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Atraumatic Bilateral Achilles Tendon Rupture: an Association of Systemic 378 Kotnis, Halstead, Hormbrey Acute compartment syndrome may be a of the body of gastrocnemius has been result of any trauma to the limb. The trauma is reported in athletes.7 8 This, however, is the J Accid Emerg Med: first published as 10.1136/emj.16.5.378 on 1 September 1999. Downloaded from usually a result of an open or closed fracture of first reported case of acute compartment the bones, or a crush injury to the limb. Other syndrome caused by a gastrocnemius muscle causes include haematoma, gun shot or stab rupture in a non-athlete. wounds, animal or insect bites, post-ischaemic swelling, vascular damage, electrical injuries, burns, prolonged tourniquet times, etc. Other Conclusion causes of compartment syndrome are genetic, Soft tissue injuries and muscle tears occur fre- iatrogenic, or acquired coagulopathies, infec- quently in athletes. Most injuries result from tion, nephrotic syndrome or any cause of direct trauma. Indirect trauma resulting in decreased tissue osmolarity and capillary per- muscle tears and ruptures can cause acute meability. compartment syndrome in athletes. It is also Chronic compartment syndrome is most important to keep in mind the possibility of typically an exercise induced condition charac- similar injuries in a non-athlete as well. More terised by a relative inadequacy of musculofas- research is needed to define optimal manage- cial compartment size producing chronic or ment patterns and potential strategies for recurring pain and/or disability. It is seen in injury prevention. athletes, who often have recurring leg pain that Conflict of interest: none. starts after they have been exercising for some Funding: none. time. There is no history oftrauma. The pain is 1 Mabee JR, Bostwick TL. Pathophysiology and mechanisms localised to the involved muscles or the entire of compartment syndrome. Orthopaedic Reviews 1993; 1 75- 80. compartment and the symptoms are very simi- 2 McQueen MM, Court-Brown CM. Compartment monitor- lar to acute compartment syndrome. The ing in tibial fractures-the pressure threshold for decom- pression. Jf Bone joint Surg Br 1995;78:99-104. symptoms often settle with rest, however if the 3 Blick SS, Brumback RJ, Poka A, et al. Compartment athlete returns to his sport after laying off, the syndrome in open tibial fractures. J Bone Joint Surg Am 1986;68: 1348-53. symptoms usually recur. The treatment of con- 4 Hargens AR, Akeson WH, Mubarak SJ, et al. Tissue fluid firmed chronic compartment syndrome is a pressures: from basic research tools to clinical applications. Jf Orthop Res 1989;7:902-9. surgical fasciotomy of the affected compart- 5 Matsen FA III, Winquist RA, Krugmire RB Jr. Diagnosis ments. and management of compartmental syndromes. J Bone Joint Surg Am 1980;62:286-9 1. Essentially, any cause of increased compart- 6 Mubarak SJ, Owen CA, Hargens AR, et al. Acute compart- ment pressure can result in a compartment ment syndromes: diagnosis and treatment with the aid of the wick catheter. J Bone joint Surg Am 1978;60: 1091-5. syndrome. Muscle rupture has been implicated 7 Mohanna PN, Haddad FS. Acute compartment syndrome in causing increased compartment pressures in following non-contact football injury. Br Jf Sports Med 1997;31:254-5. athletes after severe exercise. The diagnosis of 8 Best TM. Soft-tissue injuries and muscle tears. Clin Sports acute compartment syndrome due to rupture Med 1997;16(30):419-34. Atraumatic bilateral Achilles tendon rupture: an http://emj.bmj.com/ association of systemic steroid treatment R A Kotnis, J C Halstead, P J Hormbrey on September 26, 2021 by guest. Protected copyright. Abstract care treatment two months previously, after A case ofbilateral Achilles tendon rupture which he had been started on oral pred- associated with steroid use is reported. nisolone. His respiratory symptoms were well This case illustrates the importance of controlled at the time of presentation. There taking a thorough drug history in cases of was no history of any tendon or joint pathology Accident and tendon rupture. In lower limb tendon rup- before the steroid treatment. Emergency ture all patients, especially those on Examination revealed a palpable gap in his Department, John steroids, should be warned of the in- left Achilles tendon 2 cm proximal to the inser- Radcliffe Hospital, creased risk of contralateral injury. tion on the calcaneum. A diagnosis of ruptured Oxford (JAccid Emerg Med 1999;16:378-379) R A Kotnis Achilles tendon was made and the patient was J C Halstead Keywords: Achilles tendon; steroid use placed in an equinus plaster of Paris below P J Hormbrey knee cast. The next day repair of the tendon Case report under local anaesthetic was performed utilising Correspondence to: an open technique; at surgery the tendon Dr Rohit A Kotnis, A 67 year old man presented to the accident Department ofAccident and and emergency department with sudden onset appeared degenerate. The equinus cast was Emergency, John Radcliffe of left sided calf pain that occurred while reapplied with a plan to change to the Hospital, Headington, crossing a road. He was unable to weight bear mid-equinus position in two weeks and then to Oxford OX3 3DU. on his left leg. This previously fit male had a Samson boot for mobilisation of the ankle Accepted 29 April 1999 developed severe pneumonia needing intensive within four weeks. Atraumatic bilateralAchilles tendon rupture 379 Five days later, the patient developed mild magnetic resonance imaging may be helpful in pain in his right calf on mobilising. A further certain scenarios such as in the detection of J Accid Emerg Med: first published as 10.1136/emj.16.5.378 on 1 September 1999. Downloaded from two days later while walking at home with tendon or paratenon inflammation, where crutches, he developed severe pain in his right appropriate treatment may prevent rupture.7 calf and presented with inability to weight bear Treatment of the ruptured tendon(s) can be on the right leg. Clinical examination con- either operative or conservative; neither has firmed rupture of the right Achilles tendon. proved superior, as demonstrated by the The patient was admitted to hospital and similar recovery time and functional outcome placed in a below knee equinus plaster cast shown in our case. Surgery does facilitate early maintained for six weeks. A conservative mobilisation but wound sepsis is a risk, given approach was adopted for the rupture on the the poor local vascularity.' Repair should be right side. with strong permanent or slowly absorbable The patient was reviewed at three months sutures, and may be effected percutaneously. and was able to fully weight bear on both legs Non-operative management, however, carries a with full range of movement at the ankle joints. greater risk of re-rupture. In this case, there was no history of tendon Discussion or joint pathology before starting steroid treat- The Achilles tendon is the largest and thickest ment. The patient developed atraumatic bilat- tendon in humans. It is formed from the eral Achilles tendon rupture after two months aponeuroses of gastrocnemius and soleus and ofsteroid treatment. In addition, the rupture of inserts into the middle third of the posterior the right Achilles tendon may have been surface of the calcaneum, separated from the caused by the added load on that leg after superior part of the tuberosity by a bursa. The repair of the left tendon. two muscles are the principle plantarflexors of On assessment of the patient with a sus- the foot at the ankle joint. pected Achilles tendon rupture in the accident Achilles tendon rupture usually follows sud- and emergency department it is vital to obtain den forced movement at the ankle joint. It usu- a drug history. In most cases those on ally occurs in men between 30 and 50 years of thorough age. There are usually no prodromal symptoms steroids will need to continue their treatment, and histological examination reveals a normal but other medications such as quinolone tendon. Rupture can also occur after trivial antibiotics could be stopped or substituted. loading such as during gentle locomotion, the The patient should be advised regarding the so called atraumatic ruptures. Atraumatic rup- increased risk of rupture of the contralateral ture is incompletely understood and often tendon and encouraged to take extra care to occurs in an older age group, with prodromal decrease this risk. symptoms as in this case. Histology usually reveals inflammatory changes consistent with a Conflict of interest: none. preceding tendinitis.' In this latter group, there Funding: none. is a high association with steroid use. Tendon ruptures at the ankle have been 1 Orava S, Hurme M, Leppilahti J. Bilateral Achilles tendon rupture: a report on 2 cases. Scand J Med Sci Sports described in association with rheumatoid 1996;6:309-12. arthritis,' gout, systemic lupus erythematosus,' 2 Matsumoto K, Hukuda S, Nishioka J, et al. Rupture of the http://emj.bmj.com/ Achilles tendon in rheumatoid arthritis with histologic evi- and chronic renal failure and renal transplanta- dence of enthesitis. A case report. Clin Orthop 1992;280: tion.4 In addition, Achilles tendinopathies in- 235-40. 3 Potasman I, Bassan HM. Multiple tendon rupture in cluding rupture have been associated with systemic lupus erythematosus: case report and review of quinolone antibiotic usage.5 In a study of 10 the literature. Ann Rheum Dis 1984;43:347-9. 4 Spencer JD. Spontaneous rupture oftendons in dialysis and atraumatic cases five were associated with respi- renal transplant patients. Injury 1988;19:86-8. ratory disease treated with systemic steroids.6 5 Zabraniecki L, Negrier I, Vergne P, et al. Fluoroquinolone of six cases. J Rheumatol The mechanism ofaction is unclear but steroids induced tendinopathy: report on September 26, 2021 by guest.
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