A Closer Look At A New Protocol To Manage Achilles Tendon Rupture

Do you always position your patient’s ankle in full equinus after an Achilles tendon rupture? If so, you might want to read convincing evidence that you should avoid this age-old practice. This is true whether considering an operative or a non-operative approach to the treatment of the acute Achilles tendon rupture.

There is increasing evidence, summarized in systematic reviews, that one can successfully use a non-operative treatment protocol to manage patients who suffer an acute rupture of the Achilles tendon.^1,2 These reviews and other systematic reviews consistently show a slightly lower incidence of re-rupture with operative treatment, which is offset with concern about postoperative complications.³

What is confounding to the foot and ankle surgeon is the challenge of implementing an effective and proven protocol for managing the patient with the acute Achilles tendon rupture. Whether the patient has had surgery or non-operative treatment, certain critical questions arise.

Having studied the literature and having implemented newer protocols for treating the acute rupture of the Achilles tendon, I can offer answers to the following questions.

Should you allow the patient to bear weight? Whether or not the patient has had surgery, early weightbearing facilitates better outcomes in the treatment of the acute Achilles tendon rupture.^4,5

If my patient bears weight, how should the ankle be positioned? This issue has changed significantly over the past 10 years. Traditionally, foot and ankle surgeons would immobilize the ankle in a cast with the ankle set at 30 degrees plantarflexion (equinus) for a minimum of eight weeks after surgical repair of the Achilles tendon.⁶ This practice remained the standard of care for decades despite the fact that studies have shown that equinus positioning of the ankle may lead to decreased tension in the Achilles and calf musculature atrophy.^7,8  

Over 15 years ago, researchers reported a more aggressive protocol for managing the Achilles rupture, moving the patient out of an equinus position at the ankle within four weeks after surgical repair.^9,10 Even more impressive are studies showing no negative effects with protected weightbearing with the ankle in neutral immediately after Achilles tendon repair.^11,12

How should the patient’s Achilles be protected after Achilles tendon rupture? Rather than a cast, a removable walking boot is preferable in all studies when it comes to treating the Achilles tendon rupture. However, positioning the ankle in extreme equinus in a controlled ankle motion (CAM) boot is discouraged. A study by Froberg and colleagues showed that when patients walked in a CAM boot set at 20 degrees plantarflexion, force in the Achilles tendon was actually higher than during barefoot walking.¹³ The researchers recommend that patients be immobile in a standard walking boot with heel support (heel wedges) rather than a boot in which the footplate is plantarflexed.

Recently, the use of a carbon fiber ankle-foot orthotic (AFO) brace has shown promise in the management of the Achilles tendon rupture.¹⁴ One study concluded that patients with Achilles tendon rupture would have a more normalized gait and would have equivalent protection of their Achilles tendon when wearing a carbon fiber AFO in comparison to a walking boot.¹⁵

What is the proper combination of ankle protection and ankle positioning after Achilles tendon rupture? A 1-inch heel lift inside a walking boot will adequately protect the Achilles and avoid the deleterious effects of severe equinus positioning.^16-18 

A level I randomized clinical trial used a 20 mm heel wedge (approximately 1 inch) with early weightbearing in a walking boot to treat patients with the authors comparing an operative and non-operative treatment protocol after Achilles tendon rupture.¹⁹ The study authors gradually reduced the wedges over a period of six weeks with the ankle coming to a neutral position by six weeks post-rupture. All patients were out of their boot by eight weeks. The results for surgery in comparison to no surgery were basically identical for both groups.

There is convincing evidence from this study and many others that early protected weightbearing with the ankle in slight equinus (20 mm heel lift) is preferable in both the operative and non-operative management of the acute rupture of the Achilles tendon.^4,5,10-14

References

1. Wilkins R, Bisson LJ. Operative versus nonoperative management of acute Achilles tendon ruptures a quantitative systematic review of randomized controlled trials. Am J Sports Med. 2012;40(9):2154-2160.
2. Jiang N, Wang B, Chen A, et al. Operative versus nonoperative treatment for acute Achilles tendon rupture: a meta-analysis based on current evidence. Int Orthop. 2012;36(4):765-773.
3. Wu Y, LinL, Li H, Zhao Y, Liu L, Jia Z, Wang D, He Q, Ruan D. Is surgical intervention more effective than non-surgical treatment for acute Achilles tendon rupture? A systematic review of overlapping meta-analyses. Int J Surg. 2016; 36(A):305-311. 
4. Suchak AA, Spooner C, Reid DC, Jomha NM. Postoperative rehabilitation protocols for Achilles tendon ruptures: a meta-analysis. Clin Orthop Rel Res. 2006;445:216-221.
5. 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.
6. Wills CA, Washburn S, Caiozzo V, Prietto CA. Achilles tendon rupture. A review of the literature comparing surgical versus nonsurgical treatment. Clin Orthop. 1986; 207:156-163.
7. Rantanen J, Hurme T, Kalimo H. Calf muscle atrophy and Achilles tendon healing following experimental tendon division and surgery in rats: comparison of postoperative immobilization of the muscle- tendon complex in relaxed and tensioned positions. Scand J Med Sci Sports. 1999;9(1):57–61.
8. Maxwell LC, Enwemeka CS. Immobilization-induced muscle atrophy is not reserved by lengthening the muscle. Anat Rec. 1992; 234(1):55–61.
9. Mortensen NHM, Skov O, Jensen PE. Early motion of the ankle after operative treatment of a rupture of the Achilles tendon. J Bone Joint Surg. 1999;81(7):983–90.
10. Barfod KW, Bencke J, Lauridsen HB, Ban I, Ebskov L, Troelsen A. Nonoperative dynamic treatment of acute Achilles tendon rupture: the influence of early weight-bearing on clinical outcome: a blinded, randomized controlled trial. J Bone Joint Surg Am. 2014;96(18):1497–503.
11. Rantanen J, Hurme T, Paananen M. Immobilization in neutral versus equinus position after Achilles tendon repair. Acta Orthop Scand. 1993;64(3):333–335.
12. Kangas J, Pajala A, Ohtonen P, Leppilahti J. Achilles tendon elongation after rupture repair: a randomized comparison of 2 postoperative regimens. Am J Sports Med. 2007;35(1):59–64. 

13. Froberg A, Komi P, Ishikawa M, Movin T, Arndt A. Force in the achilles tendon during walking with ankle foot orthosis. Am J Sports Med. 2009;37(6):1200-7.
14. Costa ML, MacMillan K, Halliday D, Chester R, Shepstone L, Robinson AH, et al. Randomized controlled trials of immediate weight-bearing mobilization for rupture of the tendo Achilles. J Bone Joint Surg Br. 2006;88(1):69–77.
15. Kearney RS, Lamb SE, Achten J, Parsons NR, Costa ML. In-shoe plantar pressures within ankle-foot orthoses: implications for the management of achilles tendon ruptures. Am J Sports Med. 2011;39(12):2679–2685.
16. Akizuki KH, Gartman EJ, Nisonson B, Ben-Avi S, McHugh MP. The relative stress on the Achilles tendon during ambulation in an ankle immobilizer: implications for rehabilitation after Achilles tendon repair. Br J Sports Med. 2001;35(5):329-333, discussion 333-334.
17. Kadel NJ, Segal A, Orendurff M, Shofer J, Sangeorzan B. The efficacy of two methods of ankle immobilization in reducing gastrocnemius, soleus, and peroneal muscle activity during stance phase of gait. Foot Ankle Int. 2004;25(6):406-409.
18. Farris DJ, Buckeridge E, Trewartha G, McGuigan MP. The effects of orthotic heel lifts on Achilles tendon force and strain during running. J Appl Biomech. 2012;28(5):511-9.
19. Willits K, Amendola A, Bryant D, Mohtadi NG, Giffin JR, Fowler P, Kean CO, Kirkley A. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation. J Bone Joint Surg Am. 2010;92(17):2767-75.