Hemodialysis International International 2015; 2016; ••:••–•• 20:E19–E21 Hemodialysis

Mineral Bone Disorder Case Report

Bilateral quadriceps and triceps tendon rupture in a hemodialysis patient ˘ LU, Timur EKIZ, Didem YENIGÜN, Müfit AKYÜZ, Nes Özlem TAS ¸ OG ¸ e ÖZGIRGIN Department of Physical Medicine and Rehabilitation, Ankara Physical Medicine and Rehabilitation Training and Research Hospital, Ankara, Turkey

Abstract This paper presented a 58-year-old hemodialysis patient who had bilateral quadriceps and triceps tendon rupture, whereby the role of rehabilitation in functional parameters has been highlighted. Key words: Hemodialysis, chronic kidney disease, triceps muscle, quadriceps muscle, weakness, rehabilitation

INTRODUCTION INTRODUCTION Previous Previous studies studies have have established established that that tendon tendon ruptures ruptures are are associated with chronic kidney disease (CKD) associated with chronic kidney disease (CKD) and and hemohemodialysis. dialysis. As As the the ruptures ruptures commonly commonly involve involve only only one one tendon (i.e., quadriceps, triceps, Achilles tendon), tendon (i.e., quadriceps, triceps, Achilles tendon), mulmultiple tiple involvements involvements have have been been reported reported as as well. well. Until Until now, now, 11 22 or triceps tendon and even bilateral quadriceps bilateral quadriceps or triceps tendon and even aa case case with with unilateral unilateral quadriceps quadriceps and and triceps triceps tendon tendon rupture rupture 3 have However, to to the the best best of of our our knowlknowlhave been been reported. reported.3 However, edge, rupture of the both quadriceps and triceps edge, rupture of the both quadriceps and triceps tendons tendons (a (a total total of of 44 tendons) tendons) in in the the same same patient patient has has not not been been reported yet. In addition, previous papers lack the reported yet. In addition, previous papers lack the reharehabilitation bilitation programs programs of of the the cases cases reported. reported. Accordingly, Accordingly, this this paper presented a 58-year-old man with paper presented a 58-year-old man with bilateral bilateral quadriquadriceps ceps and and triceps triceps tendon tendon rupture, rupture, whereby whereby the the role role of of rehabilitation in functional parameters has rehabilitation in functional parameters has been been highlighted. highlighted.

CASE CASE REPORT REPORT A A 58-year-old 58-year-old man man was was seen seen due due to to lower lower extremity extremity weakweakness, gait disorder, thigh pain, and loss ness, gait disorder, thigh pain, and loss of of function. function. Correspondence Correspondence to: to: T. T. Ekiz, Ekiz, MD, MD, Department Department of of Physical Physical Medicine and Rehabilitation, Ankara Physical Medicine Medicine and Rehabilitation, Ankara Physical Medicine and and Rehabilitation Rehabilitation Training Training and and Research Research Hospital, Hospital, Türkocag Türkocag˘˘ ıı Street Street No. No. 3, 3, Sıhhiye, Sıhhiye, Ankara Ankara 06230, 06230, Turkey. Turkey. E-mail: E-mail: [email protected] [email protected]

Medical Medical history history revealed revealed hemodialysis hemodialysis delivery delivery for for 99 years years due due to to diabetic diabetic nephropathy. nephropathy. On On detailed detailed questioning, questioning, the the patient patient stated stated that that he he had had bilateral bilateral quadriceps quadriceps tendon tendon rupture rupture 33 months months apart, apart, after after falling falling from from standing standing height. height. He He underwent underwent primary primary repair repair surgery surgery for for both both of of the the tendon tendon ruptures ruptures and and after after the the operations, operations, he he had had long long leg leg casts casts for for immobilization immobilization for for 66 weeks. weeks. Physical Physical examination examination revealed revealed weakness weakness in in bilateral bilateral triceps (3/5) muscles along with bilateral quadriceps triceps (3/5) muscles along with bilateral quadriceps (3/5) (3/5) weakness. weakness. The The neuromuscular neuromuscular examination examination was was otherwise otherwise normal. normal. Although Although the the patient patient was was unaware, unaware, the the weakness weakness in both triceps tendons without concomitant in both triceps tendons without concomitant pathologic pathologic findings findings in in neuromuscular neuromuscular examination examination caused caused suspicion. suspicion. Consequently, magnetic resonance imaging Consequently, magnetic resonance imaging (MRI) (MRI) of of both both elbows showed rupture of bilateral triceps tendons elbows showed rupture of bilateral triceps tendons as as well well (Figure (Figure 1a,b). 1a,b). The The laboratory laboratory results results were were consistent consistent with with secondary secondary hyperparathyroidism hyperparathyroidism (Table (Table 1). 1). Overall, Overall, the the patient was diagnosed with bilateral triceps patient was diagnosed with bilateral triceps and and quadriquadriceps ceps tendon tendon rupture rupture related related to to CKD. CKD. As for the treatment, cold As for the treatment, cold pack pack and and electrical electrical stimulastimulation were applied primarily for pain control tion were applied primarily for pain control and and edema edema of of the the quadriceps quadriceps tendons. tendons. Range Range of of motion motion (ROM) (ROM) exercises exercises for for the the knees knees were were started started gently, gently, 2–3 2–3 times times aa day day until until aa full joint ROM is achieved. Therapeutic exercises full joint ROM is achieved. Therapeutic exercises perperformed formed for for the the lower lower extremities extremities included included gentle gentle patellar patellar mobilization, mobilization, quadriceps quadriceps isometric isometric exercises exercises (particularly (particularly for vastus medialis), gluteal isometric for vastus medialis), gluteal isometric exercises, exercises, ankle ankle resistive resistive exercises, exercises, gastrocnemius gastrocnemius and and soleus soleus stretching, stretching,

C 2015 International V © International Society Society for for Hemodialysis Hemodialysis DOI:10.1111/hdi.12319 DOI:10.1111/hdi.12319

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program, the patient was discharged with a walker assist. He was advised to use elastic bandages for both knees and elbows as kinesthetic reminders during ambulation. Control MRI of the triceps tendons showed significant improvement (Figure 1c,d).

DISCUSSION

Figure 1 Magnetic resonance images show the triceps tendon rupture bilaterally as the ondulation and mild retraction (arrows), and increased diffuse signal intensity (arrowheads) on the right (a) and left (b) T1-weighed sagittal images. T2-weighed sagittal (right) (c) and T1-weighed (left) (d) sagittal images illustrate the improvement in ondulation and retractions of the triceps tendons.

open kinetic chain exercises for gluteus medius, and maximus and hip adductor strengthening followed by closed kinetic chain exercises. Balance and proprioceptive exercises were also started at this level further facilitating ambulation. As for the triceps tendon rupture, first, a complete rest was recommended. Later on triceps isometric exercises, wrist-resistive exercises, isometric strengthening of rotator cuff muscles, and deltoid were carried out synchronously. After a 2-month inpatient rehabilitation Table 1 Some of the laboratory test results of the patient Laboratory investigation Intact PTH (pg/mL) 25-OH vitamin D (ng/mL) Serum calcium (mg/dL) Phosphorus (mg/dL) Alkaline phosphatase (U/L) PTH = parathyroid hormone.

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Patient’s data

Normal range

1147 16.3 9.5 3.6 969

(15–65) (>30) (8.5–10.5) (2.5–5.0) (30–120)

Tendon rupture in renal failure was first described by Steiner and Palmer in 1949.4 Later, in 1965 Murphy and McPhee5 reported a 39-year-old man with simultaneous and spontaneous rupture of the quadriceps, patella, and triceps tendons. Tendon ruptures predominantly occur in males and before the 4th decade of life, and it is known that the longer duration of the kidney disease and hemodialysis treatment also increases the risk of ruptures.3 The most frequently ruptured tendons seem to be quadriceps, patella, Achilles, and triceps tendons. Although rare, there are cases with multiple tendon ruptures. For instance, bilateral quadriceps1 or triceps tendon2 and a case with unilateral quadriceps and triceps tendon rupture3 have been reported. Nonetheless, to the best of our knowledge, this is the first case in the literature in which both quadriceps and triceps tendons (a total of 4 tendons) ruptured spontaneously, but not simultaneously. The mechanism of rupture is controversial and evolved from connective tissue elastosis (collagen is replaced by elastin) due to chronic acidosis5 as it was first described, to a multifactorial compound primarily affected by secondary hyperparathyroidism recently.6 The factors contributing to tendon ruptures also include malnutrition, β2-amyloidosis, chronic acidosis, impaired collagen metabolism, accumulation of uremic toxins as well as secondary hyperparathyroidism. Secondary hyperparathyroidism, a classical complication of CKD, starts with retention of phosphorus resulting from glomerular filtration rate decrease, further leading to hypocalcemia and reactional parathormone elevation. Hyperparathyroidism stimulates osteoclast activity especially at subtendinous sites contributing to weakening of the bone cortex. Finally, repeated minor avulsion fractures result in total tendon ruptures with minor trauma (spontaneous rupture).3,6,7 Apart from CKD, our patient had diabetes mellitus that might play a part in this pathologic condition. Nonenzymatic glycosylation of the collagen in diabetic patients leads to abnormal collagen cross-linking resulting in weakened tendons.8 Concerning imaging of tendon ruptures, ultrasound can be readily used with several advantages (lack of ionizing radiation, ease of use, repeatable, widely available, cheaper, high spatial resolution).9 However, MRI is the Hemodialysis International 2016; 20:E19–E21 Hemodialysis International 2015; ••:••–••

Tendon hemodialysis Tendon rupture rupture in in hemodialysis

most sensitive and specific modality, and also differentiates ruptures from other soft-tissue disorders. Surgical and/or rehabilitative approaches should be considered regarding the patient’s needs for the treatment of tendon ruptures.8 Nonetheless, once the rupture takes place, it can be quite challenging to treat due to the chronic nature of the aforementioned diseases. Moreover, lower extremity tendon ruptures may lead up to the rupture of upper extremity tendons due to the increased mechanical stress during ambulation with walking aids. Therefore, preventive strategies for falls should be indisputably taken into account. Likewise, in our patient both quadriceps tendon rupture occurred due to falling, required surgery, and probably gave way to bilateral triceps tendon rupture. In conclusion, herein presenting our unusual case we have threefold. First, this paper suggests that multiple tendon ruptures can be seen in hemodialysis patients and should be kept in mind for differential diagnosis of weakness. Second, a comprehensive rehabilitation program is important for the functional improvement. Third, we highlight once again that preventive strategies for falls are also important in hemodialysis patients.

DISCLOSURES None. For funding information, see “The Global Forum on Home Hemodialysis: Sponsorship and Disclosure Statements.”

Manuscript received March 2015; revised April 2015.

Hemodialysis International International 2016; Hemodialysis 2015; 20:E19–E21 ••:••–••

REFERENCES 1 Celik EC, Ozbaydar M, Ofluoglu D, Demircay E. Simultaneous and spontaneous bilateral quadriceps tendons rupture. Am J Phys Med Rehabil. 2012; 91:631–634. 2 Tsourvakas S, Gouvalas K, Gimtsas C, Tsianas N, Founta P, Ameridis N. Bilateral and simultaneous rupture of the triceps tendons in chronic renal failure and secondary hyperparathyroidism. Arch Orthop Trauma Surg. 2004; 124:278–280. 3 Soo I, Christiansen J, Marion D, Courtney M, Luyckx VA. Sequential rupture of triceps and quadriceps tendons in a dialysis patient using hormone supplements. Clin Nephrol. 2011; 75(Suppl 1):20–23. 4 Steiner CA, Palmer LH. Simultaneous bilateral rupture of the quadriceps tendon. Am J Surg. 1949; 78:752–755. 5 Murphy KJ, McPhee I. Tears of major tendons in chronic acidosis with elastosis. J Bone Joint Surg Am. 1965; 47:1253–1258. 6 Thaunat M, Gaudin P, Naret C, Beaufils P, Thaunat O. Role of secondary hyperparathyroidism in spontaneous rupture of the quadriceps tendon complicating chronic renal failure. Rheumatology (Oxford). 2006; 45:234–235. 7 Kim BS, Kim YW, Song EK, Seon JK, Kang KD, Kim HN. Simultaneous bilateral quadriceps tendon rupture in a patient with chronic renal failure. Knee Surg Relat Res. 2012; 24:56–59. 8 Druskin SC, Rodeo SA. Novel treatment of a failed quadriceps tendon repair in a diabetic patient using a patellaquadriceps tendon allograft. HSS J. 2013; 9:195–199. 9 Özçakar L, Kara M, Chang KV, et al. Nineteen reasons why physiatrists should do musculoskeletal ultrasound: EUROMUSCULUS/USPRM recommendations. Am J Phys Med Rehabil. 2014; DOI: 10.1097/PHM.0000000000000223 [Epub ahead of print].

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Bilateral quadriceps and triceps tendon rupture in a hemodialysis patient.

This paper presented a 58-year-old hemodialysis patient who had bilateral quadriceps and triceps tendon rupture, whereby the role of rehabilitation in...
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