had a partial tear of the tendon. To perform this test, have the patient lie prone on a table with both ankles off the edge. A positive test is noted when the normal resting ankle equinus is absent (Figs. 1 and 2). We found the Simmonds visual test to be simple and precise and as accurate as both the calf-squeeze test’2 and the presence of a palpable gap at the rupture site. Less informative was being able to see a gap in the tendon from the side, and a loss of plantar flexion. We did not use the needle test, dye test, plain roentgenograms, or magnetic resonance imaging for diagnostic purposes in this series as we do not feel they are particularly helpful.
We suggest that the physician consider the Simmonds visual test as a simple and reliable method of diagnosing Achilles tendon rupture. Richard S. Siegel, MD J. Mervyn Lloyd, MB, BChir, FRCS Frank P. Alicandri, MD Alan R. Miller, MD Westwood, New Jersey
Simmonds MB The 179 56-58, 1957
diagnosis of the ruptured Achilles tendon. Practitioner
2 Thompson TC, Doherty JH Trauma 2: 126-129, 1962
Figure 1. A positive Simmonds visual test (arrow) viewed from above, demonstrating loss of normal resting equinus.
Figure 2. Viewed from the side, a positive Simmonds visual (arrow) shows the same loss of normal resting equinus.
of tendon of Achilles. J
Dear Editor: in the article, &dquo;’1’he U Uonoghue ’1’riad Revisited by Shelbourne and Nitz (Vol. 19, pp. 474-477), the point seems to be that ACL-MCL injuries are more frequently associated with lateral meniscal rather than medial meniscal tears, therefore nullifying the significance of &dquo;The Unhappy Triad&dquo; as described by Campbell and popularized by O’Donoghue in his book Treatment of Injuries to Athletes. Perspective is necessary in an understanding of the importance of this injury as well as the findings of these authors. O’Donoghue described this injury as occurring as a result of the &dquo;familiar lateral blocking&dquo; or by the &dquo;cut-back motion of the running athlete when the foot is forced into external rotation and stress is exerted against the medial collateral ligament of the knee.&dquo;’ Classic descriptions of ACL injuries are those of a cutting injury on a flexed knee and deceleration with slight internal rotation of the tibia.2 For multiple reasons, including changing rules and changing surfaces, the pattern of injury seen has changed. Further, the injury that O’Donoghue described was the most severe type of ligament injury commonly seen and diagnosed at that time. These injuries were identified without the benefit of arthrography, MRI, or arthroscopy-all of which have increased our diagnostic accuracy. In his book, he shows a diagram of this injury in which the capsular ligament is torn (Fig. 1). Necessarily, this capsular ligament injury is associated with the disruption of the peripheral attachments of the medial meniscus. It is this specific injury in which the superficial and deep layers of the MCL, the ACL, and the peripheral attachments of the medial meniscus are disrupted that was labeled &dquo;The Unhappy Triad.&dquo; Unhappy because it was an injury from which the athletes had great difficulty in returning to a full functional status. However, this by no means acccounted for all of the injuries O’Donoghue reported. In 1950, in his report of 22 college football players, 40% had the &dquo;triad&dquo; and, in 1955, in his report of 82 surgically treated injuries, only 29% were of the &dquo;triad&dquo; type.5,6 At the time that O’Donoghue wrote, there was no understanding of rotatory laxity, secondary restraints, or the epidemiology of knee injuries. The paper in question is not an epidemiologic study either. Therefore, I think it is wise to consider the perspective that O’Donoghue had and also
REFERENCES 1. DeHaven KE: Diagnosis of acute knee injuries with hemarthrosis. Am J Sports Med 8: 9-14, 1980 2 Feagin JA: The syndrome of the torn anterior cruciate ligament. Orthop Clin North Am 10: 81-90, 1979 3. Noyes FR, Bassett RW, Grood ES, et al: Arthroscopy in acute traumatic hemarthrosis of the knee J Bone Joint Surg 62A: 687-695, 1980 4. O’Donoghue DH: Surgical treatment of injuries to ligaments of the knee. JAMA 169 : 1423-1431, 1959 5. O’Donoghue DH: An analysis of end results of surgical treatment of major injuries to the ligaments of the knee. J Bone Joint Surg 37A: 1-13, 1955 6. O’Donoghue DH Surgical treatment of fresh injuries to the major ligaments of the knee. J Bone Joint Surg 32A: 721-738, 1950 7. Terry GC, Hughston JC: Associated joint pathology in the anterior cruciate ligament-deficient knee with emphasis on a classification system and injuries to the meniscocapsular ligament menisculotendinous unit complex. Orthop Clin North Am 16: 29-39, 1985
Author’s Response: We
Figure 1. A diagram of the familiar lateral blocking injury, with capsular ligament, as described by O’Donoghue. (Reprinted with permission from O’Donoghue DH: Treatment of Injuries in Athletes. Fourth edition. Philadelphia, WB Saunders, 1984, p 504.) torn
persepctive of these authors. Both perspectives have validity in the context in which they were developed. Others have documented the frequency of lateral meniscal tear with ACL injury, and I think this is borne out in the study by Shelbourne and Nitz.1,3,7 On the other hand, in severe combined ACL-MCL injuries in which the capsular ligament is torn, the peripheral attachments of the medial meniscus are frequently disrupted and require repair. It is important that we continue to build on the information that our mentors have provided for us. That information can provide a foundation for better understanding of today’s problems. William A. Grana, MD Oklahoma City, Oklahoma the
throscopic meniscal findings in acute ACL-MCL knee injuries. His perspective of the combined ACL-MCL injury offers additional insight and meaning to our observations because of his intimate familiarity with Dr. O’Donoghue’s reports on this knee injury. Our purpose in presenting this article was to report our observations that, in our population (athletes), we found lateral meniscal tears more frequently than medial meniscal tears with the combined ACL-MCL injuries, although we did not negate the occurrence of medial meniscal tears (11% in grade II and 8% in grade III injuries in the study group). We appreciate Dr. Grana’s emphasizing that changing rules and changing surfaces have changed the pattern of injury in athletes and, with the benefits of modern technology, we have increased our diagnostic accuracy. Also, we appreciate the contributions of our sports medicine mentors. Without the foundation they have provided, we would not have been able to &dquo;revisit&dquo; nor to offer another perspective. We have found a different incidence of meniscal tears in the acute combined ACL-MCL injured knee compared to the isolated ACL-injured knee. Our hope is that our observations will alert our colleagues that we should examine the entire knee, both menisci, as well as the ligaments and the capsule, when an athlete is being evaluated for what has been clinically diagnosed as an acute ACL injury or ACLMCL injury. K. Donald Shelbourne, MD Paul A. Nitz, MD Indianapolis, Indiana