The Impact of Social Determinants of Health on Management of a Full Thickness Achilles Tendon Rupture

HPI: Our patient is a middle-aged female with ankle pain for 3 months found to have sustained a full Achilles tendon rupture. She underwent surgery with Haglund’s resection six weeks later. Her post -op management included modified weight bearing, CAM boot, home physical therapy, and outpatient rehab. She presented to the ER a month after surgery with increased leg pain and a failure of oral antibiotics for post-surgical cellulitis. She was admitted with a tentative diagnosis of cellulitis which required a PICC line for antibiotic therapy. PMH showed she suffered from chronic lower backpain, opioid abuse, tobacco use disorder for 40 years, elevated BMI, arthritis, hypertension, attention deficit disorder, cervical radiculopathy. She reported to ED frequently because she did not have a PCP at the time. Patient's education level and family support were unavailable. DIAGNOSIS, MANAGEMENT, OUTCOME: PE: hemodynamically stable patient with warm, tender erythematous left leg up to the mid-calf and shin with flaky and dry skin. Differential: enthesitis within the setting of ciprofloxacin use, gastrocnemius rupture, cellulitis, partial Achilles re-rupture, poor post-operative compliance, DVT, compartment syndrome, ankle fracture. Final Diagnosis: post-op cellulitis/Achilles re-rupture. Diagnostics: pre-op MRI Ankle, post-op CT Tibia, laboratory studies; CT Tib/Fib showed fluid collection on the periphery of the tendon suggestive of cellulitis and partial re-rupture. Ottawa ankle rules did not suggest a need for X-Ray. Lab testing showed a WBC of 14.7, Hg of 10.7, no electrolyte or coagulation abnormalities. Outcomes: initial management was surgery; patient’s post-op complications were managed with antibiotics and surgical debridement. We used a PDDM to determine the primary drivers of pain and disability that most likely contributed to a suboptimal outcome consisting of five domains: 1) nociceptive, 2) nervous system dysfunction, 3) comorbidity, 4) cognitive-affective, 5) contextual drivers. We constructed a radar plot to determine how each individual factor plays a role in patient outcome. Comorbidities, plausible low health literacy, poor compliance with medical advice and other social and contextual factors must be considered whenever complications and protracted recovery are observed.

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