Approach Considerations
Medical therapy for a patient with an Achilles tendon rupture consists of rest, pain control, serial casting, and rehabilitation to maximize function. [58] Ongoing debate surrounds the issue of whether medical or surgical therapy is more appropriate for this injury. [4, 5]
Surgical techniques for rupture repair are varied but usually involve reapproximation of the torn ends of the Achilles tendon, sometimes reinforced by the gastrocsoleus aponeurosis or plantaris tendon.
Overall healing rates with serial casting are similar to those of surgical reanastomosis, yet the return-to-activity benefits of surgery are debated.
Medical therapy for Achilles tendinosis and paratenonitis includes activity modification, orthotic therapy, physical therapy, and analgesic anti-inflammatory medication. [59, 60, 61, 3]
Deterrence
As with gastrocsoleus muscle strains, prevention of Achilles tendon injuries involves adequate stretching and conditioning prior to physical activity, especially for new activities or ones at higher levels of intensity. [62]
Conservative Management of Achilles Tendon Rupture
Nonoperative treatment for Achilles tendon rupture 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, neurovascular injury, perioperative complications).
Activity modification for a ruptured Achilles tendon requires crutch ambulation without weight bearing. Once initiated, serial casting dictates the activity level.
Overall healing rates with casting are similar to those associated with surgical reanastomosis, yet the return-to-activity benefits of surgery are debated. Nonetheless, this is viable therapy, especially for more sedentary patients and older persons. The initial cast applied is a long-leg cast with some knee flexion and ankle plantar flexion to allow free edges of the Achilles to approximate. The cast is changed in series, decreasing the plantar flexion and eventually moving toward short-leg casts in a neutral ankle position. This treatment lasts 6-12 weeks.
Serial casting usually results in some Achilles contracture, and heel lifts are used afterwards. Depending on the degree of shortening and rate and aggressiveness of physical therapy, initiate use of 1- to 2-inch heel lifts with gradual weekly or biweekly adjustment directed toward weaning the patient off of them.
Advantages of nonoperative treatment include no wound complications, 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.
In a randomized, controlled trial by Maempel et al, patient-reported outcomes at mean 15.7-year follow-up indicated that nonoperative therapy for acute Achilles tendon rupture is just as effective as surgical treatment. For example, between the operative (33 patients) and nonoperative (31 patients) groups, the investigators found no statistically significant difference in scores for the Short Musculoskeletal Function Assessment (SMFA) Dysfunction Index, the SMFA Bother Index, the Achilles Tendon Total Rupture Score (ATRS), and the five-level EuroQol five-dimension (EQ-5D-5L) instrument. Moreover, in contrast to the statement in the previous paragraph, rerupture rates did not demonstrably differ between the two groups. [63]
Similar to the Maempel trial, a study by Ecker et al found good functional outcome and patient satisfaction following nonoperative treatment for acute Achilles tendon rupture. The study, in which 114 patients were followed up for at least 12 months, reported a mean Thermann score of 82 in these individuals, with 90% of patients rating their subjective satisfaction with the treatment results as “good” or “very good.” The therapy combined the use of an equinus cast and a rehabilitation boot, allowing patients to immediately bear full weight, as well as undergo early functional rehabilitation. The study found tendon length and muscle strength to be inversely proportional but stated that the equinus cast and boot can discourage excessive lengthening of the healing tendon. [64]
Conservative Management of Achilles Tendinosis and Paratenonitis
Paratenonitis
Relative rest from activities that involve forceful and repetitive ankle plantarflexion are recommended. In athletes wishing to maintain conditioning while waiting for the injury to heal, cross training with activities that do not involve forceful plantarflexion can be employed. Examples of these exercises are swimming, biking (with the pedal on the heel), and aqua jogging. In mild cases, runners may continue to run and still allow their injury to heal by simply reducing their mileage and eliminating hills for a while. In severe cases, complete rest with crutches or a walking cast or boot may be needed for a short time.
Initially for acute Achilles paratenonitis, icing and nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce inflammation and pain are often helpful. [7]
Heel lifts of 10-15 mm for short-term use my reduce symptoms by reducing the stress and excursion of the tendon.
Fluoroquinolones should be avoided, as these agents have been associated with Achilles tendinosis and rupture.
Tendinosis
The initial treatment for tendinosis is similar to paratenonitis (above), although tendinosis tends to be less responsive to NSAIDs and ice, unless there is concomitant paratenonitis. Treatment has shifted away from traditional treatments and focuses more on intense eccentric strengthening exercises. [7]
Some clinicians feel that patients with Achilles tendinosis are predisposed to rupture and should be protected, but this is controversial.
Physical therapy
Physical therapy for patients with Achilles tendinosis consists of the following stages:
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In the first and part of the second phase of physical therapy, pain is used to guide the intensity of exercise; active ankle dorsiflexion with gentle calf stretching is performed
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In the intermediate phase, strengthening replaces active ROM, and neuromuscular control programs are initiated
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In the third phase of rehabilitation, progressive stress is applied under good control to allow the collagen to form appropriately; as pain resolves, aggressive stretching and active resisted motion are performed
Achilles tendinosis is best prevented and treated by preserving good ROM in the heel cord complex. Such motion can be gained with the use of an incline board, wall leans, or "foot-on-chair" stretching exercises. Application of moist heat or compresses before workouts and at night is beneficial. Cold modalities should be used following strenuous activities to provide pain relief and anti-inflammatory effects.
Correction of strength and flexibility deficits of the muscle-tendon unit in Achilles tendinosis, along with ultrasonography, phonophoresis, and other modalities, can be used. [7, 65] This can be done under the supervision of a physical therapist or from instructions or handouts from the physician. Calf stretches should be done with the knee in both extension (to stretch the gastrocnemius muscle) and flexion (to stretch the soleus muscle).
The cornerstone of strengthening is now the use of eccentric exercises, with most patients achieving 60-90% pain relief. [7, 8, 9] As with stretching, strengthening should be done with the knee in extension and flexion. A heavy-load, eccentric, calf-strengthening program has been shown to be highly beneficial for treating resistant tendinosis in runners and for getting them back to full activity. [66, 67] Investigators have evaluated the close correlation between good clinical results with eccentric training and a marked reduction in neovascularization of the tendon. [26]
Cross training with low-impact exercises can begin during this phase. If pain develops, the athlete should decrease the amount of activity 1 level to alleviate the pain.
If the individual is pain free with low-impact activity, the athlete can begin sport-specific training. If pain develops as activity is escalated, the patient should decrease the level of activity to one that does not cause pain.
Care must be taken to not commit another training error if that is what initially caused the tendinosis. The patient should warm up the muscle-tendon unit well before engaging in vigorous activity, such as sprinting and jumping.
In chronic, refractory cases of paratenonitis and tendinosis with a tight heel cord despite stretching, a “night splint” can be used. [68] This orthosis is similar to an orthopedic boot and is worn at night, keeping the ankle at 5° dorsiflexion.
In refractory cases with hyperpronation, a custom orthotic with a medial heel posting may be tried.
Orthotics
Orthotic therapy in Achilles tendinosis consists of the use of heel lifts; however, lifts usually are not used to the extent they are after serial casting for rupture. The goal is for the patient eventually to use conventional shoes.
Orthotic devices most often are used bilaterally to prevent a gait imbalance. Since overpronation and cavus foot deformities can cause tendinosis, custom orthotics to correct overpronation or shock-absorbing shoes for cavus deformities can alleviate pain as well.
NSAID therapy
Paratenonitis
Initially for acute Achilles paratenonitis, icing and nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce inflammation and pain are often helpful. [7]
Tendinosis
Logic dictates that anti-inflammatories should not help in tendinosis because this is not an inflammatory condition. Indeed, studies have shown no clinical benefit from NSAIDs. However, they do appear to have some effect, and most physicians use NSAIDs in nonoperative treatment regimens. This practice persists because NSAIDs enable the patient to ignore mild symptoms.
Results of laboratory studies have suggested alternate roles for the NSAID effect, wherein tendon healing is improved. Findings from other studies have suggested that a reduction in the neutrophil and macrophage count occurs within the tendon; however, these counts are known to be limited in true tendinosis anyway. [69]
Steroid injections
Steroid injections are still controversial. They can certainly provide short-term relief of painful symptoms; however, whether steroids can aid healing and should still be used as part of the tendinosis treatment regimen is open to debate. [40]
Moreover, steroid injections, especially multiple injections, may weaken the tendon, leading to tendon rupture. Indeed, Astrom found that corticosteroid injection was the only predictor of partial tendon tears in a large series of chronic Achilles tendinoses that eventually required surgery. [49]
Sclerosis of vessels
A small study has shown improvement in symptoms after the injection of a sclerosing agent (polidocanol) in painful Achilles tendinosis. The assumption is that the sclerosant reduces neovascularization and, therefore, pain. In this trial, 10 patients were monitored for 6 months, with 8 having a reduction of symptoms. [70] In a similar study of 25 patients (26 tendons) injected with polidocanol for Achilles tendinosis, 19 patients (20 tendons) reported good-to-excellent results at 6-12 months’ follow-up. [71]
Platelet injections
Platelet-rich plasma (PRP) injections have become popular for refractory tendinosis, particularly chronic lateral epicondylitis. Results of studies on the effectiveness of PRP injections have been mixed. With regard to Achilles tendinosis, some study results have indicated no difference in outcome between intratendinous PRP injections and saline injections at 1 year, whereas other studies have shown moderate (>50%) improvement of symptoms. [72, 73, 74]
Nitric oxide
Nitric oxide has been shown to “stimulate collagen synthesis in fibroblasts”—the major cell population found in healing tendon tissue—and “promote tendon remodeling.” [75, 76] Many studies have shown that increasing nitric oxide in the area of injury “improved tendon healing through collagen reorganization and tissue mass loss.” [75, 76]
Nitric oxide is used most frequently in the form of a nitroglycerin transdermal patch. One quarter of a 5-mg patch used daily for 12-24 weeks has been suggested. However, it should not be used in combination with drugs used to treat erectile dysfunction or pulmonary hypertension (eg, sildenafil, tadalafil). In addition, precaution should be observed with coadministration of rosiglitazone, certain drugs used to treat migraine headaches (ergot alkaloids such as ergotamine), and drugs that lower blood pressure (including alpha blockers such as tamsulosin).
Shock-wave therapy
Extracorporeal shock-wave therapy (ESWT) has been a source of interest for treating chronic insertional and noninsertional Achilles tendinosis. Evolving data have been extremely positive, indicating that low-energy ESWT can improve pain and function by increasing blood flow to the chronic tendinosis. [77]
High-energy ESWT has also shown promise as a treatment for insertional Achilles tendinosis. One study demonstrated that a single treatment was more effective than traditional conservative treatment in improving pain and enabling patients to return to their activities.
In a randomized, controlled study of the use of eccentric loading versus the use of eccentric loading plus shock-wave treatment for chronic midportion Achilles tendinosis, at 4-month follow-up, eccentric loading alone was less effective than the combination therapy (56% vs 82% completely recovered or much improved on the Likert scale). At 1-year follow-up, however, the difference had greatly diminished. [78]
Actovegin therapy
Pforringer compared subcutaneous injections of Actovegin (a deproteinized calf-blood extract) with subcutaneous injections of placebo. The Actovegin treatment significantly reduced pain, but the patients were monitored for only 3 weeks. [79]
Friction massage
Sparse clinical evidence supports the use of deep friction massage. A Cochrane review in 2002 showed no obvious benefit, although the reviewers were not evaluating Achilles tendons in particular. [80]
Acupuncture
For patients who want to also use complementary and alternative medicine modalities, studies have shown that acupuncture improves pain and function compared with eccentric exercises alone. [81] This can be a beneficial adjunct to offer patients.
Surgical Repair of Achilles Tendon Rupture
Conservative versus surgical treatment
Surgical techniques are varied and usually involve reapproximation of the torn ends of the Achilles tendon, sometimes reinforced by the gastrocsoleus aponeurosis or plantaris tendon. 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 associated with each approach. [4, 5, 82, 6, 83, 84, 85]
Advocates of conservative treatment cite the similar results between conservative and surgical treatment when looking at ROM, strength, power, and functional levels as a reason for avoiding surgery. Surgical advocates argue that full function is achieved more quickly with surgical therapy than with conservative therapy, especially for athletic individuals. The surgical approach is supported by a lower rate of rerupture, greater postoperative power, and low infection rate. [86]
A systematic review by Erickson et al of Achilles tendon rupture meta-analyses indicated that surgical treatment is associated with fewer reruptures and, possibly, an earlier return to work than conservative therapy, while nonoperative treatment reduces the risk of minor complications. [87]
A meta-analysis by Amendola of randomized, controlled trials found a rerupture rate of 8.8% in nonoperative Achilles tendon rupture repair, compared with 3.6% in patients treated operatively, over a 10- to 36-month follow-up period. However, the nonrupture complication rates, as follow, tended to be higher in surgical repair than in nonoperative treatment [88] :
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Deep infection: 2.36% (surgical); 0% (nonsurgical)
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Noncosmetic scar complaints (pooled rate): 13.1% (surgical); 0.62% (nonsurgical)
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Sural nerve sensory disturbances (pooled rate): 8.76% (surgical); 0.78% (nonsurgical)
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Deep venous thrombosis (pooled rate): No significant difference
Conservative clinicians state that, with early application and prolonged duration of casting, the rerupture rate is decreased significantly in nonsurgical repair. A study by Twaddle and Poon indicated that the use of controlled, early motion in the rehabilitation of patients receiving either surgical or conservative treatment results in comparable functional outcomes and low rerupture rates.
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. [89]
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, with the surgeon 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. [90]
A study by Park et al suggested that absorbable sutures may be just as effective as non-absorbable ones when repairing acute Achilles tendon ruptures. Thirty-seven patients were treated via the Krackow technique, using either braided absorbable polyglactin sutures or braided nonabsorbable polyethylene terephthalate sutures. The investigators found that at 12-month follow-up, both groups demonstrated comparable results with regard to isokinetic plantar flexion strength, the Achilles tendon Total Rupture Score (ATRS), the visual analogue scale (VAS) score for pain, and the EuroQoL five-dimension health questionnaire (EQ-5D). Re-rupture was found in neither group. [91]
Augmented repair
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.
Moreover, no significant difference in outcome between the augmented and nonaugmented repair groups was evident at 3- 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. [90]
Postsurgical care
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 (ROM) exercises (20 min twice daily), 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. [89]
Percutaneous surgery
Studies indicate that patients who undergo percutaneous, rather than an open, Achilles tendon rupture repair have a minimal rate of infection but a high rate of sural nerve entrapment (16.7% of treated cases). [6]
Surgical Treatment of Achilles Tendinosis and Paratenonitis
In paratenonitis, fibrotic adhesions and nodules are excised, freeing up the tendon. Longitudinal tenotomies may be performed to decompress the tendon. Satisfactory results have been obtained in 75-100% of cases.
In tendinosis, in addition to the above procedures, the degenerated portions of the tendon and any osteophytes are excised. Haglund’s deformity, if present, is removed. If the remaining tendon is too thin and weak, the plantaris or flexor hallucis longus tendon can be weaved through the Achilles tendon to provide more strength. The outcome is generally less favorable than it is in paratenonitis surgery.
Operative brisement (ie, injection of dilute anesthetic into the paratenon sheath under ultrasonographic guidance to break up adhesions) may be useful in patients with paratenonitis or tendinosis with paratenonitis.
More complex surgical problems, such as concurrent partial rupture of the tendon, may require the use of synthetic allografts or autografts from the flexor hallucis longus, semitendinosus, or gracilis muscle. [92]
While the reasons are not precisely known, surgery tends not to be as successful in nonathletic individuals with chronic Achilles tendinosis. Nonathletic patients tend to have a more prolonged recovery and a greater risk of complications, and they are more likely to need further surgery.
Follow-up
In a study of 78 patients with ruptured Achilles tendon, Silbernagel et al concluded that in evaluating the efficacy of treatment for tendon rupture, measuring both the number of heel-rise repetitions that patients could perform and the height of each heel rise was a better means of determining differences between injured and uninjured legs than was measurement of heel-rise repetitions alone. [93]
Employing a limb symmetry index (LSI) to determine differences in calf muscle strength between the patients' injured and uninjured legs, the authors found that 6 months after tendon rupture, the patients' mean LSI for the number of repetitions was 84%, but the mean LSI for the height/repetition combination was only 61%. At 1-year follow-up, the mean heel-rise repetition LSI was 95%, but the height/repetition LSI was only 76%.
