Crozet Annals of Medicine: Falling Down

0
951

by Dr. Robert Reiser

The case had the resident physician perplexed and worried. An elderly gentleman reported that his legs suddenly and unexpectedly could no longer hold him upright. He had been golfing all afternoon, had a beer at the bar and was walking down the steps on his way home when his left leg gave way. As he wobbled he shifted his weight to his right leg which subsequently also gave way and he collapsed on the country club steps. The paramedics were summoned and transported him to the ER. Given his age and the faint odor of alcohol on his breath the medics assumed he had been too long at the club bar and that accounted for his incapacity.

On examination in the ER he was sober, alert and neurologically intact except for his ability to walk. He could move his legs freely and fully but on standing he simply collapsed as if his legs were made of jelly.

The resident was concerned about an acute neurologic injury and had already stat paged a neurology consult. I asked him to defer the consult while we went over the exam together. You can go over the exam with me at home now. Ready? Reach down and squeeze your calf muscle firmly. This is called a Thompson’s test. What happens to your heel?  Do it again. Try the other side. Your heel should go up. Try it again. Your foot should push down as well. It can be subtle to notice, but it is there.

When I squeezed this patient’s calves nothing happened to his feet at all. No heel lift, no foot flexion. The resident was still perplexed until I pointed out that this positive Thompson’s test indicated that the patient had spontaneously ruptured both of his achilles tendons, leading to his fall and inability to walk.

The achilles tendon is a broad strong band that connects the powerful gastrocnemius (calf) muscles directly to the heel. Without it one cannot walk or even stand. The tendon is named after the mythical Greek warrior Achilles who was invincible except for one small spot at his heel. Achilles mother had dipped him as a child in the river Styx, which made him invulnerable, but she had held him by his heel, which did not get wet or invulnerable. Eventually Achilles’ enemy Paris killed him with an incredibly accurate arrow shot to the heel. In our own time the seemingly invincible NFL linebacker Lawrence Taylor was finally felled by a ruptured achilles tendon, effectively ending his career.

Spontaneous rupture of one achilles tendon is pretty rare and a simultaneous spontaneous rupture of both is nearly unheard of.

As I quizzed the patient further I learned that he had been recently placed on a powerful antibiotic called Cipro for bronchitis. Cipro has been strongly linked with these tendon ruptures. No one knows why, but the association is clear. At particular risk are the elderly, males, and those also on steroids. Other tendons can rupture as well or patients can come down with plain old tendinitis from Cipro and related antibiotics such as Levaquin, Avelox, and Floxin.

This class of antibiotics, the fluroquinolones, have proved to be truly, useful medicines, possessing clear advantages in some ways over older classes of antibiotics and I am not advocating against their usage in correctly selected patients. The tendon ruptures, while now well documented, must still be considered rare events, somewhere in the range of one in ten thousand patients. But there are a lot of Cipro prescriptions being written and there is consensus in the medical community that this and all antibiotics are being grossly overprescribed with resulting antibiotic resistance and untoward side effects.

We ended up casting our patient’s ankles and sending him home in a wheelchair. With diligent physical therapy his prognosis was for near complete recovery of function in six months to a year. And the bronchitis? Turned out to be viral and cleared up spontaneously.