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FOOT AND ANKLE

The non-operative functional management of


patients with a rupture of the tendo Achillis
leads to low rates of re-rupture
R. G. H. Wallace,
G. J. Heyes,
A. L. R. Michael
From Musgrave Park
Hospital, Belfast,
United Kingdom

R. G. H. Wallace, MCh (Orth),


MD, FRCS, Consultant
G. J. Heyes, MBBChBAO,
MRCS, PgCert (Tr & Orth),
Senior House Officer
Ulster Hospital Dundonald,
Upper Newtownards Road,
Dundonald, Belfast BT16 1RH,
UK.
A. L. R. Michael, DNB (Tr &
Orth), M.Med.Sci, FRCS,
Consultant
Northern General Hospital,
Herries Road, Sheffield, South
Yorkshire S5 7AU, UK.
Correspondence should be sent
to Mr R. G. H. Wallace; email:
r.wallace@dnet.co.uk
2011 British Editorial Society
of Bone and Joint Surgery
doi:10.1302/0301-620X.93B10.
26187 $2.00
J Bone Joint Surg Br
2011;93-B:13626.
Received 30 June 2011;
Accepted after revision 4 July
2011

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Controversy surrounds the most appropriate treatment method for patients with a rupture
of the tendo Achillis. The aim of this study was to assess the long term rate of re-rupture
following management with a non-operative functional protocol.
We report the outcome of 945 consecutive patients (949 tendons) diagnosed with a
rupture of the tendo Achillis managed between 1996 and 2008. There were 255 female and
690 male patients with a mean age of 48.97 years (12 to 86). Delayed presentation was
defined as establishing the diagnosis and commencing treatment more than two weeks
after injury. The overall rate of re-rupture was 2.8% (27 re-ruptures), with a rate of 2.9%
(25 re-ruptures) for those with an acute presentation and 2.7% (two re-ruptures) for those
with delayed presentation.
This study of non-operative functional management of rupture of the tendo Achillis is the
largest of its kind in the literature. Our rates of re-rupture are similar to, or better than, those
published for operative treatment. We recommend our regime for patients of all ages and
sporting demands, but it is essential that they adhere to the protocol.

The management of a patient with a rupture


of the tendo Achillis remains controversial.
Some authors have reported high complication rates following open surgery, 1-3 while
others note few complications and a low
rate of re-rupture. 4-8 Percutaneous repair
has been advocated with reportedly low
rates of re-rupture and fewer complications
than open repair.9 This contrasts with other
reports of much higher rates of re-rupture
and sural nerve injury following percutaneous repair than in open repair. 10-13
The literature on non-operative management demonstrates similar variability in
results. Some studies show good results
with re-rupture rates on a par with surgical
intervention, but with no wound infections,
skin necrosis or sinus formation and less
time off work. 4,14-21 However, rates of rerupture were reported to be much higher
when compared with operative groups elsewhere. 22
Recent meta-analyses have correlated the
results of randomised controlled trials and
case series comparing forms of treatment.23-27
However, inconsistencies in treatment
regimes, inclusion criteria (often not randomised or blinded), time delay to treatment, assessment of function outcome and
weight being given to smaller case studies
have led to inconclusive results.

The general consensus is that surgery offers


the lowest rate of re-rupture. There is,
however, no study of significant size reporting
the outcome of conservative management with
or without functional bracing over an
appropriate duration of follow-up.23-29
Our early results from managing ruptures of
tendo Achillis with combined conservative and
orthotic treatments were encouraging in both
objective and subjective testing.30,31 The aim of
this paper is to examine the long term rates of
re-rupture of the non-operative functional
treatment of patients with tendo Achillis
rupture.

Patients and Methods


All patients presenting with a rupture of the
tendo Achillis in Northern Ireland are referred
to the senior author (RGHW), who makes the
diagnosis on the basis of the history, classical
bruising and a palpable gap in the tendon with
no plantar flexion of the ankle produced on the
calf-squeeze test.
The decision on non-operative treatment
was based on whether the tendon ends were
found to approximate well on palpation with
the foot in plantar flexion. In a few cases the
diagnosis was confirmed in the referring unit
on ultrasound examination. The tendon ends
always approximate well on palpation when
there has been no delay in presentation.
THE JOURNAL OF BONE AND JOINT SURGERY

NON-OPERATIVE FUNCTIONAL MANAGEMENT OF PATIENTS WITH A RUPTURE OF THE TENDO ACHILLIS

1363

Present to A + E placed in an equinus cast

Referral to tendo Achillis clinic

Weeks

1 to 2

14

Diagnosis confirmed, non-weight-bearing equinus cast

Pneumatic walker with heel raises. Heel raises reduced fortnightly

Remove walker

Physiotherapy for gait training, strength and mobility training

Final assessment
Fig. 1
Algorithm showing the treatment of ruptures of tendo Achillis

In all, 69 of 1044 patients referred between 1996 and


2008 with a suspected rupture were excluded at presentation due to misdiagnosis, instead being found to have tears
of the gastrocnemius, Achilles tendinopathy, sprains or
plantar fasciitis. A total of 975 patients were diagnosed
with a closed tendo Achillis rupture, of whom 97 presented
14 or more days following rupture, which we defined as a
late presentation. Of those patients with a delayed presentation 26 were treated surgically because tendon ends did
not approximate on plantar flexion and one patient was
too obese for the ankle to be immobilised in an orthosis,
but was successfully managed in casts. In total 70 patients
with delayed presentation were treated using our functional
protocol. In addition three patients were operated on overseas prior to presentation to us. Thus a total of 945 patients
(949 ruptures), comprising 690 men and 255 women with
a mean age of 48.97 years (12 to 86), were treated using our
functional protocol. Simultaneous bilateral ruptures
occurred in four patients during the time frame of this study
and five patients had contralateral ruptures prior to 1996.
In unilateral cases the injury affected the left side on 493
occasions and the right side on 452.
The treatment algorithm rupture illustrating our nonoperative management of these patients is shown in
Figure 1.
The first 180 patients were treated with a custom-made
rigid polypropylene double shell patellar tendon bearing
orthosis. A more comfortable and cost-effective Aircast
pneumatic walker orthosis (DJO Global, Vista, California)
was introduced in 1999 and was subsequently used in
765 patients. The above management plan also applied to
bilateral ruptures, for whom cast removal was staggered by
one week.
VOL. 93-B, No. 10, OCTOBER 2011

Data were collected independently by two of the authors


(GJH, ALRM) who were not involved in establishing the
diagnosis or describing the planned management to
patients. All problems in the province related to tendo
Achillis are seen by the senior author (RGHW), ensuring
continuity of care. In order to have had least two years
follow-up data collection was stopped with patients whose
treatment was completed in December 2008.
Data collected included a previously reported subjective
assessment.30 Each completed a questionnaire that
requested information on pre- and post-injury work, preand post-injury activity levels, time to return to work and
other activities, medical history, drug history, history of
tendo Achillis injury and treatment, complications, and
details of physiotherapy. Questions were also asked about
pain, stiffness, subjective calf-muscle weakness, footwear
restrictions, and satisfaction with the result of the treatment.30 Prior to discharge documentation of any complications, return to work, delays returning to sport and reason
for failure of treatment were also made. Minor complications were defined as a limp, pain, numbness, swelling and
superficial ulceration, as these were transient. Other complications such as deep-vein thrombosis (DVT), pulmonary
embolism (PE), temporary foot drop and re-rupture were
considered major.
Patients were discharged from treatment when the objective measurement of the strength of the ankle was deemed
satisfactory by a specialist physiotherapist,30 when the
patient was happy with their result and if they failed to
attend for review on three or more occasions (< 1% of
patients).
Approval was obtained from the clinical governance
department of the institution.

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R. G. H. WALLACE, G. J. HEYES, A. L. R. MICHAEL

Table I.

Male
Female

Patient characteristics
Number

Mean age (range)

p-value

690
255

47.8 (12 to 86)


48.8 (13 to 84)

0.12

Table II. The incidence of re-rupture according the sporting


inclination
Number of
re-ruptures
Regular sport
15
(533 patients, 533 tendons)
Non-sporting activity
12
(412 patients, 416 tendons)

Rate of
re-rupture

p-value

2.8%

0.46

2.9%

Table III. Re-rupture rates according to timing of presentation


and gender
Re-ruptures
Acute presentation
25
(875 patients, 875 tendons)
Delayed presentation
2
(70 patients, 74 tendons)
Male re-ruptures
20
(692 tendons)
Female re-ruptures
7
(257 tendons)

Rate

p-value

2.9%

0.13

2.7%
2.9%

0.17

2.7%

Statistical analysis. The paired t-test was used to calculate


statistical difference between variables. The level of significance was set at p < 0.05, and p-values were calculated to
within 95% confidence intervals.

Results
The distribution of ruptures according to gender revealed
no statistically significant difference in the mean age of
patients at time of rupture (p = 0.12) (Table I). Likewise the
rate of re-rupture showed no statistically significant difference in distribution between sporting and non-sporting
individuals (p = 0.46) (Table II).
The orthosis was removed early against medical advice in
five patients, two of whom had a re-rupture. These two
patients completed, from start to finish, a second functional
protocol and all returned to pre-injury activity levels.
All the re-ruptures occurred within three months of diagnosis. There was no significant difference in the rate of rerupture between those with an acute and delayed
presentation or according to gender (p = 0.13 and p = 0.17,
respectively, paired t-test) (Table III).
Good to excellent subjective assessment on discharge
was noted in 939 patients (99.4%; 943 tendons). A total of
six patients (0.6%; six tendons) had a poor score and subsequently underwent operative repair. This was because of
tendon lengthening resulting in weakness of plantar
flexion.

The complications are recorded in Figure 2. All patients


limped on initial removal of the orthosis but following
three months of physiotherapy the gait returned to normal
in all patients. All patients returned to work within three
months of completing final functional protocol and all
patients returned to pre-injury sporting levels. Those with
reduced dorsiflexion were managed successfully with
physiotherapy.
Heel numbness, pain, foot drop (common peroneal
neuropraxia), orthosis discomfort and superficial ulcers
were all managed successfully with adjustments to the
orthosis, including graduated heel raises, and all resolved
on removal of orthosis and rehabilitation. Slight calf atrophy was common but not of functional significance in any
patient, and no formal measurements were made.
A comparison of the distribution of complications
between acute versus delayed presentation is shown in
Figure 3. Although overall the complication rates are low,
with a delayed presentation there was an increased incidence in the number of minor complications, but these were
transient and did not have an impact on the lifestyle, work
or sporting activity of the patients. The incidence of the
major complications (DVT, PE, temporary foot drop and
re-rupture) did not show the same trend; in fact their incidence is low and evenly spread between both presentations.

Discussion
These results demonstrate a non-operative approach with a
very low rate of complication. This justifies non-operative
functional treatment if the healing of the tendon is as good
as that achieved with surgery.32
Rates of re-rupture up to 29% following conservative
management have been given as an indication for surgery.33
Some studies documenting increased re-rupture rates have
not used the same immobilisation regime as their surgical
cohort.20 Saleh et al34 were amongst the first to demonstrate that a functional orthosis with early mobilisation can
improve the outcome when compared with cast immobilisation.
The Cochrane Collaboration performed a meta-analysis
to summarise the results of management of patients with a
rupture of tendo Achillis.23 The results of four randomised
controlled trials which looked at operative versus nonoperative techniques were pooled. Only Schroeder et al20
used functional orthosis for their non-operative management, the rest used immobilisation in a cast. At least three
small randomised controlled trials35-37 have subsequently
been published showing improved functional outcome and
lower rates of re-rupture when treatment involved a
functional orthosis and early mobilisation (Table IV).38
These results are encouraging but lack the numbers or long
term follow-up to influence clinical practice.
Our study provides robust information from the largest
number of conservatively treated patients published to
date. The rate of re-rupture amongst our patients includes
two patients who removed their orthosis early. Previous
THE JOURNAL OF BONE AND JOINT SURGERY

Number (%)

NON-OPERATIVE FUNCTIONAL MANAGEMENT OF PATIENTS WITH A RUPTURE OF THE TENDO ACHILLIS

30
25
20
15
10
5
0

Total number
% of total

l
ng

/ti

ss

2.2

0.7

in

in

e
bn

1365

a
lp

He

ng

of

o
nd

i
Th

er

lc

te

nn

um

0.5

0.7

on

T
DV

xi

e
ifl

rs

ed

do

0.3

y
ph

PE
lf

Ca

ric

st
Re

0.2

1.1

1.0

ro
at

0.4

0.2

rt

ro

d
ot

Fo

sc

is

di

os

rth

ur

fo

om

2.8

t
up

Re

O
Fig. 2

Bar chart showing complications (DVT, deep-vein thrombosis; PE, pulmonary embolism).

Percentage

5.0
4.0
3.0

Acute pres
Delayed pres

2.0
1.0
0

0.0
g

in

in

/ti

ss

e
bn

l
ng

um

a
lp

ee

of

er

lc

te

ni

in

Th

ng

o
nd

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ifl

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do

T
DV

y
ph

PE
lf

Ca

ct

tri

s
Re

ed

on

tro

rt

op

r
td

o
Fo

i
os

fo

di

sc

om

re

tu

p
-ru

Re

rth

O
Fig. 3

Bar chart showing a comparison of the incidence of complications according to acute or delayed presentation
(DVT, deep-vein thrombosis; PE, pulmonary embolism).

Table IV. A comparison of the literature for rate of re-rupture between


non-operative vs operative treatment
Number of tendons
treated

Re-rupture rate
Nistor19*
Cetti et al4*
Mller et al38*
Schroeder et al20
Khan et al23*
Twaddle et al35
Metz et al36
Willits et al37
Current series

Conservative

Surgical

Conservative

Surgical

8.3%
12.7%
20.8%
0%
12.6%
9.1%
15%
4.2%
2.9%

4.5%
5.4%
1.7%
0%
3.5%
15%
4.7%
2.8%

60
55
53
15
183
22
40
72
945

45
56
59
13
173
20
43
72

* conservative management consists of cast immobilisation


conservative management consists of functional bracing
surgical procedure was minimally invasive surgery

publications by the senior author (RGHW) have shown


early excellent functional results on formal objective
testing.30,31
Our results demonstrate extremely low rates of rerupture and complications in patients followed-up for at
least two years. There was no difference in the re-rupture
VOL. 93-B, No. 10, OCTOBER 2011

rate in those with regular sporting demands. Our functional


protocol can be applied to individuals whopresent late provided the tendon ends approximate well on full plantar
flexion which can be assessed by palpation. All patients
returned to work within three months of functional protocol completion; all returned to pre-injury sporting levels
and 99.4% (939 patients, 943 tendons) had good to excellent subjective assessment scores at the time of discharge.
In this retrospective study we acknowledge some deficiencies in data collection. Although we have been able to
establish that patients returned to their pre-injury sporting
levels and work, the exact time from injury to return to
sport and work was not documented. This information
would have been helpful in providing additional information for comparison with other studies.
Our results show that treatment with a functional orthosis and adherence to a rehabilitation protocol can provide
dependable results from non-operative treatment.

The authors would like to thank I. E. R. Traynor for specialist physiotherapy,


A. Kansal for help with data entry and V. Ferguson for secretarial support.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

1366

R. G. H. WALLACE, G. J. HEYES, A. L. R. MICHAEL

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