon intact’ and diagnosed a calf muscle strain.

What other information would you obtain in a case such as this?

Three weeks later Paul consulted Dr Prasad. Dr Prasad agreed with Dr du Vivier’s assessment and prescribed exercises and naproxen. Two weeks later Paul was still having difficulty walking. He attended A&E. An orthopaedic registrar diagnosed a complete Achilles tendon rupture.

Paul underwent an attempted tendon repair a week later but brought an action against Dr du Vivier and Dr Prasad for failing to diagnose the injury. It was alleged that the general practitioners had not carried out a ‘calf squeeze test’ or asked Paul to stand on tiptoe. Dr du Vivier claimed that he had asked Paul to stand on tiptoe but agreed that he had not done a ‘calf squeeze test’.

Do you think a claim against the GP will succeed?

Expert comment

In this case there was no dispute that the patient had given the ‘classic’ history of an acute onset of pain leading to the (incorrect) belief he had been struck from behind. With this history the diagnosis of Achilles tendon rupture has to be excluded and accordingly Dr du Vivier’s failure to carry out a more specific test could not be defended.

Specific tests should include Simmond’s test (sometimes known as a Thompson test). The test is probably better described as the ‘calf squeeze’ test. With the patient kneeling, squeezing the calf should cause passive plantar flexion. If the tendon is ruptured plantar flexion is diminished or absent (the degree of movement of the foot can be compared with the other side). Significant asymmetry of movement is also very suggestive of rupture.

Another commonly used test is to ask the patient to stand on tip toes. Dr du Vivier claimed that he had carried out this test. Because the Achilles tendon transmits the main force of plantar flexion, a patient with a rupture will be unable to stand on tiptoe on that side. However, a difficulty about relying completely on the (bilateral) ‘tiptoe’ test is that the patient maybe taking the majority of the weight on the uninjured side.

The cause of the error in this case can probably be characterized as a simple lack of knowledge. Achilles tendon rupture is not commonly seen in UK general practice (perhaps one case every 7 or 8 years). Many GPs do not experience orthopaedic surgery or Accident and Emergency in their training and the subject is not extensively discussed in nonspecialist orthopaedic texts.

The examination of Dr du Vivier was limited to palpation of the tendon and (as a fact disputed by the claimant) asking Paul to stand on tiptoe. Palpation of the tendon is not guaranteed to detect all tendon ruptures because swelling and haematoma can disguise the gap. Equally, a patient may be able to stand on (bilateral) tiptoe by taking the weight on the uninjured side.

Missed rupture of the Achilles tendon causes quite significant disability compared to early diagnosis and consequently these cases can be quite expensive for the medical defence organizations.

Legal comment

This failure to diagnose cannot be defended and the claim must be settled as soon as possible. Early diagnosis is the key to a good outcome. Thus it may be that by the time Dr Prasad saw Paul three and a half weeks after the injury, it was too late to alter the outcome. If so and if Dr Prasad and Dr du Vivier belong to different MDOs, then Dr Prasad’s MDO will deny responsibility and refuse to contribute to the settlement. Whether they will avoid contributing altogether depends on the orthopaedic evidence the MDOs receive.

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