Achilles Tendon Rupture – Young Adult Female Volleyball Player

CASE HISTORY: A 25-year-old professional volleyball player, who was playing in a game in Iceland, was transitioning off the net back-pedaling and pivoting as she felt something pop in her right calf. Initially, the athlete denied having any pain but was unable to plantarflex her foot or weight bear. At the time of injury, she was taking Sertraline (HCL 50 mg), Trazodone (50 mg), Wellbutrin XL (Bupropion HCL) 150 mg, Adderall (5mg) and birth control. PHYSICAL EXAM: The athlete was evaluated at an emergency room, where a Thompson squeeze test was performed and determined positive for an acute Achilles tendon rupture. The athlete was placed in a soft cast and was scheduled to be treated nonoperatively. DIFFERENTIAL DIAGNOSES: Acute Achilles tendon peritendinitis, medial gastrocnemius tear, calf muscle strain or rupture, posterior tibialis stress syndrome, posterior tibialis tendon injury, and peroneal injury. TESTS & RESULTS: Approximately one week after her initial diagnosis, she made arrangements to return to the US and to be re-evaluated by an Orthopedic surgeon. During the evaluation, the athlete reported pain over the Achilles tendon. Objectively, another positive Thompson squeeze test was performed. There was swelling over the Achilles tendon and a definite defect on the distal ⅓ of the tendon. There was no pain over the insertion point at the calcaneus or calf pain. An Ultrasound Duplex Doppler scan was performed to confirm the initial diagnosis and assess for deep vein thrombosis (DVT). Gray scale, color and imaging of the deep venous system of the right leg was performed from the level of the common femoral vein down to the level of the popliteal vein. There was no echogenic clot seen within the venous lumen. The veins tested exhibited normal compression and augmentation properties with color flow demonstrated within the tested veins. There was no evidence of DVT in the right leg. Evaluation before surgery showed obvious edema over her Achilles and a definite defect on the distal third of her Achilles. Non-operative and operative options were discussed. Surgery was elected due to nature of her sport. The athlete was made aware of the complications of surgery for this injury and the procedure was scheduled for the next day. FINAL DIAGNOSIS: Right Achilles tendon rupture. DISCUSSION: The most common mechanism of this injury is a forceful contraction of the calf and when the foot is placed into overpronation. The nature of the athlete\u27s sport made her more susceptible to this type of injury. However, it is relatively unusual for an athlete of her age/sex without previous medical history. Causes of Achilles rupture include tendinopathy, which is associated with overactivity of the sympathetic nervous system (SNS). The combination of those medications could lead to serotonin syndrome, which indicates an overactive SNS. It is possible that the duration and the interaction between this medley of medications may have increased her susceptibility to injury. OUTCOME OF THE CASE: Open repair of right Achilles tendon rupture. RETURN TO ACTIVITY AND FURTHER FOLLOW-UP: Based on physical therapy notes, there was swelling but the incision was well healed with little tenderness. Slowly, she regained ROM and her strength. The right Achilles was noted to be thicker than the contralateral side. She voluntarily discontinued all medications shortly after the surgery. After several months of extensive rehabilitation and strengthening, she was able to return to the same level of performance

Type IV, Salter Harris Fracture - Adolescent Male Soccer Player

CASE HISTORY: An amateur, 14-year-old soccer player celebrated his goal by attempting a backflip. He ended up landing abnormally on his left foot. He complained about pain and swelling in the lateral aspect of the left ankle. PHYSICAL EXAM: The athlete was admitted to Children’s Hospital. The diagnosis based on the first X-Ray was Type II, Salter Harris fracture. The patient was treated conservatively. A short, leg cast was placed and per os analgesics were given. He was hospitalized for two days. Before getting discharged, a second X-Ray showed a well-aligned fracture. Two days later, the patient was still in pain. He decided to visit a private orthopedic doctor who made the plaster rounded and placed the foot in tip-toe gait. Two days after that, the athlete decided to visit a different private doctor since the pain was not subsiding. That doctor suspected that the fracture may continue into the posterior malleolus with the fracture line going through the growth plate inside the joint of the ankle. Therefore, he ordered a MRI and spiral CT for the left ankle. DIFFERENTIAL DIAGNOSES: Salter Harris II, Salter Harris III, Salter Harris IV, Salter Harris V, or additional fractures. TESTS & RESULTS: A) Radiological evaluation: a) Posterior and anterior view: Fracture passes through most of the growth plate and up through the metaphysis. Orthopedic Classification: Salter Harris Type II and b) Lateral view: Fracture passes along the growth plate and down through the epiphysis. Orthopedic Classification: Salter Harris Type III. B) CT SCAN: The fracture line goes through the metaphysis, growth plate and down through the epiphysis. Orthopedic Classification: Salter Harris Type IV. FINAL DIAGNOSIS: Fracture across the metaphysis, physis and epiphysis: Salter Harris Type IV. DISCUSSION: Type IV Salter Harris fracture involves all three elements of the bone and is an intra-articular fracture. Chronic disability is a potential outcome as these fractures can cause premature focal fusion. Therefore, these injuries can result in growth retardation, altered joint mechanics, and functional impairment. Urgent orthopedic evaluation and surgical restoration are crucial, especially in children and adolescents. OUTCOME OF THE CASE: Due to delayed treatment, doctors had the following surgical options: 1. Close reduction and osteosynthesis with k-wires; 2. Open reduction and internal fixation with cannulated screws; and 3. Ankle joint arthroscopy in case of non-satisfactory alignment of the fracture. The final treatment decision included closed reduction with one k-wire and circular cast. RETURN TO ACTIVITY AND FURTHER FOLLOW-UP: Post operation X-Rays showed success. A month later and after additional X-Rays, the circular cast and the k-wire were removed. The athlete gradually proceeded to muscle-strengthening exercises and reached full active ROM