Treatment

management

It is important to diagnose this condition early.

• delay in treatment leads to poor outcomes such as:
  • weak plantar flexion, fatigue, limp, and inability to run, heel rise, play sports, and climb stairs caused by discontinuous or lengthened tendon
  • results in complicated surgery, with longer scars and higher risks of complications, may be required, and return to sports is not always possible
• with prompt treatment normal walking and stair climbing can be carried out at a median of 12 weeks after treatment, and return to sports at 9 months (1).

Aim of treatment is to restore continuity and normal length and tension of the Achilles tendon. Treatment can be surgical or non surgical. All patients should undergo supervised physiotherapy for several months regardless of the treatment method

Non surgical

• more suitable for older, less active patients or those with comorbidities
• success of conservative management is less likely if there is a delay in diagnosis
• methods include:
  • immobilisation with rigid casting or functional bracing
    • initially foot is positioned in full equines (30° namely full plantarflexion)
    • following this the foot is brought back into neutral position over a period of 8-12 weeks
    • weight bearing is allowed when the ankle position permits it
  • newer splints (e.g. Vacoped) has shown encouraging results

Surgical

• recommended for young people, athletes and people with high levels of activity, and those in whom non-surgical management has been unsuccessful
• correct apposition of the tendon ends is possible leading to lower rates of re-rupture.
• complication of surgery include: wound breakdown and wound infection
• surgical approaches can be:
  • open repair
  • percutaneous repair
  • augmentation of the tendon

Functional accelerated rehabilitation

• has been shown to be effective in both operative and nonoperative treatment of acute Achilles ruptures
  • especially return to pre-injury levels of activity can be achieved in patients who undergo non operative treatment methods
• principals of accelerated functional rehabilitation programs are
  • mechanical stimulation of tendon fibers
  • early protected weight bearing
  • functional bracing
  • early restricted range of motion (1,2,3)

Notes:

• a ruptured achilles tendon may be treated conservatively or operatively. Which method is best may be difficult to decide and there are no hard and fast rules. Retrospective studies suggest that both methods are equally effective when initiated within 2-3 days of injury but when treatment is delayed for more than 7 days, surgery is more efficacious. When treatment is delayed for several weeks, surgery may be the only option
• there is evidence from trials comparing early movement of the ankle between neutral and plantar flexion in a brace for 6 weeks with standard cast immobilisation
  • early mobilisation led to more excellent rated subjective responses and no difference in rerupture rate
• a small trial comparing minimally invasive surgical treatment and nonoperative treatment did not reveal stastically significant differences for the two treatments (4)

Reference:

• (1) Singh D. Acute Achilles tendon rupture. BMJ. 2015;351:h4722.
• (2) Gulati V et al. Management of achilles tendon injury: A current concepts systematic review. World J Orthop. 2015;6(4):380-6.
• (3) Pedowitz D, Kirwan G. Achilles tendon ruptures. Curr Rev Musculoskelet Med. 2013;6(4):285-93.
• (4) Metz R et al. Acute Achilles tendon rupture: minimally invasive surgery versus nonoperative treatment with immediate full weightbearing--a randomized controlled trial.Am J Sports Med. 2008 Sep;36(9):1688-94.