The Journal of Emergency
Medicine,
Vol 10, pp 559-560,
1992
Printed in the USA . Copyright 0 1992 Pergamon Press Ltd.
BILATERAL ACHILLES TENDON RUPTURE: AN UNUSUAL OCCURRENCE Dennis P. Hanlon, MD Division of Emergency Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania Reprint Address: Dennis P. Hanlon, MD, Department of Emergency Medicine, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212
0 Abstract -Bilateral Achilles tendon rupture is an unusual injury. This rare entity usually occurs in patients on chronic steroid therapy or with underlying disease. Bilateral Achilles tendon rupture is extremely rare in a previously healthy individual. A case involving traumatic Achilles tendon rupture as a result of a sky diving accident is reported. Evaluation of patients with suspected Achilles tendon rupture is briefly reviewed.
mid-portion of the Achilles tendon, and positive Thompson tests bilaterally. The patient was able to slightly plantar flex both feet, but could not overcome minimal resistance. He was unable to stand on his toes; in fact, he could not stand at all without leaning forward. Neurovascular examination of his lower extremities was intact. Radiographs of his lower extremities demonstrated no evidence of fracture or dislocation. The orthopedic consultant splinted both lower legs in plantar flexion and admitted the patient for operative repair the following day. Upon exploration, the right Achilles tendon was found to be completely ruptured 4 to 6 cm from its calcaneal insertion, and the left Achilles tendon was found to be partially ruptured and markedly macerated in the mid-portion of the tendon. Both legs were placed in anterior splints to maintain plantar flexion after surgical repair. His postoperative course was uneventful.
0 Keywords - AchiBes tendon rupture; Thompson test; lower extremity injuries
CASE REPORT
A 33-year-old man presented via the medics to the emergency department with complaints of a chin laceration and bilateral, posterior lower leg pain. During a sky diving exhibition, the patient landed on the plantar surface of his forefeet on the edge of a barge rather than the center, which was his landing target. He felt a sharp pull in the back of both lower legs above his heels and fell forward, striking his chin. He denied loss of consciousness, amnesia, headache, neck pain, malocclusion, or any other injuries besides his bilateral leg pain and chin laceration. He denied any previous heel cord symptoms. On physical examination, the vital signs were blood pressure 172/90 torr, pulse 84 beats/min, respirations 18 breaths/min, and temperature 37.3 OC. Examination of the head and neck revealed no abnormalities except a 4-cm midline chin laceration. Cardiac, pulmonary, abdominal, and rectal examinations were unremarkable. Lower extremity examination revealed tender calves, palpable defects in the =
B
DISCUSSION
Bilateral Achilles tendon rupture is an unusual injury. Although unilateral Achilles tendon rupture most often occurs in a young to early middle aged adult during vigorous physical activity, bilateral Achilles tendon rupture usually occurs in older patients with underlying systemic disease or a history of chronic steroid therapy (l-4). This patient presents the second case of a previously healthy individual suffering bilateral Achilles tendon ruptures to be reported in the English literature. Of the previous 11 cases reported, 10 patients had either an underlying
Clinical Communications, focusing primarily on adult emergencies, is coordinated by Ron Walls, MD, of Vancouver General Hospital, Vancouver, BC, Canada.
RECEIVED: 15 April
0736~4679/92 $5.00 + .OO
1991; ACCEPTED: 17 June 1991 559
Dennis P. Hanlon
560
disease or history of prolonged steroid therapy (3,4). Reported predisposing diseases include rheumatoid arthritis, systemic lupus erythematosus, polymyalgia rheumatica, gout, hyperparathyroidism, chronic renal failure, hyperlipoproteinemia Type II, syphilis, tumor, and gonorrhea (1,4). Local steroid injection will also predispose the Achilles tendon to rupture. Although in this patient the forces were applied bilaterally, he had the typical mechanism of this injury: sudden dorsiflexion against a plantar flexed foot or violent plantar flexion (5). The usual site of rupture is 2 to 6 cm proximal to its insertion due to decreased blood supply in this region (6). Some investigators believe that complete rupture is usually a sequel to previous degenerative changes in the tendon (7). Barfred’s experiments demonstrated that mechanical forces alone may be responsible for complete tendon ruptures (8). This patient denied any previous heel cord symptoms, and the force of his misguided landing probably overwhelmed his Achilles tendon unit. Unilateral Achilles tendon rupture is not an uncommon injury and its diagnosis should not be difficult, yet the diagnosis is initially missed in 20% to 25% of cases (7,9). The classic history is an instantaneous pain above the posterior heel that commences during an abrupt sprint or jump. Many patients state they felt as if a thrown object struck them above the heel. In some reports, 10% to 20% of patients had previous heel cord symptoms, such as stiffness or pain (7,9). Physical examination reveals a palpable defect, a calf muscle bulge, and a flat gait on the affected side. If a patient presents late, swelling and hemorrhage may obscure this defect. The patient may still have some active plantar flexion because of the actions of the plantaris, peroneus longus, tibialis posterior, and great toe flexors, but will be unable to
stand on the toes with only weak plantar flexion against resistance (9). The Thompson test will be pasitive with a completely ruptured Achilles tendon. This test is performed by squeezing the gastrocnemius just distal to its maximal girth with the patient in a prone position (10). An intact Achilles tendon unit will produce plantar flexion of the foot with this maneuver, while a complete rupture of the Achilles tendon will not cause plantar flexion (10). Standard x-ray studies can rule out associated fractures and dislocations, but do not reveal any information about the tendon unless there is calcification. Some investigators have used ultrasound and magnetic resonance imaging to evaluate Achilles tendon injuries. The role of these diagnostic modalities is still being defined, but they may be helpful in equivocal cases (11,12). The optimal treatment of Achilles tendon ruptures remains controversial. This patient underwent operative repair, but some authorities advocate casting in equinus position alone. There is no clearcut superiority with operative versus conservative treatment, but proponents of surgical repair report decreased risk of re-rupture (7). The choice of definitive management is best left to the orthopedic consultant.
SUMMARY Bilateral Achilles tendon rupture is a very rare injury, especially in a young patient without underlying disease or predisposing factors. Unilateral Achilles tendon rupture is not uncommon and should be readily diagnosed if evaluation focuses on tendons as well as bones. The optimal management of Achilles tendon rupture remains controversial.
REFERENCES 1. Smaill GB. Bilateral rupture of Achilles tendon. B Med J. 1961;1:1657-8. 2. Cowan MA, Alexander S. Simultaneous bilateral rupture of Achilles tendon due to triamcinolone. B Med J. 1961;1: 1658. 3. Mayer JH. Bilateral rupture of Achilles tendon. B Med J. 1961;1:1830. 4. Price AE, Evanski PM, Waugh TR. Bilateral simultaneous Achilles tendon ruptures. Clin Orthop. 1986;213:249-50. 5. Jozsa L, Kvist M, Balint BJ, et al. The role of recreational sport activity in Achilles tendon rupture. Am J Sports Med. 1989;17:338-43. 6. Lagergren C, Lindholm A. Vascular distribution in the Achilles tendon: an angiographic and microangiographic study. Acta Chir Scan. 1958;116:491-5. 7. Beskin JR, Sanders RA, Hunter SL, Hughston JC. Surgical
repair of Achilles tendon ruptures. Am J Sports Med. 1987; 15:1-8. 8. Barfred T. Experimental rupture of the Achilles tendon: comparison of experimental ruptures in rats of different ages living under different conditions. Acta Orthop Scan. 1971;42:40628. 9. Plattner PF. Tendon problems of the foot and ankle. Postgrad Med. 1989;86:155-70. 10. Thompson TC, Doherty JH. Spontaneous rupture of Achilles: a new clinical diagnostic test. J Trauma. 1962;2:126-9. 11. Marcus DS, Reicher MA, Kellerhorse LE. Achilles tendon injury: the role of MRI imaging. J Comput Assist Tomogr. 1989;13:480-6. 12. Furnage B. Achilles tendon: US examination. Radiology. 1986;159:759-64.
Medicine,
Vol 10, pp 559-560,
1992
Printed in the USA . Copyright 0 1992 Pergamon Press Ltd.
BILATERAL ACHILLES TENDON RUPTURE: AN UNUSUAL OCCURRENCE Dennis P. Hanlon, MD Division of Emergency Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania Reprint Address: Dennis P. Hanlon, MD, Department of Emergency Medicine, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212
0 Abstract -Bilateral Achilles tendon rupture is an unusual injury. This rare entity usually occurs in patients on chronic steroid therapy or with underlying disease. Bilateral Achilles tendon rupture is extremely rare in a previously healthy individual. A case involving traumatic Achilles tendon rupture as a result of a sky diving accident is reported. Evaluation of patients with suspected Achilles tendon rupture is briefly reviewed.
mid-portion of the Achilles tendon, and positive Thompson tests bilaterally. The patient was able to slightly plantar flex both feet, but could not overcome minimal resistance. He was unable to stand on his toes; in fact, he could not stand at all without leaning forward. Neurovascular examination of his lower extremities was intact. Radiographs of his lower extremities demonstrated no evidence of fracture or dislocation. The orthopedic consultant splinted both lower legs in plantar flexion and admitted the patient for operative repair the following day. Upon exploration, the right Achilles tendon was found to be completely ruptured 4 to 6 cm from its calcaneal insertion, and the left Achilles tendon was found to be partially ruptured and markedly macerated in the mid-portion of the tendon. Both legs were placed in anterior splints to maintain plantar flexion after surgical repair. His postoperative course was uneventful.
0 Keywords - AchiBes tendon rupture; Thompson test; lower extremity injuries
CASE REPORT
A 33-year-old man presented via the medics to the emergency department with complaints of a chin laceration and bilateral, posterior lower leg pain. During a sky diving exhibition, the patient landed on the plantar surface of his forefeet on the edge of a barge rather than the center, which was his landing target. He felt a sharp pull in the back of both lower legs above his heels and fell forward, striking his chin. He denied loss of consciousness, amnesia, headache, neck pain, malocclusion, or any other injuries besides his bilateral leg pain and chin laceration. He denied any previous heel cord symptoms. On physical examination, the vital signs were blood pressure 172/90 torr, pulse 84 beats/min, respirations 18 breaths/min, and temperature 37.3 OC. Examination of the head and neck revealed no abnormalities except a 4-cm midline chin laceration. Cardiac, pulmonary, abdominal, and rectal examinations were unremarkable. Lower extremity examination revealed tender calves, palpable defects in the =
B
DISCUSSION
Bilateral Achilles tendon rupture is an unusual injury. Although unilateral Achilles tendon rupture most often occurs in a young to early middle aged adult during vigorous physical activity, bilateral Achilles tendon rupture usually occurs in older patients with underlying systemic disease or a history of chronic steroid therapy (l-4). This patient presents the second case of a previously healthy individual suffering bilateral Achilles tendon ruptures to be reported in the English literature. Of the previous 11 cases reported, 10 patients had either an underlying
Clinical Communications, focusing primarily on adult emergencies, is coordinated by Ron Walls, MD, of Vancouver General Hospital, Vancouver, BC, Canada.
RECEIVED: 15 April
0736~4679/92 $5.00 + .OO
1991; ACCEPTED: 17 June 1991 559
Dennis P. Hanlon
560
disease or history of prolonged steroid therapy (3,4). Reported predisposing diseases include rheumatoid arthritis, systemic lupus erythematosus, polymyalgia rheumatica, gout, hyperparathyroidism, chronic renal failure, hyperlipoproteinemia Type II, syphilis, tumor, and gonorrhea (1,4). Local steroid injection will also predispose the Achilles tendon to rupture. Although in this patient the forces were applied bilaterally, he had the typical mechanism of this injury: sudden dorsiflexion against a plantar flexed foot or violent plantar flexion (5). The usual site of rupture is 2 to 6 cm proximal to its insertion due to decreased blood supply in this region (6). Some investigators believe that complete rupture is usually a sequel to previous degenerative changes in the tendon (7). Barfred’s experiments demonstrated that mechanical forces alone may be responsible for complete tendon ruptures (8). This patient denied any previous heel cord symptoms, and the force of his misguided landing probably overwhelmed his Achilles tendon unit. Unilateral Achilles tendon rupture is not an uncommon injury and its diagnosis should not be difficult, yet the diagnosis is initially missed in 20% to 25% of cases (7,9). The classic history is an instantaneous pain above the posterior heel that commences during an abrupt sprint or jump. Many patients state they felt as if a thrown object struck them above the heel. In some reports, 10% to 20% of patients had previous heel cord symptoms, such as stiffness or pain (7,9). Physical examination reveals a palpable defect, a calf muscle bulge, and a flat gait on the affected side. If a patient presents late, swelling and hemorrhage may obscure this defect. The patient may still have some active plantar flexion because of the actions of the plantaris, peroneus longus, tibialis posterior, and great toe flexors, but will be unable to
stand on the toes with only weak plantar flexion against resistance (9). The Thompson test will be pasitive with a completely ruptured Achilles tendon. This test is performed by squeezing the gastrocnemius just distal to its maximal girth with the patient in a prone position (10). An intact Achilles tendon unit will produce plantar flexion of the foot with this maneuver, while a complete rupture of the Achilles tendon will not cause plantar flexion (10). Standard x-ray studies can rule out associated fractures and dislocations, but do not reveal any information about the tendon unless there is calcification. Some investigators have used ultrasound and magnetic resonance imaging to evaluate Achilles tendon injuries. The role of these diagnostic modalities is still being defined, but they may be helpful in equivocal cases (11,12). The optimal treatment of Achilles tendon ruptures remains controversial. This patient underwent operative repair, but some authorities advocate casting in equinus position alone. There is no clearcut superiority with operative versus conservative treatment, but proponents of surgical repair report decreased risk of re-rupture (7). The choice of definitive management is best left to the orthopedic consultant.
SUMMARY Bilateral Achilles tendon rupture is a very rare injury, especially in a young patient without underlying disease or predisposing factors. Unilateral Achilles tendon rupture is not uncommon and should be readily diagnosed if evaluation focuses on tendons as well as bones. The optimal management of Achilles tendon rupture remains controversial.
REFERENCES 1. Smaill GB. Bilateral rupture of Achilles tendon. B Med J. 1961;1:1657-8. 2. Cowan MA, Alexander S. Simultaneous bilateral rupture of Achilles tendon due to triamcinolone. B Med J. 1961;1: 1658. 3. Mayer JH. Bilateral rupture of Achilles tendon. B Med J. 1961;1:1830. 4. Price AE, Evanski PM, Waugh TR. Bilateral simultaneous Achilles tendon ruptures. Clin Orthop. 1986;213:249-50. 5. Jozsa L, Kvist M, Balint BJ, et al. The role of recreational sport activity in Achilles tendon rupture. Am J Sports Med. 1989;17:338-43. 6. Lagergren C, Lindholm A. Vascular distribution in the Achilles tendon: an angiographic and microangiographic study. Acta Chir Scan. 1958;116:491-5. 7. Beskin JR, Sanders RA, Hunter SL, Hughston JC. Surgical
repair of Achilles tendon ruptures. Am J Sports Med. 1987; 15:1-8. 8. Barfred T. Experimental rupture of the Achilles tendon: comparison of experimental ruptures in rats of different ages living under different conditions. Acta Orthop Scan. 1971;42:40628. 9. Plattner PF. Tendon problems of the foot and ankle. Postgrad Med. 1989;86:155-70. 10. Thompson TC, Doherty JH. Spontaneous rupture of Achilles: a new clinical diagnostic test. J Trauma. 1962;2:126-9. 11. Marcus DS, Reicher MA, Kellerhorse LE. Achilles tendon injury: the role of MRI imaging. J Comput Assist Tomogr. 1989;13:480-6. 12. Furnage B. Achilles tendon: US examination. Radiology. 1986;159:759-64.
