Non-operative treatment of acute achilles tendon rupture
A review of current best practice for treating this common sports injury, by Prasad Rao, Mehek Asad and Asad Syed
Anatomy, function, aetiology and risk factors for rupture
The Achilles tendon is relatively hypovascular, especially at its distal third [1,2]; in contrast, the paratenon is a highly vascular structure . The Achilles tendon is part of a musculotendinous unit that spans three joints, producing knee flexion, tibiotalar flexion and subtalar inversion. Loads as great as 12.5 times body weight are placed on the tendon during running, cont-ributing to its high rate of injury [4,5]. Male individuals have a higher maximum tendon rupture force and stiffness, in part due to a larger cross-sectional area, than female individuals. Younger individuals have a higher maximum tendon rupture force and lower stiffness than their older counterparts .
Rupture of the Achilles tendon is one of the most common tendon injuries in the adult population. The incidence of this injury is on the rise as aging adults continue their participation in high-demand sports activities. Host anatomy and external risk factors, including high-intensity plyometric exercises, training on unfamiliar surfaces and the use of improper footwear are some of the causes for the injury . The commonest mechanism of injury remains rapid eccentric contraction of the calf muscles during sports and exertional activities brought on by sudden dorsiflexion of the ankle in a previously compromised tendon [7–10]. Treatment of the injury has been complicated with the increasing demands and patient expectation. There are numerous research papers published in favour of operative and non-operative treatment – the verdict, however, remains non-conclusive [11–16].
Treatment of an acute rupture
The optimal treatment remains controversial, and both operative and non-operative treatments have distinct advantages and disadvantages. The complications related to wound and scar problems seem to favour non-operative management, and reduced chances of re-rupture the surgical option. Non-operative treatment has gained increasing popularity during the past decade.
A number of meta-analyses comparing operative and non-operative treatment have shown a significantly lower rate of re-rupture and a higher rate of other complications among operatively treated patients [21–23]. Early management of Achilles tendon ruptures were strict immobilisation, which was initially described by Lea and Smith; and strict immobilisation for eight weeks, followed by the use of a heel lift (with concurrent institution of strengthening exercises). This was associated with an 11 per cent re-rupture rate at 26 months of follow-up . The main issues with strict immobilisation, especially in the elderly and less-active individuals, were stiff-ness and significant loss of power, strength and endurance .
Early mobilisation has been discussed since the1980s and has been shown to improve tendon healing in both in vivo and in vitro studies [18,19,24,25,30]. Early mobilisation minimises the chances of healing in the lengthened position of rupture [25,29–31]. Functional bracing has gained popularity recently, with several reviews favourably comparing functional bracing with surgical repair [20,21,24]. This concept was later adopted for non-operative management of Achilles tendon ruptures. The dynamic rehabilitation after non-operative treatment of Achilles tendon rupture has been shown to result in better functional outcomes, and the rates of re-rupture are comparable with that of surgical treatment [18–24].
Functional stimulus to healing, and early weight-bearing with protected range of movement, achieve favourable outcomes in terms of range of motion, and return to activities and strength [24–28]. An examination by Soroceanu et al., involving only studies using dynamic rehabilitation, revealed no significant difference in the rate of re-rupture between operatively and non-operatively treated patients; the increased risk of other complications in the operative group was the only significant difference .
In a multi-centre randomised trial of 144 patients, Willits and co-workers assessed accelerated functional rehabilitation in operative vs non-operative cases with acute Achilles tendon ruptures. They followed up their cases at six, 12 and 24 months after injury and found there was no clinically important difference between groups with regard to strength, range of motion, calf circumference or Leppilahti score. There were 13 complications in the operative group and six in the non-operative group, with the main difference being the greater number of soft-tissue-related complications in the operative group . They concluded that accelerated functional rehabilitation in the non-operative group had results comparable with the operated group. The operated group had an overall increased risk of surgical complications .
Costa et al. considered return to normal activities as the most important outcome parameter. They found that immediate weight-bearing led to quicker return to normal walking and stair-climbing in operatively but not non-operatively treated patients . The role of weight-bearing is of fundamental importance as it influences not only the quality of treatment but also the patient’s self-care ability. Use of an orthotic heel lift reduces the force on the Achilles tendon and the resulting strain while still allowing for isometric contractions . Suchak et al. considered quality of life as the most important outcome parameter. They found that early weight-bearing led to better health-related quality of life outcomes during treatment .
In their blind, randomised, controlled trial, Barford and colleagues compared weight-bearing and non-weight-bearing in conservatively treated achilles tendon injuries using the fixed orthosis, and showed that immediate weight-bearing can be recommended as an option in the non-operative treatment of Achilles tendon rupture . They also showed that the Achilles tendon rupture score (ATRS) was 73 in the weight-bearing group and 74 in the non-weight-bearing group, which was not statistically significant. There was no difference in either of the groups at 12 months for total heel-rise work performed by the affected limb as compared with the uninjured limb. There were three cases of re-rupture in the affected group, and two in the control group, which again was not statistically significant .
Following the success of early weight-bearing in non-operative management of Achilles tendon ruptures, the general trend in Scandinavia is changing.
Matilla and co-workers used the Finnish registry of Achilles tendon ruptures over 15 years to study a total of 15,252 patients, and reported that there was a declining trend of surgical treatment. This trend was based around the fact that the clinicians had changed their practice from surgical to non-surgical after becoming convinced by the evidence from high-quality randomised controlled trials .
A Danish study by Ganestam and others retrospectively looked at the National Patient Registry from 1994 to 2013. The incidence of acute Achilles tendon rupture increased over that period, based on increasing incidence in the older population. The researchers found a steady decline in surgical treatment over the whole period, with a noticeable decline from 2009 to 2013, possibly reflecting a rapid change in clinical practice following a range of high-quality randomised clinical trials .
The orthopaedic fraternity in the rest of the world seems to either favour surgery over conservative management or remain inconclusive on the best treatment option. Despite the trend and the evidence, orthopaedic surgeons here in the UK are still divided as to the best form of treatment protocol. In 2015, Kearney et al. looked at an online survey of British Foot and Ankle Society members, where 181 members completed the form. A wide variation in practice was noticed even between these specialist foot and ankle surgeons: 13 per cent managed these ruptures with plaster cast alone; 68 per cent followed plaster with orthosis; while 19 per cent managed it with orthosis alone. There was significant variation among the respondents about the duration, foot position and weight-bearing status .
In 2013, Osarumwense and colleagues conducted a survey of 221 orthopaedic consultants working in 28 hospitals within the greater London area. Of the 86 respondents, 62 of them treated acute ruptures using conservative and surgical means; of those, 51 used below-knee plasters while five respondents still used an above-knee plaster. Only six used functional bracing. The most common immobilisation regimen was to keep the foot in a sequence of equinus, semi-equinus and neutral positions of foot, for three weeks each. After plaster removal, a heel raise was used for a duration of four weeks. Among the foot and ankle specialists surveyed, the median range of immobilisation was eight weeks – one week less than the generalist. Mean time to weight-bearing was six weeks .
Interestingly, the American Academy of Orthopaedic Surgeons clinical practice guideline 2010 on the treatment of an Achilles tendon rupture remains inconclusive. They were unable to reach consensus on most things, and only agreed on two things: first, detailed history and examination should be performed in patients with suspected Achilles tendon rupture and, secondly, that the operative treatment should be approached more cautiously in patients over the age of 65 years or with concomitant medical problems. They do not favour conservative over surgical treatment .
In the latest review article from the USA, Uquillas et al. (2015) suggest that optimal treatment remains controversial. They recommend surgery if the gap between the two ends of the tendon is greater than 3cm. Non-surgical treatment remains non-weight-bearing immobilisation in a plaster cast in an equinus position. Functional bracing could be initiated at the two-week stage and has shown increased range of movement and an earlier return to pre-injury activity levels and comfort in the long term .
In 2004 and 2005, an Australian research team led by Khan undertook a Cochrane review of literature and concluded that open operative treatment of Achilles tendon rupture significantly reduced the risk of re-rupture compared with non-operative treatment, but that such treatment was associated with a significantly higher risk of other complications [39,40]. They published their results again in 2012, with a Cochrane review from Jones et al. that supported operative repair over non-surgical treatment .
Treatment of a chronic rupture
The term chronic rupture varies from four weeks to 2.5 months as described in the literature . There is very little evidence to show that non-surgical management improves the symptoms associated with chronic ruptures. Surgical repair with augmentation remains the gold standard [43–45]. Options for surgical treatment of chronic tears include direct repair, local tissue transfer, soft-tissue augmentation and augmentation with synthetic allografts.
Direct repair may be achieved for gaps that are less than 3cm in length after debridement. In cases of delayed or late presentations this is possibly an option to explore. But in cases where the tendon is significantly shortened, contracted and dysfunctional, the flexor hallucis longus (FHL) tendon is commonly used to augment the direct repair; it also provides good vascularity and strength to the tendon ends. Augmentation with soft tissue can be done using medial and lateral aponeurotic fascial turndown flaps, plantaris tendon, sliding V-Y advancement of the gastrocnemius-soleus complex aponeurosis, and fascia lata [46–48]. Achilles tendon allografts have been used to treat large defects (approximately 10 cm); however, results are limited only to case reports. In our unit, V-Y advancement remains our favoured technique for defects up to 5–7 cm.
Current thinking and conclusion
While there is no consensus about the treatment of acute Achilles tendon rupture, the practices remain different in different parts of the world. It would appear that the Americans and the Australians still favour surgical intervention while the Europeans are moving away from surgery and are more in line with the Scandinavian practice of conservative treatment with functional bracing and early weight-bearing as the first choice in most cases. The role of an active and constructive supervised physiotherapy regimen at the earliest opportunity favours successful outcomes.
There is now more evidence to recommend that most cases of acute Achilles tendon rupture should be treated conservatively unless dynamic ultrasound fails to show a reasonable closure of the gap or that there are risk factors against it. Weight-bearing and early use of functional orthosis could be initiated early, as it has shown to be equally safe – with the advantages of an early return to work and sports, and reduced complications. Accelerated rehabilitation regimes and biochemical manipulation of the injury site are the areas that may improve results further.
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Asad Syed is an orthopaedic and trauma consultant with a special interest in foot and ankle surgery based at Wrexham Maelor Hospital.
Prasad Rao is a specialist registrar, ST3 Welsh orthopaedic rotation.
Mehek Asad is a surgical FY1 at Royal Oldham Hospital.