Tendon Rupture

A tendon rupture is described by many reports as one of the most severe forms of tendon injury. The etiology seems to be multifactorial, as trauma and intense eccentric contractions (seen predominantly during sports activities), as well as iatrogenic causes (the use of fluoroquinolones and corticosteroids have been confirmed as risk factors for tendon rupture), seem to be equally important [1] [2] [3] [4] [5]. However, degenerative changes that have been histologically confirmed in many cases (particularly in those who suffered from Achilles tendon rupture) are considered as a prerequisite in order for tendons to rupture [1] [2] [3]. Various studies have described that virtually any tendon in the body could rupture, with respective differences in the clinical presentation [1] [2] [3] [4] [5] [6] [7] [8] [9] [10]:

• Achilles tendon rupture - The Achilles tendon, whose function is to allow plantar flexion of the ankle induced by the triceps surae muscle (two heads of the gastrocnemius and the soleus muscle) is most commonly mentioned in the literature in relation to tendon ruptures [1]. It is encountered in adults who are engaged in strenuous sports activities during their fourth and fifth decades of life and there is a significant predilection for male gender [1] [2]. A sudden onset of pain after an intense plantar flexion is the typical clinical presentation, and many patients cannot stand or bear any weight on the affected leg [2]. In addition, a "pop" sound is reported, denoting the separation of the tendon from its attachment site on the bone [2].
• Biceps rupture - Although it is not commonly encountered in clinical practice, excessive eccentric contractions of this muscle (for example, during heavy lifting) might cause rupture of its tendon, both in the proximal, and less commonly the distal part [6]. A sudden onset of pain accompanied by a tearing sensation in the antecubital region (where the rupture has occurred) is seen in virtually all cases [6]. Similar to Achilles tendon rupture, a "pop" sound is usually heard [6].
• Quadriceps and patellar tendon rupture - Tendons of the quadriceps and patella are also susceptible to rupture, most often caused by an abnormal contraction of the quadriceps muscle while the knee is in moderate flexion, during strenuous running activities (such as sprinting) or due to trauma [7] [10].
• Flexor and extensor ruptures of the fingers - As with other types of ruptures, traumatic tendon injury following excessive activity been attributed as causing the rupture of the tendons in the hand [8] [9].

A meticulous physical examination is the essential step in recognizing tendon rupture and is supported by data obtained during history taking. Information regarding prior event that led to the injury is vital in assessing the severity and extent of tissue damage, whereas recent fluoroquinolone or corticosteroid use must be excluded, given their well-established roles in the pathogenesis of tendon ruptures [4] [5]. Various probes and tests can be implemented to confirm clinical suspicion toward rupture. In the setting of Achilles tendon rupture, clinical findings include a weak strength when performing plantar flexion, a palpable and often visible defect (retraction of the tendon will produce an abnormal muscular appearance) and the absence of plantar flexion when the triceps surae muscle is mechanically compressed (known as the Thompson test) [2]. Studies have illustrated that up to 100% of ruptures are diagnosed without the need for imaging studies if the examination is conducted properly, thus illustrating the role of a good physical exam [2]. Weakness in the forearm and elbow accompanied by a lack of supination when compressing the biceps belly (the biceps squeeze test) and the inability to palpate the distal biceps tendon while the elbow is flexed and supinated (the hook test) are highly suggestive of a biceps tendon rupture [6]. Quadriceps tendon ruptures are recognized by the inability of the patients to perform active knee extension [7]. If strong clinical suspicion is raised, imaging studies may be used to confirm the diagnosis. Ultrasonography and magnetic resonance imaging (MRI) are recommended because of their ability to assess the extent of the injury [2] [6].

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10. Ciriello V1, Gudipati S, Tosounidis T, Soucacos PN, Giannoudis PV. Clinical outcomes after repair of quadriceps tendon rupture: a systematic review. Injury. 2012;43(11):1931-1938.