Clinical Sciences/Health Conditions
Yang-Chin Su, MD
Resident Doctor
Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital
Taipei City, Taipei, Taiwan (Republic of China)
Wei-Ting Lin, MD
Attending Physician
Far Eastern Memorial Hospital
Taipei City, California, Taiwan (Republic of China)
Complete tear of the right posterior tibial tendon, biceps tendon long head, and supraspinatus tendon, associated with long-term hemodialysis and secondary hyperparathyroidism.
Case Description: A 64-year-old woman with end-stage renal disease from diabetic nephropathy and IgA-type mesangial proliferative glomerulonephritis had been on hemodialysis for 18 years. Two weeks after a right ankle inversion injury, she reported pain in the right medial ankle. Examination revealed noticeable right ankle swelling, tenderness in both medial and lateral ankle areas, bilateral flatfoot deformity, and hindfoot valgus. She exhibited mild weakness in plantarflexion and inversion of the right ankle, though her range of motion remained adequate.
For the right foot, ultrasonography showed complete ruptures of the posterior tibial tendon (1 cm long, 2 cm proximal to the navicular insertion) and chronic injuries to the anterior talofibular and calcaneofibular ligaments. An MRI confirmed posterior tibial tendon dysfunction. The patient concurrently reported long-standing right shoulder pain; an ultrasound revealed complete tears of the biceps long head and supraspinatus tendons. For further management, she opted for conservative treatment rather than orthopedic referral.
Discussions:
Complete tendon ruptures are uncommon but increasingly recognized complications in long-term hemodialysis patients. This case highlights the vulnerability of tendons in patients with chronic kidney disease with secondary hyperparathyroidism. Long-term dialysis may induce chronic tendinopathy and laxity due to microglobulin amyloidosis, while hyperparathyroidism promotes tendon calcification and overall fragility. Even a minor ankle inversion can result in rupture of the posterior tibial tendon. Similarly, spontaneous tears of the long head of the biceps and supraspinatus tendons reflect systemic tendon degeneration rather than just isolated mechanical trauma in such patients.
Conclusions:
Clinicians should recognize atypical soft tissue injuries in dialysis-dependent patients, especially with hyperparathyroidism, even in the absence of major trauma. Early musculoskeletal ultrasonography can facilitate a timely diagnosis and guide both conservative and surgical management.
