January 17, 2021
achilles tendon rupture cover

Treatment of Achilles Tendon Rupture

The Achilles tendon is the largest tendon in the body and is made of a complex anatomical structure.  The gastrocnemius and the soleus musculature converge to form the Achilles tendon, which inserts onto the calcaneal tuberosity. The primary role of the Achilles tendon is plantarflexion of the ankle joint.

Case Question

A patient with an achilles tendon rupture would like to start working on her range of motion (ROM). After how many weeks should she initiate this?

A) Start early motion at day 1 from injury
B) Start early motion after 3 weeks of immobilization
C) Wait until 8 weeks to begin range of motion exercises
D) Range of motion exercises should not be started until 12 weeks and ultrasound confirms tendon healing.

Although a strong tendon, it is commonly ruptured among recreational and competitive athletes. However, they also frequently occur in the episodic athlete. Achilles tendon ruptures occur in 20-32 per 100,000 patients (Barford, 2020). Risk factors that increase the risk of rupture include fluoroquinolone use and steroid injections into the tendon. Tendon rupture typically occurs with sudden forced plantarflexion, or less commonly with violent dorsiflexion of a plantarflexed foot. Patients often describe feeling as though they were violently struck/kicked in the back of the ankle. Extreme pain is typical, but is not a sensitive finding, as up to one-third of patients do not report any pain at all.
PHYSICAL EXAM

Integrity of the Achilles tendon can be assessed by squeezing the calf, known as Thompson’s test. Absence of plantarflexion indicates a positive test (Figure 1). 

thompson test illustration

Figure 1: Illustration of Thompson Test

Other findings, such as increased resting dorsiflexion in the prone position, can also be seen (Figure 2).
clinical example of achilles tendon rupture

Figure 2: Clinical example of increased resting dorsiflexion (courtesy of orthobullets)

If clinical suspicion is high in the setting of a negative Thompson’s test, imaging modalities such as US or MRI (Figure 3) can be utilized. 
MRI of achilles tendon rupture

Figure 3: MRI demonstrating achilles tendon rupture (courtesy of orthobullets)

TREATMENT
Initial treatment of an Achilles tendon rupture consists of the well-known RICE protocol (rest, ice, compression, and elevation), along with analgesia using acetaminophen or nonsteroidal anti-inflammatory drugs. The patient should be placed into a posterior slab splint with the foot in a plantarflexed position known as resting equinus.
A rupture does warrant a surgical evaluation but does not necessarily require surgical intervention. Either nonoperative or operative treatment is reasonable, and decisions should be individualized as current evidence is mixed. If patient and physician agree to surgical intervention, it should be done within 14 days. Athletes or young patients may opt for surgical repair, as studies by Heckman et al. in 2009 and Khan et al. in 2005 showed surgical intervention resulted in a decreased risk of re-rupture, along with quicker return to full activity. However, a study in 2010 by Willitis et al. showed no significant difference in either function or re-rupture rates between operative and nonoperative groups when using early mobilization and weight-bearing modalities.
As a result of the data showing no significant re-rupture rates, many physicians choose nonoperative management of their patients with Achilles Tendon rupture. Management of an Achilles Tendon rupture begins with short term immobilization. To minimize the risk of muscle atrophy, loss of joint mobility and deep vein thrombosis patients can be placed in a functional brace with Achilles wedge as opposed to a plastered cast (Costa, 2020). The foot is placed at 20 degrees in plantar flexion, sometimes accommodated with a 2 cm heel lift (Costa, 2020).  Costa and et. al. performed a study that compared patients with Achilles Tendon ruptures and randomized them to be placed in a functional brace or a plaster cast (Costa, 2020). They found that after 8 weeks, the ATRS (Achilles Tendon Rupture Score), which was a 10 question inventory looking at patient symptoms, activity, and pain, was similar for both groups (Costa, 2020). They also found that the side effect profile including DVT were similar in both groups (Costa, 2020). 
Patients remain non-weight bearing for the first 2 weeks. Previous management favored prolonged non-weight bearing. However, in 2014 published in the Journal of Bone and Joint Surgery, Barford looked at early weight bearing vs. non-weight bearing in patients with Achilles tendon ruptures. They found that early weight bearing did not lead to any increased risk of tendon rupture. 
Another area of debate was if patients should start early range of motion exercises. In 2020 published in the British Journal of Sports Medicine, a study was done that looked at early range of motion at day 14 in patients with Achilles tendon ruptures (Barford, 2020). The control group of their study was told to remain in their functional brace with Achilles wedge for 9 weeks before they began any range of motion (Barford, 2020). They found no statistically significant benefit in early range of motion (Barford, 2020). However, they also found no increased risk of tendon rupture in the early range of motion group (Barford, 2020). 
According to the Willits protocol from 2010, after 6 weeks of protected weight bearing with an Achilles wedge, the foot is then returned to a neutral position for another 2 weeks in the walking boot. At this point, patients can start graduated resistance exercises along with weight bearing cardiovascular exercise as tolerated. Thereafter, the patient is weaned out of the boot over the course of several weeks and will continue physical therapy directed towards improving range of motion, strength, and proprioception. Once weaned out of the boot, it is recommended the patient utilize a 1 cm heel lift in their shoe wear. Most athletes are able to return to play at a range of 75% to 100% of their previous level of participation. We must stress the importance of patience to our athlete patients, as the average time to return to activity is between 5 to 7 months with potential continued improvement up to one year. 
CONCLUSION
Achilles tendon ruptures are common in a sports medicine clinic and physicians must be aware of both the nonsurgical and surgical treatment options based on the level of activity of their patient. This review showed that the nonsurgical approach to Achilles tendon ruptures can be done in place of surgical management in most patients. Physicians should refer to the Willits study for the full nonsurgical treatment protocol. 

Case Conclusion

Correct Answer: B. Range of motion exercises should begin after 3 weeks of immobilization. In June 2020 Barford et al. looked at the roll of early controlled motion after achilles tendon rupture at three weeks from the time of injury. They found that the group that performed early range of motion and those with complete immobilization did not have any difference in re-rupture rates of the tendon. However, early range of motion did not lead to any statistically significant improvement in any of their primary endpoints.

Barfod, Kristoffer Weisskirchner, et al. “Efficacy of Early Controlled Motion of the Ankle Compared with Immobilisation in Non-Operative Treatment of Patients with an Acute Achilles Tendon Rupture: An Assessor-Blinded, Randomised Controlled Trial.” British Journal of Sports Medicine, vol. 54, no. 12, June 2020, pp. 719–24. PubMed, doi:10.1136/bjsports-2019-100709.
Author

Kelsey Diemer, DO

NCH Healthcare System

Naples, Florida

REFERENCES
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  13. Barfod, Kristoffer Weisskirchner, et al. “Nonoperative Dynamic Treatment of Acute Achilles Tendon Rupture: The Influence of Early Weight-Bearing on Clinical Outcome: A Blinded, Randomized Controlled Trial.” The Journal of Bone and Joint Surgery. American Volume, vol. 96, no. 18, Sept. 2014, pp. 1497–503. PubMed, doi:10.2106/JBJS.M.01273.

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