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Bilateral spontaneous Achilles tendon rupture in a healthy individual
The Foot (1996) 6,4142 0 1996 Prarson Professional
Ltd
CASE REPORT
Bilateral spontaneous Achilles tendon rupture in a healthy individual D. Wilson, R. Dilworth The Ulster Hospital, Dundonald, UK SUMMARY. Spontaneous bilateral tendo Achillis rupture is an extremely rare occurence and is exceptionally uncommon in healthy individuals. We present a case of bilateral rupture occurring in a healthy 66-year-old man who was not taking any medication. Non-operative management was successful on one leg only and the other leg required surgical repair.
diagnosed. A further 2 weeks of conservative management in plaster for the right leg was unsuccessful and the right tendo Achillis underwent surgical repair. This was successful, and mobilization was commenced at 6 weeks following repair. The patient was finally discharged from follow-up 10 weeks after the right Achilles Tendon repair and 5 months from initial injury.
CASE REPORT
A 66-year-old man attended the accident and emergency department complaining of a sudden onset of severe bilateral ankle pain when starting to run after some thieves. After several strides of pursuit he was unable to run due to pain. No direct trauma was recalled and he did not fall. The patient was previously in good health and not taking any routine medication. On examination, localized bruising and tenderness over both Achilles tendons with loss of planterflexion of both feet was noted. The Thompson test was positive bilaterally. A two-finger breadth gap was palpable in the right tendo Achillis mid-portion and the gap could just be closed in full equinus. A one-finger breadth gap was palpable in the left tendo Achillis mid-portion and this could be closed easily in equinus. Bilateral tendo Achillis rupture was diagnosed. General examination was otherwise normal and routine biochemistry was unremarkable Both injuries were initially managed non-surgically in equinus plasters with progressive return to neutral ankle position over a 6-week period and subsequent removal of plaster and gentle mobilization. Neither gap was palpable at this time on clinical examination. Unfortunately, 2 weeks after plaster removal, the patient stumbled and was unable to avoid weightbearing on the right foot. He reattended hospital with localized swelling and tenderness at the right heel. A gap was again palpable at the site of the previous tendo Achillis injury and a re-tear of the tendon was
Correspondence to Mr 132 Upper Newtownards
DISCUSSION
Spontaneous bilateral tendo Achillis rupture is an extremely rare occurence and is usually associated with underlying systemic disease,‘J 4-quinolone use,3 steroid use, or chronic renal failure. Up to 5% of renal transplant patients suffer uni-or bilateral TA rupture4 Its occurence in an apparently healthy individual is exceptionally uncommon and we believe that our case presents only the third case reported in the English literature of a healthy person suffering spontaneous bilateral Achilles tendon rupture (previously described in a 33-year-old man as a result of a sky diving accidentj and in a 46-year-old woman who was running for a bus.‘j The patient in our report was healthy, was not on any medication and did not recall any precipitating event at the time of rupture. The site of the disruption of the tendons in our patient was similar to those described in the two previous cases. Achilles tendon rupture can be managed conservatively in non-athletic patients, especially those aged over 50 years, provided the diagnosis is made within 7 days.7 Non-surgical treatment is associated with a higher incidence of re-rupture, as occurred in the case presented. Younger and athletic patients should be managed surgically.*
Darrin Wilson, Orthpaedic Registrar, Road, Belfast BT4 3EQ, UK. 41
42
The Foot
REFERENCES 1. Formiga F, Moga I, Pat M, Valverde J, Fiter J, Palom X. Spontaneous tendinous rupture in systemic lupus erythematosus. Rev Clin Esp 1993; 192: 175-177. 2. Matsumoto K, Hukuda S, Nishioka J, Asajima S. Ruptuer of the Achilles tendon in rheumatoid arthritis with histologic evidence of enthesitis. Clin Orthop 1992: 280: 2355240. 3. Lee W T, Collins J F Ciprofloxacin associated bilateral Achilles tendon rupture. Aust N Z J Med 1992; 229: 500.
4. Beckurts K T, Haas C., Ummerle C, Holscher M. Spontaneous uni- and bilateral tendon rupture ~ a frequent complication after kidney transplantation. Chirurgie 1991 62: 7399742. 5. Hanlon D P Bilateral Achilles tendon rupture: an unusua occurrence. J Emerg Med 1992; 10: 559-60. 6. Mayer J H. Bilateral rupture of Achilles tendon. B M J 1961;l: 1830. 7. Carden D G, Noble J, Chalmers J, Lunn P, Ellis J. Rupture of the calcaneal tendon. J Bone Joint Surg [Br] 1987; 69B: 416-420. 8. Landvater S J Renstrom P A. Complete Achilles tendon ruptures, Clin Sports Med 1992; 11: 741-758.
Ltd
CASE REPORT
Bilateral spontaneous Achilles tendon rupture in a healthy individual D. Wilson, R. Dilworth The Ulster Hospital, Dundonald, UK SUMMARY. Spontaneous bilateral tendo Achillis rupture is an extremely rare occurence and is exceptionally uncommon in healthy individuals. We present a case of bilateral rupture occurring in a healthy 66-year-old man who was not taking any medication. Non-operative management was successful on one leg only and the other leg required surgical repair.
diagnosed. A further 2 weeks of conservative management in plaster for the right leg was unsuccessful and the right tendo Achillis underwent surgical repair. This was successful, and mobilization was commenced at 6 weeks following repair. The patient was finally discharged from follow-up 10 weeks after the right Achilles Tendon repair and 5 months from initial injury.
CASE REPORT
A 66-year-old man attended the accident and emergency department complaining of a sudden onset of severe bilateral ankle pain when starting to run after some thieves. After several strides of pursuit he was unable to run due to pain. No direct trauma was recalled and he did not fall. The patient was previously in good health and not taking any routine medication. On examination, localized bruising and tenderness over both Achilles tendons with loss of planterflexion of both feet was noted. The Thompson test was positive bilaterally. A two-finger breadth gap was palpable in the right tendo Achillis mid-portion and the gap could just be closed in full equinus. A one-finger breadth gap was palpable in the left tendo Achillis mid-portion and this could be closed easily in equinus. Bilateral tendo Achillis rupture was diagnosed. General examination was otherwise normal and routine biochemistry was unremarkable Both injuries were initially managed non-surgically in equinus plasters with progressive return to neutral ankle position over a 6-week period and subsequent removal of plaster and gentle mobilization. Neither gap was palpable at this time on clinical examination. Unfortunately, 2 weeks after plaster removal, the patient stumbled and was unable to avoid weightbearing on the right foot. He reattended hospital with localized swelling and tenderness at the right heel. A gap was again palpable at the site of the previous tendo Achillis injury and a re-tear of the tendon was
Correspondence to Mr 132 Upper Newtownards
DISCUSSION
Spontaneous bilateral tendo Achillis rupture is an extremely rare occurence and is usually associated with underlying systemic disease,‘J 4-quinolone use,3 steroid use, or chronic renal failure. Up to 5% of renal transplant patients suffer uni-or bilateral TA rupture4 Its occurence in an apparently healthy individual is exceptionally uncommon and we believe that our case presents only the third case reported in the English literature of a healthy person suffering spontaneous bilateral Achilles tendon rupture (previously described in a 33-year-old man as a result of a sky diving accidentj and in a 46-year-old woman who was running for a bus.‘j The patient in our report was healthy, was not on any medication and did not recall any precipitating event at the time of rupture. The site of the disruption of the tendons in our patient was similar to those described in the two previous cases. Achilles tendon rupture can be managed conservatively in non-athletic patients, especially those aged over 50 years, provided the diagnosis is made within 7 days.7 Non-surgical treatment is associated with a higher incidence of re-rupture, as occurred in the case presented. Younger and athletic patients should be managed surgically.*
Darrin Wilson, Orthpaedic Registrar, Road, Belfast BT4 3EQ, UK. 41
42
The Foot
REFERENCES 1. Formiga F, Moga I, Pat M, Valverde J, Fiter J, Palom X. Spontaneous tendinous rupture in systemic lupus erythematosus. Rev Clin Esp 1993; 192: 175-177. 2. Matsumoto K, Hukuda S, Nishioka J, Asajima S. Ruptuer of the Achilles tendon in rheumatoid arthritis with histologic evidence of enthesitis. Clin Orthop 1992: 280: 2355240. 3. Lee W T, Collins J F Ciprofloxacin associated bilateral Achilles tendon rupture. Aust N Z J Med 1992; 229: 500.
4. Beckurts K T, Haas C., Ummerle C, Holscher M. Spontaneous uni- and bilateral tendon rupture ~ a frequent complication after kidney transplantation. Chirurgie 1991 62: 7399742. 5. Hanlon D P Bilateral Achilles tendon rupture: an unusua occurrence. J Emerg Med 1992; 10: 559-60. 6. Mayer J H. Bilateral rupture of Achilles tendon. B M J 1961;l: 1830. 7. Carden D G, Noble J, Chalmers J, Lunn P, Ellis J. Rupture of the calcaneal tendon. J Bone Joint Surg [Br] 1987; 69B: 416-420. 8. Landvater S J Renstrom P A. Complete Achilles tendon ruptures, Clin Sports Med 1992; 11: 741-758.