A 91-year-old Caucasian male farmer presented at the Mayo Clinic, Rochester, Minnesota for evaluation of the acute complaint, "My feet aren't working." Specifically, he reported difficulty with balance leading to inability to walk, and extensive, painful bilateral ecchymoses of his heels (Figures 1 and 2). His distress and instability were alleviated only modestly by the use of a non-prescription cane. Barefoot ambulation was impossible. Barely functional ambulation was accomplished by wearing hard-soled shoes.
One month prior, the patient had been diagnosed with bronchitis at an outside clinic and was treated with a seven-day course of levofloxacin 500 mg by mouth, taken once a day (his estimated creatinine clearance was 32 mL/min using the Cockcroft-Gault equation). His bilateral heel pain developed insidiously over the first four days of fluoroquinolone treatment.
Even at 91, the patient had led an active lifestyle on his farm. He cooked all of his own meals, drove a tractor, and performed many other physical farm chores. On day seven of treatment, upon dismounting his tractor, he noticed sudden, severe pain in both of his heels and a compromised ability to ambulate independently.
The patient's medical history was otherwise notable for a mitral valve replacement with porcine xenograft 25 years prior, chronic hypertension, hyperlipidemia, degenerative spondylosis, depression and gastroesophageal reflux disease (GERD). He had no history of tendinopathy. The patient had never smoked, and had no exposure to second-hand smoke. He reported alcohol ingestion of two beers per month and caffeine consumption of three 8 oz cups of coffee per day.
In addition to the levofloxacin, the patient was on the following medications, with no recent changes: metoprolol ER 100 mg/d, isosorbide mononitrate ER 60 mg/d, hydrochlorothiazide/triamterene 25 mg/37.5 mg/d, spironolactone/hydrochlorothiazide 25 mg/25 mg/d, quinapril 20 mg/d, celecoxib 200 mg/d, glucosamine 1500 mg/d, sertraline 100 mg/d, omeprazole 20 mg/d, and acetaminophen 1000 mg every six hours as needed for arthritis-related pain. He had no known food or medication allergies.
On presentation to the hospital, the patient was afebrile and all vital signs were stable. Both heels were mildly edematous with overlying ecchymoses and were tender to palpation bilaterally. The patient had a palpable gap and mass-like defect distally with palpation along the left Achilles tendon. There was a similar gap, although no palpable mass defect, on the right. Dorsalis pedis and posterior tibial pulses were 2+ bilaterally, and capillary refill was less than two seconds in the great toes bilaterally. Thompson's test (also known as Simmond's sign) was abnormal bilaterally, with no movement of either foot. The patient could barely raise himself up on his tiptoes. In both lower extremities, ankle plantar flexion strength was 3/5, great toe flexion to test the flexor hallucis longus was 5/5, and ankle dorsiflexion to test the extensor hallucis longus was 5/5. The patient maintained full active and passive knee range of motion bilaterally. He demonstrated antalgic gait with significant difficulty in the toe-off (propulsion) phases bilaterally.
Radiographs of the lower extremities noted soft-tissue edema of the ankles. There were no noted bony abnormalities.
The patient was initially admitted to the hospital for in-patient care and placed on non-weightbearing status. Magnetic resonance imaging (MRI) of the ankles noted complete rupture of both Achilles tendons approximately 6 cm proximal from insertion upon the calcaneus, with the two ends approximately 3 cm apart on the left and 2 cm apart on the right. The patient was fitted with gravity equinus casts with heel extensions to keep the feet in plantar flexion. He was discharged from the hospital one day after admission.
Five weeks after hospital admission, the patient's casts were removed and he was fitted with controlled ankle motion (CAM) boots that were in plantar flexion at 15 degrees with resultant full equinus. Nine weeks after hospitalization, the patient was instructed to stop wearing the CAM boots and began wearing his own tennis shoes with three-quarter inch heel lifts to maintain relative plantar flexion.
At his initial presentation to the outpatient care center on the day of admission, the patient's primary care physician noted, "History of depression and anxiety: He is not anxious and depression is currently not a problem. He looks much brighter." However, at the meeting with his orthopedic surgeon nine weeks after hospital discharge, both the patient and family members noted decreased energy levels and general lack of enthusiasm. There was concern that these symptoms were fueled by his immobility.
Ten weeks after diagnosis, the patient presented to the Emergency Department with a 22-pound weight loss over the prior two months as well as generalized lethargy. He was hospitalized for evaluation where he was hydrated and his antihypertensive regimen was modified (quinapril, spironolactone, and hydrochlorothiazide were discontinued). He was discharged with blood pressures well within the normal range and with close follow-up with his primary care physician.
The patient was readmitted for inpatient care the following day with hospital-acquired pneumonia. He subsequently developed kidney failure, sepsis, heart failure, and a myocardial infarction. After consultation with the patient and his family, care was withdrawn and comfort care measures were initiated until the patient passed away 11 weeks after the initial diagnosis of bilateral complete Achilles tendon rupture.