Conservative Management of Bilateral Tendoachilles (TA) Rupture—A Case Report

doi:10.4236/ss.2011.25050

Paper Menu >>

Journal Menu >>

Surgical Science, 2011, 2, 224-227

doi:10.4236/ss.2011.25050 Published Online July 2011 (http://www.SciRP.org/journal/ss)

Conservative Management of Bilateral Tendoachilles (TA)

Rupture—A Case Report

Rahul Kakkar, Simon Chambers, Malcolm M. Scott

North Tyneside General Hospital, Rake lane, North Shields, NE29 8NH

E-mail: [email protected]

Received March 11, 20 1 1; revised April 27, 2011; accepted May 5, 2011

Abstract

Tendo Achilles ruptures are generally traumatic in origin and while bilateral tendo Achilles ruptures are a

rare occurrence, most of them are associated with risk factors or pre-existing disease and generally involve

trauma or sporting activities. Most of the cases of bilateral rupture are generally treated operatively. A spon-

taneous onset case of bilateral tendo achilles rupture is reported in a healthy man and its conservative (non

operative) management discussed with a review of the literature.

Keywords: Bilateral Tendoachilles Rupture, Non-Traumatic, Spontaneous, Conservative Treatment, Cast

Management

1. Introduction

The Achilles tendon is the thickest and strongest tendon

in the body [1,2] and although forces up to 12 times body

weight can be tolerated by it, it still accounts for 20% of

all large tendon ruptures [2]. Trauma and sporting activ i-

ties have been implicated as the most common cause of

tendoachilles rupture [3,4] with the injury mechanism

involving sudden and powerful contraction of the gas-

trocnemius and soleus muscles on a dorsiflexed foot and

usually affecting men aged 30 - 50 years [5].

But, spontaneou s bilateral Achilles tendon ruptures are

a rare occurrence [1,6-12] and account for about 1% of

all Achilles tendon ruptures [9,1 1]. Risk factors for these

type of injuries include corticosteroid use [12], limb

ischemia [13], anabolic steroids [14], fluoroquinolones

[15], chronic pain, previous Achilles tend on rupture [16]

and rheumatoid arthritis, SLE [17] .To our knowledge,

only a few reports on spontaneous bilateral Achilles ten-

don tears have been published, most with associated risk

factors but with satisfactory outcomes and there is only

one other case report of a bilateral rupture of the tendo

Achilles without any associated risk factors [18]. We

present a case of spon taneous bilateral tendoachilles rup-

ture in an otherwise healthy 49 year old man which was

successfully treated conservatively with two different

management protocols.

2. Case Report

A 49 year-old man attended fracture clinic with a right

TA rupture which was confirmed clinically. He had been

on holiday and was walking near a waterfall wh en h e felt

pain in his right tendo Achilles area and was unable to

walk after that. H e had no obvious risk factors for tendon

rupture; he was a non-smoker, with no recent or past

history of steroid or fluoroquinolone use. He had no me-

tabolic derangements, and blood tests (FBC, U+E, LFT,

TFT,cholesterol, rheumatoid factor and urate) were all

within normal limits. Following a discussion about the

relative merits and risks of operative versus non-opera-

tive treatment, he opted for non-operative treatment. He

had an above knee equinus cast applied with knee flexed

about 20 degrees and was asked to be non weight bear ing

on the right leg.

Unfortunately he re-attended casualty 10 days into his

course of non-operative treatment complaining of left TA

rupture. He was going upstairs using his crutches, when

he felt his left TA rupture, which he described as a ‘tear-

ing’ sensation. On examination he had bruising; swelling

and tenderness of the left TA with a palpable gap present

approximately 4 cm proximal to its insertion into os cal-

cis. The calf squeeze test was positive, i.e. no ankle

plantar flexion was present on squeezing the calf. He was

placed into a short-leg (below knee) equinus cast and

admitted to the ward while arrangements were put in

R. KAKKAR ET AL.225

place to allow his safe discharge. We treated both sides

differently with the right leg in above knee equinus cast

and the other in below knee equines cast (Figure 1) for

first three weeks in an effo rt to provide him some mobil-

ity as putting both legs in Above Knee casts would be

cumbersome for him. Happily his brother had an adapted

home due to being a wheelchair user himself, and so our

patient was able to be discharged fairly promptly despite

being non-weight-bearing with bilateral-leg casts. This

initial equinus cast was followed by a below knee mid-

equinus for three weeks and then a walking plantigrade

cast for three weeks (total time in casts was 9 weeks for

each leg). Both sides healed well and there was no ap-

parent difference in the two sides and healing times were

similar.

3. Discussion

Bilateral TendoAchilles rupture is rare, but is docu-

mented in the medical literature. In 2004 Hayes, et al.

[19] reviewed all of the published cases of bilateral rup-

ture and found that of 26 cases, 13 were due to exoge-

nous steroid treatment, three were due to significant

trauma, three occurred in renal transplant patients, two

were attributable to antibiotics of the fluoroquinilone

family, one was due to endogenou s corticostero id excess

Figure 1. Clinical picture showing above knee cast on right

side and below knee cast on the le ft.

(Cushing’s), one due to limb ischaemia, one diabetes,

one systemic lupus. Only one report had no cause identi-

fied, [20] but there was no other information about the

medical background other than that she was not on ster-

oids. Hayes, et al. [19] presented their case and sug-

gested that smoking may have been a causative factor.

Rao, et al. [21] reported another case but their patient

had hypothyroidism and was taking thyroxine and they

surmised that hypercholesterolemia and hypothyroidism

lead to degenerate tendon which eventually ruptured.

Habusta [9] reported two cases in healthy patients how-

ever both patients had long term Achilles tendonitis and

were gymnasts. Specific bilateral forces generated

through the Achilles tendons of experienced older gym-

nasts predispose them to ch ronic bilateral wear and acute

bilateral simultaneous ruptures during specific manoeu-

vres. The only other case report in the literature without

any causative factor is by Garg, et al. [18] and their pa-

tient was a healthy woman but they treated her opera-

tively.

Conservative treatment of Achilles tendon tears has

been considered a reasonable form of treatment. It has a

relatively good outcome and the risk of wound break-

down is eliminated. In a retrospective cohort study pub-

lished in 2003, Weber, et al. [22], found that non-opera-

tive treatment with an equinus ankle cast and boot for 12

weeks was as effective as surgical treatment in return to

sports and ultimate strength as operative treatment.

Moreover, they also reported that non-operative treated

patients had a much faster subsidence of pain, return to

unaided walking, and return to work. Eames, et al. [23],

showed similar outcomes between surgical and non-sur-

gical treatment but closed treatment had a lower minor

complication rate.

Sekiya, et al. [24] and Wray, et al. [25] have demon-

strated in cadaveric studies that knee flexion position

does not influence the separation of the tendo Achilles

ends while the plantarflexion position of the ankle does

significantly affect the separation of the tendoachilles

ends. Wray, et al. [25] also showed that the ankle needs

to be in at least 28 degrees of plantarflexion for the two

ruptured ends of the tendo achilles to meet. Therefore the

only factor to be controlled is the ankle position, which

can be con tr olled in a be low kn ee c ast an d an ab ov e kne e

cast is not necessary. There is only one other report in

the literature where the patient was treated conserva-

tively for bilateral tendo Achilles ruptures [26]. Their

patient had severe COPD and had been treated with ster-

oids. Bilateral cast brace treatment was provided for this

patient considering the poor general health. Unfortu-

nately, their patients’ right tendo-achilles did not heal

with brace management perhaps as result of him being

on steroids. We think that our patient achieved satisfac-

R. KAKKAR ET AL.

226

tory healing as he was not on steroids and did not have

any other risk factors and thus, possibly had healthier

tendons to start with which healed without any conse-

quence.

Our case presents a unique opportunity to examine

conservative treatment methods in a healthy patient. Al-

though different management was used (above knee

versus below knee casts) for each side, the outcomes on

both sides were similar and in this case it did not make a

difference whether an above knee or a below knee cast

was used for the initial treatment as the tendons healed

on both the sides and the patient returned to their

pre-injury activity levels. This also demonstrates that th e

amount of knee extension/flexion has no bearing on the

tendoachilles healing and that the only factor affecting

the separation of tendoachilles ends and thus their heal-

ing is the plantarflexion of the ankle.

This case is only the second reported case of bilateral

rupture in a healthy patient and our case demonstrates

that bilateral tendoachilles rupture can be treated con-

servatively with a good outcome.

4. References

[1] A. Mehra, R. Case and C. Croucher, “Bilateral Simulta-

neous Spontaneous Rupture of the Achilles Tendon,”

Hospital Medicine, Vol. 65, No. 5, 2004, pp. 308-309.

[2] N. Maffulli, M. G. Kenward, V. Testa, G. Capasso, R.

Regine and J. B. King, “Clinical Diagnosis of Achilles

Tendinopathy with Tendinosis,” Clinical Journal of Sport

Medicine, Vol. 13, No. 1, 2003, pp. 11-15.

doi:10.1097/00042752-200301000-00003

[3] M. Paavola, P. Kannus, T. Paakkala, M. Pasanen and M.

Jarvinen, “Long-Term Prognosis of Patients with Achilles

Tendinopathy. An Observational 8-Year Follow-up Study,”

American Journal of Sports Medicine, Vol. 28, No. 5,

2000, pp. 634-642.

[4] M. Paavola, S. Orava, J. Leppilahti, P. Kannus and M.

Jarvinen, “Chronic Achilles Tendon Overuse Injury: Com-

plications after Surgical Treatment. An Analysis of 432

Consecutive Patients,” American Journal of Sports Medi-

cine, Vol. 28, No. 1, 2000, pp. 77-82.

[5] L. Jozsa, M. Kvist, B. J. Balint, et al., “The Role of Rec-

reational Sport Activity in Achilles Tendon Rupture. A

Clinical, Pathoanatomical, and Sociological Study of 292

Cases,” American Journal of Sports Medicine, Vol. 17,

No. 3, 1989, pp. 338-343.

doi:10.1177/036354658901700305

[6] D. P. Hanlon, “Bilateral Achilles Tendon Rupture: An

Unusual Occurrence,” Journal of Emergency Medicine,

Vol. 10, No. 5, 1992, pp. 559-560.

doi:10.1016/0736-4679(92)90136-H

[7] D. R. Baruah, “Spontaneous Rupture of Bilateral Achilles

Tendon of a Patient on Long-Term Systemic Steroid The-

rapy,” Unfallheilkunde, Vol. 87, No. 1, 1984, pp. 35-36.

[8] W. Dickey and V. Patterson, “Bilateral Achilles Tendon

Rupture Simulating Peripheral Neuropathy: Unusual

Complication of Steroid Therapy,” Journal of the Royal

Society of Medicine, Vol. 80, 1987, pp. 386-387.

[9] S. F. Habusta, “Bilateral Simultaneous Rupture of the

Achilles Tendon. A Rare Traumatic Injury,” Clinical Or-

thopaedics and Related Research, Vol. 320, 1995, pp.

231-234.

[10] J. F. Haines, “Bilateral Rupture of the Achilles Tendon in

Patients on Steroid Therapy,” Annals of the Rheumatic

Diseases, Vol. 42, No. 6, 1983, pp. 652-654.

doi:10.1136/ard.42.6.652

[11] M. Kelly, M. Dodds, J. S. Huntley and C. M. Robinson,

“Bilateral Concurrent Rupture of the Achilles Tendon in

the Absence of Risk Factors,” Hospital Medicine, Vol. 65,

2004, pp. 310-311.

[12] S. Orava, M. Hurme and J. Leppilahti, “Bilateral Achilles

Tendon Rupture: A Report on Two Cases,” Scandinavian

Journal of Medicine and Science in Sports, Vol. 6, No. 5,

1996, pp. 309-312.

doi:10.1111/j.1600-0838.1996.tb00476.x

[13] D. D. Shukla, “Bilateral Spontaneous Rupture of Achilles

Tendon Secondary to Limb Ischemia: A Case Report,”

Journal of Foot and Ankle Surgery, Vol. 41, No. 5, 2002,

pp. 328-329. doi:10.1016/S1067-2516(02)80052-7

[14] V. Battista, J. Combs and W. J. Warme, “Asynchronous

Bilateral Achilles Tendon Ruptures and Androstenediol

Use,” American Journal of Sports Medicine, Vol. 31, No.

6, 2003, pp. 1007-1009.

[15] W. T. Lee and J. F. Collins, “Ciprofloxacin Associated

Bilateral Achilles Tendon Rupture,” Australian and New

Zealand Journal of Medicine, Vol. 22, No. 5, 1992, p. 500.

[16] A. Aroen, D. Helgo, O. G. Granlund and R. Bahr, “Con-

tralateral Tendon Rupture Risk is Increased in Individuals

with a Previous Achilles Tendon Rupture,” Scandinavian

Journal of Medicine & Science in Sports, Vol. 14, No. 1,

2004, pp. 30-33. doi:10.1111/j.1600-0838.2004.00344.x

[17] K. Matsumoto, S. Hukuda, J. Nishioka and S. Asajima,

“Rupture of the Achilles Tendon in Rheumatoid Arthritis

with Histologic Evidence of Enthesitis. A Case Report,”

Clinical Orthopaedics and Related Research, Vol. 280,

1992, pp. 235-240.

[18] S. Garg and M. Thilagarajah, “Bilateral Rupture of

Achilles Tendon (bilrat) without Predisposing Systemic

Disease or Steroid Use: A Case Report and Review of the

Literature,” The Internet Journal of Orthopedic Surgery.

Vol. 13, No. 2, 2009.

[19] T. Hayes, D. McClelland and N. Mafulli, “Metasynchro-

nous Bilateral Achilles Tendon Rupture. Bulletin,” Hos-

pital for Joint Diseases, Vol. 61, No. 3-4, pp. 2003-2004.

[20] J. H. Mayer, “Correspondence. Bilateral Rupture of

Achilles Tendons,” British Medical Journal, Vol. 1, 1961,

p. 1830. doi:10.1136/bmj.1.5242.1830

[21] S. K. Rao, B. C. Navadgi and A. Vasdev, “Bilateral Spon-

taneous Rupture of Achilles Tendons: A Case Report,”

Journal of Orthopaedic Surgery, Vol. 13, No. 2, 2005, 178

-180

[22] M. Weber, M. Niemann, R. Lanz and T. Muller, “Non-

R. KAKKAR ET AL.

227

operative Treatment of Acute Rupture of the Achilles

Tendon: Results of a New Protocol and Comparison with

Operative Rreatment,” American Journal of Sports Med-

icine, Vol. 31, 2003, pp. 685-691.

[23] M. H. Eames, N.W. Eames, K. R. McCarthy and R. G.

Wallace, “An Audit of the Combined Non-Operative and

Orthotic Management of Ruptured Tendo Achillis,” In-

jury, Vol. 28, No. 4, 1997, pp. 289-292.

[24] J. K. Sekiya, K. E. Evensen, P. J. L. Jebson and J. E.

Kuhn, “The Effect of Knee and Ankle Position on Dis-

placement of Achilles Tendon Ruptures in a Cadaveric

Model. Implications for Nonoperative Management,”

American Journal of Sports Medicine, Vol. 27, No. 5,

1999, pp. 632-635.

[25] W. H. Wray, C. Regan, S. Patel, R. May and S. Parekh,

“Positional Effects of the Knee and Ankle on the Ends of

Acute Achilles Tendon Ruptures,” Foot & Ankle Special-

ist, Vol. 2, No. 5, 2009, pp. 214-218.

doi:10.1177/1938640009346449

[26] M. A. Ramirez and L. C. Richardson, “Pulmonary Em-

bolism Associated with Spontaneous Bilateral Achilles

Tendon Rupture,” Journal of Foot and Ankle Surgery,

Vol. 46, No. 4, 2007, pp. 283-287.

doi:10.1053/j.jfas.2007.03.014