Treatment of Achilles Tendon Rupture: What Do the Experts Say?
Researchers from the University of Western Australia are well-known for their reports and findings about Achilles tendon ruptures. Less than 10 years ago, they published a report on the use of splinting to treat this problem. Now they address the results between surgery and conservative care for this same type of injury.
The Achilles tendon is a strong, fibrous band that connects the calf muscle to the heel. The calf is actually formed by two muscles, the underlying soleus and the thick outer gastrocnemius. Together, they form the gastroc-soleus muscle group. When they contract, they pull on the Achilles tendon, causing your foot to point down and helping you rise on your toes. This powerful muscle group helps when you sprint, jump, or climb. Several different problems can occur that affect the Achilles tendon, some rather minor and some quite severe.
These problems affect athletes most often, especially runners, basketball players, and anyone engaged in jumping sports. They are also common among both active and sedentary (inactive) middle-aged adults. These problems cause pain at the back of the calf. Severe cases may result in a rupture of the Achilles tendon.
The best way to manage acute Achilles tendon ruptures has not been discovered. One important outcome of successful treatment is to avoid rerupture or other complications (e.g., infection, bleeding into the muscle, adhesions, altered skin sensation, blood clots). This meta-analysis of 14 studies with over 1000 patients provides some helpful information.
All patients were adults who had injured their Achilles tendon in the previous three weeks. Most were males who were engaged in athletic activities at the time of their injury. Analysis of all the data collected from the studies showed the following:
There were fewer cases of rerupture when patients had surgery to repair the torn tendon.
When short-term immobilization in a cast is followed by the use of a functional brace, rates of re-rupture were the same as with surgery. This approach is referred to as accelerated rehabilitation.
The best way to avoid rerupture appears to be with surgical intervention followed by cast immobilization.
The highest rate of reruptures occurred in patients treated nonoperatively just with cast immobilization.
Complications (other than rerupture) were higher in the surgical patients.
Sports athletes or other participants in sports activities can expect to get back to full swing of daily activities and sports involvement six months after surgery. Whether the surgery is done percutaneously (through the skin) or with open incisions doesn't seem to affect the results in terms of the rerupture rate. Patients in the open incision group had significantly higher rates of postoperative infection.
Despite the studies already done, we still don't know whether or not bracing right away should be the recommended treatment. We don't know if speeding up rehab is a better way to go compared with immobilizing the leg in a cast and giving it time to heal. And it's unclear why more people than ever before are injuring this part of the body.
The authors say what is clear: the need for more, large randomized controlled trials to compare different treatment approaches. Surgeons and other physicians treating this problem need evidence-based guidelines for the early treatment of acute Achilles tendon injuries. High-quality, well-designed studies with clear methodology are needed!
And a final note for surgeons: comparing different surgical techniques is also in need of some good, high-quality study designs. For now, with the limited number of studies available, the authors suggest that the six-strand repair method is not better or more advantageous than the two-strand repair. More complex reconstructions (over simple surgical repairs) don't really yield better results either.
Matthew P. Jones, MBBS, BSc, et al. Surgical Interventions for Treating Acute Achilles Tendon Rupture: Key Findings from a Recent Cochrane Review. In The Journal of Bone and Joint Surgery. June 20, 2012. Vol. 94A. No. 12. Pp. e88(1)-e88(6).