case_images: PMC6402071_01
case_images: Magnetic resonance imaging performed at emergency room showed small hyper-intensity images on white substance at protuberance, probably of vascular origin due to small vessel disease.. Sub-cortical and cortical atrophy of the brain were also observed. No signs of acute hemorrhagic or ischemic attack were observed.
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case_images: The MRI showed no radiological signs of stroke; for that reason, a transient ischemic attack (TIA) was suspected, and only hyper-intensity of white substance at the protuberance probably secondary to small vessel disease was observed (Figure 1).
case_images: On clinical evaluation of the feet and ankles, a bilateral gap sign is observed on our patient (see blue marks on the skin).
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case_images: When we examined the feet, a gap sign was observed in both heels (Figure 2).
case_images: On clinical evaluation of Thompson's test, failure of plantar flexion after compression of the gastrocnemious muscle corresponds to a positive test, confirming tendon rupture, on both sides.
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case_images: He was asked to knee over a chair and the Thompson's test was performed, being positive in both feet (Figure 3).
case_images: On ultrasound evaluation of Achilles tendon, a discontinuity of 5 cm on calcaneal insertion of left tendon (upper image), and a 4.4-cm discontinuity (lower image) on calcaneal insertion of right tendon confirms bilateral rupture.. Ultrasound images show correlation with gap sign.
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case_images: With the suspicion of bilateral Achilles tendon rupture, an ultrasound (US) scan was ordered immediately, and the results confirmed a total rupture of 5 cm of separation in the left heel and a 4.4 cm total gap in the right heel (Figure 4).
case_images: After 4 weeks of rehabilitation programme, patient was able to walk unassisted, only with the help of a cane.
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case_images: After 4 weeks of treatment, the patient was able to walk just with the assistance of a cane and without any ankle-foot orthosis (Figure 5).