Nonoperative Treatment Options for Achilles Tendon Ruptures
The Achilles tendon is the thick tendon that connects your calf muscles to your heel. Injury to this structure can range from a simple, but painful, tendinopathy to full rupture where the calf muscle can no longer act to plantarflex the ankle. Rate of Achilles tendon rupture is on the rise and can be quite debilitating, preventing participation in sports and limiting walking ability. Despite the rising prevalence, treatment for Achilles tendon rupture is not consistent. Most research shows that surgical repair results in significantly lower rerupture rates at three and a half percent compared to non-surgical repair, which has a rerupture rate around twelve and a half percent. More recently, however, research has indicated that a functional non-operative protocol results in rerupture rates similar to those who have undergone surgical repair, with one study reporting seven percent and another reporting eight percent rerupture rate.
Functional non-operative management is a relatively new bracing concept that involves early weight-bearing and range of motion. These two rehabilitation factors have shown to prevent detrimental alterations in muscle characteristics and increase maturation of collagen fibers during the tendon healing process. There is some difficulty with beginning early range of motion, in that the brace or orthosis must be removable which is more costly and requires patient compliance. Simply adding weight bearing to the early rehabilitation protocol, however is much easier, and involves changing casts to one that has a weight bearing device, such as a Bohler iron, added.
A recent study looking at long-term outcomes and rerupture rates of the Achilles tendon using a weight-bearing cast fit with a Bohler iron found that only one in 37 patients suffered a rerupture two years after initial injury. Some of the potential side-benefits of early weight bearing may include earlier return to work, higher self-reported functional testing scores, faster gains in ankle plantar flexion strength, and less pain or weakness after cast removal. These side-benefits have not been significant effects reported in the literature, but that is likely due to the lack of research looking at this relatively new nonsurgical approach. At this time the protocols for early weight bearing and early range of motion for non-surgical Achilles tendon repair and very inconsistent and are not research supported. As previously mentioned, basic science supports the concepts of early weight bearing and early range of motion for the beneficial effects it has on the muscle composition and tendon healing.
It is clear that more research is warranted to help surgeons and patients justify their choice of surgical vs. nonsurgical repair and decide to participate in rehabilitation that incorporates early weight bearing and early range of motion. At this time, research does show that non-surgical repair with early weight bearing is a viable option that does not seem to increase risk of rerupture rate or other complications.
Simon Young, et al. Weight Bearing in the Nonoperative Treatment of Acute Achilles Tendon Ruptures. In The Journal of Bone and Joint Surgery. July 2, 2014. Vol 96A. No. 13. Pp 1973-1079.