Decoding Achilles tendon rupture: Evidence and informed treatment choices

The Achilles is the most commonly ruptured tendon in the lower extremity; it can be a traumatic and painful event which most commonly occurs in adults aged 30-50. Unfortunately, there is a lack of evidence to guide clinicians in treatment decision-making, and best-practice management remains a contentious topic. There are a range of factors which need to be taken into consideration, and decision-making should be done in collaboration with the client. This blog aims to outline the current evidence, and factors which should be considered in the decision-making process.

Luckily, in his latest Research Review, Dr Seth O’Neill outlines a recently developed decision-making tool to help inform and guide your clients when deciding between conservative or surgical management of their Achilles tendon rupture (1), check it out HERE.

The current evidence

There is conjecture over the best treatment option for acute Achilles tendon rupture. Research indicates there are little differences between operative and non-operative management, with the risks somewhat ‘balanced’ between slightly higher re-rupture rates in non-operative care, and higher complication rates in operative care. There seem to be no significant differences in functional outcomes in operative versus non-operative care (2); a recent study found there to be no difference in clinical outcomes or Magnetic Resonance Imaging (MRI) findings in surgically and conservatively managed groups, with considerable elongation and thickening of the injured tendon found in both groups (3).

Part of the difficulty in assessing the best practice for management of acute Achilles rupture is the disparity in management protocols out there. There are a range of different protocols for both conservative and postoperative management, with approaches varying between early functional mobilisation, and strict cast immobilisation. However, on a basic level (regardless of surgical or conservative management), you can expect your client will take 6-9 months to return to sport and they will be in a Controlled Ankle Motion (CAM) walker for 2-3 months. See a common ‘early functional mobilisation’ conservative management protocol below:

Phase 1 : 0-2 weeks

• Cast immobilisation in 20-degrees plantarflexion
• Non weight bearing with crutches

Phase 2: 2-4 weeks

• CAM walker with 2-4cm heel lift 25-50% weight-bearing
• Avoid moving ankle beyond plantigrade in exercises

Phase 3: 4-6 weeks

• CAM walker with progressive weight bearing to full weight bearing by six weeks
• Avoid moving ankle beyond plantigrade in exercises

Phase 4: 6-8 weeks

• CAM walker weight bearing as tolerated
• Gradually remove heel lift
• Avoid moving beyond plantigrade
• Introduce light Achilles strengthening in plantarflexion

Phase 5: 8-12 weeks

• Wean CAM walker over 2-5 days
• Begin pain-free gentle movement into dorsiflexion
• No strengthening past neutral

Phase 6: 16+ weeks

• Full range of motion in strengthening
• Aiming return to full sporting activities at six months

The decision

Your role as a physio is to inform your client of the up-to-date evidence, and work with them to come to a decision which is appropriate for them. The ultimate decision should be the client’s and made on individual factors, such as:

❓Comorbidities

• Do they have health conditions which would increase the risks of surgery?
• Do they have other ipsilateral injuries which may impact management?
• Do they have health conditions which will affect the healing of the tendon?

❓Personal factors

• The client’s age
• What are their own beliefs regarding surgical versus conservative management?
• What kind of social support do they have around them?
• Do they have previous experiences with surgical and/or conservative management of other issues?
• Have they had a previous Achilles rupture?
• Do they have risk factors for postoperative wound complications (smoker, steroid use)

❓Client goals

• Do they want to return to a high-level sport which puts them at higher risk of re-rupture?
• Do they have something important coming up for which they want to be mobile for (e.g. daughter’s wedding)?

❓Client preferences

• Do they have a predetermined preference toward surgery?
• Do they have fear/anxiety around surgery?

❓Financial factors

• Do they have private health insurance to cover the cost of surgery?
• Do they have a stable income/sick leave to assist with days of work missed due to surgical recovery times?

These are just a few examples of factors that may influence treatment decisions. In his Review, Dr Seth O’Neill outlines the mixed-methods study used to develop a tool which can help supplement the decision-making process – the study synthesised data from 18 health professionals and 15 patients to produce an easy to understand tool which outlines important, evidenced-based information. Seth encourages the use of this tool when making decisions with clients, and also outlines a few extra expert tips around client education, so be sure to check it out!

Wrapping up

Lack of clarity in the research makes it difficult to help your clients make treatment decisions which are right for them. In these cases, it becomes paramount to consider the person in front of you, as well as providing them with the most up-to-date information to ensure they are making an informed decision; decision-making tools can be an excellent way to inform your client of the benefits and risks of conservative versus surgical options, and empower them in the process to decide which is the best option for them.

Physio Network’s Research Reviews help you to stay on top of the evidence so you can provide your clients with the most up-to-date information. If you’d like to learn more, check out Dr Seth O’Neill’s Review HERE.