Keywords: Achilles rupture; steroid; complication; chemotherapeutic agents
After the ankle pain and difficulty walking persisted
for 2 weeks, the patient was referred. On physical examination,
both ankles appeared to be swollen over the
Achilles' tendon region. Tenderness was elicited over both Achilles' tendons, near the insertions into the calcaneus.
Bilaterally, a gap was determined by palpation
of the tendon next to the swollen sites. Thompson's test
was positive. Bilaterally, active plantar flexion could
only be performed with difficulty. Active and passive
plantar flexion of the ankle was 20° and 30°, respectively.
Active and passive dorsiflexion was limited in a neutral
position. No neurological deficit was determined.
From these findings, a preliminary diagnosis of Achilles'
tendon rupture was considered, and magnetic resonance
imaging (MRI) revealed a complete tear of the
left Achilles' tendon 9 cm proximal to the calcaneal insertion,
and a complete tear of the right Achilles' tendon
8.5 cm proximal to the calcaneal insertion (Figure
Upon consultation with an orthopedic surgeon, surgical repair was not recommended, due to the delay in the event. The patient undertook a 4-week rehabilitation program of 5 days per week, which included stretchingstrengthening exercises and analgesic physical modalities. Transcutaneous electrical nerve stimulation with a protocol of 20 minutes/100 Hz/day was administered for pain. Stretching exercises, a cycling program, resistance strengthening with elastic bands, and closed-chain exercises of the gastrocnemius-soleus-Achilles motor unit were performed for 30 minutes a day. The patient was capable of walking with a cane. Pain was assessed with a 10-mm visual analog scale (VAS). At the end of the 4-week rehabilitation program, VAS score had reduced from 6 to 0, and the patient was able to walk up and down stairs. Active and passive plantar flexion of the ankle was 30° and 40°, respectively. Active and passive dorsiflexion were 10°, though the patient was still unable to walk on the toes.
Foot and ankle problems were evaluated by the Foot
and Ankle Outcome Score (FAOS) at the beginning of
therapy. FAOS was developed to assess problems in patients
with lateral ankle instability, Achilles' tendonitis,
and plantar fasciitis. Reliability and validity studies of
the FAOS among the Turkish population have been
conducted.[
Achilles rupture may also occur spontaneously. Risk
factors for spontaneous rupture have been reported as
rheumatoid arthritis, diabetes mellitus, organ transplantation,
renal failure, gout, systemic lupus erythematosus,
and systemic corticosteroid and fluoroquinolone
treatment.[
The mechanism of rupture associated with steroid
use is not yet fully understood, though several mechanisms
have been suggested. Corticosteroids cause inhibition
of fibroblast proliferation and maturation, leading
tendon repair process and collagen synthesis to
decrease. In addition, degenerative changes occur in the
Achilles' tendon following the third decade of life, and
the suppressing effect of corticosteroids on healing in a
degenerative tendon may lead to tendon rupture as a result
of only minor trauma.[
Diagnosis of Achilles' tendon rupture is usually clinical,
relying upon the presence of a palpable gap in the
tendon and bulging in the muscle. MRI and ultrasonography
are used to aid in confirmation of diagnosis.
Open surgery, percutaneous surgery or conservative
methods may be used in the treatment of Achilles' tendon rupture. Conservative treatment typically includes
immobilization of the ankle joint in the equinus position,
a semi-equinus position, and a neutral position.
Immobilization is provided by cast or cast-boot, though
duration of knee cast use has yet to be clarified.[
In conclusion, chemotherapy agents can cause many
complications. Diagnosis of Achilles rupture may be
challenging during chemotherapy protocol. Spontaneous
rupture of the Achilles' tendon induced by corticosteroid
use is a rare complication. However, it should be
considered in cases of patients who are taking chemotherapy
agents including steroids.
Disclosure Statement
The authors declare no conflicts of interest.
