From Gains To Pains Acute Ankle Pain In The Recreational Athlete

HISTORY: 40 year old male recreational athlete with medical history significant for complete left Achilles tendon rupture s/p repair 9 years prior presents to the ED with worsening pain and swelling the size of a racquet ball over scar of left Achilles tendon after strenuous workout 10 days prior. MRI ordered, orthopedics consulted (covering for podiatry) and recommended admission with IV antibiotics, NPO, and podiatry consult. Podiatry performed operating room incision and drainage with debridement of Achilles and biopsy with delayed closure. Partial tendon rupture and tophaceous crystals within and adjacent to tendon found. PHYSICAL EXAMINATION: Left lower extremity revealed unroofed fluctuant mass along posterior ankle with sanguinous drainage, mild erythema, mildly necrotic wound borders, no purulence. Wound probed 1 cm to tendon which was frayed and partially ruptured. Mild tenderness along posterior ankle wound, ROM intact (left ankle, all toes), Sensation intact to light touch, 2+ pedal pulse with capillary refill of <2 seconds. Thompson test was negative. Differential Diagnosis1.Cellulitis with abscess 2.Achilles tendon rupture3.Achilles bursitis Test and results MRI LEFT LOWER EXTEMITY WITH AND WITHOUT CONTRAST-Evidence of prior surgery of Achilles, metallic artifact present. Markedly thickened Achilles tendon with increased signal within tendon concerning for recurrent tear. Increased tissue at anterolateral aspect of tendon, post contrast images with peripheral enhancement without central enhancement of this material. Central area measuring 7 mm x 8 mm. Non-enhancing material extending from posterior skin surface to focal collection noted prior.CBC- WBC- 10,000 HGB- 13.1, Platelets- 311,000URIC ACID- 7.4 mg/dL LEFT ACHILLES TENDON BIOPSY- Soft tissue with inflammation and amorphous material with granulomatous reaction may represent gouty tophusBlood Cultures- Negative Final Diagnosis- Tophaceous gout of Achilles tendon with partial tendon tear Treatment and outcomes-Allopurinol titration to goal uric acid of less than 5-Colchicine as needed for flares-CAM boot for 8 weeks-Physical therapy with focus on ROM and strengthening exercises 4 weeks post surgery.-Patient resumed regular activities as tolerated 3 months post injury with full painless ROM and strength