Biceps, Achilles and Quadriceps Tendon Rupture Review

Here’s Dr. Alsup with today’s Morning Report!

Tendon Rupture

Background:

-Galen described in 130-201 CE. In which he described a young man injured during a wrestling match

-Young people: trauma/sports

-40-60 yo: chronic inflammation

Sx: pain, swelling, loss of assoc muscle function.

– frequently is an immediate ‘pop’ or tearing sensation.

Risk factors

PMH

-SLE, Ankylosing spondylitis, RA

-DM

-CRF

-Hyperparthyroidism

-Gout/ chronic synovitis

-Leukemia/ solid tumors

-Infection

-Obesity

-Repetitive motion (jumper’s knee)

-Iatrogenic (post-op after tendon repair/ joint work, steroid injections)

Meds

-Fluroquinolones (alter cytoarchitechure of tendons)- at least 3x relative risk, 5 to 20 per 100,000 patients

-Steroids: (po or in cases of patella rupture- injection for patella tendonitis)

-Statins ?

Workup: Ultrasound! –> MRI. Sometimes Xrays.

ULTRASOUND

Hypoechogenicity is associated with acute tears, while thickening of the tendon at the rupture site and disruption of the normal echo pattern is observed with chronic tears.

MRI

“If the diagnosis cannot be established based on clinical and radiographic examination, an MRI is the imaging study of choice.”

Biceps tendon rupture

Rupture of the proximal biceps tendon comprises 90-97% of all biceps ruptures and almost exclusively involves the long head.

Generally chronic inflammation with acute truama

-Catching/lifting a heavy object

-weightlifting, sporting activities (eg, snowboarding, football).

-Swelling of muscle as it retracts (popeye deformity)

-pain and weakness to flexion of the elbow

Complications of compartment syndrome- v. rare

Tx:

Conservative management includes rest, nonsteroidal anti-inflammatory drugs, and ice packs in the acute phase, and range-of-motion and strengthening exercises subsequently.

Lose 8–16% of their flexion strength
Lose 11–21% of supination strength
Generally does not significantly affect adl’s

Surgical treatment (anatomic reattachment) is generally recommended for young or athletic patients requiring full supination strength or for patients with cosmetic concerns

Achilles

Incidence 7 and 13/100,000 per year
Recent increases in recreational sport and exercise participation
Highest incidence in the 30–39-year age group
1 and 16.7 times more common in males
Up to 75% of acute injuries can be attributed to sports activity

HPI

-Sudden snap/pop

-“I was shot/kicked/hit”

-unable to plantar flex affected foot, unable to stand on toes

-Thompson test (sens/spec (0.96 and 0.88, respectively))

Treatment:

surgical reattachment vs plantar splint for 4+ weeks

-meta-analysis of 5 studies comprising 421 patients in 2002 (Bhandari et al., 2002) reported no significant difference in surgical patients returning to normal function (71%) compared to those managed non-operatively (63%).

Quadriceps & Patellar tendon rupture:

The quadriceps is a short tendon is formed by the convergence of all 4 muscles just proximal to the superior patella.

-Quads: distal 0-2 cm from the superior pole of the patella, through pathologic tissue.

-Patellar- Mostly assoc with sports but also s/p ACL autograft surgery

HPI

-Typical mechanism is a sudden eccentric contraction of the quadriceps, usually with the foot planted and the knee flexed

(extensor mechanism has been reported to be as high as 17.5 times body weight)

-Position of patella

-quads-low riding

-patella- high riding

-Unable to extend at knee with otherwise stable joint

“Testing for full, active extension against gravity is the most important aspect of the examination.”

Dx:

Plain radiographs (anteroposterior [AP], lateral, axial)

-can have other direct injuries, evaluate patella

Contralateral films- if equivocal- can compare patellar height

Tx:

1887, McBurney reported on the first surgical repair in the United States. The injury was a direct blow to the knee, and the tendon was repaired using catgut and silver wire.

– Inability to walk needs to be fixed. –> to OR non-emergently

References

Patella tendon rupture emedicine (accessed 9/1/14) http://emedicine.medscape.com/article/1249472
Quadracepts tendon rupture http://emedicine.medscape.com/article/1249621
Biceps tendon rupture http://emedicine.medscape.com/article/327119
Rajpal S et al. Acute Achilles tendon rupture .Trauma p67-81 14(1)2011