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Tendon Rupture

Tendon rupture is a severe type of tendon injury and may involve virtually any tendon in the body. Although trauma and sports-related activities are principal mechanisms of tendon rupture, preexisting degenerative changes seem to be the most important factor for this soft tissue injury. The diagnosis is primarily made through a physical examination. Imaging studies are used to support clinical findings.


Presentation

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].
Malingering
  • The differential diagnosis is vast and includes but is not limited to: spinal cord injury, Guillain-Barré syndrome, myopathies, and even malingering. This case report details an uncommon cause for a common ED presentation.[ncbi.nlm.nih.gov]
Soft Tissue Mass
  • CASE: We present a case of rice-body formation and partial flexor tendon rupture in a 3-year-old child with seronegative juvenile idiopathic arthritis (JIA), which presented as a painless soft-tissue mass of the volar aspect of the hand.[ncbi.nlm.nih.gov]
Hypotension
  • Side effects of rituximab include fever, rash, cytopenia and hypotension, back pain, arthralgia, and myalgia. Here, we report on 3 patients who developed moderate to severe tendonitis after the second infusion of rituximab.[ncbi.nlm.nih.gov]
Hip Pain
  • We are reporting a case of apparently spontaneous iliopsoas tendon rupture that occurred in an elderly patient presenting with severe debilitating hip pain whose etiology initially was unrecognized.[ncbi.nlm.nih.gov]
  • This older woman presented with non-traumatic, sudden onset hip pain which was diagnosed as a right iliopsoas rupture on MRI. Despite stopping ciprofloxacin, she went on to develop rupture of the contralateral iliopsoas tendon.[ncbi.nlm.nih.gov]
Muscle Strain
  • Strain Cramps DOMS - Delayed Onset Muscle Soreness Overuse Injuries Systemic Conditions Rheumatoid Arthritis Fibromyalgia Psoriatic Arthritis Lupus Neurological Conditions Sciatica Restless Leg Syndrome Pinched Nerve References Cary DV. (2009) How to[physioworks.com.au]
Guillain-Barré Syndrome
  • The differential diagnosis is vast and includes but is not limited to: spinal cord injury, Guillain-Barré syndrome, myopathies, and even malingering. This case report details an uncommon cause for a common ED presentation.[ncbi.nlm.nih.gov]

Workup

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].

Cytopenia
  • Side effects of rituximab include fever, rash, cytopenia and hypotension, back pain, arthralgia, and myalgia. Here, we report on 3 patients who developed moderate to severe tendonitis after the second infusion of rituximab.[ncbi.nlm.nih.gov]
Polyps
  • RESULTS: The association between the exposure of low 25(OH)D levels and myofascial pain was compared to all cancers, colon polyps, and tendon ruptures.[ncbi.nlm.nih.gov]

Treatment

  • OBJECTIVE: There is discordance in the results from meta-analyses on surgical versus non-surgical treatment for acute Achilles tendon rupture.[ncbi.nlm.nih.gov]
  • Abstract Background: Volar plate fixation with locked screws has become the preferred treatment of displaced distal radius fractures that cannot be managed nonoperatively. This treatment, however, is not without complication.[ncbi.nlm.nih.gov]
  • Abstract Treatment of total ruptures of adductor longus is challenging in professional sports.[ncbi.nlm.nih.gov]
  • We performed subgroup analyses by sex, age, treatment duration, and statin dose.[ncbi.nlm.nih.gov]
  • Logistic regression analysis failed to show any significant effect of age at rupture, gender, or mode of treatment on ATRS.[ncbi.nlm.nih.gov]

Prognosis

  • Concomitant rotator cuff disease may have important implications in the prognosis and natural history of this shoulder condition.[ncbi.nlm.nih.gov]
  • Early intervention was the key to better prognosis. 2015 BMJ Publishing Group Ltd.[ncbi.nlm.nih.gov]
  • Treatment and prognosis Early surgical repair is necessary to ensure good functional outcome.[radiopaedia.org]
  • Ruptured Achilles Tendon Prognosis You will normally be in your CAM brace for between 6 to 12 weeks. If everything goes perfectly during your rehabilitation it takes at least 12 weeks before a return to sport is possible.[physioworks.com.au]
  • Ruptured Tendon Prognosis The prognosis for both surgery and nonsurgical treatment varies with the location and severity of the rupture. Surgical repair, in concert with additional physical therapy, can result in return to normal strength.[emedicinehealth.com]

Etiology

  • Only a few case reports have discussed the different etiologies, options for diagnosis, and therapeutic interventions for acute cases.[ncbi.nlm.nih.gov]
  • We are reporting a case of apparently spontaneous iliopsoas tendon rupture that occurred in an elderly patient presenting with severe debilitating hip pain whose etiology initially was unrecognized.[ncbi.nlm.nih.gov]
  • Kienböck disease is avascular necrosis of the lunate, with an unknown etiology.[ncbi.nlm.nih.gov]
  • A 38-year-old female presented for evaluation of a painful bump of unknown etiology on the dorsolateral aspect of her non-dominant wrist.[ncbi.nlm.nih.gov]
  • 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[symptoma.com]

Epidemiology

  • Achilles tendon rupture with special reference to epidemiology and results of surgery. Thesis. Acta Universitas Ouluensis, D Medica 383. University of Oulu, 1996 Paavola M. Achilles tendon overuse injuries. Thesis.[ebm-guidelines.com]
  • Epidemiology . Accessed November 30, 2015. Medscape. Surgical intervention . Accessed November 30, 2015. *PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI).[moveforwardpt.com]
  • Some cadaveric studies suggest a watershed area approximately 2 cm to 6 cm above the Achilles’ insertion, although this has not been supported in vivo. 8 Epidemiology of Achilles tendinopathy The incidence of Achilles rupture is 7 out of 100,000 in the[lermagazine.com]
  • Achilles tendon disorders: etiology and epidemiology. Foot Ankle Clin, 2005; 10(2):255-266. 4. Gebauer M, Beil FT, Beckmann J, Sárváry AM, Ueblacker P, Ruecker AH, Holste J, Meenen NM.[podiatrytoday.com]
  • Epidemiology The true incidence of patellar tendon rupture is not known, but this injury is observed less frequently than rupture of the quadriceps tendon and usually occurs in those younger than 40 years.[emedicine.medscape.com]
Sex distribution
Age distribution

Pathophysiology

  • Pathophysiology and pathogenesis of visceral fat obesity. Obes Res 1995;3 Suppl 2:187S-194S. 42. Magnusson SP, Hansen M, Langberg H, et al. The adaptability of tendon to loading differs in men and women. Int J Exp Pathol 2007;88(4):237-240. 43.[lermagazine.com]
  • Pathophysiology Unilateral traumatic ruptures of the patellar tendon tend to occur when a violent contraction of the quadriceps is resisted by the flexed knee (eg, during landing after a jump).[emedicine.medscape.com]

Prevention

  • As the patient has tendon weakness, extensive repair will increase the risk of patella baja, and the use of end-to-end suturing technique alone will not be enough to prevent a rupture recurring; however, augmentation could be used to address the tendon[ncbi.nlm.nih.gov]
  • Ankle block anesthesia is used to allow the patient's active movement of the interphalangeal (IP) joint to determine the appropriate length of the reconstructed tendon for maintaining balance and preventing the tendon from being too tight or too loose[ncbi.nlm.nih.gov]
  • The identification and early treatment of PTT tears is essential for good functional outcomes to prevent the main mid- to long-term complication of disabling acquired flatfoot due to tendon failure.[ncbi.nlm.nih.gov]
  • After removal of the cast, physical therapy is recommended to prevent stiffness and restore lost muscle tone.[orangeorthopaedics.com]

References

Article

  1. Thomopoulos S, Parks WC, Rifkin DB, Derwin KA. Mechanisms of tendon injury and repair. J Orthop Res 2015;33(6):832-839.
  2. Pedowitz D, Kirwan G. Achilles tendon ruptures. Curr Rev Musculoskelet Med. 2013;6(4):285-293.
  3. Sharma P, Maffulli N. Tendon injury and tendinopathy: healing and repair. J Bone Joint Surg Am. 2005;87(1):187-202.
  4. Lewis T, Cook J. Fluoroquinolones and Tendinopathy: A Guide for Athletes and Sports Clinicians and a Systematic Review of the Literature. J Athl Train. 2014;49(3):422-427.
  5. Lu H, Yang H, Shen H, Ye G, Lin X-J. The clinical effect of tendon repair for tendon spontaneous rupture after corticosteroid injection in hands: A retrospective observational study. Grewal. P, ed. Medicine (Baltimore). 2016;95(41):e5145.
  6. Quach T, Jazayeri R, Sherman OH, Rosen JE. Distal biceps tendon injuries--current treatment options. Bull NYU Hosp Jt Dis. 2010;68(2):103-111.
  7. Roudet A, Boudissa M, Chaussard C, Rubens-Duval B, Saragaglia D. Acute traumatic patellar tendon rupture: Early and late results of surgical treatment of 38 cases. Orthop Traumatol Surg Res. 2015;101(3):307-311.
  8. Gilman L, Cage DN, Horn A, Bishop F, Klam WP, Doan AP. Tendon rupture associated with excessive smartphone gaming. JAMA Intern Med. 2015;175(6):1048-1049.
  9. Proubasta IR, Lamas CG, Natera L, Arriaga N. Delayed rupture of all finger flexor tendons (excluding thumb) following nonoperative treatment of Colles’ fracture: A case report and literature review. J Orthop. 2015;12(1):S65-S68.
  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.

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Last updated: 2018-06-22 10:48