Achilles Tendon Acute Rupture

Introduction

Achilles tendon rupture is a common injury. It has a male to female ratio of 4.8:1. It affects athletes and those of middle-age.

 

Presentation

  • Acute pain in Achilles tendon
  • 'Pop' may be felt or heard
  • Difficulty in bearing weight or walking due to pain and weakness
  • Follows sudden acceleration activity e.g. playing raquet sports, running for a bus

 

History and Examination

Thorough history and examination are required to differentiate from:

  • Deep vein thrombosis
  • Stress fracture
  • Claudication

Clinical tests include Simmonds' triad:

  • Calf squeeze
  • Altered angle of declination
  • Palpable gap

The combination of all three signs confirms the injury in the vast majority of cases.

 

Imaging

Presentation with pain and swelling at the insertion will require plain radiographs to exclude a tongue type calcaneal fracture.

Ultrasound is useful to identify if the rupture is mid-substance or at the myotendinous junction; partial or complete and; gap between the ends of the tendon and how much this reduces to on plantar flexion. All these factors will influence how management proceeds.

 

Aetiology

Aetiology is multifactorial and risk factors include:

  • Increased physical activity
  • Use of quinolones e.g. ciprofloxacin
  • Use of corticosteroids
  • Increasing age
  • Male gender

Olsson et al. found that increasing age and higher BMI were strong and significant predictors of decreased function and having a greater degree of symptoms after 1 year of injury. They also noted major functional deficits and decreased physical activity level persist for 2 years after acute Achilles rupture, in those players who returned to sports, regardless of surgical or non-surgical treatment.

Approximately 78 % of ruptures occur in athletic activities during a sudden acceleration and deceleration. 

 

​Management

Initial management tends to involve immobilsation in a backslab plaster but beyond this, there is controversy regarding the optimal treatment for acute Achilles tendon ruptures with both conservative and surgical treatments reported with variable results and complications rates. Surgical repair can be open, minimally invasive or percutaneous. The decision for treatment in patients with an Achilles tendon rupture should be individualized as patients with high activity levels or challenging jobs may accept the risk of a higher complication rate to reduce the rate of re-rupture while less active patients or those with comorbidities may choose the nonoperative route to decrease the risk of infection, adhesions, and other complications. Inappropriate treatment of Achilles tendon ruptures can lead to considerable functional impairment.

​

Conservative vs. Surgical Treatment

For decades, open surgical intervention was considered the gold standard for acute Achilles ruptures due to a concern for an unacceptable rate of re-rupture with conservative treatment. However, over the last 15 years, the incidence of surgical intervention has decreased despite the overall incidence of ruptures increasing. The paradigm shift to increased non-operative management is concurrent with multiple well-designed randomized controlled trials comparing operative and non-operative treatments of acute Achilles ruptures with comparable results.

Erickson et al. performed a systematic review of overlapping meta-analyses comparing nonoperative and operative treatments. A total of 5842 patients were included. Seven studies found a higher rate of re-rupture in the nonoperative group but a higher rate of complications in the operative group. One study found no differences in re-rupture or complication rates, and 1 study found surgery decreased re-rupture rates only when compared with nonoperative treatment without a functional brace. Three studies also identified an earlier return to work in the operative group.

The meta-analysis by Soroceanu et al. compared the surgical and nonsurgical management of Achilles tendon ruptures with regards to the re-rupture rate, overall rate of other complications, return to work, strength, calf circumference and functional outcomes and explored the effects of early range of motion on the re-rupture rate. Surgical treatment included open or minimally invasive techniques, and nonsurgical management included casting or splinting. Ten studies were included consisting of 418 patients treated surgically and 408 patients treated nonsurgically. The results showed that if a functional rehabilitation protocol with early range of motion was used, surgical and nonsurgical treatments were equivalent with regards to the re-rupture rate suggesting that no absolute risk reduction was achieved with surgical treatment. However, if the treatment protocol used after the rupture included prolonged immobilization, the absolute reduction in the re-rupture risk obtained by surgical intervention was 8.8%. Patients undergoing surgery returned to work an average of 19 days sooner than patients treated nonsurgically. The difference in active plantarflexion between the 2 groups was not clinically important, and no significant differences were found between nonsurgical and surgical treatment with regards to calf circumference, strength, or functional outcomes.

Lim et al. in a recent prospective level II study on 132 patients with an average follow up of 6.5 years, reported no significant difference detectable in ATRS (Achilles tendon total rupture score) between operative and nonoperative treatments of acute Achilles tendon ruptures using an identical rehabilitation program with functional bracing.

In a prospective randomized trial comparing surgical and nonsurgical treatment of acute ruptures, Lantto et al. found similar results between the two options in Achilles tendon performance scores but found surgery restored calf muscle strength earlier with maintained increased strength at 18 months.

Keating et al. in the recent prospective randomised trial found that operative repair was associated initially with increased range of ankle movement and plantarflexion power when compared with cast management, however by 26 weeks there was no difference between the two groups.

 

Percutaneous vs Open Surgical Repair

It is generally recommended that percutaneous repairs are performed within 2 weeks of injury to reduce the risk of adhesion formation in the retracted state and to prevent end-to-end juxtaposition. Khan et al. found that the percutaneous surgical repair resulted in a lower complication rate than open surgery.

McMahon et al. performed a meta-analysis to compare the outcomes of open versus percutaneous minimally invasive surgical repair of Achilles tendon ruptures. The results showed that while there were no differences in re-rupture rate, tissue adhesion formation, and deep infection, the percutaneous technique had a significantly lower rate of superficial wound infections. Hence, as superficial infection is a common complication plaguing patients who undergo surgical treatment of Achilles tendon ruptures, thought should be given to using percutaneous techniques to minimize wound complications postoperatively.

Percutaneous techniques have been found to have a complication profile superior to that of both conservative and open operative techniques. A systematic review of 13 studies, including 670 patients, treated with a variety of percutaneous repair techniques was performed by Ververidis et al. They found re-rupture rate of 2%. The most frequent complication was sural nerve damage. Average functional outcomes were excellent. Up to 91.4% continued practicing sports after surgery and 78–84% returned to the same or higher sports level with an average time of return was 18 weeks.

Carmont et al. reported that there was no significant difference in complications between percutaneous and open surgical techniques: (Open 35 vs. Percutaneous 49 patients). overall rates 14.3 versus 10.4 %: infection; 2.7 versus 2.0 %, transient sural nerve damage: 5.6 versus 8.1 %, wound breakdown: 2.8 versus 0.0 %, re-rupture: 2.8 versus 2.0 %. Achilles Total Rupture Scores (ATRS) were comparable at 12 months. Theatre occupancy and hospital stay were significantly longer with open repair (43 min and 2.9 days) compared to percutaneous repair (15 min and 1.2 days). Excluding the costs of running the operating theatre, they estimated the costs of surgery for open repair to be £935 and percutaneous repair to be £574.They suggested that percutaneous repair resulted in reduced costs and yet had comparable outcome and complications rates to open repair.

​

Rehabilitation

Based on the reports of high-level clinical studies and meta-analyses the results of early functional rehabilitation have been found superior over conventional immobilization.

Suchak et al. conducted a meta-analysis that analyzed the results of postoperative early functional treatment versus cast immobilization. It was reported that early functional treatment would lead to better subjective responses with no increasing re-ruptures. Another analysis performed by Khan et al. reported that patients who underwent an early functional regimen had a similar re-rupture rate but a significantly lower rate of other complications compared with patients who were cast immobilized. However, because early functional rehabilitation consists of 2 different regimens, which was not addressed in their meta-analyses, the validity of their results may be questionable. The outcome measurements such as the functional scale assessment, time to recovery, tendon elongation, muscle strength, and ankle range of motion have also not been evaluated in this meta-analysis, notwithstanding the vital importance of these parameters in the postoperative management of AT ruptures.

A systematic review of meta-analyses by Wang et al. demonstrated that after the surgical repair of acute ruptures, the patients who underwent early weightbearing combined with ankle motion exercises achieved significantly superior clinical results and satisfaction rates than those patients who received conventional immobilization.

Maffulli et al. indicated that the improved subjective satisfaction rates were mainly related to the shorter recovery time and less negative influences on daily life, such as the use of crutches. A greater number of patients who were treated with early weightbearing and ankle motion exercises exhibited the restoration of normal ankle range of motion and significant improvement in strength recovery parameters such as the calf circumference, heel-raise test, and percentage of plantarflexion strength loss.

Animal studies have demonstrated that early loading rehabilitation could improve tendon characteristics through the maturation and orientation of collagen fibers as well as decreased muscle atrophy. It is considered to stimulate the activity of fibroblasts and the synthesis of type III collagen. Kearney and Costa demonstrated a trend towards early full weightbearing after the surgical repair of AT ruptures.

​Clinical practice guidelines on the treatment of AT ruptures from the American Academy of Orthopaedic Surgeons also provide a moderate recommendation for the use of this postoperative rehabilitation method. The ankle is initially positioned in plantar flexion during weight loading and gradually shifted to a neutral position after 3.5 weeks on an average. Barefoot weightbearing is usually allowed at a minimum of 4 weeks after surgery. A systematic review conducted by Kearney et al. reported diversity among protocols for immediate weightbearing at present, and their efficacy remains unclear.

The STAR (study of tendo Achilles rehabilitation) trial is a multicentre randomised trial of plaster cast immobilisation versus functional bracing for patients with a non-operatively managed Achilles tendon rupture. It identified that traditional plaster casting was not found to be superior to early weight-bearing in a functional brace.

 

References

  • Maffulli N, Tallon C,Wong J, Lim KP, Bleakney R. Early weight-bearing and ankle mobilization after open repair of acute midsubstance tears of the Achilles tendon. Am J Sports Med. 2003;31:692-700.

  • Metz R, Verleisdonk EJ, van der Heijden GJ, et al. Acute Achilles tendon rupture: minimally invasive surgery versus nonoperative treatment with immediate full weightbearing. A randomized controlled trial. Am J Sports Med. 2008;36 (9):1688-1694.

  • Costa ML, MacMillan K, Halliday D, et al. Randomised controlled trials of immediate weight-bearing mobilisation for rupture of the tendoAchillis. J Bone Joint Surg Am. 2006;88:69-77.

  • Kangas J, Pajala A, Siira P, Hamalainen M, Leppilahti J. Early functional treatment versus early immobilization in tension of the musculo tendinous unit after Achilles rupture repair. J Trauma. 2003;54(6):1171-1180.

  • Kearney RS, McGuinness KR, Achten J, Costa ML. A systematic review of early rehabilitation methods following a rupture of the Achilles tendon. Physiotherapy. 2012;98(1):24-32.

  • Khan RJ, Fick D, Keogh A, Crawford J, Brammar T, Parker M. Treatment of acute Achilles tendon ruptures: a meta-analysis of randomized, controlled trials. J Bone Joint Surg Am. 2005;87(10):2202-2210.

  • Soroceanu A, Sidhwa F, Aarabi S, Kaufman A, Glazebrook M. Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials. Am J Sports Med. 2012;40 (9): 2154-2160.

  • Suchak AA, Spooner C, Reid DC, Jomha NM. Postoperative rehabilitation protocols for Achilles tendon ruptures: a metaanalysis. Clin Orthop Relat Res. 2006;445:216-221.

  • Wong J, Barrass V, Maffulli N. Quantitative review of operative and nonoperative management of Achilles tendon ruptures. Am J Sports Med. 2002;30:565-575.

  • Jiazhang Huang, Chen Wang, Xin Ma, Xu Wang,Chao Zhang,Li Chen; Rehabilitation Regimen After Surgical Treatment of Acute Achilles Tendon Ruptures; A Systematic Review With Meta-analysis, The American Journal of Sports Medicine, Vol. 43, No. 4.

  • B.J. Erickson,R Mascarenhas, B.M. Saltzman, D. Walton, S. Lee, B.J. Cole,B.R. Bach; Is Operative Treatment of Achilles Tendon Ruptures Superior to Nonoperative Treatment? The Orthopaedic Journal of Sports Medicine, 3(4), 2325967115579188; DOI: 10.1177/2325967115579188.

  • McMahon SE, Smith TO, Hing CB. A meta-analysis of randomised controlled trials comparing conventional to minimally invasive approaches for repair of an Achilles tendon rupture. Foot Ankle Surg. 2011;17:211-217.

  • Lim CS, Lees D, Gwynne-Jones DP; Functional Outcome of Acute Achilles Tendon Rupture With and Without Operative Treatment Using Identical Functional Bracing Protocol. Foot Ankle Int. 2017 Dec;38(12):1331-1336. doi: 10.1177/1071100717728687.

  • Lantto I, Heikkinen J, Flinkkila T, et al. A prospective randomized trial comparing surgical and nonsurgical treatments of acute Achilles tendon ruptures. Am J Sports Med. 2016;44(9):2406–2414. doi: 10.1177/0363546516651060.

  • Ververidis, A. N., Kalifis, K. G., Touzopoulos, P., Drosos, G. I., Tilkeridis, K. E., & Kazakos, K. I. (2016). Percutaneous repair of the Achilles tendon rupture in athletic population. Journal of Orthopaedics, 13(1), 57–61. http://doi.org/10.1016/j.jor.2015.09.004.

  • Carmont MR, Heaver C, Pradhan A, Mei-Dan O, Gravare Silbernagel K; Surgical repair of the ruptured Achilles tendon: the cost-effectiveness of open versus percutaneous repair; Knee Surg Sports Traumatol Arthrosc. 2013 Jun; 21(6):1361-8. doi: 10.1007/s00167-013-2423-1.

  • Matthew L Costa, Juul Achten, Ioana R Marian, Susan J Dutton, Sarah E Lamb, Benjamin Ollivere, Mandy Maredza, Stavros Petrou, Rebecca S Kearney, UKSTAR trial collaborators; Plaster cast versus functional brace for non-surgical treatment of Achilles tendon rupture (UKSTAR): a multicentre randomised controlled trial and economic evaluation; Lancet. 2020 Feb 8;395(10222):441-448. doi: 10.1016/S0140-6736(19)32942-3.