Complete Achilles tendon rupture after local infiltration of corticosteroids in the treatment of deep retrocalcaneal bursitis

Abstract

Complete rupture of the Achilles tendon is relatively rare, but it is an injury of considerable clinical relevance. A common cause of non-traumatic tendon rupture is local corticosteroid infiltration. Corticosteroid injections may start a degenerative process resulting in partial rupture and subsequent complete rupture of the tendon due to a direct toxic effect, because corticosteroids inhibit production of extracellular matrix collagen and also because of poor local vascularization. This paper describes the case of a patient who presented with complete rupture of the Achilles tendon shortly after administration of local corticosteroid injections in the treatment of deep retrocalcaneal bursitis. This confirms that corticosteroid treatment which is not correctly and accurately administered may be a factor contributing to major injury. It demonstrates that the physician must take all necessary precautions when administering corticosteroid infiltration. It is particularly important that corticosteroid injection is performed under ultrasound guidance which permits visualization of the needle tip and therefore exact identification of the injection site. Keywords Achilles tendon Á Ultrasound Á Corticosteroid injectionsRiassunto Le rotture complete del tendine d'Achille sono piuttosto rare, ma hanno una notevole rilevanza clinica. Tra le cause atraumatiche di rottura sono abbastanza frequenti quelle che riconoscono come concausa i trattamenti infiltrativi locali di corticosteroidi. Questi, sia con un'azione tossica diretta, sia con l'inibizione sulla produzione della matrice extracellulare del collagene, sia con una riduzione della vascolarizzazione locale, determinano un processo degenerativo che progredendo determina dapprima una lesione parziale e poi una rottura completa del tendine. Il caso riportato si riferisce ad una paziente che, per il trattamento di una borsite retrocalcaneale profonda, veniva trattata con terapia infiltrativa locale con cortisone e, a breve distanza di tempo, presentava una rottura completa del tendine d'Achille; è esplicativo come un trattamento terapeutico con corticosteroidi, eseguito in maniera non del tutto corretta, possa essere concausa di lesioni importanti. E' indicativo del fatto che sia necessario rispettare tutte le precauzioni quando si procede a terapia infiltrativa locale di corticosteroidi, in particolare come sia importante iniettare sotto guida ecografica perché ciò consente di valutare in tempo reale la posizione della punta dell'ago e quindi di conoscere esattamente la sede di iniezione.

Effect of High-Volume Injection, Platelet-Rich Plasma, and Sham Treatment in Chronic Midportion Achilles Tendinopathy: A Randomized Double-Blinded Prospective Study

“…In some individuals, returning to sport after receiving steroid-containing injections without adequate rehabilitation of the muscle-tendon unit may increase the risk of further injury, such as a tendon rupture, 45 and the incidence of setbacks as seen in a few of the patients in the HVI group between 12- and 24-week follow-up. Anecdotal reports have linked steroid injection and tendon rupture, 57 but so far no rupture complications have been reported in the HVI literature. The more likely outcome of sudden return to sport may simply be symptom provocation once the steroid effect has subsided, 16 and this may partly explain late-term symptom recurrences observed after steroid injection.…”

Effectiveness of a high volume injection as treatment for chronic Achilles tendinopathy: randomised controlled trial

“…The hypothesis is that the saline solution in the injection mechanically damages the neovascularisation and its adjacent nerves 14. Corticosteroids are discouraged as treatment for tendinopathies owing to detrimental long term effects and the risk of ruptures to the Achilles tendon 373839. Therefore, we decided not to include corticosteroids in the injection mixture.…”

“… 14 Corticosteroids are discouraged as treatment for tendinopathies owing to detrimental long term effects and the risk of ruptures to the Achilles tendon. 37 38 39 Therefore, we decided not to include corticosteroids in the injection mixture. This could explain the difference in outcomes between our study and previous studies.…”

The Achilles tendon and the retrocalcaneal bursa

“… 11 , 13 However, there are reports in the literature of an increased risk of tendon rupture. 6 , 7 , 14 , 15 In the study by Turmo-Garuz et al, 8 the authors found some evidence of a clinically relevant link between the RB and the AT. However, the main limitation of their study was small sample size and a reliance on macroscopic anatomical findings might not be sufficient to determine the precise mechanism of fluid spreading from the RB to the adjacent AT.…”

“…The area where the ink was visible was measured using an electronic caliper (Mitutoyo Corp., Kawasaki, Japan) with the superior border of the calcaneum used as a reference point. 6 …”