Assisting in Diagnosis of Acute Achilles Tendon Traumatic Injury in Emergency Patients
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Achilles tendon injuries are a common emergency department complaint, with athletes and active people most common. And it is misdiagnosed far more frequently, leading to delayed treatment, prolonged rehabilitation and really severe limitations in mobility. Sensitivity of such advanced imaging techniques as ultrasound and MRI are the gold standard for diagnosis, but often limited to open hours. A retrospective qualitative study was undertaken over 5 months in May 2021 and May 2024 in 109 patients presenting with suspected Achilles tendon ruptures to an emergency department. An x-ray exam to see if Kagers triangle had become disrupted, was confirmed by two radiologists. Available standards of diagnostic tool were MRI or ultrasound. Results demonstrated considerable variability in Length of Stay (LOS) of patients with acute Achilles tendon injuries with mean LOS of 1.26 days suggests patient centric care is needed. Trauma is the major cause of injury (69.8%), though data inconsistencies limit accuracy, suggesting a male predominance (82.7%) though this attributable to gender related risk factors. Imaging is limited to complex cases but relies on X-rays (62.3%), with MRI (1.2%) and ultrasound (17.3%) restricted to costly situations. This supports efficient imaging practices, in which MRI is selectively used for complicated diagnoses, and where a significant correlation (p < 0.05) exists between X-ray and MRI findings. This study demonstrates the role of lateral ankle X-ray, with particular emphasis on Kagers triangle, in diagnosing Achilles tendon ruptures in the setting of an emergency in which radiologic capacity is limited. In 75% of cases, rupture was correlated with disruption of Kagers triangle, suggesting its utility as a practical diagnostic tool. Physical barriers and small sample size indicate that X-rays should be used in conjunction with clinical assessment with advanced imaging whenever possible.
Achilles tendon injuries are not uncommon in emergency medicine and predominantly refer to sportsmen and physically active persons (Kara et al., 2023). These injuries occur up to 1 million athletes per year with incidence of 40 per 100,000 of the population, and may be devastating to mobility and performance if not diagnosed and treated on time (Shamrock et al., 2023). There is high chances of misdiagnosis and the minimum figure that is given is 20% of the ruptures go unnoticed hence delay of treatment and therefore low improvement rates (Shamrock et al., 2023). Such incorrect or late diagnosis leads to lengthy rehabilitation several times painful existence and considerable limitation in function, hindering ones ability to play or work. Challenges of diagnosis in emergency departments can involve prolonged, and especially after hours, access to advance imaging modalities such as Magnetic resonance imaging (MRI) (Pass et al., 2022). Oluku et al. (2021) emphasised that diagnosis of an acute abdominal pain is usually done by assessing the patients history, performing a clinical assessment, and more recently, and using the ultrasound at the bedside (Oluku et al., 2021). However, there are few reports that lateral ankle X-rays, mainly the assessment of Kagers triangle, has been evaluated in diagnosing Achilles tendon ruptures, in situations where USG or MRI is not available (Kokulu et al., 2023).
According to Nordenholm et al. (2022), 25% of patients with Achilles tendon ruptures receive an incorrect diagnosis, leading to longer recovery and poor prognosis (Nordenholm et al., 2022). Ugur Bezirganb, (2023) research elaborated that ultrasound is commonly used because of its availability and relative cheapness compared to other imaging methods MRI is regarded as the most accurate diagnostic technique for determination of partial tendon ruptures (Bezirgan et al., 2023). However, in another study by Atta et al. (2019), diagnostic applications of an X-ray imaging modality namely Kagers triangle disruption in Achilles tendon rupture diagnosis was investigated especially in low resource environment (Atta et al., 2019; Tuante MB., 2023).
The hypothesis of this study is incorporating lateral ankle X-rays and specifically the area of Kagers triangle in adjunct to clinical examination in the emergency setting and without the delay caused by awaiting ultrasound or MRI. The study focuses overall rate of early identification of acute Achilles tendon ruptures and allow for early management when needed without being confined to operating hours. This research aims at examining the application of ALX namely Kagers Triangle used as an ancillary test for diagnosing acute Achilles tendon rupture within emergency departments. This research objectives focus on early diagnosis and treatment as a way to tackle this sort of injury especially when further imaging such as ultrasound or MRI may not be viable with enhancing its management.
The author declares no competing interest.
Study Design and Setting
This patient record review retrospective study was carried out from May 2021 to May 2024 in a single tertiary care healthcare facility. This work focused on assessing the effectiveness of using lateral ankle X- rays for diagnosing acute Achilles tendon rupture charges in an emergency department.
Patient enrollment and criteria for inclusion
The sample had 264 patients with clinically and by MRI or ultrasound - confirmed acute Achilles tendon rupture. Of these, 109 patients had an initial lateral ankle X-ray as the exclusive imaging modality done in the ED. X rays of these patients were stored in NIMIS and SYNGO software for further analysis, 155 patients who undergone ultrasound as primary imaging model were excluded from the study.
Diagnostic standards and the evaluation process
Diagnosis of Achilles tendon tear in all included patients was made by MRI or ultrasound, which are the gold standard modalities for imaging the Achilles tendon. Lateral ankle X-rays were examined strictly for interruption of Kagers triangle seen as a fat filled region on the radiological image that turns out to be an Achilles tendon if twisted. In total 109 X-rays of patients lower limbs were analyzed to diagnose the disruption of Kagers triangle assessed by two senior consultants in radiology, and both of them should give a positive response (Fig. 1).
Acquisition and Visualization Software
Imaging data of the patients was retrieved, stored and analyzed with NIMIS and SYNGO software to ensure safety and quick image access for diagnosis. Of these systems, features for centralizing access to images, as well as for optimizing the review of images within the radiology department, were most beneficial.
Data Analysis
The evaluation aimed at determining the degree of association between the altered Kagers triangle on lateral ankle X ray and confirmed Achilles tendon rupture. Others included the percentage of X-rays that demonstrated an interruption of Kagers triangle amidst the confirmed cases. Also included in the study was instances where imaging was limited by physical structure such as casts or fracturs as well as the study documented the cases of other findings like calcaneal or trimalleolar fractures.
All the ethical consideration was followed with permission from the research ethical committee. Patient data was de-identified, using medical image data by excluding all information that could identify the patient, during the research.
The study focuses on understanding the importance of anteroposterier lateral ankle X rays with the focus placed on Kagers triangle in cases of acute Achilles tendon rupture in emergency departments. The findings suggests that X-rays which are easily accessible in emergency departments might make a useful addition to imaging as a means of reducing time to diagnosis and starting treatment in facilities where ultrasound or MRI is unavailable. Moreover, other related fractures including calcaneal and trimalleolar, occurred in 3.6% of patients and should raise suspicion on Achilles injury and accurate evaluation of radiographs. The study by Dams et al. (2017) on clinical examination was identified to be important but confirmation by radiology is usually required due to uncertainty especially in high-risk athletes and early first time presentations (Dams et al., 2017). In addition, Tarantino et al. (2020) research pointed out that early diagnosis of Achilles tendon ruptures is crucial to reducing functional deficits and the duration of rehabilitation (Tarantino et al., 2020). However, Park et al. (2022) further showed that alteration in this triangle may point to other soft tissue injuries, including the Achilles tendon (Park et al., 2022).
Fig. 1: Distribution and Diagnosis Rate of Achilles tendon Rupture Confirmation by X ray.
Furthermore, the research highlighted that in 8 patients the presence of Kagers triangle injury was not confirmed, which gives one more evidence that X-ray evidence is inconclusive in some cases (Fig. 1). This is in line with literature because Jain et al. (2018) emphasised that though X-Rays are useful in part, should not substitute for patient assessment or other high sensitivity imaging like ultrasound or MRI which are more accurate (Jain et al., 2018). On the other hand, the conclusions drawn in this research are useful. This 75% of confirmed Achilles tendon ruptures may allow initially emergency practice to use lateral ankle X-ray, when Kagers triangle is disrupted. In their study, Atta et al. (2019) recommended that early therapy was required without the benefit of timely access to ultrasound or MRI, which might not be found with odd or at some services (Atta et al., 2019).
Descriptive Statistics
Descriptive statistics for the Length of Stay (LOS) in 161 emergency patients diagnosed with acute Achilles tendon traumatic injury are presented in the Table 1. The LOS is between 1 and 30 days with the mean (average) LOS of 1.26 days. The standard deviation is 2.339 which mean that while most patients stay brief, some patients stay a long time, perhaps due to complications, or additional care needs (Table 1). LOS of patients is highly variable and a function of injury severity and treatment requirements.
Table 1: Descriptive Statistics.
Gender
Gender distribution of 162 emergency patients in the diagnosis of acute Achilles tendon traumatic injury was broken down in the Table 2. Most of the patients (M) are male, 82.7% (134 patients) and females (F) are 11.7% (19 patients). Furthermore, 5.6% (9 patients) of them are “Valid” though the gender is not reported (Table 2). The fact that this is a male predominance raises the possibility that there is a greater incidence of acute Achilles tendon injuries in men for reasons, such as activity and risk factors, so that it can lead to diagnostic and management strategies in emergency settings.
Table 2: Gender.
Mode of Injury
This Table 3 describes the mode of injury for 162 emergency patients with acute Achilles tendon traumatic injury. We record most cases, 113 (69.8%), as "Trauma." In addition, 47 cases (29%) are identified as trauma, but uncapitalized consistently. Two outliers at 0.6%, labeled with typographical variations ("Trauma" and "trauma"), are in place as shown in Table 3. This indicates that trauma is predominant cause of injury which need to be addressed as data entry inconsistencies suggest potential problems in data accuracy and standardization and should be taken in consideration to perform reliable analysis.
Table 3: Mode of injury.
Xray Kagers triangle
Table 4 shows x ray findings in Kagers triangle in 162 patients with acute Achilles tendon injuries. 62.3% of patients are marked Nimis, that is a notable characteristic in the X-ray findings. Smaller groups are identified with different notations. They appear to have never had X-ray imaging, as nearly half were listed as "R Xray" (33.3%), "No Xray" (33.3%), and "Nimis Xr" or "Nimis XR" or on its own (6% or 3.7%, respectively). There is also inconsistency in labeling (e.g. "Nimis," "Nimis Xr"), which need standardisation so the labels are clear (Table 4).
Table 4: Xray Kagers triangle.
US
Data were collected on ultrasound (US) use to diagnose acute Achilles tendon injuries in 162 emergency patients and are presented in the Table 5. About half (51.2%) did not undergo ultrasound as indicated by initial clinical assessment or other imaging priority. Scans that reflect routine assessments had about 30.9% labeled generically, something about 30.5% had a dysfunctional uterine anomaly or adeno-myosis, and 13.4% had polyps alone. A confirmed ultrasound diagnosis was obtained for only 17.3% of abdominal masses, whereas 0.6% (1,479) was marked "Yes nimis," which indicates specific findings that should be further clarified as shown in Table 5.
Table 5: US.
The results of the discussion and presenting the anteroposterier lateral ankle view with the projection of Kagers triangle as the promising method of the confirmation of acute Achilles tendon rupture in the EDs. Lateral ankle X-rays, however, are a more accessible alternative than advanced imaging modalities in settings without such. In 75% of cases with confirmed Achilles tendon rupture, disruption of Kagers triangle was observed and to a degree made it a significant radiologic indicator. This is consistent to the previous research like de Kok et al. (2022) that emphasises the need for fast diagnosis in time of intervention and radiographic indicators that assist in this aim in urgent facilities (de Kok et al., 2021). It also supported by Endara-Mina et al. (2023) study claimed that 70% alterations in X-rays seen in this triangle signal an Achilles tendon rupture (Endara-Mina et al., 2023).
However, the study also noted that in some cases such as when back slabs or casts obscured visibility of Kagers triangle, X-rays were noncontributory. In line with Malone et al. (2022) study, X-rays offer quick preliminary insight into what may have happened, but such diagnostic value may be compromised by physical barriers or other injuries that complicate interpretation (Malone, 2020). In the study, fractures of the calcaneus, or trimalleolar region, complicated the diagnosis for 3.6% of the cases. X-rays are extremely helpful clues. Also, Perone et al. (2021) supported this studys findings that radiographic evaluation of Achilles tendon injuries may be helpful in emergency settings but should always be supported by ultrasound (Perone & Yablon, 2021). However, Akpan et al. (2021) also indicated that radiography can be the practical adjunct to clinical evaluation in the environments where availability of limited resources and lacking advanced imaging techniques are present (Akpan et al., 2021). Despite this, the study shows the criticality to incorporate lateral ankle X-rays in any emergency arena, especially places where advanced imaging is not easily accessible.
These findings emphasize some aspects of the clinical presentation and diagnostic procedures in emergency room patients with acute Achilles tendon injuries. The length of stay (LOS) is wide ranging, ranging from short stays for most of the patients, to prolonged hospitalizations for those with complications. The predominance of male patients suggests an increased gender predisposition to Achilles tendon injuries, presumed by the influence of activity and related risk factors. Patel et al. (2023) carried out a study which demonstrated that the use of lateral X-ray on the ankle can aid in streamlining patient management on an emergency department with less resources by reducing wait time to diagnosis and initiating timely treatment (Patel & Russell, 2023). Most X-ray findings in Kagers triangle are labeled as ‘Nimis and gaps in imaging standardization are indicated by other labels such as patients that werent imaged, or had imaged but incomplete labeling. Though SUV usage is limited, lack of use is seen in most patients by-passing this imaging modality, perhaps due to initial clinical assessment or priority for other methods. Only a small proportion did confirm diagnoses by ultrasound, and ultrasound is used selectively in complex cases. Even MRI is only used less frequently; its use as a second line diagnostic tool in unusual cases.
X-ray and MRI findings have a significant association, and MRI changes are seen in a selective way depending on the X-ray findings. This association is confirmed by the Chi square test, but a large number of cells with low expected counts suggests possible limitations to test efficacy. These results demonstrate the importance of consistent data entry and case specific use of advanced imaging to accurately assess Achilles tendon injury. Several recommendations for healthcare professionals, emergency departments to enhance practical application of this study findings are suggested. Although, Strudwick et al. (2018) study recommend that emergency room protocols should need to be changed to including, routine lateral ankle X-rays for those presenting with suspected Achilles tendon (Strudwick et al., 2018). Since radiographic sign of disruption in Kagers triangle can help in early diagnosis, radiologists and emergency physicians need training programs for them to appreciate the sign and its importance (Minkowitz et al., 2017). Also, Mohammed et al. (2022) emphasised to save expensive referral for X-ray integration with emergency protocols is performed, which reduce unnecessary referrals to advanced imaging, streamline patient care (Mohammed et al., 2022). Furthermore, Haleem et al. (2021) highlighted that time required to make a diagnosis can be shortened by creating telemedicine support networks, where radiologists can review X- rays from facilities with no specialist staff (Haleem et al., 2021).
Although this study brings much about the effectiveness of lateral ankle X-rays in the emergency departments for the diagnosis of acute Achilles tendon ruptures, it has its limitations. The primary limitation was the reliance on X-ray imaging which is readily available in most emergency settings. X-rays were noncontributory in the presence of physical barriers such as back slabs or casts as noted in 7% of cases. A relatively small sample size of 109 patients which is sufficient for initial insights, but may fall short in representing the broader population. However, future studies should elaborate on improving the use of lateral ankle X-rays in the diagnosis of Achilles tendon injuries in the emergency department adopting standardized emergency department protocols. In addition, future research should assess the cost effectiveness of including X-rays in routine protocols and determine if equipment improvement for rural or resource limited settings can be implemented to shorten the time from referral to advanced imaging techniques.
This study aimed at addressing the problem of timely and accurate diagnosis of acute Achilles tendon ruptures in emergency settings, particularly were ultrasound, or MRI might not be readily available. Kagers triangle was utilized in the study aiming to add an ancillary diagnostic tool for the use of lateral ankle X- rays. The research findings showed that physical barriers and a small patient sample limited the use of X- rays for diagnosis exclusively. The results of this research support the use of lateral ankle X-rays in the early triage and management of Achilles tendon injuries and highlight the need more sensitive imaging methods such as ultrasound or MRI. Main takeaways are practicality of including X-rays into emergency protocols, the necessity for training emergency physicians and radiologists, and the possibility of telemedicine to improve diagnostic accuracy in under resourced areas.
All authors have contributed equally in research.
Data will be available upon request.
The authors are thankful to the participants for the successful research study.
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Academic Editor
Dr. Phelipe Magalhães Duarte, Professor, Department of Veterinary, Faculty of Biological and Health Sciences, University of Cuiabá, Mato Grosso, Brazil
Department of Orthopedic and Trauma, St. Vincents University Hospital Dublin, Ireland
Imran A, Waters D, Quin S, and Akber A. (2025). Assisting in diagnosis of acute achilles tendon traumatic injury in emergency patients, Eur. J. Med. Health Sci., 7(1), 442-450.
https://doi.org/10.34104/ejmhs.025.04420450
