BrJ Sports Med 1996;30:246-250

A high prevalence of abnormal personality traits inchronic users of anabolic-androgenic steroids

Craig J Cooper, Timothy D Noakes, Timothy Dunne, Michael I Lambert, Kevin Rochford

AbstractObjective-(1) To assess the personalityprofiles ofthe anabolic androgenic steroidusers (AAS) and (2) to determine whethervalid premorbid personality traits couldbe obtained from cross sectional assess-ment using multisource data.Methods-The first author became aparticipant-observer in a group of bodybuilders. An experimental group of bodybuilders who had been using AAS for nomore than 18 months (n=12) was identi-fied. A group of control subjects, each ofwhom claimed that he did not, and neverhad, used AAS (n=12) was also recruitedduring this period. Key informants playeda crucial role in recruiting subjectsrepresentative ofthe AAS and body build-ing communities. An interview schedulebased on the Diagnostic and statisticalmanual of mental disorders (DSM3-R)personality disorder criteria was con-ducted with each subject. Additional datawere obtained from an AAS using inform-ant and significant others including familyand friends.Results-The user group was significantlyheavier than the control group andshowed abnormal personality traits, incontrast to the control group. Personalitytraits of AAS users before the onset ofAAS use, assessed retrospectively, werenot different from personality traits ofcontrol subjects. There were significantdifferences between the before and afterpersonality traits in AAS user group.Conclusions-The results suggest (1) thatAAS use is associated with significant dis-turbances in personality profile, and (2)that these personality disturbances arepossibly the direct result ofAAS use.(BrJ Sports Med 1996;30:246-250)

Key terms: anabolic steroids; personality trait; bodybuilding

Before the mid-1970s the illicit use ofanabolic-androgenic steroids (AAS) was re-stricted mainly to highly trained athletes,particularly those involved in power activitiessuch as weight lifting.' Since then the use ofAAS has extended beyond the confines ofcompetitive sport to include recreational andnon-competitive athletes and school chil-dren,2" who now make up the large majority ofAAS users.

Although the physical and physiologicaleffects of AAS use have been studied exten-sively, the real psychological and behavioural

effects associated with their use are less wellunderstood. This state of affairs may in partresult from the fact that (1) most informationof the psychological effects of these agents isanecdotal, and (2) most recent studies arecross sectional, so that the personality profilesof the subjects before AAS use began are notknown. In addition, the effects of largenon-therapeutic doses and combinations ofAAS can be studied only in free living popula-tions, as ethical constraints prevent such stud-ies being performed under medical supervi-sion.

Nevertheless, concurrent with the morewidespread abuse of AAS has come a series ofstudies linking their use with marked psychiat-ric effects including personality disorders."6Included among these disorders are theparanoid, schizotypal, antisocial, borderline,histrionic, narcissistic, and passive-aggressivepersonality trait disorders. These disorders aresocially and personally debilitating and at timesmay profoundly affect the social functioning ofthe individual.

Accordingly, this study was designed todetermine the effects of AAS use on personal-ity traits in a group of body builders ingestinghigh doses of AAS in multiple combinations(stacking). Data were obtained from an inter-view schedule based on the Diagnostics and sta-tistical manual of mental disorders (DSM3-R)personality disorder criteria.7 After months ofobservation of the subjects' behaviour, the firstauthor and knowledgeable informants such asfriends were able to validate the subjects'assessment of their own personality traits. Ifdiscrepancies occurred between the assess-ments of a subject, criteria were scored on thebasis of consensus reached by the abovepersons.The first author (CJG) became a non-AAS

using member of a subgroup of bodybuilderswho used AAS. This study allowed the person-ality traits to be observed uniquely at first handin subjects using high doses and multiple com-binations of AAS. However, a potential weak-ness of the study was that the premorbidpersonality traits of the AAS users could not beassessed directly as they had already been usingAAS chronically for varying periods. Thus pre-morbid personality traits were assessed fromhistorical recall of subjects and were comparedto data from a group of non-using bodybuild-ers drawn from the same socioeconomic popu-lation and matched for age.

MethodsIn order to assess the effects of anabolic steroiduse on personality traits and separate underly-

University ofCapeTown, Cape Town,South Africa:Faculty of ScienceC J Cooper

Statistical SciencesT Dunne

School of EducationK Rochford

MRCIUCTBioenergetics ofExercise ResearchUnit, Sports ScienceInstitute of SouthAfrica, NewlandsT D NoakesM I Lambert

Correspondence to:Professor T D Noakes,MRC/UCT Bioenergetics ofExercise Research Unit,Sports Science Institute ofSouth Africa, BoundaryRoad, Newlands 7700,Republic of South Africa.

Accepted for publication16 January 1996

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Personality traits and anabolic steroids

ing psychiatric symptoms from those inducedby AAS exposure, it was necessary for CJC towork closely with bodybuilders from five CapeTown gymnasia. This proximity was made pos-sible by his becoming a participant observer,by taking part in all the activities of the group,and in so doing gaining their trust. The initialinfiltration was made possible by his gainingthe friendship of two key individuals in thegroup; their friendship led to his acceptance bymost of the members of the group.As CJC's acceptance into the group in-

creased, he was able to identify an experimen-tal group of bodybuilders who had been usingAAS for no more than 18 months (n= 12).Recruitment of subjects for the study occurredover a five week period. Key informants playeda crucial role with respect to recruitment ofsubjects representative of the AAS and bodybuilding communities. A group of control sub-jects, each of whom claimed that he did not,and never had, used AAS (n=12), was alsorecruited during this period.As a result of the selection process, the 24

male subjects, aged between 17 and 26, wererecruited from an estimated population ofbetween 400 and 600 committed body build-ers. Equal numbers of subjects were availablein each group (n= 12).Through frequent discussions during the

observational period, subjects were madeaware of CJC's interest in drug relatedresearch, and of his interest in their personallives and of the possible effects ofAAS on theirpersonalities. Subjects were fully informedseveral weeks before the interviews of the goalof the intended interviews. In particular therewas complete transparency of the intentions ofthe authors. Support for the proposed studywas given by all the subjects for varyingpersonal reasons including the desire to knowmore about themselves and the wish to partici-pate in furthering scientific knowledge in thisfield.Each subject was interviewed once for data

collection. The first 20 minutes of the inter-views were unstructured and were used, if nec-essary, to relax the subjects and to assure themof the confidential nature of the study.Interviews took place where subjects felt mostrelaxed, but were conducted under schedules.The interview schedules were based on theDiagnostic and statistical manual of mental disor-ders (DSM3-R) criteria for personality traitdisorders.7 For each of the 11 personalitydisorders, subjects were given a list of the crite-ria denoting that personality trait disorder, andasked to consider carefully which if any of thecriteria they satisfied. There was completeresponse on all the criteria by all the subjects.Moreover, subjects were consistent in nomi-nating or denying criteria that were common toseveral disorders. After five months of observa-tion of the subjects' behaviour, CJC andknowledgeable informants such as friends wereable to validate the subjects' assessment oftheir own personality traits. If discrepanciesoccurred between these assessments, criteriawere scored on the basis of consensus reachedby the above persons.

The DSM3-R provides diagnostic criteria,which identify behaviours or traits that arecharacteristic of the person's recent or longterm psychological functioning since earlyadulthood. Personality traits are enduring pat-terns of perceiving, relating to, and thinkingabout the environment and oneself, and aredisplayed in a wide range of important socialand personal contexts. Personality disordersare diagnosed when the score for certain traitsexceeds specified threshold criteria on theDSM3-R personality disorders.

Personality disorders are grouped into threeclusters. Cluster A includes paranoid, schizoid,and schizotypal personality disorders andidentifies persons who often appear to be oddor eccentric. Cluster B includes antisocial, bor-derline, histrionic, and narcissistic personalitydisorders. Persons with these disorders oftenappear dramatic, emotional, or erratic. ClusterC includes avoidant, dependent, obsessive-compulsive, and passive-aggressive personalitydisorders. Persons with these disorders oftenappear anxious.Users of AAS underwent an additional

second interview similar in format to the earlierinterview except that subjects were asked toselect, from memory, item responses forcriteria within personality traits that wouldhave applied before they began to use AAS.Special care was exercised in focusing subjectson that earlier period, such as interviewingsubjects in places they frequented shortlybefore AAS use, as such settings facilitatememory recall. Second interviews were heldwithin five weeks of the initial ones.

STATISTICAL METHODSGroup average scores for each personality traitwere derived from the numbers of criteria fordisorders satisfied by members of the controlgroup, and of the AAS group before and afterAAS use.

Paired Student's t statistics were used tocompare differences within the AAS usergroup, and the unpaired two sample Student'st statistic between the control group and theAAS users. The Kruskal-Wallis test was used toevaluate differences between the control groupand estimated scores of the AAS users beforeand after AAS use as a precaution against anyunrecognised small sample violations of t testassumptions. Differences were considered sta-tistically significant for P less than 0.05.

ResultsThe mean (SD) age, height, and mass of theuser group was 22.3(2.5) years; 1.83(0.52) m,and 103(13.4) kg respectively; and that of thecontrols was 20.9(2.3) years; 1.82(0.70) m,and 82.5(9.1) kg. Although the age and heightof the two groups were similar, reportedmasses were greater in AAS users (P<0.05) .

All the experimental subjects used two ormore AAS concurrently on at least oneoccasion during the study. This activity, calledstacking, was a common occurrence, thesubjects often using combinations of AASdepending on what was both available andaffordable. As a result combinations and

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Cooper, Noakes, Dunne, Lambert, Rochford

Table 1 Average dosages and numbers of users for thedifferent anabolic steroids used by the 12 AAS using bodybuilders in this study

Table 2 Measured traits based on counts ofDSM3-Rpersonality disorder criteria in users before and after use,and in non-users. Values are means (SD)

RecommendedAnabolic steroids dose

Users (experimental group)Reported dose n=12)

400 mg d'1 79mg±42/daily (n=7)

2-3 mg kg-' d-' 36mg±18/daily (n=2)

(1) Depo-Testosterone 50-100 mg/1-2weeks

(2) Deca-durabolon 20-30 mg/1-3weeks

(3) Sustanon 250 250 mg/every 4weeks

(4) Primabolon Depot 100 mg/every 2weeks

(5) Depotrone

(C) Veterinary preparations (injectables)(1) Tribolon 0

(2) Equipoise 0

180 mg +84/weekly (n=5)100 mg _50/weekly (n=3)250 mg ±

0/weekly (n=2)100 mg ±

0/weekly (n=2)250 mg ±

100/weekly (n=4)

144 mg +52/weekly (n=4)75 mg ±0/weekly (n=2)

Note: Subjects used an average of 2.5 (SD 1) different drugsduring any one month period. Dosages are thought to be a

minimum approximation. The recommended dose for depo-trone is not available as the drug has been discontinued.

dosages frequently varied each week, making itdifficult to record the specified drugs and exactdosages used. All the different AAS and corre-

sponding average dosages used over a period ofone month have been listed, as accurately as

possible, as the best representation of the typi-cal pattern of AAS abuse in the user group(table 1).

Subject used an average of 2.5(1.0) AASthroughout the month. The doses used for themajority of the drugs were greatly in excess ofthe recommended doses used for legitimatemedical reasons.

Table 2 lists the average scores and standarddeviations for numbers of disorder criteria on

11 personality traits measuring eccentric,flamboyant, and anxious features of behaviourin the control and user groups. There were no

statistically significant differences on thesescales between the control and recall groupscores (columns A and C). Four individuals(33%) within each of these two groups showedat least one threshold criterion somewhereamong these scales, though the total number ofthresholds attained was higher in the AASrecall scores," than in the control scores.6

A twelfth variable did indicate a significantdifference between control and recall scores,but was eliminated from further analysis on thebasis that at least one such statistical artefactwill arise by chance in a study of 12 variableswith a probability of about 46%. On this basiswe postulate the a priori comparability of thetwo samples as reasonable on the remaining 11variables.The AAS current user scores were higher

than the controls on measures of paranoid,schizoid, antisocial c, borderline, histrionic,narcissistic, and passive-aggressive personalitytraits (column A versus B).On the same seven variables there was a sig-

nificant difference between AAS recall andcurrent scores. Moreover, whereas there were

(A) Non-users (B) CurrentPersonality (control (while usingtraits group) AAS)

ParanoidSchizoidSchizotypalAntisocial CBorderlineHistrionicNarcissisticAvoidantDependent0. CompulsiveP. Aggressive

1.17 (0.27)0.58 (0.26)0.92 (0.38)0.92 (0.34)0.67 (0.26)1.00 (0.35)2.50 (0.53)0.75 (0.35)0.92 (0.31)1.42 (0.40)1.50 (0.29)

4.00 (0.37)*0.75 (0.25)2.83 (0.51)*3.50 (0.56)*3.17 (0.44)*2.92 (0.42)*3.92 (0.26)*1.33 (0.31)0.67 (0.40)2.17 (0.47)3.67 (0.53)*

(C) Estimated(before AASuse)

1.92 (0.50)t0.67 (0.22)1.25 (0.41)t1.67 (0.47)t1.50 (0.45)t1.33 (0.48)t2.08 (0.40)t0.83 (0.27)0.75 (0.33)1.75 (0.33)2.17 (0.55)t

O = Obsessive, P = Passive.*P < 0.05, current users (column B) v non-users (column A).tP < 0.05, current users (column B) v estimated before AASuse (column C).

on recall four individuals with at least one

threshold attained and two with at least twoattained, there were 10 AAS users (83%)meeting the criterion for at least one personal-ity disorder and seven with at least twodisorders on current scores.

DiscussionResearch into personality assessment is fraughtwith difficulty.89 Serious issues to the validity ofdata were (1) the unknown validity of stand-ardised self report questionnaires such as thePDQ-R and SCID 2, and (2) intentional or

unintentional underreporting or over reportingby subjects on self report questionnaires.

Despite the fact that instruments are essen-

tially a direct translation ofDSM3-R personal-ity disorder diagnostic criteria into a self reportformat, it is unclear how representative eachquestion is of its respective criterion. Theresulting problem of data reliability may beillustrated by comparison of any two instru-ments used in the same subject, which revealson average more diagnostic disagreement thanagreement."'0 The problem is further ampli-fied because each subjects' interpretation of a

question may be somewhat idiosyncratic.8Intentional misreporting includes lying and

efforts to meet sociably acceptable stand-ards." 12 Unintentional misreporting includesstate effects and personality traits. Misreport-ing may be a problem for data validity9 as AASusers satisfying the diagnostic number of crite-ria for the paranoid disorder were reluctant tofill in self report measures in this study. Evenwhen interviewed they were likely to deny or

minimise their disorder. On the other handAAS users with the antisocial or borderlinedisorder were inclined to overreport or embel-lish their disorder.

It is increasingly realised, in the light of theabove, that assessment using multisource data,particularly those from observation and signifi-cant others, is important if valid data are to beobtained.8 Hence the methodological design ofthis study.AAS are psychoactive drugs which alter

mood and awareness of the external (sur-roundings) and internal (cognitive) environ-

(A) Oral preparations(1) Anapolon 4

(2) Primabolon S 2

(B) Injectable preparations

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Personality traits and anabolic steroids 249

ments of an individual.'7 It might therefore beexpected that large doses of these agents couldalter personality traits in which individualsrespond to other individuals and situations.These changes may then lead to abnormal per-sonality traits or personality disorders, whichthen interfere with personal functioning orcause the individual to become distressed.7Our study supports this thesis by showing

increased scores in AAS users in seven person-ality traits (table 2). These scores are in generalhigher than those for controls and for histori-cally reported values for the same AAS usersbefore the start of AAS use.Although some studies have reported rela-

tively minor psychological effects ofAAS use,'2other more recent studies have identified morepsychological and behavioural changes associ-ated with their use.""53'4. Thus Yates et al'found that 85% of 20 AAS users showedpersonality disorders or abnormal personalitytraits on the personality disorder questionnaire(PDQ). Our results are similar (83%). Simi-larly, although the findings of Perry andHughes'4 were not as clear and marked as inthe aforementioned studies, they found thatAAS users showed more personality distur-bances overall than a control group of non-AAS users. Su et al5 also found a significantimpact on personality even during short term,relatively low dose AAS use without stacking.The issue of publication bias arises in such

cases. Journal articles are generally required toshow statistically significant results beforebeing accepted for publication. Thus studieswhich might give contrasting evidence of anabsence of effects never reach a wider reader-ship. In this instance we have not been able totrace any such studies. Furthermore, webelieve that the interpretation of AAS as acause of behavioural change is reasonable andnot an artefact of publication bias.

In general the interpretation of most studiesof the purported effects ofAAS use on person-ality has been hampered by the absence ofinformation about premorbid personality traitsin current AAS users. For example, anindividual may satisfy the diagnostic number ofcriteria for a personality disorder before AASexposure. AAS use may exacerbate the disor-der. Ifno premorbid data are available, the dis-order may be attributed to the effects of AASabuse. This notion is corroborated by the find-ing that one in three users (33%) in this studysatisfied the diagnostic number of criteria for atleast one disorder before AAS exposure. Incontrast, no such abnormalities were present inthe control group. The possibility that person-ality disorders may predispose to AAS useshould be considered.Furthermore retrospective assessment of

personality traits is problematic. The few stud-ies which have attempted to control forpremorbid personality traits had non-AAS-using controls to determine an average pre-morbid proffle.4"1 However, because a drugeffect is dependent on the interaction ofvarious influences in a particular context, therecan be a wide variation in the manner in whichdifferent individuals respond to the same

drugs. In addition, because of varying influ-ences affecting drug responses, psychologicaleffects may vary between differentsocioeconomic settings, different AAS anddosages used, and between different AAS usingcommunities. Hence, if these factors are notcontrolled, choosing of non-AAS-users as sub-jects to control for premorbid traits in the AASusing community may not be valid.The controls in this study were carefully

matched for socioeconomic background andage. There were no significant differences inpersonality disorders between the control anduser group before AAS exposure. We suggestthat cross sectional assessment using multi-source data was successful in assessing the pre-morbid personalities of users, despite majormethodological problems.The importance of controlling for premor-

bid personality traits cannot be overempha-sised because effective diagnosis, intervention,and treatment in a clinical setting may dependon knowing which disorders or symptoms are anatural part of the patient's personality andwhich are induced by substance abuse.

In conclusion, this study suggests (1) thatAAS use significantly increases the frequencyand severity of symptoms of personality disor-ders; and (2) that cross sectional assessmentusing multisource data may allow valid retro-spective assessment of premorbid personalityprofiles. This study adds to the growingevidence of the dangers of AAS use andsuggests that observation, and informationobtained from significant others, can beimportant in the retrospective assessment ofpersonality.'s15

The authors with to thank Drs Bryan Dirks and Elanor Nash ofthe Department of Psychiatry, University of Cape Town andGroote Schuur Hospital, for constructive criticism and advice.

This study was supported by the Medical Research Council andthe Nellie Atkinson and Harry Crossley Research Funds of theUniversity of Cape Town.

1 Kaskin KB, Klebber HD. Hooked on hormones? Ananabolic steroid addiction hypothesis. JAMA1989;262:3166-70.

2 Buckley WE, Yesalis CE, Anderson W, Streit AL, Wright J.Estimated prevalence of anabolic steroid use among malehigh school seniours. JAMA 1988;260:3441-5.

3 Schwellnus MP, Lambert MI, Todd MP, Juritz JM. Andro-genic anabolic steroid use in matric pupils. A survey ofprevalence of use in the Western Cape. S Afr Med 7 1992;82:154- 8.

4 Pope H, Katz DL. Affective and psychotic symptomsassociated with anabolic steroid use. AmJPsychiatry 1988;145:487-90.

5 Su TP, Pagliaro M, Schmidt PJ, Pickar D, Wolkowitz 0,Rubinow DR Neuropsychiatric effects of anabolic steroidsin male normal volunteers.JAMA 1993;296:2760-4.

6 Yates WR, Perry PJ, Anderson KH. Illicit anabolic steroiduse: a controlled personality study. Acta Psychiatr Scand1990;81:548-50.

7 American Psychiatric Association. Diagnostic and statisticalmanual of mental misorders. Washington DC:AmericanPsychiatric Association, 1987.

8 Perry JC. Problems and considerations in the validassessment of personality disorders. Am _J Psychiatry 1992;149:1645-53.

9 Hyler SE, Rieder RO, Williams JBW, Spitzer RL, Lyons M,Hendler JA. Comparison of clinical and self-report diagno-sis of DSM-3 personality disorders in 555 patients. ComprPsychiatry 1989;30:170-8.

10 Hyler SE, Skodal AE, Keilman HD, Oldham JM, Rosnick L.Validity of the personality questionnaire - revised: Com-parison with two structured interviews. Am Jf Psychiatry1990;147: 1043-8.

11 Yesalis CE. Incidence of anabolic steroid use: a discussion ofmethodological issues. In Yesalis CE, ed. Anabolic steroids insport and exercise. Champalgn, Illinois: Human KineticsPublishers, 1993:49-70.

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12 Brower K, Eliopulos GA, Blow FC, Catlin DH, BeresfordTP. Evidence for physical and psychological dependenceon anabolic androgenic steroids in eight weight lifter. Am JPsychiatry 1990;147:510-2.

13 Bahrke MS, Wright JE, Strauss RH, Catlin DH. Psychologi-cal moods and subjectivity perceived behavioural andsomatic changes accompanying anabolic-androgenic ster-oid use. AmJSports Med 1993:20:717-22.

14 Perry H, Hughes G. A case of affective disorder associatedwith the misuse of "anabolic steroids". Br J Sports Med1992;26:219-20.

15 Reis R. Co-occurance of substance abuse disorders, psychi-atric disorders-separation "an art". Psycholink Aug 8,1993.

OCCASIONAL PIECE

Clinical tests in sports medicine: more on Achillestendon

The diagnosis of Achilles tendon rupture canbe difficult even for experienced practitioners,and a significant number of patients can be ini-tially misdiagnosed.When examined soon after the injury, a tear

in the substance of the tendon can be seen andpalpated. With increased time after the tear,the gap can be obliterated by oedema, and pal-pation becomes unreliable.

In addition to the tests described in thisjournal in the June issue (volume 30, page124), two other clinical tests should bementioned.

Matles testThe patient, lying prone and with feet over theend of the examination couch, is asked to flexthe knee actively to 90°. The position of theankle and feet is observed during this move-ment. If the foot on the affected side falls intoneutral or into dorsiflexion, an Achilles tendonrupture is diagnosed. In normal patients, thefoot remains in slight planter flexion when theknee is flexed to 90'.1

Needle testWith the patient prone, a small gauge needle isinserted at a right angle through the skin of thecalf, just medial to the midlline, 10 cmproximal to the superior border of the calca-neum. The needle should be inserted only untilthe tip is just within the substance of thetendon. The foot is then passively andalternately dorsiflexed and plantarflexed. Tworesponses may occur. The needle may swivel sothat it points in the direction opposite to themotion of the ankle (that is, when the ankle isdorsiflexed, the needle points distally). Thisindicates that the tendon is intact in theportion distal to the needle insertion point.The other possible response is that the needledoes not move, or moves slightly in the same

direction of the motion of the ankle (that is,when the ankle is dorsiflexed, the needle pointsproximally). In this second instance, the Achil-les tendon has lost its continuity between theneedle and its insertion.2

More on the calf squeeze testGiven the history of the test, the correctdenomination should be Simmond's test. Sim-monds described his test in a paper on thediagnosis ofAchilles tendon rupture, publishedfive years before Thompson's papers.3 Thomp-son and Doherty published jointly an article inan American journal solely on this test in1962.4 Practically the same paper was pub-lished by Thompson, without his colleague,some months later in a European journal.5

In the British Isles, the calf squeeze test iscalled "Simmond's test", and in most of therest of the world "Thompson's test", notacknowledging that Doherty was one of theoriginal authors. To avoid offending the sensi-tivities of British or American influencedsurgeons, it is better to describe the test as the"calf squeeze test" and cite the fact thatSimmonds described it well before Thompsonand Doherty. To avoid confusion on what con-stitutes a positive test, one should probably justmention whether the ankle plantar flexes onsqueezing the calf muscles. If it does, thetendon is most likely intact (but beware of theplantaris!).

NICOLA MAFFULLI

1 Matles AL Rupture of the tendo Achilles. Another diagnos-tic test. Bull Hosp joint Dis 1975;36:48-51.

2 O'Brien T The needle test for complete rupture of theAchilles tendon. J Bone Joint SurgAm 1984;66: 1099-101

3 Simmonds FA The diagnosis of the ruptured Achillestendon. Practitioner 1957;179;56-8

4 Thompson TC, Doherty JC. Spontaneous rupture of theAchilles tendon: a new clinical diagnostic test. J Trauma1962;2: 126-9.

5 Thompson TC. A test for rupture of the tendo Achillis. ActaOrthop Scand 1962;32:4615.

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