Case Report

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American Journal of Emergency Medicine

journal homepage: www. elsevier. com/ locate/ajem

Bilateral spontaneous atraumatic rupture of the Achilles tendon in an athlete

Abstract

We report a case of spontaneous, bilateral Achilles rupture in a 33- year-old man with no specific risk factors. The rupture occurred after a heavy impact during a sports activity, and although the rupture was painful, he was able to mobilize slowly. After a clinical examination con- firmed the diagnosis, ultrasonography and magnetic resonance imaging evaluation of the Achilles tendons revealed bilateral ruptures. The pa- tient underwent bilateral conservative treatment and subsequently embarked on a comprehensive rehabilitation program with a good functional outcome at follow-up. The patient’s return to premorbid work and social life was uneventful. A Spontaneous rupture in a patient without any predisposing risk factors is uncommon, and for it to occur bilaterally is notably rare.

Rupture of the Achilles tendon is a relatively common and serious in- jury [1]. Achilles tendon ruptures occur most frequently in the age groups of 30 to -39 years and 40 to - 49 years in men and women, with a predominance in males being observed [2]. Bilateral Achilles ten- don rupture, however, is not common; if it occurs, a predisposing issue such as long-term corticosteroid use (as in systemic lupus erythematous and rheumatoid arthritis), diabetes, chronic renal failure, or use of fluroquinolones is usually observed in association [3,4]. Approximately 75% to 80% of cases can be attributed to participation in athletic activi- ties, including ball and racquet sports [5]. The mechanisms of injury in- clude a sudden pushing off from the weight-bearing forefoot with the knee in extension, unexpected ankle dorsiflexion, and violent dorsiflexion of a plantar-flexed foot [6].

To the best of our knowledge, few cases have developed spontane-

ous bilateral ruptures of the Achilles tendons without any apparent pre- disposing factors [7,8]. In this report, we present an interesting case of spontaneous bilateral Achilles tendon rupture.

A 33-year-old athlete man presented to the emergency department with spontaneous onset of severe pain in both ankles, and the man was unable to stand without support. There was no history of trauma. There was nothing in the patient’s history to suggest chronic disease or drug use. The patient presented with partial limitation of plantar flexion of the foot, complete limitation of standing on tiptoes and propulsion, and a positive Thompson test. Palpation found a gap and tenderness above the insertion of the Achilles tendon.There was no neurologic def- icit distally. A clinical diagnosis of bilateral spontaneous Achilles tendon rupture was suspected. Magnetic resonance imaging scans were obtain- ed for both ankles, which confirmed bilateral Achilles tendon ruptures 4 cm proximal to insertion into the calcaneus. There were no features suggestive of preexisting tendinopathy on the magnetic resonance im- aging scans. A decision to apply conservative management was made

in consideration of the patient’s age, comorbidities, and activity level. The patient was placed in bilateral below-knee plasters in gravity equinus for 4 weeks and in midequinus for 2 weeks. He was discharged to home and was followed up with regularly. After removal of the cast, he ambulated with ankle-foot orthoses. At 4 months of follow-up, he was doing very well and ambulating without the brace. On examination, he had an adequate range of motion in dorsiflexion and plantar flexion. The Achilles tendon is the tendinous extension of 3 muscles in the lower leg: the gastrocnemius, the soleus, and the plantaris. This tendon is the thickest and strongest tendon in the body. The primary function of the Achilles tendon is to transmit the power of the calf to the foot, en- abling walking and running. The Achilles tendon is subjected to exten- sive static and dynamic loads and can be subjected to loads 2 to 3 times body weight with walking and up to 10 times body weight with certain other athletic activities [9]. Achilles tendon injuries are mostly sports related [10]. The spontaneous rupture of both Achilles tendons is highly rare. This condition is generally associated with a systemic dis-

ease, especially entailing long-term hemodialysis [11].

Nonoperative management plays a role in acute ruptures. Advances in this method, especially with regard to functional bracing of tendons that are well opposed on ultrasound have yielded encouraging results [12,13].

Bilateral ruptures are a notably rare event, especially in the absence of risk factors. The literature describes both conservative treatment, with a knee-high cast in equine being used, and surgical treatment. Ac- cording to our experience and in agreement with the literature, conser- vative treatment is preferable [12], if there are no contraindications or if the patient is not suitable for casting.

Fatih Karaaslan, MD

Department of Orthopedics and Traumatology Bozok University Faculty of Medicine, TR-66200, Yozgat, Turkey

Emre Yurdakul, MD

Department of Orthopedics and Traumatology, Osmaniye State Hospital

TR-80020, Osmaniye, Turkey Corresponding author at: Osmaniye devlet hastanesi, Ortopedi ve Travmatoloji Bolumu, Osmaniye, Turkey. Tel.: +90 328 826 12 00

E-mail address: [email protected]

Murat Baloglu, MD

Department of Orthopedics and Traumatology, Memorial Hospital

TR-38200, Kayseri, Turkey

Musa Ugur Mermerkaya, MD

Department of Orthopedics and Traumatology Bozok University Faculty of Medicine, TR-66200, Yozgat, Turkey

0735-6757/(C) 2015

Sinan Karaoglu, MD

Department of Orthopedics and Traumatology, Memorial Hospital

TR-38200, Kayseri, Turkey

http://dx.doi.org/10.1016/j.ajem.2015.04.037

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