Surgical Science, 2011, 2, 224-227
doi:10.4236/ss.2011.25050 Published Online July 2011 (http://www.SciRP.org/journal/ss)
Conservative Management of Bilateral Tendoachilles (TA)
Rupture—A Case Report
Rahul Kakkar, Simon Chambers, Malcolm M. Scott
North Tyneside General Hospital, Rake lane, North Shields, NE29 8NH
Received March 11, 20 1 1; revised April 27, 2011; accepted May 5, 2011
Abstract
Tendo Achilles ruptures are generally traumatic in origin and while bilateral tendo Achilles ruptures are a
rare occurrence, most of them are associated with risk factors or pre-existing disease and generally involve
trauma or sporting activities. Most of the cases of bilateral rupture are generally treated operatively. A spon-
taneous onset case of bilateral tendo achilles rupture is reported in a healthy man and its conservative (non
operative) management discussed with a review of the literature.
Keywords: Bilateral Tendoachilles Rupture, Non-Traumatic, Spontaneous, Conservative Treatment, Cast
Management
1. Introduction
The Achilles tendon is the thickest and strongest tendon
in the body [1,2] and although forces up to 12 times body
weight can be tolerated by it, it still accounts for 20% of
all large tendon ruptures [2]. Trauma and sporting activ i-
ties have been implicated as the most common cause of
tendoachilles rupture [3,4] with the injury mechanism
involving sudden and powerful contraction of the gas-
trocnemius and soleus muscles on a dorsiflexed foot and
usually affecting men aged 30 - 50 years [5].
But, spontaneou s bilateral Achilles tendon ruptures are
a rare occurrence [1,6-12] and account for about 1% of
all Achilles tendon ruptures [9,1 1]. Risk factors for these
type of injuries include corticosteroid use [12], limb
ischemia [13], anabolic steroids [14], fluoroquinolones
[15], chronic pain, previous Achilles tend on rupture [16]
and rheumatoid arthritis, SLE [17] .To our knowledge,
only a few reports on spontaneous bilateral Achilles ten-
don tears have been published, most with associated risk
factors but with satisfactory outcomes and there is only
one other case report of a bilateral rupture of the tendo
Achilles without any associated risk factors [18]. We
present a case of spon taneous bilateral tendoachilles rup-
ture in an otherwise healthy 49 year old man which was
successfully treated conservatively with two different
management protocols.
2. Case Report
A 49 year-old man attended fracture clinic with a right
TA rupture which was confirmed clinically. He had been
on holiday and was walking near a waterfall wh en h e felt
pain in his right tendo Achilles area and was unable to
walk after that. H e had no obvious risk factors for tendon
rupture; he was a non-smoker, with no recent or past
history of steroid or fluoroquinolone use. He had no me-
tabolic derangements, and blood tests (FBC, U+E, LFT,
TFT,cholesterol, rheumatoid factor and urate) were all
within normal limits. Following a discussion about the
relative merits and risks of operative versus non-opera-
tive treatment, he opted for non-operative treatment. He
had an above knee equinus cast applied with knee flexed
about 20 degrees and was asked to be non weight bear ing
on the right leg.
Unfortunately he re-attended casualty 10 days into his
course of non-operative treatment complaining of left TA
rupture. He was going upstairs using his crutches, when
he felt his left TA rupture, which he described as a ‘tear-
ing’ sensation. On examination he had bruising; swelling
and tenderness of the left TA with a palpable gap present
approximately 4 cm proximal to its insertion into os cal-
cis. The calf squeeze test was positive, i.e. no ankle
plantar flexion was present on squeezing the calf. He was
placed into a short-leg (below knee) equinus cast and
admitted to the ward while arrangements were put in

R. KAKKAR ET AL.225
place to allow his safe discharge. We treated both sides
differently with the right leg in above knee equinus cast
and the other in below knee equines cast (Figure 1) for
first three weeks in an effo rt to provide him some mobil-
ity as putting both legs in Above Knee casts would be
cumbersome for him. Happily his brother had an adapted
home due to being a wheelchair user himself, and so our
patient was able to be discharged fairly promptly despite
being non-weight-bearing with bilateral-leg casts. This
initial equinus cast was followed by a below knee mid-
equinus for three weeks and then a walking plantigrade
cast for three weeks (total time in casts was 9 weeks for
each leg). Both sides healed well and there was no ap-
parent difference in the two sides and healing times were
similar.
3. Discussion
Bilateral TendoAchilles rupture is rare, but is docu-
mented in the medical literature. In 2004 Hayes, et al.
[19] reviewed all of the published cases of bilateral rup-
ture and found that of 26 cases, 13 were due to exoge-
nous steroid treatment, three were due to significant
trauma, three occurred in renal transplant patients, two
were attributable to antibiotics of the fluoroquinilone
family, one was due to endogenou s corticostero id excess
Figure 1. Clinical picture showing above knee cast on right
side and below knee cast on the le ft.
(Cushing’s), one due to limb ischaemia, one diabetes,
one systemic lupus. Only one report had no cause identi-
fied, [20] but there was no other information about the
medical background other than that she was not on ster-
oids. Hayes, et al. [19] presented their case and sug-
gested that smoking may have been a causative factor.
Rao, et al. [21] reported another case but their patient
had hypothyroidism and was taking thyroxine and they
surmised that hypercholesterolemia and hypothyroidism
lead to degenerate tendon which eventually ruptured.
Habusta [9] reported two cases in healthy patients how-
ever both patients had long term Achilles tendonitis and
were gymnasts. Specific bilateral forces generated
through the Achilles tendons of experienced older gym-
nasts predispose them to ch ronic bilateral wear and acute
bilateral simultaneous ruptures during specific manoeu-
vres. The only other case report in the literature without
any causative factor is by Garg, et al. [18] and their pa-
tient was a healthy woman but they treated her opera-
tively.
Conservative treatment of Achilles tendon tears has
been considered a reasonable form of treatment. It has a
relatively good outcome and the risk of wound break-
down is eliminated. In a retrospective cohort study pub-
lished in 2003, Weber, et al. [22], found that non-opera-
tive treatment with an equinus ankle cast and boot for 12
weeks was as effective as surgical treatment in return to
sports and ultimate strength as operative treatment.
Moreover, they also reported that non-operative treated
patients had a much faster subsidence of pain, return to
unaided walking, and return to work. Eames, et al. [23],
showed similar outcomes between surgical and non-sur-
gical treatment but closed treatment had a lower minor
complication rate.
Sekiya, et al. [24] and Wray, et al. [25] have demon-
strated in cadaveric studies that knee flexion position
does not influence the separation of the tendo Achilles
ends while the plantarflexion position of the ankle does
significantly affect the separation of the tendoachilles
ends. Wray, et al. [25] also showed that the ankle needs
to be in at least 28 degrees of plantarflexion for the two
ruptured ends of the tendo achilles to meet. Therefore the
only factor to be controlled is the ankle position, which
can be con tr olled in a be low kn ee c ast an d an ab ov e kne e
cast is not necessary. There is only one other report in
the literature where the patient was treated conserva-
tively for bilateral tendo Achilles ruptures [26]. Their
patient had severe COPD and had been treated with ster-
oids. Bilateral cast brace treatment was provided for this
patient considering the poor general health. Unfortu-
nately, their patients’ right tendo-achilles did not heal
with brace management perhaps as result of him being
on steroids. We think that our patient achieved satisfac-

R. KAKKAR ET AL. 226
tory healing as he was not on steroids and did not have
any other risk factors and thus, possibly had healthier
tendons to start with which healed without any conse-
quence.
Our case presents a unique opportunity to examine
conservative treatment methods in a healthy patient. Al-
though different management was used (above knee
versus below knee casts) for each side, the outcomes on
both sides were similar and in this case it did not make a
difference whether an above knee or a below knee cast
was used for the initial treatment as the tendons healed
on both the sides and the patient returned to their
pre-injury activity levels. This also demonstrates that th e
amount of knee extension/flexion has no bearing on the
tendoachilles healing and that the only factor affecting
the separation of tendoachilles ends and thus their heal-
ing is the plantarflexion of the ankle.
This case is only the second reported case of bilateral
rupture in a healthy patient and our case demonstrates
that bilateral tendoachilles rupture can be treated con-
servatively with a good outcome.
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