The effect of steroids on Achilles tendon pathology should be considered according to whether they are corticosteroids or anabolic steroids.

Oral Corticosteroids

Oral corticosteroids are prescribed for a wide range of diseases. An increased risk of Achilles tendon rupture following the use of oral cortico-steroids has been recognized for some time.

Newnham62 reported on 10 patients who received corticosteroids for respiratory problems who experienced spontaneous Achilles tendon ruptures.

Inflammatory disorders such as rheumatoid arthritis, ankylosing spondylitis, giant cell arteri-tis, and gout are frequently controlled by prescribing corticosteroids. These conditions have been associated with an increased risk of Achilles tendon rupture per se. This raises the question of whether the disease process itself, the use of steroids to manage it, or a combination of both elements is important in the pathogenesis of the rupture.

Similarly, patients receiving corticosteroids as part of their immunosuppression therapy following major organ transplantation are at risk of suffering spontaneous Achilles ruptures.30 The concomitant use of oral corticosteroids and fluo-roquinolone antibiotics increases the risk of spontaneous Achilles tendon rupture63 especially in the elderly.

Most patients on corticosteroid therapy and sustaining spontaneous Achilles tendon ruptures have been on the medication for some time, suggesting that the cumulative damage to the tendon may well be duration dependent. The majority of bilateral, simultaneous ruptures of the Achilles have been in patients taking oral corticosteroids for a variety of conditions.64-66

However, a few patients experience a spontaneous rupture following a short duration of therapy with high doses of steroids.67 This suggests, in certain susceptible individuals, that dose dependency can be important.

Anabolic Steroids

The abuse of anabolic steroids has been associated with increased risk of tendon rupture.68

Medico-Legal Implications

• Oral corticosteroids can produce spontaneous rupture of the Achilles tendon. The benefits of these drugs for a widespread range of conditions are well-documented, and concern over the possibility of ruptures should not preclude their prescription based on sound clinical grounds. However, physicians should be aware of this potential risk, and patients should be sensitive to any symptoms from the tendon. • Anabolic steroids increase the risk of spontaneous Achilles tendon rupture.

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