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Snap, crackle and pop: What to do with a ruptured Achilles

Following on from our previous blog on Achilles tendon rupture it is time to focus on the current options for treatment and what we can learn from research evidence.

In the early 1900s, conservative treatment coupled with a long period of immobilisation was the accepted treatment for a complete Achilles rupture.3 However by the turn of the century improved surgical techniques and an increase in expectations to return to sport led to surgery becoming a popular treatment choice. The early 2000s saw surgery becoming the treatment of choice for all but the elderly and those at high risk of surgical complications. Traditional immobilisation involved casting in some degree of ankle plantarflexion and this type of immobilisation was also used post surgically for 6 to 8 weeks.

Of course, tendon healing is not the only important outcome after Achilles tendon rupture. Prolonged immobilisation leads to gross muscle wasting and frequent complications such as deep vein thrombosis, fibrotic adhesions and pressure sores. Recent research has not only highlighted these adverse events but has emphasized the benefits of early tendon loading and mobilisation with improved vascularity around tendon, improved fibre orientation, decreased collagen cross linkages, increased size and number of collagen fibrils.3-4 Regardless of whether conservative or surgical management is elected, the rehabilitation of complete Achilles ruptures can now comprise of slow, controlled range of movement exercises (4 weeks), and functional bracing to allow for some ankle movement followed by an intense ankle and calf strengthening program. Jogging can be started as early as 12 weeks and return to contact sport by 20 to 24 weeks. But is there a preference for management?

Two recent systematic reviews of randomised control trials compared conservative with surgical management for complete Achilles tendon ruptures.1, 4 Both reviews found a greater rate of re-rupture in conservatively managed patients. The incidence of complications such as infection, non-cosmetic scar complaints and sural nerve sensory disturbances were significant in the surgical group. One review listed known risk factors for infection as age greater than 60 years, diabetes, corticosteroid therapy, smoking, delay in treatment greater than seven days and pain in the tendon before the injury.4 These risk factors should be acknowledged and addressed when considering management options with patients.

In terms of return to work, one review4 found no significant difference between the groups, the other1 found that time off work was significantly shorter in the surgical group. Interestingly only one review evaluated return to sport rates and found no significant difference between the groups for return to pre-injury level.1 Disappointingly, no evaluation was made on the overall rate of return to pre-injury level of sport.1

A recent study has evaluated the short-term recovery of function after an acute Achilles tendon rupture, measured by a single-legged heel-rise test at 12 weeks after injury.2 Both surgical and conservative management groups were included. No significant difference was found between the groups in the ability to perform a heel raise at the 12 week mark. Further analysis showed that only 23 out of 40 (58%) in the surgical group and 18 out of 41 (44%) in the non-surgical group were actually able to perform the heel raise successfully. When the data was analysed in terms of those that could and those that couldn’t perform the test, those that could were significantly younger, more often of male gender and had a higher degree of physical activity. Additionally those that could not perform the heel raise reported a significant reduction in lower leg function and poorer general health status.

Given that most rehabilitation protocols recommend returning to running and non-contact sports between 16 and 20 weeks, assessing the ability to perform a single heel-rise at 12 weeks may be a useful clinical predictor of poor functional outcome. Chapter 37 of the clinical sports medicine textbook (CSM4ed) acknowledges that not all patients may be able to perform a single heel raise at 12 weeks and suggests that between 3 to 6 months is a more realistic aim. Having a strength deficit of 10-30% in the calf on the injured side can be considered normal after injury and may become permanent. Therefore continual monitoring of calf strength and foot function should ideally be ongoing past 6 months and even after return to sport.

So what have we learnt? Both surgical and conservative management of Achilles tendon ruptures have their pros and cons. Continued research into the application of growth factors and stem cells for the purpose of musculoskeletal repair and regeneration may help to reduce the rate of re-rupture and surgical complications.

References

  1. Jiang N, Wang B, Chen A et. al. ‘Operative versus non operative treatment for acute Achilles tendon rupture: a meta-analysis based on current evidence’ International Orthopaedics (SICOT) 2012 36: 765–773
  2. Olsson N, Karlsson J, Eriksson BI et. al. ‘Ability to perform a single heel-rise is significantly related to patient-reported outcome after Achilles tendon rupture’ Scand J Med Sci Sports 2012 Published ahead of print
  3. Schepsis AA, Jones H, and Haas AL ‘Achilles Tendon Disorders in Athletes’ American Journal of Sports Medicine 2002 30(2): 287-305
  4. Wilkins R and Bisson LJ ‘Operative Versus Non operative Management of Acute Achilles Tendon Ruptures: A Quantitative Systematic Review of Randomized Controlled Trials’ American Journal of Sports Medicine 2012 40(9): 2154-2160

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