Journal of Science and Medicine in Sport (2008) 11, 566—568

CASE REPORT

Achilles tendon rupture in an elite athletefollowing multiple injection therapies

Bruce Hamiltona,∗, Denis Remediosd,Mike Loosemoreb, Nicola Maffulli c

a UK Athletics, High Performance Centre, United Kingdomb London English Institute of Sport, Olympic Medical Institute, United Kingdomc Department of Trauma and Orthopaedic Surgery, Keele University School of Medicine, United Kingdomd Department of Radiology, Northwick Park Hospital, Harrow, United Kingdom

Received 17 January 2007; received in revised form 14 March 2007; accepted 21 March 2007

KEYWORDSAchilles tendon;Rupture

Summary Achilles tendinopathy is common, and its management continues to bechallenging, especially in elite athletes. Despite a wide range of novel managementoptions, none guarantees a rapid return to high level sporting activity. Eccentricexercise has been shown to reduce symptoms and normalise imaging abnormalities,but time constraints on professional athletes often make this an unrewarding iso-lated management strategy. Eccentric exercises concurrent with ongoing trainingmay not be as successful as eccentric training alone, reducing one’s confidence inthis modality for the ‘‘in-season’’ tendinopathy in the elite athlete. When a pro-fessional athlete is faced with a tendinopathy recalcitrant to eccentric exercise,manual therapy and orthotics, a more invasive approach is often attempted to expe-dite a return to unencumbered training. Numerous injection therapies are described,ranging from homeopathic products to glucocorticosteroids. The robustness of theliterature surrounding these techniques is variable, but when an athlete is desperateto return to full training, clinicians working with elite athletes are often temptedto utilise more empirical management options. We present a patient who illustratesthe potential dangers of injection therapy in the elite athlete, in particular sequen-tial injection therapy involving vascular sclerosants, which to our knowledge has

not previously been described. Written consent for the presentation of this case wasobtained from the athlete concerned.

Aus

© 2007 Sports Medicine

∗ Corresponding author.E-mail address: Bruce.Hamilton@eis2win.co.uk

(B. Hamilton).

AsooA

1440-2440/$ — see front matter © 2007 Sports Medicine Australia. Publishedoi:10.1016/j.jsams.2007.03.008

tralia. Published by Elsevier Ltd. All rights reserved.

33-year-old male world-class pole vaulter pre-

ented with a 6-week history of pain and tendernessver the body of the right Achilles tendon. Previ-usly, he had a 4-year history of intermittent rightchilles tendinopathy which had been managed

d by Elsevier Ltd. All rights reserved.

A

wacatG(comrtscTta

iatai

tmttawoiTtewcpd

attbpodmfp

oAAub

finj

fiucttts

ttcu(tweiOst

taoddpmosBTowwfl

ebdfturabt

chilles tendon rupture and injection therapies

ith deep tissue therapy, eccentric strengtheningnd injection therapy. In 2002, following a failure ofonservative management and a season of trainingnd competing with pain, he had a course of threeo four injections of combined Traumeel® (HeelmbH, Baden-Baden, Germany) and Actevegin®

Nycomed Austria GmbH, Innsbruck, Austria) withomplete resolution of his symptoms. Recurrencesf his symptoms in 2003 and 2004 were bothanaged with a combination of manual therapy,

est and eccentric exercises, and resolved spon-aneously. In 2005, a low-grade right-sided soleustrain was managed with rest, strengthening exer-ises and Traumeel® injections, and fully resolved.here was no family history of tendinopathy or rup-ure. The athlete had never used fluoroquinolonentibiotics.

The current symptoms began following anncrease in training intensity, initially presenting aslateral calf tightness and mild Achilles tendinopa-

hy. At the time of first presentation to the mainuthor (BH), the athlete had already had numerousnterventions.

Over the first 2 weeks of symptoms, deepissue work and local joint mobilisation from aanual therapist had failed to improve his symp-

oms, although the athlete was able to continueraining. Approximately 2 weeks after the initi-tion of symptoms, his right Achilles paratenonas infiltrated (unguided) with a combinationf Traumeel® and local anaesthetic, and train-ng (including eccentric strengthening) continued.here was no change in his symptoms and injectionherapy was repeated 5 days later, again with littleffect. Five days later, with ongoing Achilles painhile training, the athlete was given an unguidedorticosteroid/local anaesthetic injection into thearatenon, and instructed to rest completely for 5ays.

Following the corticosteroid injection there wascomplete resolution of both calf and Achilles

endon symptoms, and a rapid return to fullraining was initiated. For two further weeksoth full training and one competition were com-leted with no symptoms, but gradually symptomsver the lateral aspect of the Achilles ten-on returned until the athlete presented to theain author (BH) after being forced to withdraw

rom an international competition with Achillesain.

Examination revealed tenderness and swelling

ver the lateral aspect of the mid portion of thechilles tendon, and a diagnosis of acute on chronicchilles tendinopathy was made. High-frequencyltrasound with colour flow doppler, performedy a qualified musculoskeletal radiologist con-

nrrto

567

rmed the presence of Achilles tendinopathy witheovascularity close to the musculo-tendinousunction.

With the mid point of the competitive track andeld season rapidly approaching, the athlete wasnder pressure to train and compete, and the physi-ians involved were being challenged to providereatments to meet these goals. Failure to meethese goals would probably mean a premature (inhe eyes of the athlete) forced retirement from theport.

As a result, and following a complete descrip-ion of the risks involved, in particular highlightinghe increased risk of injection therapy following aorticosteroid injection, a further course of twonguided injections, 5 days apart, of Traumeel®

2 ml), Zeel® (1 ml) and local anaesthetic (1 ml) intohe paratenon was performed. This was combinedith cessation of all training including eccentricxercises, use of a night splint, VISA-A score mon-toring and a continuation of soft tissue therapy.n return to training approximately 7 days later,ymptoms had improved, but continued to impederaining.

Eight days following the second injection, a fur-her doppler ultrasound was performed confirmingn area of neovascularisation on the deep surfacef the Achilles tendon, corresponding with the ten-er area identified by the athlete. Following a fulliscussion and obtaining consent it was decided toerform an image guided vascular sclerosant treat-ent. Eight blood vessels outside the substance

f the tendon were identified and injected underterile conditions with a 50% glucose solution andupivacaine 0.5% (Pharmaceuticals Ltd., England).he procedure took approximately 1 h, and a totalf 3 ml of 50% glucose were injected. The athleteas pain free at the end of the procedure, and thereas complete and immediate resolution of dopplerow.

Over the following 2 days, the athlete experi-nced a transient increase in Achilles pain, buty day 4 was feeling significantly improved. Onay 5, the athlete felt so well that he was per-orming pain free runways and ‘‘pop-ups’’ ontohe pole vault mat. On the fourth of these ‘‘pop-ps’’, the athlete described a sudden pain in theight Achilles. Subsequent examination confirmedmidsubstance tear of the Achilles tendon, at the

order between the proximal third and the distalwo-thirds of the tendon. He underwent percuta-

eous repair the following day. His post-operativeehabilitation was along described lines, and hisehabilitation proceeded uneventfully. He returnedo training, including vaulting, 6 months after theperation.

WSbdditpt

rmababMbte

tpmpia

R

568

Discussion

In this patient, many factors may have contributedto the rupture of the Achilles tendon, and thereare several issues pertinent to physicians caring forelite athletes. Increasingly, in the era of profes-sional sports, athletes are choosing to prolong theircompetitive careers. Subsequently, physicians arenow faced with the management of tendinopathiesin athletes who in previous generations may haveretired. It is recognised that collagen turnoverslows with age,1 and spontaneous rupture may haveoccurred even without any therapeutic interven-tion.

It is possible that either a single injection (mis-placed or accurately infiltrated), the sequence ofinjections or a specific combination of injectiontherapies contributed to the tendon rupture. Thecorticosteroid injection was probably a significantcontributor, but we may be biased by the fact thatrupture is a frequently recognised negative out-come of peri-tendinous corticosteroid injections.2

A theoretical risk of sclerosing therapy is wellrecognised as a result of devascularising tissue,3

but to date reported outcomes have been uni-formly good.3—5 Alfredson and colleagues did notexclude those patients with previous corticosteroidinjections,3—5 however they used the local anaes-thetic polidocanol rather that the 50% glucosesolution used in this case. Polidocanol is neitherlicensed for use nor readily available in the UnitedKingdom, but we have found similar sclerosing ben-efits from using hypertonic glucose solution andit was chosen for this reason. Hypertonic glu-cose has been used successfully for prolotherapyin tendons,6 but its use in this manner is notdescribed. It is possible that the use of concen-trated glucose has had a significant impact, butthis has not been our past experience. Rupturerate following the use of homeopathic productssuch as Traumeel® is unreported, and evidence fortheir use is largely empirical and case based. Inour experience, they have little role in establishedtendinopathy, but are sought after by athletes

because of their ‘‘homeopathic’’ origins and pre-sumed (by athletes) low side-effect profile.

Except for the final injection, all injectionswere performed in the absence of image guidance.

Available online at www.s

B. Hamilton et al.

hile all injections were performed by experiencedports Physicians, there is still a risk of them havingeen misplaced. The absence of any significant ten-on pathology prior to the image-guided injectionsoes however suggest that a prior intratendinousnjection with resultant intratendinous degenera-ion is unlikely. While it would be our preference toerform all injections under ultrasound guidance,his is not always logistically possible.

Several peri-tendinous interventions are cur-ently used in the United Kingdom for theanagement of tendinopathy, including prolother-

py, vascular sclerosis, homeopathic preparations,risement (i.e. paratenon dilation with normosalinend/or corticosteroid), corticosteroid, aprotinin,lood and blood derivatives, and dry needling.any of these interventions have little clinical orasic science support for their use and interac-ion between these injections as well as cumulativeffects cannot be excluded in our patient.

We recognise the difficulties in managingendinopathies and understand the desire of bothhysicians and patients to try innovative treat-ents. Elite athletes more that any other grouplace the physician in a position of having to bennovative. In many instances, this carries with itn unquantifiable risk.

eferences

1. Tuite D, Renstrom P, O’Brien M. The aging tendon. Scand JMed Sci Sports 1997;7:72—7.

2. Nichols A. Complications associated with the use of corticos-teroids in the treatment of athletic injuries. Clin J Sport Med2005;15(5):370—5.

3. Ohberg L, Alfredson H. Sclerosing therapy in chronic Achillestendon insertional pain—–results of a pilot study. Knee SurgSports Traumatol Arthrosc 2003;11:339—43.

4. Ohberg L, Alfredson H. Ultrasound guided sclerosis of neoves-sels in painful chronic Achilles tendinosis: pilot study of anew treatment. Br J Sports Med 2002;36(3):173—5, discus-sion 176—7.

5. Alfredson H, Ohberg L. Sclerosing injections to areas of neo-vascularisation reduce pain in chronic Achilles tendinopathy:a double-blind randomised controlled trial. Knee Surg Sports

Traumatol Arthrosc 2005;13(4):338—44.

6. Kim S, Stitik T, Foye P, Greenwald B, Campagnolo D. Criticalreview of prolotherapy for osteoarthritis, low back pain, andother musculoskeletal conditions: a physiatric perspective.Am J Phys Med Rehabil 2004;83(5):379—89.

ciencedirect.com