Clinical Kit 11-03-2015 Acute Achilles Rupture - What would you advise?

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I am not sure about your situation, but in our practice and small rural community, we are occasionally faced with the situation of providing professional advice on the management of acute achilles injuries, including ruptures. I have previously blogged on managing tendonopathy, you can review these;

while this Clinical Kit will be focusing on acute achilles rupture.

Achilles Rupture

Background: To date, studies directly comparing the rerupture rate in patients with an Achilles tendon rupture who are treated with surgical repair with the rate in patients treated nonoperatively have been inconclusive but the pooled relative risk of rerupture favored surgical repair. In most studies the ankle is immobilized for six to eight weeks. Published studies of animals and humans have shown a benefit of early functional stimulus to healing tendons. The purpose of this Cllinical Kit was to consolidate 2 research articles (European 2010) and one review article (USA 2015) looking at the outcomes of patients with an acute Achilles tendon rupture treated with operative repair and accelerated functional rehabilitation with the outcomes of similar patients treated with accelerated functional rehabilitation alone.

European Article 1: Willits et al

A total of 144 patients (seventy-two treated operatively and seventy-two treated nonoperatively) were randomized. There were 118 males and twenty-six females, and the mean age (and standard deviation) was 40.4 ± 8.8 years. Rerupture occurred in two patients in the operative group and in three patients in the nonoperative group. There was no clinically important difference between groups with regard to strength, range of motion, calf circumference, or Leppilahti score. There were thirteen complications in the operative group and six in the nonoperative group, with the main difference being the greater number of soft-tissue-related complications in the operative group.

The Functional Rehabilitation Program

Clients started in a back slab (NWB) for 2 weeks. From 2-6 weeks protected weight bearing and an Aircast walking boot with a 2 cm lift (approximately holds ankle in 20 plantarflexion). Commencement of hip and knee exercises, cardio (deep water running, single leg exercise bike and hydrotherapy) but with ankle remaining in plantarflexion at all times. At 6 -8 weeks the heel lift was removed, bilateral cardio started, and gentle stretching into dorsiflexion commenced. At 8 -12 weeks the brace was weaned (return to crutches if necessary) and increase range, strength and proprioception drills. After 12 weeks sport specific, plyometrics, power and endurance commenced.

Conclusion: It appears, that the addition of early weight-bearing and mobilization may have resulted in a substantially reduced rate of rerupture (4.6%). This study supports accelerated functional rehabilitation and nonoperative treatment for acute Achilles tendon ruptures. All measured outcomes of nonoperative treatment were acceptable and were clinically similar to those of operative treatment. In addition, this study suggests that the application of a nonoperative protocol involving accelerated rehabilitation will avoid serious complications related to surgical management.

European Article 2: Nilsson-Helander et al

There were 6 (12%) reruptures in the nonoperative group and 2 (4%) in the operative group (P=0.377). The mean 6 and 12 month achilles tendon total rupture score (ATRS) were 72 and 88 points in the operative group and 71 and 86 points in the nonoperative group, respectively. Improvements in ATRS between 6 and 12 months were significant for both groups, with no significant between-group differences. At the 6-month evaluation, the operative group had better results compared with the nonoperative treated group in some of the muscle function tests; however, at the 12-month evaluation there were no differences between the 2 groups except for the heel-rise work test in favor of the operative group. At the 12-month follow-up, the level of function of the injured leg remained significantly lower than that of the uninjured leg in both groups.

The Functional Rehabilitation Program

Clients started in a back slab (NWB) for 2 weeks. This was followed by 6 weeks in a Donjoy brace. At 2 weekly intervals the brace was moved from 30 degrees plantar flexion, to 10 degrees plantarflexion to 10 degrees dorsiflexion. Weight bearing as tolerated was allowed after 6 to 8 weeks. At 8 weeks the client moved in shoes (1.5 cm heel) and commenced a rehabilitation program;

Exercise bike
Ankle range of motion
Sitting heel-rise, Standing heel-rise (2 legs)
Gait training
Balance exercises
Leg press
Leg extension and leg curl

This was progressed with plyometrics and rebounding starting around weeks 16-18 and jogging at 20 weeks.

Conclusion: Results of this study did not demonstrate any statistically significant difference between operative and nonoperative treatment. Furthermore, the study indicates that early mobilization is beneficial for patients with acute achilles tendon rupture, whether they are treated operative or nonoperative.

USA Article Wang et al

From 2007 to 2011 in total, 12,570 patients were treated for an acute Achilles tendon rupture. The ratio of operative to nonoperative treatment increased from 1.41 to 1.65. Males were more likely to undergo surgery than females. There were no significant differences in short-term rerupture rate for operative (2.1%) versus nonoperative (2.4%) treatment. The proportion of patients who received operative treatment for an acute Achilles tendon rupture increased slightly during the 5-year period, suggesting that surgeons in the United States have been slower to adopt nonoperative treatment than their European counterparts.

General Comments

USA model has a stronger tendency to surgery, even though European data showing no significance in rerupture rates or physical outcome measures, but more complications and greater financial cost
In addition to rerupture rates, need to also take into consideration surgery specific complications; DVT, pulmonary embolism, deep and superficial infection, scar keloid, adhesions and irritations cf. non operative
Protected weight bearing needs to be around 6- 8 weeks. I test this around 4 weeks with Thomson squeeze test. If there is a responding plantarflexion, I start very gentle PF isometrics
At 12 months all outcome measures including rerupture & client satisfaction, between operative and non operative were non significant
Comparisons between injured and non-injured limbs in both groups, showed a 100% gain in dorsiflexion and 80% plantar flexion strength at 12 months. Willits et al study followed their groups for 2 years and found the results unchanged.

References

Nilsson-Helander, K et al. Acute Achilles Tendon Rupture. A Randomized, Controlled Study Comparing Surgical and Nonsurgical Treatments Using Validated Outcome Measures. Am J Sports Med 2010 38: 2186.

Willits K et al. Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures.A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation. J Bone Joint Surg Am. 2010;92:2767-75.

Wang, D et al. Operative versus nonoperative treatment of acute Achilles tendon rupture: An analysis of 12,570 patients in a large healthcare database Foot and Ankle Surgery 2015. Article in press.

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Doug Cary FACP
Specialist Musculoskeletal Physiotherapist (awarded by Australian College of Physiotherapy, 2009)
PhD Candidate Curtin University
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