This is a case of severe unilateral lower leg oedema in a 77-year-old man, due to a spontaneous, complete Achilles tendon rupture. What makes this case unusual is the absence of trauma in the patient’s history. The correct diagnosis was made only after magnetic resonance imaging. However, a thorough clinical re-examination of the patient revealed an inability to stand and walk on toes and a palpable defect of the Achilles tendon, which was difﬁcult to detect due to the marked oedema. This case reminds physicians that an Achilles tendon rupture can also occur without clear history of trauma and should be considered as a cause of unilateral lower leg oedema, especially in presence of pain. Moreover, it illustrates the crucial role of a thorough clinical examination (including standing and walking on toes) for the correct diagnosis, even when restricting factors such as oedema and pain are present. had begun ~6 weeks ago, without any obvious trigger and had INTRODUCTION been gradually expanding from the toes towards the knee. Unilateral leg oedema is a common presenting symptom in the During the same time the patient had noticed pain at the calf emergency room and in medical outpatient settings. Differential when walking; he reported a feeling ‘as though he was walking diagnoses include conditions causing venous or lymphatic stasis, on a metal bar’. He did not feel pain at rest; moreover he but musculoskeletal pathology is also a possible aetiology. reported no weakness of the leg and no sensory abnormalities. In the case reported here, a patient presenting with unilat- The patient had normal body weight (BMI 24); his medical eral leg oedema without any history of trauma was diagnosed history was remarkable for type 2 diabetes, treated with met- with complete Achilles tendon rupture. To our knowledge, no formin, vildagliptin and gliclazid, as well as coronary artery dis- similar cases have been published so far. ease treated with aspirin, metoprolol and simvastatin. He had no history of arthritis and denied travelling or immobilization CASE REPORT before the onset of the symptoms. Moreover, he denied any A 77-year-old patient presented in our Medical Outpatient trauma and this was conﬁrmed by his wife. He mentioned that he had been working everyday in his garden by the time the Clinic due to a persistent swelling of his left leg. The swelling Received: January 18, 2018. Revised: March 29, 2018. Accepted: April 9, 2018 © The Author(s) 2018. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact firstname.lastname@example.org Downloaded from https://academic.oup.com/omcr/article-abstract/2018/6/omy022/5026601 by Ed 'DeepDyve' Gillespie user on 21 June 2018 Leg oedema due to tendon rupture 169 swelling and pain occurred. However, these daily gardening haematoma was seen (Fig. 3), with diffuse accompanying mus- activities were not unusual for him. Due to the pain while cle oedema in the posterior leg compartment. walking, he was unable to go on with his gardening at the time A clinical re-examination of the patient revealed an inability of presentation at our clinic. to stand or walk on his left toes, as well as a positive The clinical examination revealed a severe, pitting oedema of Thompson test on the left. Moreover, we could palpate an the left foot and lower leg (up to the level of the knee; Fig. 1)with actual defect of the tendon, which was previously not noted, diffuse tenderness. There was no redness of the skin, but the left probably due to the marked oedema. lower leg was slightly warmer than the right. The Homans sign Surgical therapy was chosen, mainly due to the severe impact was negative. The dorsalis pedis artery pulses were bilaterally of the symptoms on everyday life. The repair of the Achilles tendon palpable; the posterior tibial artery pulse was not deﬁnitely palp- rupture was augmented with a ‘turn down ﬂap technique’ using able on the left, possibly due to the marked oedema. There were no signsofinguinallymphadenopathy. Passive movements of the left foot, especially the dorsal extension, were painful. The muscle strength examination in lying position showed no weakness. The sensory functions were intact besides a mild reductioninvibra- tion sense on both lower extremities, which was attributed, together with bilaterally absent ankle jerk reﬂexes, to a mild per- ipheral neuropathy, probably diabetic. The patient’s walking ability was observed in the examin- ation room, a limping on the left was attributed to the reported pain in the left leg, while walking. During this ﬁrst clinical examination a comprehensive assessment of standing and walking was not performed. D-dimer-testing was just above the age-adjusted cut-off value  (820 μg/l with age-adjusted normal values: <770 μg/l). Based on the high probability of DVT in our patient according to the clinical model proposed by Wells et al.  (score ≥ 2 due to unilateral pitting oedema, difference in calf circumference ≥ 3 cm, no likely alternative diagnosis), we performed a venous duplex ultrasonography which showed no signs of DVT. However, it revealed diffuse subcutaneous ﬂuid entrapment as well as a small ruptured Baker’s cyst, which was not considered a likely cause of the marked oedema. To further investigate the soft tissues of the leg, we ﬁnally performed a magnetic reson- ance imaging (MRI), which showed a complete acute to sub- Figure 2: TIRM (Turbo Inversion Recovery Magnitude) MRI sequence of the left acute rupture of the left Achilles tendon (Fig. 2). Moreover, a foot and distal leg (sagittal plane). Note the ~30 mm defect of the Achilles ten- partial rupture of the soleus muscle with intramuscular don (arrow), representing a total Achilles tendon rupture. Figure 3: T2 fat suppressed MR images (axial plane) of the left lower leg. Note Figure 1: Severe pitting oedema of the left leg at initial presentation. The arrow the haematoma (H) between the medial head of M. gastrocnemius (GM) and M. indicates a thumbprint. soleus (SM). Downloaded from https://academic.oup.com/omcr/article-abstract/2018/6/omy022/5026601 by Ed 'DeepDyve' Gillespie user on 21 June 2018 170 A. Papadopoulou et al. tendon ruptures is high (between 80 and 100%) . In our particu- lar case, the ultrasound may have been negative, due to the low clinical suspicion of a tendon problem at the time (the indication for the ultrasound was only to rule out a DVT). To conclude, rupture of the Achilles tendon is a (rare) cause of leg oedema, even without clear history of trauma. The exam- ination of standing and walking on the toes should be per- formed in patients with unilateral painful lower leg oedema. In suspicion of Achilles tendon rupture, ultrasound and—in our case—MRI can conﬁrm the diagnosis. CONFLICT OF INTEREST STATEMENT The authors report no conﬂicts of interest. FUNDING The authors report no targeted funding for this work. Figure 4: Complete regression of the oedema, 8 months after surgery. ETHICAL APPROVAL the plantaris-longus-tendon. The patient showed an excellent The authors declare that no formal ethical approval was recovery. The follow-up examination 8 months after the operation needed for this work. showed a complete regression of the leg oedema (Fig. 4). Moreover, the patient had no pain and could walk again on his toes. CONSENT The case report contains no direct patient identiﬁers and no DISCUSSION relevant indirect identiﬁers (as speciﬁed in the journal policy). In unilateral leg oedema differential diagnostic thinking is The patient was however explicitly and adequately informed related to the chronological development [3, 4]. An acute by the corresponding author regarding the potential publication appearance (<72 h) has to be differentiated from a chronic of this case and the photographs submitted here and has given oedematous swelling. Deep vein thrombosis, ruptured Baker’s his consent. cyst, muscular rupture and compartment syndrome are the most frequent causes for an acute unilateral leg swelling. They GUARANTOR can all present with pain. Common causes for a chronic unilateral swelling are: The ﬁrst author guarantees for the accuracy of the data and the chronic venous insufﬁciency, secondary lymphoedema, pelvic article. tumour or lymphoma causing pressure on the veins and com- plex regional pain syndrome (CRPS) . Of these only the latter REFERENCES is typically associated with pain. In our case, the oedema was already 6-week old at the time 1. Schouten HJ, Geersing GJ, Koek HL, Zuithoff NP, Janssen KJ, of the presentation. However, the patient could particularly Douma RA, et al. Diagnostic accuracy of conventional or age recall the time-period when the swelling ﬁrst occurred, so that adjusted D-dimer cut-off values in older patients with sus- an acute onset with persisting symptoms and delayed seeking pected venous thromboembolism: systematic review and of medical care was possible. meta-analysis. Br Med J 2013;346:f2492. The acute rupture of the Achilles tendon typically presents 2. Wells PS, Hirsh J, Anderson DR, Lensing AW, Foster G, with severe pain in the lower calf. Usually the cause is an Kearon C, et al. Accuracy of clinical assessment of deep-vein injury, as in running and sports like soccer . thrombosis. Lancet 1995;345:1326–30. However, there are cases of ‘atraumatic’ ruptures, with vari- 3. Ely JW, Osheroff JA, Chambliss ML, Ebell MH. Approach to leg ous risk factors being discussed, such as obesity and corticos- edema of unclear etiology. J Am Board Fam Med 2006;19: teroids . Neither these, nor other possible risk factors such as 148–60. use of ﬂuoroquinolone antibiotics were present in our patient. 4. Trayes K, Studdiford JS, Pickle S, Tully AS. Edema: diagnosis Diabetes was also considered a risk factor, but a recent system- and management. Am Fam Physician 2013;88:102–10. atic review found no such association . Since in our case, the 5. Holm C, Kjaer M, Eliasson P. Achilles tendon rupture—treat- Achilles tendon rupture was accompanied by a rupture and ment and complications: a systematic review. Scand J Med Sci haematoma of the soleus muscle, the underlying cause must Sports 2015;25:e1–10. have been an injury, which remained unnoticed by the patient. 6. Claessen FM, de Vos RJ, Reijman M, Meuffels DE. Predictors The frequent crouching and kneeling during his gardening of primary Achilles tendon ruptures. Sports Med 2014;44: activities could represent a form of consistent low-grade stress 1241–59. on the tendon, which could have contributed to the rupture. 7. Dams OC, Reininga IHF, Gielen JL, van den Akker-Scheek I, The diagnosis in our case was made by a 3T MRI, while a pre- Zwerver J. Imaging modalities in the diagnosis and monitor- vious ultrasound did not report any tendon abnormalities. In gen- ing of Achilles tendon ruptures: a systematic review. Injury eral, the sensitivity of ultrasound for the detection of Achilles 2017;48:2383–99. Downloaded from https://academic.oup.com/omcr/article-abstract/2018/6/omy022/5026601 by Ed 'DeepDyve' Gillespie user on 21 June 2018
Oxford Medical Case Reports – Oxford University Press
Published: Jun 1, 2018
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