Tendon Rupture

Tendon ruptures can usually be diagnosed by clinical assessment. X-rays and ultrasound are used to establish or confirm the diagnosis but MRI gives the most definitive information about the nature and extent of the rupture. Tendon ruptures are uncommon but may cause severe initial pain and lead to permanent disability if untreated. Management may be surgical or non-surgical depending on the site and severity of the rupture, and the clinical features and disability caused by the rupture.

The most common tendon ruptures are discussed below. Achilles tendonitis and rupture are discussed in greater detail in a separate article. Shoulder rotator cuff tears are discussed in the article Shoulder pain.

• Proximal biceps tendon rupture is usually transverse and either within the shoulder joint or within the proximal part of intertubercular groove.

Presentation

• The biceps muscle bunches up in the distal arm causing the characteristic 'Popeye muscle' appearance. There is minimal loss of function.

Management

• Patients can be treated conservatively as most will become asymptomatic after 4-6 weeks.
• Operative treatment may be indicated for cosmetic reasons or if shoulder reconstruction is required for other reasons.

• Distal biceps tendon rupture is usually caused by a single traumatic event involving flexion against resistance, with the elbow at a right angle.
• Most often occurs in a 50-60 year old active male.

Presentation

• A sudden sharp tearing sensation results in a painful swollen elbow with weakness of flexion and supination.
• In a partial rupture, the biceps tendon will still be palpable in the antecubital fossa.

Management

• Surgery must be performed early in order to avoid scarring of biceps.

Complications

• Rupture may lead to biceps tendonitis and median nerve compression.

• Patellar tendon rupture is usually unilateral and due to a sports injury in patients younger than 40 years.
• Bilateral ruptures, with more minor trauma can occur in patients with systemic conditions such as inflammatory disease, diabetes mellitus, or chronic renal failure.

Presentation

• There is an immediate onset of pain with a tearing sensation.
• Diffuse tender swelling with bruising develops in the anterior knee.
• A defect at the level of the rupture may be palpable.
• Active extension may be completely lost and the patient unable to maintain the passively extended knee against gravity.

Management

• Immediate surgical repair of the ruptured patella tendon is recommended for optimal return of function.

• Quadriceps tendon rupture is relatively infrequent and usually occurs in patients older than 40 years.
• Are most often unilateral and bilateral ruptures usually result from systemic disease and prior degenerative changes.

Presentation

• Patients typically present with acute knee pain, swelling, and functional loss following a stumble, fall, or a giving way of the knee.
• There may be no history of prior knee pain. Supra-patellar swelling, bruising and tenderness are present.
• There is also variable loss of knee extension.

Management

• Early surgical repair yields the best results for complete quadriceps tendon ruptures.
• Partial tears can be treated conservatively.

• The posterior tibial tendon maintains the arch of the foot and posterior tibial tendon rupture is one of the most common causes of acquired flat foot in adults.
• The foot may become so deformed that severe ankle arthritis develops.

Presentation

• Pain frequently begins just behind the medial malleolus.
• The foot rolls inwards and becomes flat.

Management

• The foot should be supported with an orthotic arch support.
• Surgery is indicated for greater degrees of foot deformity.

• Most peroneal tendon ruptures are longitudinal tears of the peroneus brevis tendon and this usually occurs as the result of a lateral ankle sprain.
• The longer the injury takes to heal, the greater the suspicion of a tendon rupture.
• Many cases of peroneal tears are too small to find with any test other than exploratory surgery.

Management

• Most peroneal brevis tendon ruptures do not heal and require surgical repair.

• Most often the flexor tendons are damaged by a cut, which may also damage adjacent nerves.
• Sports injuries are also common causes of hand flexor tendon ruptures, usually in football, wrestling or rugby.
• People with rheumatoid arthritis may experience a spontaneous rupture of the hand tendons.

Presentation

• There is tenderness over the flexor aspect of the finger.
• The patient is unable to flex one or more joints of the finger and attempting to do so causes pain.

Management

• Flexor tendon injuries require surgical repair and this should be performed as soon as possible after the injury.

• Extensor tendons are easily injured, even by a minor cut. Jamming a finger may cause the tendon to tear from the attachment to bone.

Presentation

• Hand extensor tendon rupture can cause a Mallet finger (fixed flexion of the distal interphalangeal joint) or Boutonniere deformity (fixed flexion at the middle interphalangeal joint).
• Lacerations on the back of the hand that go through the extensor tendons can cause inability to extend the finger at the metacarpo-phalangeal joint.

Management

• Partial extensor tendon injuries are treated conservatively, with a splint.
• Complete rupture is treated by operative repair.
• Surgery to free scar tissue may be needed if there is significant loss of finger movement.