Achilles Tendon Rupture Treatment & Management

Rehabilitation Program

Physical Therapy

An individual who ruptures his or her Achilles tendon should seek prompt medical treatment. Physical therapy is generally not indicated in the acute phase of treatment, but it later becomes a crucial part of rehabilitation once adequate healing of the tendon has occurred.

The course of treatment (nonoperative vs operative) is determined on a patient-by-patient basis. Typically, both nonoperative and operative treatment options are offered to patients, with particular emphasis on the benefits and risks of each procedure. The recommendations provided in this section regarding operative versus nonoperative treatment are guidelines only and must be personalized to each patient’s needs and condition.

Surgical Intervention

Controversy exists regarding whether to conservatively manage a first-time Achilles tendon rupture or to surgically reconstruct the ruptured tendon. There are distinct benefits and risks for each approach.^{[1, 14, 15, 16, 17]}

According to Kahn et al, there was a consistent finding of an approximately 33% higher rate of complications (other than rerupture) in those treated surgically^[1] ; nonoperatively treated patients had a rerupture rate approximately 3 times higher than those treated surgically, but these patients had minimal risk for other complications. Listed complications resulting from open surgical repair included deep infections (1%), fistulae (3%), necrosis of the skin or tendon (2%), rerupture (2%), and minor complications (percentage not documented).^[1]

Studies indicate that patients who had a percutaneous rather than an open surgical approach had a minimal rate of infection, but it was also demonstrated that there were relatively high rates of injury to the sural nerve.^{[1, 16]}

Conservative repair

Early reports of rerupture in conservatively treated patients noted rates as high as 40%. In newer protocols with shorter immobilization periods, the rates of rerupture appear to be much less and are comparable to the rerupture rate for surgically repaired tendons.

Twaddle and Poon reported on a protocol in which surgical and nonsurgical patients were treated with the same casting and splinting regimen.^[15] Patients in the surgical group underwent Achilles tendon repair using a Krackow procedure, followed by 10 days in a plaster-of-Paris hanging equinus cast, whereas nonsurgical patients were placed directly in the cast. After removal of the cast, patients were placed in a removable below-the-knee orthosis with the ankle at 20º of plantar flexion. They were to remove the splint for 5 minutes of every hour, and while sitting with the leg hanging, practice active dorsiflexion and passive plantar flexion, allowing the foot to fall as far as was comfortable.^[15]

At the 4-week point of the study, the orthosis was brought to neutral, with the same range-of-motion protocol as the previous weeks. At 6 weeks, the patients were allowed to bear weight as tolerated while wearing the orthosis. At this time, they were also allowed to remove the orthosis at night. At 8 weeks, patients were weaned from the brace and then began physical therapy for stretching and strengthening.^[15] There were 3 cases of reruptures, 2 in the surgical and 1 in the nonsurgical group. Of the 2 surgical reruptures, 1 fell down stairs, and the other was hit by a car while trying to stop a robbery. The nonsurgical patient slipped off an embankment at 16 weeks. All reruptures were treated surgically.^[15]

Other, more recent conservative protocols employ a period of nonweight-bearing casting, either above or below the knee, with the foot in equinus for approximately 2-4 weeks, and then serial casting or functional splinting with decreasing degrees of plantar flexion to neutral at 2- to 4-week intervals.

The average time for immobilization in these protocols is 9 weeks. The success and complication rates in this longer treatment protocol appear less favorable than with protocols of shorter duration. Good functional results were reported in the shorter protocols, as were relatively low rates of rerupture. Immobilization in these studies averaged 2 weeks, and follow-up lasted an average of 22.3 months.

In all conservatively treated patients, the rate of skin complications was 0.5% (3 of 578); other minor unspecified general complications accounted for problems in another 8.5% of patients, major complications in 0.6% of patients, and rerupture in 9.8% of patients.

Percutaneous surgery

Ma and Griffith reported on 18 tendon repairs using percutaneous sutures to reapproximate the ruptured stumps.^[18] Through stab wounds, sutures were passed through the distal and proximal ends, which were approximated while the ankle was held in maximal equinus. The sutures were then cut short, tied off using a surgeon’s knot, and pushed subcutaneously. The 6 small wounds were cleaned and dressed with dry, sterile dressings. Afterward, the patients were placed in short leg, nonweight-bearing casts for 4 weeks, followed by 4 weeks in a weight-bearing, low-heeled cast.

In later studies, minor variations of this procedure were employed along with general or local anesthesia. High rates of sural nerve entrapment were reported in these studies, accounting for 16.7% of treated cases. Further studies analyzed outcomes of percutaneous surgery followed by either early mobilization or prolonged immobilization.^[19] Of those mobilized early, 6.6% reported minor wound complications, 3.3% reported major wound complications, 14.8% reported minor general complications, and 0.8% reported major general complications. Of those immobilized, 4.9% reported minor wound complications, 8.5% reported minor general complications, 0.8% reported major general complications and 6.6% reported rerupture.^[19]

Open surgical repair

Open reconstruction is undertaken using a medial longitudinal approach. Medial incisions have the advantage of better visualization of the plantaris tendon, as well as avoidance of injury to the sural nerve. Midline incisions are rarely used because of higher rates of wound complications and adhesions.^[20]

After application of the tourniquet and palpation of the rupture gap, the incision is made through the skin and subcutaneous fat to the paratenon. The paratenon is then divided longitudinally to expose the ruptured ends, which are irrigated and debrided. The ends are then reapproximated and sutured with a heavy nonabsorbable suture using a modified Kessler, Krackow, or Bunnell technique, while being careful not to overtighten.

If the repair is insecure and reinforcement is required, a pull-out wire or multiple interrupted sutures may be used. These may be augmented with a turn-down fascial graft or a woven tendon graft; however, a study by Pajala et al found no advantage for augmented techniques in the surgical repair of fresh complete Achilles tendon rupture.^[21]

Although use of a down-turned gastrocnemius fascia flap (augmented repair) offers the theoretical advantage of stronger pullout strength, Pajala et al's randomized trial in 60 patients who underwent the Krackow locking loop technique showed that mean operative time was 25 minutes longer and the incision was 7 cm longer with augmented versus nonaugmented repair, and no significant difference in outcome between the augmented and nonaugmented repair groups was evident at 3-month and 12-month checkups with regard to pain, stiffness, subjective calf muscle weakness, footwear restrictions, range of ankle motion, overall outcome, isokinetic calf muscle strength, mean peak work-displacement relationships, or tendon elongation.^[21]

Following surgery, the ankle is maintained in flexion as a cast or rigid orthosis is applied. After a period of immobilization, the foot is brought into neutral or slight plantar flexion in a rigid orthosis, and the patient is allowed partial weight bearing. Immobilization is typically discontinued 4-6 weeks after repair. At that point, active and active-assisted range of motion, swimming, stationary cycling, and walking in a shoe fitted with a heel lift can be initiated. In most cases, patients can progress to full activity within 4 months of surgery.^[20]

In general, surgical treatment is advocated for young and athletic individuals who frequently subject their Achilles tendon to relatively high-demand activity. Conservative approaches with lower rerupture rates are being investigated. These conservative protocols show rerupture rates approaching those of surgical rerupture rates and have the advantage of fewer complications, in particular infections of the surgical wound and other wound-related problems.

In summary, operative repair of Achilles tendon ruptures has been reported to have lower rerupture rates; increased postoperative muscle strength, power, and endurance; and an earlier return to activities compared with nonoperative treatment. Wound complications occasionally do occur after operative treatment and may include infection, drainage, sinus formation, and skin sloughing.

Other Treatment

Nonoperative treatment is usually indicated for patients who are elderly and/or inactive, as well as for those with systemic illnesses or poor skin integrity. Patients with diabetes, wound healing problems, vascular disease, neuropathies, or serious systemic comorbidities are encouraged to opt for nonoperative treatment because of the significant risks of operative treatment (eg, infection, wound breakdown, repair dehiscence, perioperative complications).

• A short-leg cast is applied to the affected leg while the ankle is placed in slight plantar flexion (gravity equinus). By keeping the foot in this position, the tendon ends are theoretically better apposed. Cast immobilization is continued for about 6-10 weeks. Forced dorsiflexion is contraindicated. The ankle may gradually be dorsiflexed to a more neutral position after a period of immobilization (~4-6 wk). This position is sustained with serial casting or adjustable ankle orthotics. Walking in the cast is allowed at this time. Following cast removal, a 2-cm heel lift in the shoe is worn for an additional 2-4 months. During this time, a rehabilitation program is initiated.
• Advantages of nonoperative treatment include no wound complications (eg, skin breakdown, infection, scar formation, neurovascular injury), decreased hospital costs and physician fees, lower morbidity, and no exposure to anesthesia.
• Disadvantages of nonoperative treatment include a higher incidence of rerupture (up to 40%) and more difficult surgical repair following rerupture. In addition, the tendon edges may heal in an elongated position because of a gap in the unapposed tendon ends, resulting in decreased plantar flexion power and endurance.

Rehabilitation Program

Physical Therapy

Following cast removal, gentle passive range of motion of the ankle and subtalar joints is initiated. After 2 weeks, progressive resistance exercises (PREs) are added to the regimen. This is followed by aggressive gait training exercises at about 10 weeks following the injury (nonoperative patients) or surgery (operative patients), leading toward activity-specific maneuvers and a return to activities at 4-6 months. The patient's recovery is largely dependent on the quality of the rehabilitation program, his/her motivation and focus, as well as his/her desired postinjury activity level.