Simultaneous bilateral Achilles tendon ruptures associated with statin medication despite regular rock climbing exercise

doi:10.1016/j.ptsp.2009.01.003

Physical Therapy in Sport

Volume 10, Issue 4, November 2009, Pages 150-152

https://doi.org/10.1016/j.ptsp.2009.01.003 Get rights and content

Abstract

Introduction

Ruptures of the Achilles tendon are common however simultaneous ruptures occur less frequently. Eccentric loading exercise programmes have been used to successfully treat Achilles tendinopathy.

Case report

We report a case of simultaneous bilateral Achilles tendon rupture in a patient predisposed to rupture due to longstanding raised serum lipoprotein and recently introduced therapeutic statin medication. The patient was also a keen rock climber and had regularly undertaken loading exercise.

Conclusion

This case illustrates that the therapeutic effect of mixed loading exercises for the Achilles tendon may not be adequate to overcome the predisposition to rupture caused by hyperlipidaemia and statin medication.

Introduction

Statin medication has been shown to reduce the risk of heart attack and cerebrovascular accident and so lipid lowering medication is being prescribed to younger and more active patients (Mihaylova, Briggs, Armitage, Parish, Gray, & Collins, 2006). Simultaneous bilateral Achilles tendon rupture occurs rarely. Both elevated lipoprotein levels (Mathiak, Wening, Mathiak, Neville, & Jungbluth, 1999) and the use of statin medication have been associated with tendinopathy, predisposing to rupture (Marie, Delenetre, Massy, Thuillez, & Noblet, 2008). Eccentric loading exercises have been shown to normalise tendon structure and decrease the thickness of pathological tendon (Ohberg, Lorentzon, & Alfredson, 2004) which may reduce the risk of tendon rupture.

We report a case of simultaneous bilateral Achilles tendon rupture in a patient who undertook regular loading exercise during sport climbing. Twelve weeks of regular statin therapy had significantly reduced his serum cholesterol level.

Section snippets

Case report

A 47 year old physiotherapist suffered acute onset of pain to both heels and two audible “pops” whilst apprehending a pickpocket. There had been no previous tendinopathic pain to either Achilles tendon.

Previous investigations for a family history of cardiac problems had revealed an elevated lipid profile (cholesterol of 9.6 mmol/L, triglyceride of 1.9 mmol/L, high density lipid lipoprotein (HDL) of 1.46 mmol/L, low density lipid lipoprotein (LDL) 7.3 mmol/L and a cholesterol/HDL ratio of 6.6

Discussion

Bilateral Achilles tendon rupture is a rare event and is likely to be associated with tendon pathology or other predisposing factors (Chiodo & Wilson, 2006). Eighty three percent of patients sustaining Achilles tendon rupture have elevated serum cholesterol (Mathiak et al., 1999). The use of statin medication to reduce serum lipid profile has been shown to cause tendinopathy (Marie et al., 2008). Simvastatin and ezetimibe rechallenge tests have produced tendinopathy in a patient who had

Conflict of interest

The authors can confirm that there is no conflict of interest.

The patient has given written consent for publication.

Ethical statement

The patient has given written consent for publication.

Acknowledgments

We would like to thank the Health Library and Heather Allen of the Department of Medical Illustration at the Northern General Hospital for their assistance with this research.

References (11)

R.C. Pullatt et al.
Tendon rupture associated with simvastatin/ezetimibe therapy
American Journal of Cardiology
(2007)
J.D. Calder et al.
Independent evaluation of a recently described Achilles tendon repair technique
Foot & Ankle International
(2006)
C.P. Chiodo et al.
Current concepts review: acute ruptures of the Achilles tendon
Foot & Ankle International
(2006)
E. Karousou et al.
Collagens, proteoglycans, MMP-2, MMP-9 and TIMPS in human Achilles tendon rupture
Clinical Orthopaedics Related Research
(2008)
R.J. Khan et al.
Treatment of acute Achilles tendon ruptures. A meta-analysis of randomized controlled trials
Journal of Bone and Joint Surgery American Volume
(2005)

There are more references available in the full text version of this article.

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Structural and biomechanical changes in the Achilles tendon after chronic treatment with statins
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Citation Excerpt :
These injuries to the tendons are more often associated with the use of simvastatin and atorvastatin, the two most prescribed statins in the treatment of hypercholesterolemia (Marie et al., 2008; Maron et al., 2000). Some studies have also indicated that the Achilles tendon appears to be the main injured tendon (Beri et al., 2009; Carmont et al., 2009; Chazerain et al., 2001; Kirchgesner et al., 2014). The doses of statins used in this study were determined by allometric scaling (Pachaly and Brito, 2001).
Cases of tendinopathy and tendon ruptures have been reported as side effects associated with statin therapy. This work assessed possible changes in the structural and biomechanical properties of the tendons after chronic treatment with statins. Wistar rats were divided into the following groups: treated with atorvastatin (A-20 and A-80), simvastatin (S-20 and S-80) and the group that received no treatment (C). The doses of statins were calculated using allometric scaling, based on the doses of 80 mg/day and 20 mg/day recommended for humans. The morphological aspect of the tendons in A-20, S-20 and S-80 presented signals consistent with degeneration. Both the groups A-80 and S-80 showed a less pronounced metachromasia in the compression region of the tendons. Measurements of birefringence showed that A-20, A-80 and S-80 groups had a lower degree of organization of the collagen fibers. In all of the groups treated with statins, the thickness of the epitenon was thinner when compared to the C group. In the biomechanical tests the tendons of the groups A-20, A-80 and S-20 were less resistant to rupture. Therefore, statins affected the organization of the collagen fibers and decreased the biomechanical strength of the tendons, making them more predisposed to ruptures.
Statin adverse events in primary prevention: Between randomized trials and observational studies
2015, American Journal of the Medical Sciences
Citation Excerpt :
The spectrum of statins AEs identified in RCTs is different from observational studies. Observational studies have noted that statin-associated musculoskeletal AEs encompass a wide array of symptoms and diseases,29,30 including rhabdomyolysis, serum creatine kinase elevation, myalgias, muscle weakness, muscle cramps, aches, pain as “all over the body,” pain during physical exertion,31 and a variety of tendinous diseases.32–37 There is no standard definition for “muscle aches or cramps.”
Considerable debate exists regarding who might benefit from statins for primary prevention. Statins have wide pleotropic effects, which contribute to their efficacy in lowering cardiovascular disease but may also result in adverse events (AEs). Caveats in identifying AEs in randomized controlled trials (RCTs) include the lack of a standardized definition of statin-associated AEs, the differences in properties of different statins, the selectivity of RCTs in choosing their participants, the presence of high rate of nonadherence/withdrawal from trials and other concerns related to study design and conflict of interest. Caveats in identifying or overestimating AEs in observational studies include failure to identify baseline confounders, ascertainment bias, confounding by indication and healthy user bias. Statin use in observational studies may be a surrogate marker for higher socioeconomic standards, access to health care or use of other preventive services. Integrating evidence from both RCTs and observational studies is of paramount importance for appropriate patient-centered decision.
Statins induce biochemical changes in the Achilles tendon after chronic treatment
2013, Toxicology
Citation Excerpt :
These drugs are effective and relatively safe with few adverse effects (O'Sullivan, 2007). However, there have been reports of tendon complications because of statin therapy (Beri et al., 2009; Carmont et al., 2009; Marie et al., 2008; Nesselroade and Nickels, 2010; Pullatt et al., 2007). This is the first report in the literature showing the effect of the different doses of statins in the tendon of rats.
Statins have been widely prescribed as lipid-lowering drugs and are associated with tendon rupture. Therefore, this study aimed to evaluate the possible biochemical changes in the Achilles tendon of rats after chronic treatment with statins. Dosages of statins were calculated using allometric scaling with reference to the 80 mg/day and 20 mg/day, doses recommended for humans. The rats were divided into the following groups: treated with simvastatin (S-20 and S-80), treated with atorvastatin (A-20 and A-80), and the control group that received no treatment (C). Measurements of low-density lipoprotein (LDL) in the plasma were performed. The levels of non-collagenous proteins, glycosaminoglycans (GAGs) and hydroxyproline were quantified. Western blotting for collagen I was performed, and the presence of metalloproteinases (MMPs)-2 and -9 was investigated through zymography. The concentration of non-collagenous proteins in S-20 was less than the C group. There was a significant increase in pro-MMP-2 activity in A-80 group and in active MMP-2 in S-20 group compared to the C group. A significant increase in latent MMP-9 activity was observed in both the A-80 and S-20 groups when compared to C group. In the A-20 group, there was a lower amount of collagen I in relation to C group. In addition, a higher concentration of hydroxyproline was found in the S-20 group than the C group. The analysis of GAGs showed a significant increase in the A-20 group when compared to C group. The treatment induced remarkable alterations in the Achilles tendon and the response of the tissue seems to depend of the used statin dosage. The presence of MMP-2 and MMP-9 is evidence of the degradation and remodeling processes in the extracellular matrix of the tendons. Our results show that statins induce imbalance of extracellular matrix components and possibly induce microdamage in tendons.
Incidence of musculoskeletal and neoplastic diseases in patients on statin therapy: Results of a retrospective cohort analysis
2013, American Journal of the Medical Sciences
Citation Excerpt :
It is conceivable that statin effects on apoptosis, the mitochondrial respiratory chain, selenoprotein synthesis, and muscle and tendon toxicity (as detailed in the following) may result in increased incidence of arthropathies. Statin-associated musculoskeletal disease includes a wide array of clinical presentations including myositis, rhabdomyolysis, serum creatine kinase elevation, myalgias, muscle weakness, muscle cramps, aches or tenderness, and a variety of tendinous diseases.8–11,39 Examination of data from 31 French Phamarcovigilance Centers from 1990 to 2005 found 96 patients with tendon-related diseases.8
Because of their beneficial cardiovascular effects, several studies have recently advocated starting statins at a young age for primary prevention. However, some reports suggest that statin therapy may be associated with an increased incidence of musculoskeletal and neoplastic diseases. This study was conducted to investigate the incidence of various musculoskeletal and neoplastic diseases in statin users and nonusers.
A retrospective cohort study of patients in the San Antonio Military Multi-Service Market during the period from October 1, 2003, to March 5, 2010, was conducted. The International Classification of Diseases, 9th edition, diagnosis codes between 2 cohort groups—statin users and nonusers—were compared. Statin users were those patients with at least one 3-month prescription for a statin in the fiscal year 2004. Nonusers were those patients who received a prescription—but not a statin—during the period of the study. Both groups were assessed for the development of musculoskeletal and neoplastic diseases in the following 4-year period (October 1, 2004, to September 30, 2009).
A total of 92,360 patients were identified: 12,980 statin users and 45,997 nonusers. After adjusting for age, sex and Charlson comorbidity index, statin users had significantly higher rates of osteoarthritis and arthropathy (odds ratio: 1.26; 95% confidence interval: 1.19–1.33), and dorsopathies, rheumatism and chondropathies (odds ratio: 1.20; 95% confidence interval: 1.12–1.27).
In this retrospective analysis, statin use was associated with an increased incidence of musculoskeletal diseases, including arthropathy. Further studies are needed to provide physicians and their patients with adequate information regarding statin therapy, particularly if recommended for primary prevention in younger populations.
Multiple tendon ruptures associated with statin therapy
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We present the case of a 44-year-old physician with familial heterozygous hypercholesterolemia who experienced multiple tendon ruptures during 19 years of statin therapy and no tendon injuries in the 5 years since statins were discontinued. Statins may deleteriously affect tendon extracellular matrix by inhibiting synthesis of matrix metalloproteinases and cell cycle regulatory proteins. Clinicians should be aware of this possible association between statins and tendinopathy.
Effects of Statin Treatment on the Development of Tendinopathy: A Nationwide Population-Based Cohort Study
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Case studiesSimultaneous bilateral Achilles tendon ruptures associated with statin medication despite regular rock climbing exercise

Abstract

Introduction

Case report

Conclusion

Introduction

Section snippets

Case report

Discussion

Conflict of interest

Ethical statement

Acknowledgments

American Journal of Cardiology

Independent evaluation of a recently described Achilles tendon repair technique

Foot & Ankle International

Current concepts review: acute ruptures of the Achilles tendon

Foot & Ankle International

Collagens, proteoglycans, MMP-2, MMP-9 and TIMPS in human Achilles tendon rupture

Clinical Orthopaedics Related Research

Treatment of acute Achilles tendon ruptures. A meta-analysis of randomized controlled trials

Journal of Bone and Joint Surgery American Volume

Case studies
Simultaneous bilateral Achilles tendon ruptures associated with statin medication despite regular rock climbing exercise