Question for Physiotherapists
QUESTION | It is my
understanding that Achilles tendon ruptures in Australia have traditionally
been treated surgically, but Achilles tendon ruptures in Canada have
traditionally been treated non-surgically. Why the difference? What is the evidence?
ANSWER | Since the
randomised controlled trial by Willets et al, (2010) we have
noted a declining rate of acute Achilles tendon surgery in Australia.
rupture is traditionally thought of as the injury of the “weekend warrior”, and is rarely seen in the seasoned athlete. The patient, usually a male of 40 years of
age, requires some form of treatment, otherwise, function will be poor and strength
will not return.
treatment is done as a day surgical procedure and the operation is not “pretty”.
The surgery involves re-approximating
the ends of what look like two “hairy mops” together (see image
surgery (open repair), I suggest:
and non-weight bearing are essential to prevent wound complications for
approximately 2 weeks.
then allow the patient to weight-bear in a removable boot firstly in
plantarflexion, gradually returning to neutral at 6 weeks at which time the
boot can be discontinued.
can walk/cycle/swim and drive at 6 weeks.
can run at between 6 and 9 months.
non-operative protocol of 8 weeks in plaster in full plantarflexion has been
modified by numerous authors to include earlier protected range of motion and
earlier protected weight-bearing.
The protocol of
Prof Bruce Twaddle from Auckland (a proponent of non-surgical treatment)
What is agreed
on is that surgical treatment is faster in terms of recovery but carries the
risks of surgery including wound infection.
weeks of non-weight bearing,
2 weeks of touch weight-bearing in a boot then a final 2 weeks in a boot.
movement is commenced at 2 weeks.
What is less
agreed upon is the risk of re-rupture and rapidity of return to strength and
study there was no significant difference in rates of re-rupture.
by Wilkins et al. (2012) of 7 Level 1 randomised
controlled trials stated that open operative treatment carried a significantly
lower risk of re-rupture.
A similar meta
analysis by Ochen et al. (2019) of 29 studies (10 randomised trials and 19
observational studies) suggested once again a lower re-rupture with surgical
treatment but that early functional treatment and early weight-bearing lessened
would I do if I ruptured my Achilles tendon?
I would have
surgery by an experienced foot and ankle surgeon. At the recent Australian
Orthopaedic Foot and Ankle Meeting in 2018 the question was put to all the
surgeons in the room and the majority agreed that they would have surgical treatment.
They believed it resulted in less down time, a stronger tendon sooner and a
lower rate of re-rupture.
infection however would “spoil the party”!
Willits K, Amendola A, Bryant D, Mohtadi NG, Giffin
JR, Fowler P, Kean CO, Kirkley A. (2010). Operative versus
nonoperative treatment of acute Achilles tendon ruptures: a multicenter
randomized trial using accelerated functional rehabilitation. Journal of
Bone Joint Surgery Am. 92 (17) 2767-75
Wilkins R, Bisson L.J. (2012). Operative Versus Nonoperative Management of Acute
Achilles Tendon Ruptures: A Quantitative Systematic Review of Randomized
Controlled Trials. The American Journal
of Sports Medicine. 40 (9)
Ochen Y, Beks R, van Heijl M, Hietbrink F, Leenen
L, van der Velde D, Heng M, van der Meijden O, Groenwold R, Houwert R. (2019). Operative
treatment versus nonoperative treatment of Achilles tendon ruptures: systematic
review and meta-analysis. Review and meta-analysis. BMJ 2019; 364
Dr John Negrine
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