When an Achilles tendon ruptures, the forces placed on the tendon exceed its tensile limits. Patients who sustain these injuries often experience sudden pain in the affected leg, difficulty with weight-bearing, and weakness of the affected ankle. “The Achilles tendon is one of the strongest tendons in the body, and a rupture can be quite disabling,” explains Christopher P. Chiodo, MD. “The healing period after a rupture requires time away from work and limits athletic activity. Time away from work may have a financial impact on patients, and limiting activity may affect patients’ overall health and well-being.”
Achilles tendon rupture is more common in men who are in their 30s and 40s, but more people are staying active as they age, meaning that these injuries can occur in older age groups. An acute Achilles tendon rupture affects 5.5 to 9.9 of every 100,000 people in North America each year. There are currently no treatment regimens that are universally agreed upon. The aims of treatment include ascertaining a timely and accurate diagnosis, achieving pain relief, restoring functional status, and returning to pre-rupture activities. “Once a timely and accurate diagnosis is made, clinicians and patients must discuss both conservative strategies (eg, casts or braces) and surgical treatment,” Dr. Chiodo says.
New Evidence-Based Guidelines
The American Academy of Orthopaedic Surgeons (AAOS) has released an evidence-based clinical practice guideline on the diagnosis and treatment of acute Achilles tendon rupture. Available on AAOS’s website (www.aaos.org), the goal of the guidelines is to provide assistance to providers who are qualified to treat Achilles tendon ruptures. “These recommendations give guidance on how to select treatment options for these patients in order to optimize outcomes,” says Dr. Chiodo, who chaired the work group that was responsible for the guidelines.
To develop the clinical practice guidelines, the AAOS work group formulated a set of preliminary recommendations that specified what should be done in whom, when, where, and how often or for how long. The group assembled and categorized relevant published articles by level of evidence to develop final recommendations with one of the following grades:
Strong (good quality evidence).
Moderate (fair quality evidence).
Weak (poor quality evidence).
Inconclusive (insufficient or conflicting evidence).
In the absence of reliable evidence, the work group made consensus recommendations, which were based on clinical opinion.
Immobilization & Weight-Bearing Are Important
The AAOS work group recommended both nonsurgical and surgical treatment as options for all patients with acute Achilles tendon ruptures (Table). “Published data demonstrate that the ankle should be mobilized, and some weight-bearing should be allowed postoperatively in surgically-managed patients,” says Dr. Chiodo. “Controlled early motion and weight-bearing activities appear to be beneficial, especially with regard to return of function. Within the first 2 weeks after surgery, protected weight-bearing should be initiated. Early mobilization by 2 to 4 weeks after surgery may also enhance recovery.”
A consensus recommendation was made by the AAOS work group on the need for a detailed history and physical examination to establish the diagnosis of an acute Achilles tendon rupture. The work group also recommended that surgical treatment be approached more cautiously in patients who are elderly, have sedentary lifestyles or are obese, are immunocompromised, use tobacco, and those with diabetes, neuropathy, and vascular disorders. No evidence supported the use of biological agents, autograft, or synthetic tissue when surgically repairing Achilles tendon ruptures, but more research is necessary.
There are few high-quality studies that provide strong evidence for various aspects of the diagnosis and treatment of Achilles tendon rupture. The AAOS work group identified the following areas as focal points for future trials:
Routine use of MRI, ultrasonography, and/or radiography to confirm a diagnosis.
Preoperative immobilization or restricted weight bearing.
Allograft, autograft, xenograft, synthetic tissue, or biologic adjuncts.
“There’s a need for larger studies which utilize multi-center protocols and databases,” adds Dr. Chiodo. “For example, some studies have shown possible advantages to minimally invasive repair, specifically with regard to wound healing, but this needs to be validated with more research. More data are also needed on functional outcomes with non-operative management, such as braces or casts. We also need to establish patient registries that include large case volumes so that these patients can be followed and sufficiently evaluated for long-term outcomes. Decision-making doesn’t end at the time of surgery, and establishing appropriate postoperative protocols is important.”
American Academy of Orthopaedic Surgeons. The Diagnosis and Treatment of Acute Achilles Tendon Rupture. Available at: http://www.aaos.org/Research/guidelines/atrguideline.asp.
Costa ML, MacMillan K, Halliday D et al. Randomised controlled trials of immediate weight bearing mobilisation for rupture of the tendo Achillis. J Bone Joint Surg Br. 2006;88:69-77.
Margetic P, Miklic D, Rakic-Ersek V, Doko Z, Lubina ZI, Brkljacic B. Comparison of ultrasonographic and intraoperative findings in Achilles tendon rupture. Coll Antropol. 2007;31:279-284.
Twaddle BC, Poon P. Early motion for Achilles tendon ruptures: is surgery important? A randomized, prospective study. Am J Sports Med. 2007;35:2033-2038.