514272
research-articleXXXX
FASXXX10.1177/1938640013514272Foot & Ankle SpecialistFoot & Ankle Specialist
74
February 2014
Foot & Ankle Specialist
〈 Case Report 〉 A Case of Spontaneous Bilateral Achilles Tendon Rupture
Dominic Yue, MBBS, BSc, MRCS, Nawfal Al-Hadithy, MBBS, MSc, MRCS, and Peter Domos, MBBS, MRCS
Surgical Treatment With Early Mobilization Abstract: Background. TendoAchilles (TA) rupture is the most commonly ruptured tendon in the lower limb despite being one of the toughest tendons. Typically, it occurs unilaterally in middleaged individuals who participate in strenuous activity. Spontaneous ruptures without any risk factors predisposing the patient is uncommon and for it to occur bilaterally is very rare. Objectives. To raise awareness of the potential for TA ruptures to occur bilaterally and thus the importance of assessing the TA contralateral to a seemingly unilateral rupture. This is particularly the case in patients with risk factors, which are reviewed in this report. A summary of the main treatment options is also described. Case report. We report a case of spontaneous, bilateral TA rupture in a 40-year-old man with no identifiable risk factors. It occurred following a heavy impact during a sports activity and although painful, was able
to mobilize slowly. After a clinical Keywords: Achilles; tendon; rupture; examination confirmed the diagnosis, bilateral; spontaneous the patient underwent early bilateral surgical repair and subsequently Introduction embarked on a comprehensive rehabilitation program with a good Rupture of the tendo-Achilles (TA) is the functional outcome at follow-up. His most frequently ruptured tendon in the return to premorbid work and social life was uneventful. Rupture of the tendo-Achilles (TA) is Conclusions. Bilateral TA ruptures are rare but the most frequently ruptured tendon in increased awareness the lower limb even though it is one of would help avoid a tear or rupture of the the strongest tendons.” contralateral side being missed. All patients presenting clinically with any TA rupture should have risk lower limb even though it is one of the factors reviewed. Surgical repair must strongest tendons.1,2 It most commonly be accompanied by a comprehensive occurs unilaterally in active individuals rehabilitation program for adequate during their fourth to fifth decade when recovery and return of function. performing high-energy movements with eccentric loading, such as during sports.3 Levels of Evidence: Therapeutic, Incidence of spontaneous TA ruptures Level IV, Case study is 0.02% in the general population and
“
DOI: 10.1177/1938640013514272. From the Luton and Dunstable Hospital, Luton, UK. Address correspondence to: Dominic Yue, MBBS, BSc, MRCS, Hammersmith Hospital, Du Cane Road, London W12 OHS, UK; e-mail: [email protected] For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2013 The Author(s)
Downloaded from fas.sagepub.com at IOWA TESTING PROGRAMS on March 18, 2015
vol. 7 / no. 1
Foot & Ankle Specialist
increases with certain risk factors, such as increasing age, steroid and fluoroquinolone use, or certain systemic conditions. Reports of bilateral ruptures are infrequent, occurring in less than 1% of presentations, and even rarer in the absence of predisposing risk factors. There have been only a few reports of Caucasians without identifiable risk factors who have had a similar presentation.4-7 We report a case of surgically treated spontaneous simultaneous bilateral TA rupture in a young gentleman with no established predisposing factors.
Figure 1.
Figure 3.
A positive Simmonds’ test on the right lower leg.
Intraoperative view of the left tendo-Achilles with the tendon discontinuation clearly seen.
Clinical Presentation
Figure 2.
A 40-year-old male patient, previously fit and well, developed acute bilateral ankle pain whilst snowboarding. At the time, he was landing awkwardly from a jump and impacted heavily with his body thrown forward, causing both his ankles to suddenly hyperdorsiflex. The pain subsided but had some paraesthesia around the posterior aspect of his ankles. He was able to weight-bear and walk slowly, reporting that his feet felt like they were “dragging” along. There were no other injuries or history of trauma. He reports no chronic steroid or fluoroquinolone use and no previous tendon abnormalities. He is a nonsmoker with a weekly alcohol consumption of approximately 24 units. On examination, there was bruising and swelling over the posterior aspect of both ankles and was tender over the region of the Achilles tendons. There were also palpable gaps along both tendons, approximately 4 cm proximal to the tendon insertion. Range of movement was decreased and painful, but neurovascular supply was intact. Simmonds’ test clinically confirmed the diagnosis of bilateral tendon rupture (Figures 1 and 2). His blood results were unremarkable and bilateral ankle radiographs revealed no evidence of bony injuries. One day after his admission, he underwent a simultaneous bilateral TA direct repair under general anesthetic without the use of tourniquets. After the routine
A positive Simmonds’ test on the left lower leg.
paramedian surgical approach, the bilateral ruptures were identified and number 5 Tycron sutures were used for the Krakow type core repair, which was reinforced with absorbable Vicryl continuous circumferential peritendinous sutures (Figures 3 and 4). Strong repair with good approximation of tendon edges was achieved without gap or tension. The repair was also covered and protected with absorbable interrupted closure of the paratenon. Careful skin closure was performed with absorbable sutures without tension. Below-knee volar plaster of Paris backslabs were applied in equinus position and remained until the wound healed. He had an uneventful postoperative period and was discharged the following day with advice to be non–weight bearing for 2 weeks and to use a wheelchair until the follow-up appointment. After a postoperative wound check at 2 weeks,
Figure 4. Intraoperative view of the right tendo-Achilles with Tycron sutures in situ.
mobility was promoted with the application of a below-knee plaster of Paris walking cast with the feet in a neutral position. At 6 weeks, the plaster was removed and the patient was started on active physiotherapy, including gastrocnemius and soleus stretching and active ankle range of motion exercises, concentrating on Achilles tendon strengthening. He was also recommended to wear a raised heel insole. At 12 weeks, he had resumed his usual preinjury work and social life. By 1 year, he had restarted his sporting activities and was discharged from the clinic.
Discussion This is an unusual case of TA rupture and in the assessment of this patient, intrinsic and extrinsic risk factors for
Downloaded from fas.sagepub.com at IOWA TESTING PROGRAMS on March 18, 2015
75
76
February 2014
Foot & Ankle Specialist
rupture were considered, but none explained why he would have ruptures bilaterally. This is especially since his fall was asymmetrical and although heavy on impact, it would ordinarily be unexpected for symmetrical complete tears to be sustained. A commonly reported association made with TA ruptures is chronic steroid use.1 Local corticosteroid injections have been a contentious issue regarding benefits and associated risks of tendon rupture.8 Fluoroquinolones are another group of medications to have been implicated.9 There are systemic conditions, mainly rheumatological in nature, which have been reported to increase incidence. Reported conditions include rheumatoid arthritis, gout, chronic renal failure, diabetes mellitus, systemic lupus erythematosis, and polymyalgia rheumatica.10 The patient had none of these factors that would predispose his condition. In addition to the above extrinsic elements, some intrinsic tendon properties add to the propensity for rupture and include hyperpronation of the foot, leg length discrepancies, and obesity causing excessive or unequal distribution of tensile loads.11 These biomechanical instabilities cause a decrease in the overall shock-absorbing capacity of the tendon. Inadequate technique in sports training or conditions that lead to poor joint proprioception can lead to poor ankle-foot positioning. With such long-term tendon misuse or overuse, instability from uneven TA loading is exacerbated.12,13 As age progresses, blood supply to the TA diminishes to a degree, especially in the region of 3 to 6 cm proximal to its calcaneal insertion. This resultant relative ischemia increases likelihood of ruptures.14 Some intrinsic factors may be difficult to assess in a premorbid state and would be especially challenging now that the injury has occurred. Physiotherapy however can help identify and rectify any hyperpronation or abnormal gait.
The management of TA rupture has been controversial,15 with studies showing that conservative management with an early application of an equinus cast have similar rerupture rates compared with surgical repair and may avoid the risk of wound complications.16 Systematic reviews have reported that in young individuals who present acutely, surgical intervention may still be a preferred option. Prompt operative treatment was shown to result in better long-term tendon integrity with lower recurrence rates.17,18 The patient described here complied well with the rehabilitation program and this is crucial in helping individuals return to their pre-morbid mobility and function.
6. Garneti N, Holton C, Shenolikar A. Bilateral Achilles tendon rupture: a case report. Accid Emerg Nurs. 2005;13: 220-223.
Conclusion
11. Hess GW. Achilles tendon rupture: a review of etiology, population, anatomy, risk factors, and injury prevention. Foot Ankle Spec. 2010;3:29-32.
In conclusion, we have presented a rare occurrence of spontaneous bilateral TA rupture, in a patient without predisposing risk factors and who made an uneventful recovery following early open surgical repair. As patients can appear to weight-bear and even walk after TA ruptures, it is important to consider the contralateral side whenever a unilateral case is suspected. This is especially if the patient has any of the risk factors outlined above.
References 1. Haines JF. Bilateral rupture of the Achilles tendon in patients on steroid therapy. Ann Rheum Dis. 1983;42:652-654. 2. Arner O, Lindholm A, Orell SR. Histologic changes in subcutaneous rupture of the Achilles tendon: a study of 74 cases. Acta Chir Scand. 1959;116:484-490. 3. Schepsis AA, Jones H, Haas AL. Achilles tendon disorders in athletes. Am J Sports Med. 2002;30:287-305. 4. Taylor TL, Simon D, Feibel R. Idiopathic simultaneous bilateral Achilles tendon rupture. BMJ Case Rep. 2009;2009. doi:10.1136/bcr.07.2009.2055. 5. Hanlon DP. Bilateral Achilles tendon rupture: an unusual occurrence. J Emerg Med. 1992;10:559-560.
7. Audenaert EA, Van Nuffel J, Deroo KF, Vuylsteke M, Verdonk R. Bilateral simultaneous traumatic Achilles tendon rupture. Foot Ankle Surg. 2004;10:49-50. 8. Mahler F, Fritschy D. Partial and complete ruptures of the Achilles tendon and local corticosteroid injections. Br J Sports Med. 1992;26:7-14. 9. Doyle HE. Tendinopathy resulting from the use of fluoroquinolones: managing risks. JAAPA. 2010;23(12):18-21, 54. 10. Park JH, Kim SB, Shin HS, Jung GH, Jung YS, Rim H. Spontaneous and serial rupture of both Achilles tendons associated with secondary hyperparathyroidism in a patient receiving long-term hemodialysis. Int Urol Nephrol. 2013;45:587-590.
12. Simoneau GG, Derr JA, Ulbrecht JS, Becker MB, Cavanagh PR. Diabetic sensory neuropathy effect on ankle joint movement perception. Arch Phys Med Rehabil. 1996;77:453-460. 13. Bressel E, Larsen BT, McNair PJ, Cronin J. Ankle joint proprioception and passive mechanical properties of the calf muscles after an Achilles tendon rupture: a comparison with matched controls. Clin Biomech (Bristol, Avon). 2004;19: 284-291. 14. Lagergren C, Lindholm A. Vascular distribution in the Achilles tendon: an angiographic and microangiographic study. Acta Chir Scand. 1959;116: 491-495. 15. Chalmers J. Review article: treatment of Achilles tendon ruptures. J Orthop Surg (Hong Kong). 2000;8:97-99. 16. Nistor L. Surgical and non-surgical treatment of Achilles tendon rupture. A prospective randomized study. J Bone Joint Surg Am. 1981;63:394-399. 17. Khan RJ, Carey Smith RL. Surgical interventions for treating acute Achilles tendon ruptures. Cochrane Database Syst Rev. 2010;(9):CD003674. 18. Wong J, Barrass V, Maffulli N. Quantitative review of operative and nonoperative management of Achilles tendon ruptures. Am J Sports Med. 2002;30:565-575.
Downloaded from fas.sagepub.com at IOWA TESTING PROGRAMS on March 18, 2015
research-articleXXXX
FASXXX10.1177/1938640013514272Foot & Ankle SpecialistFoot & Ankle Specialist
74
February 2014
Foot & Ankle Specialist
〈 Case Report 〉 A Case of Spontaneous Bilateral Achilles Tendon Rupture
Dominic Yue, MBBS, BSc, MRCS, Nawfal Al-Hadithy, MBBS, MSc, MRCS, and Peter Domos, MBBS, MRCS
Surgical Treatment With Early Mobilization Abstract: Background. TendoAchilles (TA) rupture is the most commonly ruptured tendon in the lower limb despite being one of the toughest tendons. Typically, it occurs unilaterally in middleaged individuals who participate in strenuous activity. Spontaneous ruptures without any risk factors predisposing the patient is uncommon and for it to occur bilaterally is very rare. Objectives. To raise awareness of the potential for TA ruptures to occur bilaterally and thus the importance of assessing the TA contralateral to a seemingly unilateral rupture. This is particularly the case in patients with risk factors, which are reviewed in this report. A summary of the main treatment options is also described. Case report. We report a case of spontaneous, bilateral TA rupture in a 40-year-old man with no identifiable risk factors. It occurred following a heavy impact during a sports activity and although painful, was able
to mobilize slowly. After a clinical Keywords: Achilles; tendon; rupture; examination confirmed the diagnosis, bilateral; spontaneous the patient underwent early bilateral surgical repair and subsequently Introduction embarked on a comprehensive rehabilitation program with a good Rupture of the tendo-Achilles (TA) is the functional outcome at follow-up. His most frequently ruptured tendon in the return to premorbid work and social life was uneventful. Rupture of the tendo-Achilles (TA) is Conclusions. Bilateral TA ruptures are rare but the most frequently ruptured tendon in increased awareness the lower limb even though it is one of would help avoid a tear or rupture of the the strongest tendons.” contralateral side being missed. All patients presenting clinically with any TA rupture should have risk lower limb even though it is one of the factors reviewed. Surgical repair must strongest tendons.1,2 It most commonly be accompanied by a comprehensive occurs unilaterally in active individuals rehabilitation program for adequate during their fourth to fifth decade when recovery and return of function. performing high-energy movements with eccentric loading, such as during sports.3 Levels of Evidence: Therapeutic, Incidence of spontaneous TA ruptures Level IV, Case study is 0.02% in the general population and
“
DOI: 10.1177/1938640013514272. From the Luton and Dunstable Hospital, Luton, UK. Address correspondence to: Dominic Yue, MBBS, BSc, MRCS, Hammersmith Hospital, Du Cane Road, London W12 OHS, UK; e-mail: [email protected] For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2013 The Author(s)
Downloaded from fas.sagepub.com at IOWA TESTING PROGRAMS on March 18, 2015
vol. 7 / no. 1
Foot & Ankle Specialist
increases with certain risk factors, such as increasing age, steroid and fluoroquinolone use, or certain systemic conditions. Reports of bilateral ruptures are infrequent, occurring in less than 1% of presentations, and even rarer in the absence of predisposing risk factors. There have been only a few reports of Caucasians without identifiable risk factors who have had a similar presentation.4-7 We report a case of surgically treated spontaneous simultaneous bilateral TA rupture in a young gentleman with no established predisposing factors.
Figure 1.
Figure 3.
A positive Simmonds’ test on the right lower leg.
Intraoperative view of the left tendo-Achilles with the tendon discontinuation clearly seen.
Clinical Presentation
Figure 2.
A 40-year-old male patient, previously fit and well, developed acute bilateral ankle pain whilst snowboarding. At the time, he was landing awkwardly from a jump and impacted heavily with his body thrown forward, causing both his ankles to suddenly hyperdorsiflex. The pain subsided but had some paraesthesia around the posterior aspect of his ankles. He was able to weight-bear and walk slowly, reporting that his feet felt like they were “dragging” along. There were no other injuries or history of trauma. He reports no chronic steroid or fluoroquinolone use and no previous tendon abnormalities. He is a nonsmoker with a weekly alcohol consumption of approximately 24 units. On examination, there was bruising and swelling over the posterior aspect of both ankles and was tender over the region of the Achilles tendons. There were also palpable gaps along both tendons, approximately 4 cm proximal to the tendon insertion. Range of movement was decreased and painful, but neurovascular supply was intact. Simmonds’ test clinically confirmed the diagnosis of bilateral tendon rupture (Figures 1 and 2). His blood results were unremarkable and bilateral ankle radiographs revealed no evidence of bony injuries. One day after his admission, he underwent a simultaneous bilateral TA direct repair under general anesthetic without the use of tourniquets. After the routine
A positive Simmonds’ test on the left lower leg.
paramedian surgical approach, the bilateral ruptures were identified and number 5 Tycron sutures were used for the Krakow type core repair, which was reinforced with absorbable Vicryl continuous circumferential peritendinous sutures (Figures 3 and 4). Strong repair with good approximation of tendon edges was achieved without gap or tension. The repair was also covered and protected with absorbable interrupted closure of the paratenon. Careful skin closure was performed with absorbable sutures without tension. Below-knee volar plaster of Paris backslabs were applied in equinus position and remained until the wound healed. He had an uneventful postoperative period and was discharged the following day with advice to be non–weight bearing for 2 weeks and to use a wheelchair until the follow-up appointment. After a postoperative wound check at 2 weeks,
Figure 4. Intraoperative view of the right tendo-Achilles with Tycron sutures in situ.
mobility was promoted with the application of a below-knee plaster of Paris walking cast with the feet in a neutral position. At 6 weeks, the plaster was removed and the patient was started on active physiotherapy, including gastrocnemius and soleus stretching and active ankle range of motion exercises, concentrating on Achilles tendon strengthening. He was also recommended to wear a raised heel insole. At 12 weeks, he had resumed his usual preinjury work and social life. By 1 year, he had restarted his sporting activities and was discharged from the clinic.
Discussion This is an unusual case of TA rupture and in the assessment of this patient, intrinsic and extrinsic risk factors for
Downloaded from fas.sagepub.com at IOWA TESTING PROGRAMS on March 18, 2015
75
76
February 2014
Foot & Ankle Specialist
rupture were considered, but none explained why he would have ruptures bilaterally. This is especially since his fall was asymmetrical and although heavy on impact, it would ordinarily be unexpected for symmetrical complete tears to be sustained. A commonly reported association made with TA ruptures is chronic steroid use.1 Local corticosteroid injections have been a contentious issue regarding benefits and associated risks of tendon rupture.8 Fluoroquinolones are another group of medications to have been implicated.9 There are systemic conditions, mainly rheumatological in nature, which have been reported to increase incidence. Reported conditions include rheumatoid arthritis, gout, chronic renal failure, diabetes mellitus, systemic lupus erythematosis, and polymyalgia rheumatica.10 The patient had none of these factors that would predispose his condition. In addition to the above extrinsic elements, some intrinsic tendon properties add to the propensity for rupture and include hyperpronation of the foot, leg length discrepancies, and obesity causing excessive or unequal distribution of tensile loads.11 These biomechanical instabilities cause a decrease in the overall shock-absorbing capacity of the tendon. Inadequate technique in sports training or conditions that lead to poor joint proprioception can lead to poor ankle-foot positioning. With such long-term tendon misuse or overuse, instability from uneven TA loading is exacerbated.12,13 As age progresses, blood supply to the TA diminishes to a degree, especially in the region of 3 to 6 cm proximal to its calcaneal insertion. This resultant relative ischemia increases likelihood of ruptures.14 Some intrinsic factors may be difficult to assess in a premorbid state and would be especially challenging now that the injury has occurred. Physiotherapy however can help identify and rectify any hyperpronation or abnormal gait.
The management of TA rupture has been controversial,15 with studies showing that conservative management with an early application of an equinus cast have similar rerupture rates compared with surgical repair and may avoid the risk of wound complications.16 Systematic reviews have reported that in young individuals who present acutely, surgical intervention may still be a preferred option. Prompt operative treatment was shown to result in better long-term tendon integrity with lower recurrence rates.17,18 The patient described here complied well with the rehabilitation program and this is crucial in helping individuals return to their pre-morbid mobility and function.
6. Garneti N, Holton C, Shenolikar A. Bilateral Achilles tendon rupture: a case report. Accid Emerg Nurs. 2005;13: 220-223.
Conclusion
11. Hess GW. Achilles tendon rupture: a review of etiology, population, anatomy, risk factors, and injury prevention. Foot Ankle Spec. 2010;3:29-32.
In conclusion, we have presented a rare occurrence of spontaneous bilateral TA rupture, in a patient without predisposing risk factors and who made an uneventful recovery following early open surgical repair. As patients can appear to weight-bear and even walk after TA ruptures, it is important to consider the contralateral side whenever a unilateral case is suspected. This is especially if the patient has any of the risk factors outlined above.
References 1. Haines JF. Bilateral rupture of the Achilles tendon in patients on steroid therapy. Ann Rheum Dis. 1983;42:652-654. 2. Arner O, Lindholm A, Orell SR. Histologic changes in subcutaneous rupture of the Achilles tendon: a study of 74 cases. Acta Chir Scand. 1959;116:484-490. 3. Schepsis AA, Jones H, Haas AL. Achilles tendon disorders in athletes. Am J Sports Med. 2002;30:287-305. 4. Taylor TL, Simon D, Feibel R. Idiopathic simultaneous bilateral Achilles tendon rupture. BMJ Case Rep. 2009;2009. doi:10.1136/bcr.07.2009.2055. 5. Hanlon DP. Bilateral Achilles tendon rupture: an unusual occurrence. J Emerg Med. 1992;10:559-560.
7. Audenaert EA, Van Nuffel J, Deroo KF, Vuylsteke M, Verdonk R. Bilateral simultaneous traumatic Achilles tendon rupture. Foot Ankle Surg. 2004;10:49-50. 8. Mahler F, Fritschy D. Partial and complete ruptures of the Achilles tendon and local corticosteroid injections. Br J Sports Med. 1992;26:7-14. 9. Doyle HE. Tendinopathy resulting from the use of fluoroquinolones: managing risks. JAAPA. 2010;23(12):18-21, 54. 10. Park JH, Kim SB, Shin HS, Jung GH, Jung YS, Rim H. Spontaneous and serial rupture of both Achilles tendons associated with secondary hyperparathyroidism in a patient receiving long-term hemodialysis. Int Urol Nephrol. 2013;45:587-590.
12. Simoneau GG, Derr JA, Ulbrecht JS, Becker MB, Cavanagh PR. Diabetic sensory neuropathy effect on ankle joint movement perception. Arch Phys Med Rehabil. 1996;77:453-460. 13. Bressel E, Larsen BT, McNair PJ, Cronin J. Ankle joint proprioception and passive mechanical properties of the calf muscles after an Achilles tendon rupture: a comparison with matched controls. Clin Biomech (Bristol, Avon). 2004;19: 284-291. 14. Lagergren C, Lindholm A. Vascular distribution in the Achilles tendon: an angiographic and microangiographic study. Acta Chir Scand. 1959;116: 491-495. 15. Chalmers J. Review article: treatment of Achilles tendon ruptures. J Orthop Surg (Hong Kong). 2000;8:97-99. 16. Nistor L. Surgical and non-surgical treatment of Achilles tendon rupture. A prospective randomized study. J Bone Joint Surg Am. 1981;63:394-399. 17. Khan RJ, Carey Smith RL. Surgical interventions for treating acute Achilles tendon ruptures. Cochrane Database Syst Rev. 2010;(9):CD003674. 18. Wong J, Barrass V, Maffulli N. Quantitative review of operative and nonoperative management of Achilles tendon ruptures. Am J Sports Med. 2002;30:565-575.
Downloaded from fas.sagepub.com at IOWA TESTING PROGRAMS on March 18, 2015
