Achilles Rupture Management – Surgery vs Conservative Management

Mimi Yamakawa-Armstrong

September 1, 2020

 

Ruptured Achilles Tendon: Surgery vs Conservative Management

(Image thanks to https://www.boneandjointclinicbr.com/blog/5-ways-to-prevent-an-achilles-tendon-rupture).

 

As a physiotherapist, we see a variety of muscle and bone related issues and some injuries are debilitating and require a long-period of rehabilitation.

Ruptured Achilles Tendon is one of those that require long rehabilitation and can be daunting when you have acutely torn your Achilles to know about the two different options of management (surgery vs conservative).

We have written a blog to guide you on the risk factors, diagnosis, management options and return to sports/activities.

Risk Factors:

  • There are many examples of males aged between 20-59 years-old and who participate in sports (and may be blood group B+) that have ruptured their Achilles compared to other population groups.
  • David Beckham, Kobe Bryant, Jarryd Roughhead ETC.

 

(Image thanks to https://www.sbnation.com/2010/3/14/1372848/david-beckham-achilles-injury-world-cup).

The rate of Achilles ruptures is increasing especially in the population group of males aged between 40-59 years-old group. This may be due to the increasing participation of sporting activities in this age group. Tendinopathy (chronic overload/damage to the tendon) is another condition that affects the achilles tendon, however, if you already have Achilles pain you are unlikely to rupture your Achilles when its painful.

Most ruptures are sustained during sporting activities (approx. 80%), however, ruptures can happen in non-sports related activities especially in older populations.

 

Mechanism:

The mechanism of injury (how we do it) is mostly during plyometric activities (ie jumping) when the muscle is contracting eccentrically (lengthening) then concentrically (shortening). You often hear a pop/bang, and many describe that it feels like something hitting leg from behind. Surprisingly, for some you may not feel pain and can even walk on it. But for others it is very painful.

Diagnosis:

An Achilles rupture is reasonably easy to diagnose by a trained professional such as a physiotherapist on field/court side. So when you are told you have most likely ruptured you should go to an emergency department and then see a highly trained GP or sports physician.

When a rupture is suspected, your leg will be placed in an equinus cast (pointed toe position) to try and keep the ends of the ruptured tendon as close as possible.

While an x-ray DOES NOT show an Achilles rupture, it does show something called an avulsion fracture (bone pulled off by tendon) so it should be done as management of this diagnosis will be different from a pure Achilles tendon rupture.

An ultrasound scan will give you a definitive diagnosis and is the preferred method over a MRI scan.

Achilles ruptures can also happen in non-sports related activities such as up/down stairs, leaning forward to door or sink, especially in older patients. So if you suspect rupture, orthopaedic tests by qualified health professionals as well as imaging should be done as soon as possible.

 

Management

If you are an unlucky person who experiences an Achilles rupture, your next question is how to manage it !

“to-repair or not-to-repair?”

Non-surgical management involves casting for 2-weeks with non-weight bearing followed by approximately 10 weeks of walking in a moon boot with heel wedges (keeping tendon in shortened position). A gradual increase in weight bearing is done in the first 4 weeks of walking in the moon boot followed by gradual lengthening of the tendon.

Surgical management involves day surgery (normally) to stitch ruptured tendon followed by 2-weeks of non-weight bearing. Once reviewed by surgeon around 2 weeks post-operation, you will be wearing moon boots with heel wedge for approximately 10 weeks. Full weight bearing is permitted if you feel comfortable as soon as you are in the moon boot and gradual lengthening of tendon with reducing heel wedges can start.

Both managements should be monitored closely by orthopaedic surgeons and physiotherapist to optimise tendon recovery.

 

(Image credit thanks to www.ndorms.ox.ac.uk).

Decision of Management

If you are young and active surgical repair may be more commonly chosen. However, if you are older (say late 40’s) and the tendon is no more than 1cm apart, you will probably be managed conservatively (non-surgical).

Current recommendation for Achilles rupture is to treat “conservatively” which means let the body heal the ruptured site. With surgical management there are complications to consider.

Recent meta-analysis (a study where researcher has collated all good available scientific evidence), suggest there are no differences in outcome whether you do surgical or conservative management.

In the past, conservative management involved restricted movement and non-weight bearing for prolonged periods of time that had increased risk of re-rupturing tendon. However, with increasing knowledge of tendon recovery with early mobilisation and tendon loading re-rupture rates have reduced dramatically.

Surgical Risks:

With any surgery, there are the risks! Although it is a reasonably uncomplicated surgical procedure (approximately 1 hour surgery) for experienced surgeons, Achilles surgery does come with the risk of complications.  The main complication surgeons are concerned with is the risk of infection which although the rates are low the consequences can be very high. The “deep infection” can also happen and if that happens it is very serious. The tissue damage to deep structures, such as muscle & tendons, may result in long hospital periods and may even require needing muscle and skin grafts.

The Achilles is also one of the most distal (lowest) parts of the body and this can have an impact on its ability to heal quickly.

 

(Image thanks to https://www.apollocosmeticclinics.com/cosmetic-surgery-pros-and-cons/).

There are always pros and cons of both management and below is a summary:

Pros of conservative management will be

  • Large reduction in risk of infection
  • Cost
  • With early mobilisation – good result without re-rupture

 

Cons will be

  • Slightly increased risk of re-rupture
  • Delay in full-weight bearing
  • Fear factor of re-rupture
  • Bump in tendon and lengthened tendon (less strength).

Pros of surgery are:

  • Early full-weight bearing (may be earlier return to work)
  • Reduced risk of re-rupture (as compared to conservative)
  • Increased confidence and assurance that tendon is repaired

Cons

  • Risk of infection
  • Risk of general anaethetic and other anaesthesia
  • Cost
  • Post-surgical pain and risk of nerve damage

 

As I have mentioned previously, the current trend is to treat conservatively (depending on patient’s demographic and sporting needs).

If the ruptured tendon naturally retracts back very close to its normal insertion point with little to no gap between the two ruptured ends, you have a good chance of the tendon healing with the conservative management plan. However, if the two ends are more than 10mm apart it may take longer to heal and may end up as a slightly longer length which is less desirable for strength and power.

If you have the tendons more than 10mm apart and you are a healthy individual and aged less than 60 years-old, you may be managed surgically. With older patients however, suspected degenerative changes and questionable tendon integrity, increased risks of infections (i.e diabetes, heart disease etc) you may still be managed conservatively.

 

Return to sports/activities:

Whether your injury is managed conservatively or surgically, the next question is “when can I go back to playing sports?”

If you ask surgeons, physios and even patients, they will all tell you it takes a long time. As you can imagine, time to return to sports will vary depending on previous level of fitness and the level of sports competition that you were participating in prior to injury.

The general professional opinion for return to sport is generally 10 to 12 months. However, a recently published systematic review suggested otherwise with nearly 80% of patients reporting a return to sports at an average of 21-weeks. This is much quicker than most professionals would recommend but is likely impacted on by factors such as the level of competition (elite vs recreational) and access to resources such as physiotherapy/gyms etc.

However, depending on the type of sport it is possible to return at 5-6 months after injury and this will give you a good target if you are serious about going back to what you like doing.

Physiotherapists have an excellent knowledge of rehabilitation and understand what’s required to facilitate a return to sport. Rehabilitation can start with a physiotherapist as early as 2 weeks or pre-surgery as they are able to give advice around maintenance of general fitness and keeping the other leg muscles strong regardless of whether you are allowed to weight-bear yet.  If you are in the unfortunate position of starting the Achilles rehabilitation journey feel free to get in contact with us to help facilitate your recovery!

 

References:
Ochen, Yassine & Beks, Reinier & Heijl, Mark & Hietbrink, Falco & Leenen, Luke & Velde, Detlef & Heng, Marilyn & van der Meijden, Olivier & Groenwold, Rolf & Houwert, R.. (2019). Operative treatment versus nonoperative treatment of Achilles tendon ruptures: Systematic review and meta-analysis. BMJ British Medical Journal. k5120. 10.1136/bmj.k5120.
Zellers, J. A., Carmont, M. R., & Grävare Silbernagel, K. (2016). Return to play post-Achilles tendon
rupture: a systematic review and meta-analysis of rate and measures of return to play. British journal 
of sports medicine50(21), 1325–1332. doi:10.1136/bjsports-2016-096106