Management of Acute Achilles Tendon Rupture

THE DIAGNOSIS AND TREATMENT OF ACUTE
ACHILLES TENDON RUPTURE

GUIDELINE AND EVIDENCE REPORT
Adopted by the American Academy of Orthopaedic Surgeons

Board of Directors
December 4, 2009
Disclaimer
This Clinical Practice Guideline was developed by an AAOS physician volunteer Work
Group based on a systematic review of the current scientific and clinical information and
accepted approaches to treatment and/or diagnosis. This Clinical Practice Guideline is not
intended to be a fixed protocol, as some patients may require more or less treatment or
different means of diagnosis. Clinical patients may not necessarily be the same as those
found in a clinical trial. Patient care and treatment should always be based on a
clinician’s independent medical judgment, given the individual patient’s clinical
circumstances.
Disclosure Requirement
In accordance with AAOS policy, all individuals whose names appear as authors or
contributors to Clinical Practice Guideline filed a disclosure statement as part of the
submission process. All panel members provided full disclosure of potential conflicts of
interest prior to voting on the recommendations contained within this Clinical Practice
Guidelines.
Funding Source
This Clinical Practice Guideline was funded exclusively by the American Academy of
Orthopaedic Surgeons who received no funding from outside commercial sources to
support the development of this document.
FDA Clearance
Some drugs or medical devices referenced or described in this Clinical Practice Guideline
may not have been cleared by the Food and Drug Administration (FDA) or may have
been cleared for a specific use only. The FDA has stated that it is the responsibility of the
physician to determine the FDA clearance status of each drug or device he or she wishes
to use in clinical practice.
Copyright
All rights reserved. No part of this Clinical Practice Guideline may be reproduced, stored
in a retrieval system, or transmitted, in any form, or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without prior written permission
from the AAOS.
Published 2009 by the American Academy of Orthopaedic Surgeons

6300 North River Road
Rosemont, IL 60018
First Edition
Copyright 2007 by the American Academy of Orthopaedic Surgeons
ii
Summary of Recommendations
The following is a summary of the recommendations in the AAOS’ clinical practice
guideline, The Diagnosis and Treatment of Acute Achilles Tendon Rupture. The scope of
this guideline is specifically limited to acute Achilles tendon rupture. This summary does
not contain rationales that explain how and why these recommendations were developed
nor does it contain the evidence supporting these recommendations. All readers of this
summary are strongly urged to consult the full guideline and evidence report for this
information. We are confident that those who read the full guideline and evidence report
will also see that the recommendations were developed using systematic evidence-based
processes designed to combat bias, enhance transparency, and promote reproducibility.
This summary of recommendations is not intended to stand alone. Treatment decisions
should be made in light of all circumstances presented by the patient. Treatments and
procedures applicable to the individual patient rely on mutual communication between
patient, physician and other healthcare practitioners.
1. In the absence of reliable evidence, it is the opinion of this work group that a
detailed history and physical exam be performed. The physical examination
should include two or more of the following tests to establish the diagnosis of
acute Achilles tendon rupture:
o Clinical Thompson test (Simmonds squeeze test)

o Decreased ankle plantar flexion strength
o Presence of a palpable gap (defect, loss of contour)
o Increased passive ankle dorsiflexion with gentle manipulation
Strength of Recommendation – Consensus*
Description: The supporting evidence is lacking and requires the work group to make a
recommendation based on expert opinion by considering the known potential harm and
benefits associated with the treatment. A Consensus recommendation means that expert
opinion supports the guideline recommendation even though there is no available
empirical evidence that meets the inclusion criteria of the guideline’s systematic review.
Implications: Practitioners should be flexible in deciding whether to follow a

recommendation classified as Consensus, although they may set boundaries on
alternatives. Patient preference should have a substantial influencing role.
iii
2. We are unable to recommend for or against the routine use of magnetic resonance
imaging (MRI), ultrasound (ultrasonography), and radiograph (roentgengrams, x-
rays) to confirm the diagnosis of acute Achilles tendon rupture.
Strength of Recommendation – Inconclusive
Description: Evidence from a single low quality study or conflicting findings that do not
allow a recommendation for or against the intervention. An Inconclusive
recommendation means that there is a lack of compelling evidence resulting in an unclear
balance between benefits and potential harm.
Implications: Practitioners should feel little constraint in deciding whether to follow a

recommendation labeled as Inconclusive and should exercise judgment and be alert to
future publications that clarify existing evidence for determining balance of benefits
versus potential harm. Patient preference should have a substantial influencing role.
3. Non-operative treatment is an option for all patients with acute Achilles tendon
rupture.
Strength of Recommendation: Limited
Description: Evidence from two or more “Low” strength studies with consistent findings,
or evidence from a single “Moderate” quality study recommending for or against the
intervention or diagnostic. A Limited recommendation means the quality of the
supporting evidence that exists is unconvincing, or that well-conducted studies show little
clear advantage to one approach versus another.
Implications: Practitioners should be cautious in deciding whether to follow a

recommendation classified as Limited, and should exercise judgment and be alert to
emerging publications that report evidence. Patient preference should have a substantial
influencing role.
4. For patients treated non-operatively, we are unable to recommend for or against

the use of immediate functional bracing for patients with acute Achilles tendon
rupture.
Strength of Recommendation: Inconclusive

iv
5. Operative treatment is an option in patients with acute Achilles tendon rupture.

influencing role.
6. In the absence of reliable evidence, it is the opinion of the work group that
although operative treatment is an option, it should be approached more
cautiously in patients with diabetes, neuropathy, immunocompromised states, age
above 65, tobacco use, sedentary lifestyle, obesity (BMI >30), peripheral vascular
disease or local/systemic dermatologic disorders.
Strength of Recommendation: Consensus
recommendation based on expert opinion by considering the known potential harm and
benefits associated with the treatment. A Consensus recommendation means that expert
opinion supports the guideline recommendation even though there is no available
empirical evidence that meets the inclusion criteria of the guideline’s systematic review.
Implications: Practitioners should be flexible in deciding whether to follow a

recommendation classified as Consensus, although they may set boundaries on
alternatives. Patient preference should have a substantial influencing role.
7. For patients who will be treated operatively for an acute Achilles tendon rupture,
we are unable to recommend for or against preoperative immobilization or
restricted weight bearing.

v
8. Open, limited open and percutaneous techniques are options for treating patients
with acute Achilles tendon rupture.

influencing role.
9. We cannot recommend for or against the use of allograft, autograft, xenograft,

synthetic tissue, or biologic adjuncts in all acute Achilles tendon ruptures that are
treated operatively.

10. We cannot recommend for or against the use of antithrombotic treatment for
patients with acute Achilles tendon ruptures.

vi
11. We suggest early (≤ 2 weeks) post-operative protected weight bearing for patients
with acute Achilles tendon rupture who have been treated operatively
Strength of Recommendation: Moderate
Description: Evidence from two or more “Moderate” strength studies with consistent
findings, or evidence from a single “High” quality study for recommending for or against
the intervention. A Moderate recommendation means that the benefits exceed the
potential harm (or that the potential harm clearly exceeds the benefits in the case of a
negative recommendation), but the strength of the supporting evidence is not as strong.
Implications: Practitioners should generally follow a Moderate recommendation but

remain alert to new information and be sensitive to patient preferences.
12. We suggest the use of a protective device that allows mobilization by 2- 4 weeks
post operatively.
Strength of Recommendation: Moderate
Description: Evidence from two or more “Moderate” strength studies with consistent
findings, or evidence from a single “High” quality study for recommending for or against
the intervention. A Moderate recommendation means that the benefits exceed the
potential harm (or that the potential harm clearly exceeds the benefits in the case of a
negative recommendation), but the strength of the supporting evidence is not as strong.
Implications: Practitioners should generally follow a Moderate recommendation but

remain alert to new information and be sensitive to patient preferences.
13. We are unable to recommend for or against post-operative physiotherapy for

patients with acute Achilles tendon rupture

vii
14. In all patients with acute Achilles tendon rupture, irrespective of treatment type,
we are unable to recommend a specific time at which patients can return to
activities of daily living.

15. In patients who participate in sports it is an option to return them to sports within
3-6 months after operative treatment for acute Achilles tendon rupture.

influencing role.
16. In patients with acute Achilles tendon rupture treated non-operatively, we are
unable to recommend a specific time at which patients can return to athletic
activity.

Implications: Practitioners should feel little constraint in deciding whether to follow

a recommendation labeled as Inconclusive and should exercise judgment and be alert to
viii
* While we strongly encourage reviewers to read the full guideline, please refer to the
sections titled “Judging the Quality of Evidence” and “Defining the Strength of the
Recommendations Table 1” for a detailed description of the link between the evidence
supporting the Strength of a Recommendation and the language of the guideline.
ix
Work Group
Christopher P Chiodo MD, Chair Guidelines and Technology Oversight
Brigham Orthopedic Associates Chair:
75 Francis Street William C. Watters, III, MD
Boston MA 02115 6624 Fannin #2600
Houston, TX 77030
Mark Glazebrook MD, Vice-Chair
Queen Elizabeth Health Sciences Center Guidelines and Technology Oversight Vice-
Halifax Infirmary Suite 4867 Chair:
1796 Summer Street Michael J. Goldberg, MD
Halifax NS B3H 3A7 Canada Department of Orthopaedics
Seattle Children’s Hospital
Eric Michael Bluman MD PhD 4800 Sand Point Way NE
Madigan Army Medical Center Seattle, WA 98105
ATTN: MCHJ-SOP (Ortho Clinic)
9040 A Reid Street Evidence Based Practice Committee Chair:
Tacoma WA 98431-1100 Michael Keith, MD
2500 Metro Health Drive
Bruce E Cohen MD Cleveland, OH 44109-1900
1783 Sterling Road
Charlotte NC 28209 AAOS Staff:
Robert H. Haralson III, MD, MBA
John E Femino MD AAOS Medical Director
Department of Orthopedics 6300 N River Road
University of Iowa Hospital and Clinics Rosemont, IL 60018
JPP 01022
200 Hawkins Drive Charles M. Turkelson, PhD
Iowa City IA 52242 Director of Research and Scientific Affairs
Eric Giza MD Janet L. Wies MPH

UC Davis Dept of Orthopaedics AAOS Clinical Practice Guideline Mgr
Ambulatory Care Services Bldg
4860 Y St #3800 AAOS Research Analysts
Sacramento, CA 95817 Laura Raymond MA - Lead Analyst
Sara Anderson MPH – Lead Analyst
Kevin Boyer BS
Patrick Sluka MPH
x
Peer Review
Participation in the AAOS peer review process does not constitute an endorsement
of this guideline by the participating organization or the individuals listed below nor
does it is any way imply the reviewer supports this document.
The following organizations participated in peer review of this clinical practice guideline
and gave explicit consent to be listed as a peer review organization of this document:
American Academy of Family Practitioners

American Academy of Physical Medicine and Rehabilitation
American College of Foot and Ankle Surgeons
American Orthopaedic Foot and Ankle Society
American Orthopaedic Society for Sports Medicine
American Physical Therapy Association
American Podiatric Medical Association
Individuals who participated in the peer review of this document and gave their explicit
consent to be listed as reviewers of this document are:
Avrill Roy Berkman, MD

Christopher R. Carcia, MD
Michael Heggeness, MD
Harvey Insler, MD
John Kirkpatrick, MD
Michael S. Lee, DPM, FACFA
Angus McBryde Jr., MD
Ariz R. Mehta, MD
Lawrence Oloff, DPM
Steven Raikin, MD
Charles Reitman, MD
John Richmond, MD
Kevin Shea, MD
Naomi Sheilds, MD
Nelson F. Soohoo, MD
Glenn Weinraub, DPM, FACFAS
xi
Table of Contents
SUMMARY OF RECOMMENDATIONS .............................................................. III
WORK GROUP ................................................................................................... X
PEER REVIEW ................................................................................................... XI
TABLE OF CONTENTS .................................................................................... XII
LIST OF TABLES ............................................................................................. XVI
I. INTRODUCTION ........................................................................................... 1
Overview........................................................................................................................................................ 1
Goals and Rationale ..................................................................................................................................... 1
Intended Users .............................................................................................................................................. 1
Patient Population ........................................................................................................................................ 2
Incidence ....................................................................................................................................................... 2
Burden of Disease ......................................................................................................................................... 2
Etiology .......................................................................................................................................................... 2
Risk Factors .................................................................................................................................................. 2
Emotional and Physical Impact of Achilles Tendon Rupture .................................................................. 2
Potential Benefits, Harms, and Contraindications .................................................................................... 2
II. METHODS ..................................................................................................... 3
Formulating Preliminary Recommendations ............................................................................................. 3
Study Inclusion Criteria ............................................................................................................................... 4
Outcomes Considered .................................................................................................................................. 4
Literature Searches ...................................................................................................................................... 5
Data Extraction............................................................................................................................................. 6
Judging the Quality of Evidence ................................................................................................................. 6
xii
Defining the Strength of the Recommendations ........................................................................................ 7
Consensus Development ..............................................................................................................................10
Statistical Methods ......................................................................................................................................10
Peer Review ..................................................................................................................................................11
Public Commentary.....................................................................................................................................11
The AAOS Guideline Approval Process ....................................................................................................12
Revision Plans ..............................................................................................................................................12
Guideline Dissemination Plans ...................................................................................................................12
III. RECOMMENDATIONS AND SUPPORTING EVIDENCE ....................... 13
Recommendation 1 ......................................................................................................................................13
Summary of Evidence...............................................................................................................................13
Excluded Articles......................................................................................................................................14
Study Quality ............................................................................................................................................15
Study Results ............................................................................................................................................16
Recommendation 2 ......................................................................................................................................17
Study Quality ............................................................................................................................................19
Study Results ............................................................................................................................................20
Recommendation 3 ......................................................................................................................................21
Study Quality ............................................................................................................................................27
Study Results ............................................................................................................................................28
Recommendation 4 ......................................................................................................................................34
Study Quality ............................................................................................................................................39
Recommendation 5 ......................................................................................................................................42
Study Quality ............................................................................................................................................55
Recommendation 6 ......................................................................................................................................59
Recommendation 7 ......................................................................................................................................60
Recommendation 8 ......................................................................................................................................61
Percutaneous vs Open Repair ...................................................................................................................62
Summary of Evidence- Percutaneous vs. Open ........................................................................................63
Limited Open vs Open Repair ..................................................................................................................64
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Summary of Evidence- Limited Open vs. Open .......................................................................................65
Study Quality ............................................................................................................................................69
Study Results ............................................................................................................................................73
Recommendation 9 ......................................................................................................................................77
Autograft Tissue vs Open Repair..............................................................................................................77
Augmentation with Synthetic Tissue vs Open Repair ..............................................................................78
Study Quality ............................................................................................................................................82
Study Results ............................................................................................................................................86
Recommendation 10 ....................................................................................................................................90
Excluded Studies ......................................................................................................................................90
Recommendation 11 ....................................................................................................................................91
Summary of Complications ......................................................................................................................99
Excluded Articles....................................................................................................................................101
Study Quality ..........................................................................................................................................102
Study Results ..........................................................................................................................................111
Recommendation 12 ..................................................................................................................................116
Summary of Evidence.............................................................................................................................117
Summary of Complications ....................................................................................................................123
Study Quality ..........................................................................................................................................126
Study Results ..........................................................................................................................................131
Recommendation 13 ..................................................................................................................................136
Excluded articles .....................................................................................................................................137
Recommendation 14 ..................................................................................................................................138
Study Quality ..........................................................................................................................................147
Recommendation 15 ..................................................................................................................................150
Study Quality ..........................................................................................................................................155
Recommendation 16 ..................................................................................................................................160
Study Quality ..........................................................................................................................................163
Future Research ........................................................................................................................................166
Appendix I ..................................................................................................................................................168
Work Group ............................................................................................................................................168
Appendix II ................................................................................................................................................169
xiv
Time from rupture to treatment ..............................................................................................................169
Appendix III ...............................................................................................................................................173

AAOS Bodies That Approved This Clinical Practice Guideline ............................................................173
Documentation of Approval ...................................................................................................................174
Appendix IV ...............................................................................................................................................175
Literature Searches for Primary Studies .................................................................................................175
Appendix V ................................................................................................................................................177
Study Attrition Flowchart .......................................................................................................................177
Appendix VI ...............................................................................................................................................178
Data Extraction Elements .......................................................................................................................178
Appendix VII .............................................................................................................................................179

Judging the Quality of Diagnostic Studies..............................................................................................179
Judging the Quality of Treatment Studies ..............................................................................................180
Appendix VIII ............................................................................................................................................182

Form for Assigning Strength of Recommendation (Interventions) ........................................................182
Appendix IX ...............................................................................................................................................184
Voting by the Nominal Group Technique ..............................................................................................184
Appendix X ................................................................................................................................................185
Structured Peer Review Form .................................................................................................................185
Appendix XI ...............................................................................................................................................188
Peer Review Panel ..................................................................................................................................188
Public Commentary ................................................................................................................................189
Appendix XII .............................................................................................................................................190

Description of Symbols Used in Tables..................................................................................................190
Appendix XIII ............................................................................................................................................191

Conflict of Interest ..................................................................................................................................191
Appendix XIV ............................................................................................................................................192

References ..............................................................................................................................................192
Excluded articles after full text review ...................................................................................................197
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List of Tables
Table 1 Strength of Recommendation Descriptions ........................................................... 9
Table 2 AAOS Guideline Language ................................................................................. 10
Table 3. Excluded Articles ................................................................................................ 14
Table 4. Study Quality ...................................................................................................... 15
Table 5. Sensitivity and specificity of Palpation, Calf Squeeze and Matles tests ............ 16
Table 6. Excluded Articles ................................................................................................ 18
Table 7. Study Quality ...................................................................................................... 19
Table 8. Sensitivity and Specificity .................................................................................. 20
Table 9. Operative vs. Cast – Function ............................................................................. 22
Table 10. Operative vs. Cast – Pain .................................................................................. 22
Table 11. Operative vs. Cast – Return to Work ................................................................ 23
Table 12. Operative vs. Cast - Return to Sport ................................................................ 23
Table 13. Operative vs. Cast - Rerupture .......................................................................... 23
Table 14. Operative vs. Cast - Satisfaction ....................................................................... 24
Table 15. Operative vs. Cast – Complications.................................................................. 24
Table 16. Systematic Review Summary ........................................................................... 25
Table 17. Excluded Articles .............................................................................................. 26
Table 18. Study Quality .................................................................................................... 27
Table 19. Open vs. Cast - Function................................................................................... 28
Table 20. Cast vs. Open Repair - Pain .............................................................................. 29
Table 21. Operative vs. Cast - Return to Work................................................................. 30
Table 22. Operative vs. Cast - Return to Sport ................................................................. 31
Table 23. Operative vs. Cast - Rerupture .......................................................................... 31
Table 24 Cast vs. Open - Complications .......................................................................... 32
Table 25. Cast + Functional Brace vs. Cast - Rerupture................................................... 35
Table 26. Summary of Results - Case Series .................................................................... 35
Table 27. Summary of Systematic Reviews ..................................................................... 35
Table 28. Functional Bracing – Satisfaction (VAS) ......................................................... 36
Table 29. Functional Bracing - Satisfaction (%) .............................................................. 36
Table 30. Functional Bracing - Pain ................................................................................. 36
Table 31. Functional Bracing - Function .......................................................................... 36
Table 32. Functional Bracing - Strength ........................................................................... 37
Table 33. Functional Bracing - Return to Work and Sports ............................................. 37
Table 34. Functional Bracing - Return to Work and Sports (days) .................................. 37
Table 35. Functional Bracing - Complications ................................................................. 38
Table 36. Functional Bracing - Rerupture ........................................................................ 38
Table 37. Functional Bracing - Excluded Studies ............................................................ 38
Table 38. Study Quality - Randomized Control Trials ..................................................... 39
Table 39. Study Quality - Non-Randomized Comparative Study .................................... 39
Table 40. Study Quality - Case Series .............................................................................. 40
Table 41. Open Repair – All Outcomes ............................................................................ 44
Table 42. Open Repair - Return to work........................................................................... 44
Table 43. Open Repair - Activities of daily living............................................................ 45
Table 44. Open Repair- Mean time until return to athletic activity .................................. 45
Table 45. Open Repair- Percent of patients able to return to activities of daily living .... 46
xvi
Table 46. Open Repair- Percent of patients able to return to work .................................. 46
Table 47. Open Repair- Percent of patients able to return to sports ................................. 46
Table 48: Open Repair- Percent of patients with pain ..................................................... 47
Table 49. Open Repair- Percent of patients able to complete functional activities .......... 47
Table 50. Open Repair- Percent of patients with excellent satisfaction ........................... 47
Table 51. Minimally Invasive Repair- All outcomes....................................................... 48
Table 52. Minimally Invasive Repair- Percent of Patients able to return to activity........ 48
Table 53. Minimally Invasive Repair - Percent of patients able to return to sports ......... 49
Table 54. Minimally Invasive Repair - Satisfaction ......................................................... 49
Table 55. Minimally Invasive Repair - Mean time until return to activity ....................... 49
Table 56. Minimally Invasive Repair-Percent of patients able to return to sports ........... 49
Table 57. Minimally Invasive Repair-Percent of patients able to return to work............. 50
Table 58. Minimally Invasive Repair-Pain ....................................................................... 50
Table 59. Excluded Articles .............................................................................................. 50
Table 60. Study Quality .................................................................................................... 55
Table 61. Percutaneous and Limited Open vs. Open - Global Outcomes ........................ 63
Table 62. Percutaneous vs. Open - Return to Activities and Function ............................. 63
Table 63. Percutaneous vs. Open - Satisfaction ............................................................... 63
Table 64. Percutaneous vs. Open- Complications ........................................................... 63
Table 65. Percutaneous vs. Open- Rerupture................................................................... 64
Table 66. Minimally Invasive vs. Open- Pain ................................................................. 65
Table 67. Minimally Invasive vs. Open- Global Outcomes ............................................ 65
Table 68. Limited Open vs. Open- Return to Activity .................................................... 65
Table 69. Mini-Open vs. Open- Symptoms ..................................................................... 65
Table 70. Limited Open Repair vs. Open - Complications............................................... 66
Table 71. Mini-Open vs. Open – Rerupture ..................................................................... 66
Table 72. Excluded Studies - All Operative Techniques .................................................. 67
Table 73. Study Quality - RCTs ....................................................................................... 69
Table 74. Quality of Studies - Comparative Studies......................................................... 71
Table 75. Limited open vs. Open - Global Outcomes .................................................... 73
Table 76. Percutaneous vs. Open - Return to Activities ................................................... 73
Table 77. Percutaneous vs. Open - Satisfaction ................................................................ 73
Table 78. Percutaneous vs. Open - Complications ........................................................... 73
Table 79. Minimally Invasive vs. Open- Pain ................................................................. 74
Table 80. Minimally Invasive vs. Open- Global Outcomes ............................................ 74
Table 81. Minimally Invasive vs. Open - Function .......................................................... 74
Table 82. Minimally Invasive vs. Open - Complications ................................................. 75
Table 83. Minimally Invasive vs. Open - Symptoms ....................................................... 75
Table 84. Minimally Invasive vs. Open - Return to Sport ................................................ 76
Table 85. Minimally Invasive vs. Open - Complications ................................................. 76
Table 86. Autograft vs. Open - Pain and Stiffness ........................................................... 78
Table 87. Autograft vs. Open - Satisfaction ..................................................................... 78
Table 88. Autograft - Return to Activities and Sports ..................................................... 78
Table 89. Autograft vs. Open - Footwear Restrictions ..................................................... 79
Table 90. Autograft vs. Open - Hospitalization and Immobilization ............................... 79
Table 91. Autograft vs. Open - Complications ................................................................. 79
xvii
Table 92. Excluded Studies - Allograft............................................................................. 80
Table 93. Excluded Studies - Autograft ............................................................................ 80
Table 94. Excluded Studies - Synthetic Tissue ................................................................. 81
Table 95- Biologic Adjuncts ............................................................................................. 81
Table 96. Study Quality – Autograft RCTs ...................................................................... 82
Table 97. Study Quality - Autograft Comparative Studies .............................................. 83
Table 98. Study Quality - Synthetic Tissue Case Series .................................................. 85
Table 99 Autograft vs. Open Pain and Stiffness ............................................................... 86
Table 100. Autograft vs. Open - Satisfaction ................................................................... 86
Table 101. Autograft vs. Open - Return to Sports ............................................................ 87
Table 102. Autograft vs. Open - Return to Activities ....................................................... 87
Table 103. Autograft vs. Open - Footwear Restrictions ................................................... 87
Table 104. Autograft vs. Open - Hospitalization vs. Immobilization ............................... 88
Table 105. Autograft vs. Open - Complications ............................................................... 88
Table 106. Synthetic Tissue - Results ............................................................................... 89
Table 107. Antithrombotic Treatment - Excluded Studies ............................................... 90
Table 108: Description of treatment groups .................................................................... 92
Table 109 Time until return to activity ............................................................................. 94
Table 110 Pain .................................................................................................................. 94
Table 111 Function ........................................................................................................... 96
Table 112 EuroQoL, Rand-36........................................................................................... 97
Table 113 Patient Subjective Results................................................................................ 97
Table 114 Reruptures ........................................................................................................ 98
Table 115 Reported Complications .................................................................................. 99
Table 116 Systematic Reviews ....................................................................................... 100
Table 117 Article Inclusion List- Early weight bearing vs. non-weight bearing............ 101
Table 118. Quality- Weight bearing vs. non-weight bearing- RCT ............................... 102
Table 119. Quality- Weight bearing vs. non-weight bearing- Comparative.................. 105
Table 120 Study Data: Weight Bearing vs. Non-Weight Bearing .................................. 111
Table 121. Description of Treatment Groups ................................................................. 117
Table 122. Time to Return to Activity ............................................................................ 117
Table 123. Pain .............................................................................................................. 119
Table 124. Function ........................................................................................................ 119
Table 125. EuroQoL, E5D, Ankle Performance Score ................................................... 120
Table 126. Patient opinion of results .............................................................................. 121
Table 127. Footwear restrictions..................................................................................... 122
Table 128. Rerupture ...................................................................................................... 122
Table 129. Early Motion vs. Cast - Complications......................................................... 123
Table 130. Systematic Reviews ...................................................................................... 124
Table 131. Mobilization vs. Immobilization Included Articles ...................................... 125
Table 132. Mobilization vs. Immobilization Quality...................................................... 126
Table 133. Mobilization vs. Immobilization Study Data ................................................ 131
Table 134. Post Operative Physiotherapy Regiments .................................................... 136
Table 135. Excluded Articles .......................................................................................... 137
Table 136. Non-Operative treatment - Percent of patients able to return to work.......... 138
Table 137. Non-Operative Treatment -Percent of patients able to return to ADL ......... 139
xviii
Table 138. Operative Treatment - Percent of patients returning to ADL ....................... 139
Table 139. Operative Treatment - Percent of patients able to return to work ................ 140
Table 140. Non-Operative Treatment - Mean time until return to work ........................ 142
Table 141. Non-Operative Treatment - Mean time until return to walking.................... 142
Table 142. Operative Treatment - Mean time to return to ADL..................................... 143
Table 143. Operative Treatment - Mean time until return to work ................................ 144
Table 145. Patient return to activities of daily living...................................................... 147
Table 146. Operative Treatment - Return to Recreational Activity................................ 151
Table 147. Operative Treatment - Return to sports ........................................................ 151
Table 148. Operative Treatment - Mean time to return to athletic activity .................... 153
Table 150. Return to sports ............................................................................................. 155
Table 151. Non-Operative Treatment - Percent of patients returning to athletic activity
......................................................................................................................................... 160
Table 152. Non-Operative Treatment - Mean time until patients return to athletic activity
......................................................................................................................................... 162
Table 153. Excluded studies ........................................................................................... 163
Table 154. Study Quality ................................................................................................ 163
Table 155. Time from injury to treatment ..................................................................... 169
xix
I. INTRODUCTION
OVERVIEW
This clinical practice guideline is based on a systematic review of published studies on
the treatment of acute Achilles tendon rupture in adults. Adults were defined as older
than 19 years of age for this guideline. Acute Achilles tendon ruptures were defined for
the literature search as those treated within the first six weeks of injury to capture all
applicable literature; the patient population of the majority of studies included in this
guideline are patients treated within the first two weeks of injury (See Appendix II). In
addition to providing practice recommendations, this guideline also highlights gaps in the
literature and areas that require future research.
This guideline is intended to be used by all appropriately trained surgeons and all
qualified physicians diagnosing and treating Achilles tendon ruptures. It is also intended
to serve as an information resource for decision makers and developers of practice
guidelines and recommendations.
GOALS AND RATIONALE

The purpose of this clinical practice guideline is to help improve treatment based on the
current best evidence. Current evidence-based practice (EBP) standards demand that
physicians use the best available evidence in their clinical decision making. To assist in
this, this clinical practice guideline consists of a systematic review of the available
literature regarding the treatment of Achilles tendon ruptures. The systematic review
detailed herein was conducted between December 2008 and June 2009 and demonstrates
where there is good evidence, where evidence is lacking, and what topics future research
must target in order to improve the treatment of patients with acute Achilles tendon
ruptures. AAOS staff and the physician work group systematically reviewed the available
literature and subsequently wrote the following recommendations based on a rigorous,
standardized process.
Musculoskeletal care is provided in many different settings by many different providers.

We created this guideline as an educational tool to guide qualified physicians through a
series of treatment decisions in an effort to improve the quality and efficiency of care.
This guideline should not be construed as including all proper methods of care or
excluding methods of care reasonably directed to obtaining the same results. The ultimate
judgment regarding any specific procedure or treatment must be made in light of all
circumstances presented by the patient and the needs and resources particular to the
locality or institution.
INTENDED USERS
This guideline is intended to be used by orthopaedic surgeons and all qualified physicians
managing patients with acute Achilles tendon rupture. Typically, orthopaedic surgeons
will have completed medical training, a qualified residency in orthopaedic surgery, and
some may have completed additional sub-specialty training. It is also intended to serve as
an information resource for professional healthcare practitioners and developers of
practice guidelines and recommendations. Diagnosis and treatment for patients with acute
Achilles tendon rupture are based on the assumption that decisions are predicated on
1 v1.0 12.04.09
patient and physician mutual communication including discussion of available treatments
and procedures applicable to the individual patient. Once the patient has been informed of
available therapies and has discussed these options with his/her physician, an informed
decision can be made. Clinician input based on experience with both conservative
management and surgical skills increases the probability of identifying patients who will
benefit from specific treatment options.
PATIENT POPULATION
This document addresses the diagnosis and treatment of acute Achilles tendon rupture in
adults (defined as patients 19 years of age and older).
INCIDENCE
The incidence of Achilles tendon ruptures has been estimated to range from an annual
average of 5.5 ruptures to 9.9 ruptures per 100,000 people in North America (Edmonton,
Canada).1 Studies of European communities report comparable values ranging from 6 to
18 ruptures per 100,000 people.1-4
BURDEN OF DISEASE
Those afflicted with an acute Achilles tendon rupture face a healing period that requires
time away from work and limited athletic activity. Time away from work may impact the
patient financially and limiting activity may impact the patient’s health.5
ETIOLOGY
Most acute Achilles tendon ruptures are traumatic in origin. Some studies have shown
that ruptured Achilles tendons have occult degeneration.3
RISK FACTORS
Most ruptures of the Achilles tendons occur during sports activities, are more common in
males in the third or fourth decade of life, and occur more frequently on the left side.1
EMOTIONAL AND PHYSICAL IMPACT OF ACHILLES TENDON

RUPTURE
Acute Achilles tendon rupture often results in sudden pain in the affected leg, the
inability to bear weight and noticeable weakness of the affected ankle.3 The injury often
results in the patient’s inability to walk or perform their regular activities of daily living.
Patients face possible deformity if the tendon does not heal correctly and a substantial
recovery period. Possible complications associated with Achilles tendon rupture include
rerupture and, in cases of surgical repair, infection.
POTENTIAL BENEFITS, HARMS, AND CONTRAINDICATIONS

The aim of treatment is pain relief and improvement or maintenance of the patient’s
functional status. Long term results were often not available and complications varied by
study (frequently they were not reported) in the literature available for this guideline.
Most treatments are associated with some known risks, especially invasive and operative
treatments. In addition, contraindications vary widely based on the treatment
administered. Therefore, discussion of available treatments and procedures applicable to
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the individual patient rely on mutual communication between the patient and physician,
weighing the potential risks and benefits for that patient.
II. METHODS
Each recommendation in this clinical practice guideline is based on a systematic review
of the relevant medical literature. We developed systematic reviews for this guideline
because these reviews employ specific processes designed to minimize bias in the
selection, summary, and analysis of this literature.6, 7 In referring to bias, we explicitly
mean both the biases that can arise from financial conflicts of interest and biases that can
arise from intellectual conflicts if interest.
This section of the present document describes how we conducted our systematic reviews
and how the guideline was developed. Accordingly, in this section we describe our
strategies for finding relevant literature, our criteria for selecting articles to include in this
guideline, how we extracted data, how we appraised and graded the evidence, our
methods of statistical analysis, and the review and approval steps this guideline went
through. Elsewhere in this document, we provide extensive documentation so that
interested readers can assure themselves that we attempted to combat bias wherever
possible.
This guideline and the underlying systematic reviews were prepared by an AAOS
physician work group with the assistance of the AAOS Clinical Practice Guidelines Unit
in the Department of Research and Scientific Affairs at the AAOS (Appendix I). The
work group met on December 13, 2008 to establish the guideline’s scope. The work
group met again on July 31 and August 1, 2009 to write and vote on the final
recommendations and rationales for each recommendation. The resulting draft guidelines
were then peer-reviewed, subsequently sent for public commentary, and then sequentially
approved by the AAOS Evidence Based Practice Committee, AAOS Guidelines and
Technology Oversight Committee, AAOS Council on Research, Quality Assessment, and
Technology, and the AAOS Board of Directors (see Appendix III for a description of the
AAOS bodies involved in the approval process)
FORMULATING PRELIMINARY RECOMMENDATIONS

The work group began work on this guideline by constructing a set of preliminary
recommendations. These recommendations specify [what] should be done in [whom],
[when], [where], and [how often or how long]. They function as questions for the
systematic review that underpins each preliminary recommendation, and they do not
function as final recommendations or conclusions. Preliminary recommendations do not
need to be true.
Once established, these a priori preliminary recommendations cannot be modified until

the final work group meeting. The a priori and inviolate nature of the preliminary
recommendations combats bias by preventing a “change in course” if a systematic review
yields results that are not to someone’s liking. The results of each systematic review are
presented and discussed at the final work group meeting. At this time the preliminary
recommendations are modified in response to the evidence in the systematic review. All
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of the systematic reviews conducted for a given guideline are presented in it and, in
general, all preliminary recommendations are modified.
STUDY INCLUSION CRITERIA

We developed a priori article inclusion criteria for our review. These criteria are our
“rules of evidence” and articles that do not meet them are, for the purposes of this
guideline, not evidence.
To be included in our systematic reviews (and hence, in this guideline) an article had to
be a report of a study that:
• Evaluated a treatment for acute Achilles tendon rupture. Acute Achilles

tendon ruptures are defined as a rupture treated within zero to six weeks post
injury.
• Was a full report of a clinical study and was published in the peer reviewed
literature
• Was an English language article published after 1965
• Was not a cadaveric, animal, in vitro, or biomechanical study
• Was not a retrospective case series, medical records review, meeting abstract,
unpublished study report, case report, historical article, editorial, letter, or
commentary
• Was the most recent report of a study or the report with the largest number of
enrolled patients in a study with multiple publications
• Enrolled ≥ 10 patients in each of its study groups
• Enrolled a patient population comprised of at least 80% of patients with acute
Achilles tendon rupture
• Reported quantified results
• Must have followed 50% or more of its patients on at least one outcome; if
less than 80% follow up the outcome was down graded.
• Study must use validated outcome measures
When considering studies for inclusion, we included only the best available evidence.
Accordingly, we first included Level I evidence. In the absence of two or more studies of
this Level, we sequentially searched for and included Level II through Level IV evidence,
and did not proceed to a lower level if there were two or more studies of a higher level.
For example, if there were two Level II studies that addressed a recommendation, we did
not include Level III or IV studies.
OUTCOMES CONSIDERED
Clinical studies often report many different outcomes. We included only patient-oriented
outcomes when they were available. As the term implies, patient-oriented outcomes are
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outcomes that matter to the patient. “They tell clinicians, directly and without the need
for extrapolation, that a diagnostic, therapeutic, or preventive procedure helps patients
live longer or live better.”8 Examples of patient-oriented outcomes include pain and
quality of life.
We included surrogate outcomes only when patient-oriented outcomes were not

available. Surrogate outcomes are laboratory or other measurements that are used as
substitutes for how a patient feels, functions, or survives.9 Radiographic results are an
example of a surrogate outcome.
We only included data for an outcome if ≥ 50% of the patients were followed for that
outcome. For example, some studies report short-term outcomes data on nearly all
enrolled patients, and report longer-term data on less than half of the enrolled patients. In
such cases, we did not include the longer-term data. Additionally, we downgraded the
Level of Evidence by one in instances where 50% to ≤80% of patients were followed. For
example, if an otherwise perfect randomized controlled trial reported data on all enrolled
patients one week after patients received a treatment but reported data on only 60% of
patients one year later, we considered data from the later follow-up time as Level II
evidence.
We only included data for outcomes reporting the average length of time to return to an
activity if >80 % of the patients were included in the calculation. For example, some
studies report the mean time for return to work as 6 weeks but are only including data for
patients who have actually returned to work and are ignoring patients who are unable to
return. An outcome such as this would not be included.
LITERATURE SEARCHES
We attempted to make our searches for articles comprehensive. Using comprehensive
literature searches ensures that the evidence we considered for this guideline is not biased
for (or against) any particular point of view.
We searched for articles published from January 1966 to June 2009. Strategies for
searching electronic databases were constructed by a Medical Librarian and reviewed by
the work group. The search strategies we used are provided in Appendix IV. We searched
six electronic databases; PubMed, EMBASE, CINAHL, The Cochrane Library, The
National Guidelines Clearinghouse and TRIP database.
All searches of electronic databases were supplemented with manual screening of

bibliographies of all retrieved publications. We also searched the bibliographies of recent
systematic reviews and other review articles for potentially relevant citations. Finally, a
list of potentially relevant studies not identified by our searches was provided by the
work group members. Fifty-six studies met the inclusion criteria and were included.
A study attrition diagram (provided in Appendix V) documents, for each

recommendation, the number of articles we identified, where we identified these articles,
the number of articles we included, and the number of articles we excluded.
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DATA EXTRACTION
Data elements extracted from studies were defined in consultation with the physician
work group. Two analysts completed data extraction independently for all studies. The
evidence tables were audited by the work group. Disagreements about the accuracy of
extracted data were resolved by consensus. The elements extracted are provided in
Appendix VI.
The use of extracted data in our systematic reviews is another of our methods to combat
bias. It ensures that our results are based on the numerical results reported in published
articles and not on the authors’ conclusions in the “Discussion Sections” of their articles.
Such author conclusions can be influenced by bias.
JUDGING THE QUALITY OF EVIDENCE

Determining the quality of the included evidence is vitally important when preparing any
evidence-based work product. Doing so conveys the amount of confidence one can have
in any study’s results. One has more confidence in high quality evidence than in low
quality evidence.
We assessed the quality of the evidence for each outcome at each time point reported in a
study. We did not simply assess the overall quality of a study. Our approach follows the
recommendations of the Grading of Recommendations, Assessment, Development, and
Evaluation (GRADE) working group10 as well as others.11
We evaluated quality on a per outcome basis rather than a per study basis because quality
is not necessarily the same for all outcomes and all follow-up times reported in a study.
For example, a study might report results immediately after patients received a given
treatment and after some period of time has passed. Often, nearly all enrolled patients
contribute data at early follow-up times but, at much later follow-up times, only a few
patients may contribute data. One has more confidence in the earlier data than in the later
data. The fact that we would assign a higher quality score to the earlier results reflects
this difference in confidence.
We assessed the quality of treatment studies using a two step process. First, we assigned
a Level of Evidence to all results reported in a study based solely on that study’s design.
Accordingly, all data presented in randomized controlled trials were initially categorized
as Level I evidence, all results presented in non-randomized controlled trials and other
prospective comparative studies were initially categorized as Level II, all results
presented in retrospective comparative and case-control studies were initially categorized
as Level III, and all results presented in case-series reports were initially categorized as
Level IV. We next assessed each outcome at each reported time point using a quality
questionnaire and, when quality standards were not met, downgraded the Level of
evidence (for this outcome at this time point) by one level (Appendix VII).
In studies investigating a diagnostic test, we used the Quality Assessment of Diagnostic

Accuracy Studies (QUADAS) instrument to identify potential bias and assess variability
and the quality of reporting in studies reporting the effectiveness of diagnostic
techniques. We utilized a two step process to assess the quality of diagnostic studies. All
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studies enrolling a prospective cohort of patients are initially categorized as Level I
studies. Any study that did not enroll the appropriate spectrum of patients (e.g. case-
control studies) was initially categorized as a Level IV study. A study that we determined
contained methodological flaws (i.e. QUADAS question answered ‘no’) that introduce
bias were downgraded in a cumulative manner for each known bias (Appendix VII). For
example, a study that is determined by the QUADAS instrument to have two biases is
downgraded to Level III and a study that is determined to have four or more biases is
downgraded to a Level V study. Those studies that do not sufficiently report their
methods for a potential bias are downgraded to Level II since we are unable to determine
if the bias did or did not bias the results of the study.
Assigning a Level of Evidence on the basis of study design plus other quality
characteristics ties the Levels of Evidence we report more closely to quality than Levels
of Evidence based only on study design. Because we tie quality to Levels of Evidence,
we are able to characterize the confidence one can have in their results. Accordingly, we
characterize the confidence one can have in Level I evidence as high, the confidence one
can have in Level II and III evidence as moderate, and the confidence one can have in
Level IV and V evidence as low.
DEFINING THE STRENGTH OF THE RECOMMENDATIONS

Judging the quality of evidence is only a stepping stone towards arriving at the strength
of the guideline recommendation. Unlike Levels of Evidence (which apply only to a
given result at a given follow-up time in a given study) strength of the recommendation
takes into account the quality, quantity, and applicability of the available evidence.
Strength of the recommendation also takes into account the trade-off between the benefits
and harms of a treatment or diagnostic procedure, and the magnitude of a treatment’s
effect.
The strength of a recommendation expresses the degree of confidence one can have in a
recommendation. As such, the strength expresses how possible it is that a
recommendation will be overturned by future evidence. It is very difficult for future
evidence to overturn a recommendation that is based on many high quality randomized
controlled trials that show a large effect. It is much more likely that future evidence will
overturn recommendations derived from a few small case series. Consequently,
recommendations based on the former kind of evidence are rated as “strong” and
recommendations based on the latter kind of evidence are given strength of
recommendation of “limited”.
To develop the strength of a recommendation, AAOS staff first assigned a preliminary

strength rating for each recommendation that took only the quality and quantity of the
available evidence into account (see Table 1).Work group members then modified the
preliminary strength rating using the ‘Form for Assigning Grade of Recommendation
(Interventions)’ shown in Appendix VIII. This form is based on recommendations of the
GRADE Working group10 and requires the work group to consider the harms, benefits,
and critical outcomes associated with a treatment. It also requires the work group to
evaluate the applicability of the evidence. The final strength of the recommendation is
assigned by the physician work group, which modifies the preliminary strength rating on
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the basis of these considerations.
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Table 1 Strength of Recommendation Descriptions
Statement Description of Evidence Strength Implication for Practice

Rating
Strong Evidence is based on two or more “High” strength studies Practitioners should follow a Strong
with consistent findings for recommending for or against the recommendation unless a clear and compelling
intervention. rationale for an alternative approach is present.
A Strong recommendation means that the benefits of the

recommended approach clearly exceed the potential harm (or
that the potential harm clearly exceeds the benefits in the case
of a strong negative recommendation), and that the strength
of the supporting evidence is high.
Moderate Evidence from two or more “Moderate” strength studies with Practitioners should generally follow a
consistent findings, or evidence from a single “High” quality Moderate recommendation but remain alert to
study for recommending for or against the intervention. new information and be sensitive to patient
preferences.
A Moderate recommendation means that the benefits exceed
the potential harm (or that the potential harm clearly exceeds
the benefits in the case of a negative recommendation), but
the strength of the supporting evidence is not as strong.
Limited Evidence from two or more “Low” strength studies with Practitioners should be cautious in deciding
consistent findings, or evidence from a single Moderate whether to follow a recommendation classified
quality study recommending for or against the intervention or as Limited, and should exercise judgment and
diagnostic. be alert to emerging publications that report
evidence. Patient preference should have a
A Limited recommendation means the quality of the substantial influencing role.
supporting evidence that exists is unconvincing, or that well-
conducted studies show little clear advantage to one approach
versus another.
Inconclusive Evidence from a single low quality study or conflicting Practitioners should feel little constraint in
findings that do not allow a recommendation for or against deciding whether to follow a recommendation
the intervention. labeled as Inconclusive and should exercise
judgment and be alert to future publications that
An Inconclusive recommendation means that there is a lack clarify existing evidence for determining balance
of compelling evidence resulting in an unclear balance of benefits versus potential harm. Patient
between benefits and potential harm. preference should have a substantial influencing
role.
Consensus 1 The supporting evidence is lacking and requires the work Practitioners should be flexible in deciding
group to make a recommendation based on expert opinion by whether to follow a recommendation classified
considering the known potential harm and benefits associated as Consensus, although they may set boundaries
with the treatment. on alternatives. Patient preference should have a
substantial influencing role.
A Consensus recommendation means that expert opinion
supports the guideline recommendation even though there is
no available empirical evidence that meets the inclusion
criteria.
1
The AAOS will issue a consensus-based recommendation only when the service in question has virtually no
associated harm and is of low cost (e.g. a history and physical) or when not establishing a recommendation could have
catastrophic consequences.
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Each recommendation was written using language that accounts for the final strength of
the recommendation. This language, and the corresponding strength of recommendation,
is shown in Table 2.
Table 2 AAOS Guideline Language

Strength of
Guideline Language
Recommendation
We recommend Strong
We suggest Moderate
Is an option Limited
We are unable to recommend for or against Inconclusive
In the absence of reliable evidence, it is the
Consensus
opinion of this work group
CONSENSUS DEVELOPMENT
The recommendations and their strength were voted on using a structured voting
technique known as the nominal group technique.12 We present details of this technique
in Appendix . Voting on guideline recommendations was conducted using a secret ballot
and work group members were blinded to the responses of other members. If
disagreement between work group members was significant, there was further discussion
to see whether the disagreement(s) could be resolved. Up to three rounds of voting were
held to attempt to resolve disagreements. If disagreements were not resolved following
three voting rounds, no recommendation was adopted. Lack of agreement is a reason that
the strength for some recommendations is labeled “Inconclusive.”
STATISTICAL METHODS
When possible, we report the results of the statistical analyses conducted by the authors
of the included studies. In some circumstances, statistical testing was not conducted;
however, the authors reported sufficient quantitative data, including measures of
dispersion or patient level data for statistical testing. In these circumstances we used the
statistical program STATA (StatCorp LP, College Station, Texas) to conduct our own
analysis to interpret the results of a study. P-values < 0.05 were considered statistically
significant. Any statistical analysis conducted by the AAOS authors is denoted in the
tables.
STATA was also used to determine 95% confidence intervals, using the method of
Wilson, when authors of the included studies reported counts or proportions. The
program was also used to determine the magnitude of the treatment effect. For data
reported as means (and associated measures of dispersion) we calculated a standardized
mean difference by the method of Hedges and Olkin.13 For proportions, we calculated the
odds ratio as a measure of treatment effect. When no events occur (“zero event”) in a
proportion, the variance of the arcsine difference was used to determine statistical
significance (p < 0.05).14
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We used the program TechDig 2.0 (Ronald B. Jones, Mundelein, Illinois) to estimate
means and variances from studies presenting data only in graphical form.
When published studies only reported the median, range, and size of the trial, we
estimated their means and variances according to a published method.15
PEER REVIEW
The draft of the guideline and evidence report were peer reviewed by outside specialty
organizations that were nominated by the physician work group prior to the development
of the guideline. Peer review was accomplished using a structured peer review form
(Appendix X).
In addition, the physician members of the AAOS Guidelines and Technology Oversight
Committee, the Evidence Based Practice Committee and the Chairpersons of the AAOS
Occupational Health and Workers’ Compensation Committee and the Medical Liability
Committee were given the opportunity to provide peer review of the draft document.
We forwarded the draft guideline to a total of 38 peer reviewers and 17 returned reviews.
The disposition of all non-editorial peer review comments was documented and the
guideline was modified in response to peer review. The peer reviews and the responses to
them accompanied this guideline through the process of public commentary and the
subsequent approval process. Peer reviewing organizations and peer reviewing
individuals are listed in this document if they explicitly agree to allow us to publish this
information (Appendix X).
Peer review of an AAOS guideline does not imply endorsement. This is clearly stated on
the structured review form sent to all peer reviewers and is also posted within the
guideline. Endorsement cannot be solicited during the peer review process because the
documents may still undergo substantial change as a result of both the peer review and
public commentary processes. In addition, no guideline can be endorsed by specialty
societies outside of the Academy until the AAOS Board of Directors has approved it.
Organizations that provide members who participate on the work group or peer review of
a draft guideline will be solicited for endorsement once the document has completed the
full review and approval processes.
PUBLIC COMMENTARY
After modifying the draft in response to peer review, the guideline was submitted for a
thirty-day period of “Public Commentary.” Commentators consist of members of the
AAOS Board of Directors (BOD), members of the Council on Research, Quality
Assessment, and Technology (CORQAT), members of the Board of Councilors (BOC),
and members of the Board of Specialty Societies (BOS). Based on these bodies, up to
185 commentators had the opportunity to provide input into the development of this
guideline. Of these, 4 returned public comments.
For this guideline, outside specialty societies could post the confidential draft of the
guideline to their “member only” website. The responses garnered from these postings
were compiled by the specialty society and submitted as one succinct public commentary.
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In addition, members of the AAOS Board of Specialties (BOS) and Board of Councilors
(BOC) were encouraged to provide input; including encouragement to seek input from
colleagues not necessarily members of the BOS or BOC. As a result, the opportunity to
comment on this guideline exceeds the number of public commentators for previously
published AAOS guidelines as well as the numbers listed above.
THE AAOS GUIDELINE APPROVAL PROCESS

In response to the non-editorial comments submitted during the period of public
commentary, the draft was again modified by the AAOS Clinical Practice Guidelines
Unit and physician work group members. The AAOS Guidelines and Technology
Oversight Committee, the AAOS Evidence-based Practice Committee, the AAOS
Council on Research, Quality Assessment, and Technology, and the AAOS Board of
Directors approved the final guideline draft. Descriptions of these bodies are provided in
Appendix III.
REVISION PLANS
This guideline represents a cross-sectional view of current treatment and/or diagnosis and
may become outdated as new evidence becomes available. This guideline will be revised
in accordance with this new evidence, changing practice, rapidly emerging treatment
options, and new technology. This guideline will be updated or withdrawn in five years in
accordance with the standards of the National Guideline Clearinghouse.
GUIDELINE DISSEMINATION PLANS

The primary purpose of the present document is to provide interested readers with full
documentation about not only our recommendations, but also about how we arrived at
those recommendations. This document is also posted on the AAOS website at
http://www.aaos.org/research/guidelines/guide.asp.
Shorter versions of the guideline are available in other venues. Publication of most
guidelines is announced by an Academy press release, articles authored by the work
group and published in the Journal of the American Academy of Orthopaedic Surgeons,
and articles published in AAOS Now. Most guidelines are also distributed at the AAOS
Annual Meeting in various venues such as on Academy Row and at Committee Scientific
Exhibits.
Selected guidelines are disseminated by webinar, an Online Module for the Orthopeadic
Knowledge Online website, Radio Media Tours, Media Briefings, and by distributing
them at relevant Continuing Medical Education (CME) courses and at the AAOS
Resource Center.
Other dissemination efforts outside the AAOS include submitting the guideline to the
National Guideline Clearinghouse and distributing the guideline at other medical
specialty societies’ meetings.
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III. RECOMMENDATIONS AND SUPPORTING EVIDENCE
RECOMMENDATION 1
In the absence of the reliable evidence, it is the opinion of this work group that a detailed
history and physical exam be performed. The physical examination should include two
or more of the following tests to establish the diagnosis of acute Achilles tendon rupture:
o Clinical Thompson test (Simmonds squeeze test)
o Decreased ankle plantar flexion strength
o Presence of a palpable gap (defect, loss of contour)
o Increased passive ankle dorsiflexion with gentle manipulation
AAOS Strength of Recommendation – Consensus
recommendation based on expert opinion by considering the known potential harm and benefits
associated with the treatment. A Consensus recommendation means that expert opinion supports
the guideline recommendation even though there is no available empirical evidence that meets the
inclusion criteria of the guideline’s systematic review.
Implications: Practitioners should be flexible in deciding whether to follow a recommendation

classified as Consensus, although they may set boundaries on alternatives. Patient preference
should have a substantial influencing role.
Rationale:
A systematic review of the literature did not identify adequate evidence for or against the
use of specific history and physical examination findings to confirm the diagnosis of
acute Achilles tendon rupture. There was only one level V study16 identified that did not
provide adequate data in support of any individual or combination of the physical tests.
The prompt and accurate diagnosis of acute Achilles tendon rupture is essential to
providing patients with timely, effective, and appropriate care. A history and physical
examination adds no cost or risk to patients. The work group therefore agreed that an
opinion-based recommendation is warranted.
Supporting Evidence:
One Level V prospective study that enrolled patients with unilateral complete Achilles
tendon tears was included.16
SUMMARY OF EVIDENCE
The study16 used visual inspection at surgery as the gold standard for the diagnosis in
patients who had open repair. The study author also used clinical exam, ultrasound and
MRI as the reference standard for diagnosis when deciphering if patients had an Achilles
tendon tear and to confirm the extent of the tear in patients treated non-operatively.
Healthcare providers were not routinely blinded to the results of any given test. All
patients received a physical examination; palpation (presence of a gap) and the calf
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squeeze test (Thompson/Simmonds squeeze test) were performed by the author in all
patients. The author performed the Matles test (increased passive ankle dorsiflexion) on
107 of 174 patients.
The study author reported sensitivities and specificities for the tests based on the 133
patients treated with open repair and the 28 patients treated who did not have an Achilles
tendon rupture. The author reported these test results individually. He did not consider if
incremental value exists for any combination of the given physical tests when the tests
are all performed during the physical examination.
EXCLUDED ARTICLES
Table 3. Excluded Articles
Author Title Exclusion Reason
Copeland SA; Rupture of the Achilles tendon: a new clinical test Not relevant
Matles AL Rupture of the tendo achilles: another diagnostic sign Commentary
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STUDY QUALITY
Table 4. Study Quality
Differential verification bias avoided

Disease progression bias avoided
Uninterruptable/Intermediate test
Partial verification bias avoided
Diagnostic review bias avoided

Appropriate reference standard
Index test execution described
Reference standard execution
Clinical review bias avoided

Selection criteria described
Incorporation bias avoided
Test review bias avoided
Withdrawals explained
Spectrum bias avoided
● = Yes ○ = No X = Not Reported
result(s) reported
n/a = not applicable
described
Reference
Author N Index Test
Standard
Open
Repair,Ultrasound
Maffulli 161 Palpation X ○ ● ● ● ○ ● ● ● ● ○ ● ● ●
or MRI or
Clinical tests
Calf Squeeze
Open Repair,
Test
Ultrasound or
Maffulli 161 (Thompson X ○ ● ● ● ○ ● ● ● ● ○ ● ● ●
MRI or Clinical
test/Simmonds
tests
squeeze test)
Matles Test Open Repair,
(increased Ultrasound or
Maffulli 105 X ○ ● ● ● ○ ● ● ● ● ○ ● ● ○
passive ankle MRI or Clinical
dorsiflexion) tests
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STUDY RESULTS
Table 5. Sensitivity and specificity of Palpation, Calf Squeeze and Matles tests
Sensitivity‡ Specificity‡
Author N Test
(95% CI) (95% CI)
Palpation 0.73 0.89

Maffulli 161
(presence of a gap) (0.65, 0.80) (0.72, 0.98)
Calf Squeeze Test
0.96 0.93
Maffulli 161 (Thompson test /
(0.91, 0.99) (0.76, 0.99)
Simmonds squeeze test)
Matles Test (increased 0.88 0.86
Maffulli 105
passive ankle dorsiflexion) (0.79, 0.95) (0.67, 0.96)
‡ AAOS Calculation
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RECOMMENDATION 2
We are unable to recommend for or against the routine use of magnetic resonance
imaging (MRI), ultrasound (ultrasonography), and radiograph (roentgengrams, x-rays) to
confirm the diagnosis of acute Achilles tendon rupture.
AAOS Strength of Recommendation – Inconclusive
Description: Evidence from a single low quality study or conflicting findings that do not allow a
recommendation for or against the intervention. An Inconclusive recommendation means that
there is a lack of compelling evidence resulting in an unclear balance between benefits and
potential harm.

recommendation labeled as Inconclusive and should exercise judgment and be alert to future
publications that clarify existing evidence for determining balance of benefits versus potential
harm. Patient preference should have a substantial influencing role.
Rationale:
A systematic review of the literature failed to identify adequate evidence to make a

recommendation for or against the routine use of MRI, ultrasound, or radiographs to
confirm the diagnosis of acute Achilles tendon rupture.
There were no studies that address MRI or radiographs as confirmatory tests and there
were only two level V studies16, 17 that addressed ultrasound. These two studies contain
unreliable data and cannot be combined to provide adequate evidence.
No studies were identified to adequately answer this recommendation. To answer this

recommendation the ideal study must investigate the incremental benefit added by one of
the specified technologies (MRI, Ultrasound or plain radiograph). We found no studies
that addressed MRI or plain radiographs as a confirmatory test. Studies were found that
addressed ultrasound but they did not adequately address the recommendation using the
necessary study design.
The ideal study design required to address this recommendation compares two groups of
patients. Group one patients undergo the Thompson test and then surgery (gold standard).
Group two patients undergo the Thompson test and the test of interest (MRI, ultrasound,
or plain radiographs) and then surgery. Sensitivity, specificity and likelihood ratios would
be calculated and compared between groups to determine the incremental benefit added
by the technology. No study included both of the groups.
17 v1.0 12.04.09
SUMMARY OF EVIDENCE
Two Level V prospective studies that enrolled patients with complete Achilles tendon
tears were found.16, 17 The studies used visual inspection at surgery as the gold standard
for the diagnosis. One study had patients that underwent the Thompson test and then
surgery. Patients in the second study underwent the Thompson test and Ultrasound and
then surgery. The authors of the studies reported sensitivities and specificities or provided
enough information for these parameters to be determined.
EXCLUDED ARTICLES
Less than 10 patients
Fornage, 1986 Achilles tendon: US examination
per group
MR imaging of the Achilles tendon: overlap of
Haims, et al. Does not investigate
findings in symptomatic and asymptomatic
2000 the diagnostic test
individuals
Full- versus partial-thickness Achilles tendon tears:
Hartgerink, Retrospective Chart
sonographic accuracy and characterization in 26
et al. 2001 Review
cases with surgical correlation
Hollenberg, et Sonographic appearance of nonoperatively treated Does not investigate
al. 2000 Achilles tendon ruptures the diagnostic test
Kabbani, et al. Magnetic resonance imaging of tendon pathology
Commentary
1993 about the foot and ankle. Part I. Achilles tendon
Kalebo, et al. Diagnostic value of ultrasonography in partial Chronic/neglected
1992 ruptures of the Achilles tendon Achilles tendon rupture
Partial rupture of the proximal Achilles tendon: a
Kayser, et al.
differential diagnostic problem in ultrasound Partial Rupture
2005
imaging
Surgical correlation of preoperative MRI findings of
Less than 10 patients
Kuwada, 2008 trauma to tendons and ligaments of the foot and
per group
ankle
Lehtinen, et Sonography of Achilles tendon correlated to Chronic/neglected
al. 1994 operative findings Achilles tendon rupture
Marshall, et Contrast-enhanced magic-angle MR imaging of the Less than 10 patients
al. 2002 Achilles tendon per group
Mathieson, et Sonography of the Achilles tendon and adjacent Less than 10 patients
al. 1988 bursae per group
Ultrasonography in the differential diagnosis of
Paavola, et al. Achilles tendon injuries and related disorders. A Retrospective Chart
1998 comparison between pre-operative ultrasonography Review
and surgical findings
18 v1.0 12.04.09
Author
N
plus
Test
Test
STUDY QUALITY
Index Test
Ultrasound
(Thompson
Maffulli 161 (Thompson
squeeze test)
squeeze test)
Calf Squeeze
Calf Squeeze
Margetic 88 test/Simmonds
test/Simmonds
● = Yes ○ = No X = Not Reported
Open
Repair
Surgery
Standard
Reference
X
X
Spectrum bias avoided
○
○ Selection criteria described
●
●
Appropriate reference standard
●
●
Disease progression bias avoided
19
●
●
Partial verification bias avoided

○
○
Differential verification bias avoided

●
●
Incorporation bias avoided

●
●
v1.0 12.04.09
Index test execution described
●
●
Reference standard execution

described
○
●
Test review bias avoided

○
○
Diagnostic review bias avoided

●
●
Clinical review bias avoided
Uninterruptable/Intermediate test result(s)

●
●
reported
○
●
Withdrawals explained
STUDY RESULTS
Table 8. Sensitivity and Specificity
Sensitivity Specificity
Author N Test
(95% CI) (95% CI)
Calf Squeeze Test
0.96 0.93
Maffulli 161 (Thompson test /
(0.91, 0.99) (0.76, 0.99)
Simmonds squeeze test)
Calf Squeeze Test
Margetic (Thompson test / 0.91 1.00
88
et. al. Simmonds squeeze test) (0.83, 0.96) (0.16, 1.00)
plus ultrasound
20 v1.0 12.04.09
RECOMMENDATION 3
Non-operative treatment is an option for patients with acute Achilles tendon rupture.
AAOS Strength of Recommendation: Limited
Description: Evidence from two or more “Low” strength studies with consistent findings, or
evidence from a single “Moderate” quality study recommending for or against the intervention or
diagnostic. A Limited recommendation means the quality of the supporting evidence that exists
is unconvincing, or that well-conducted studies show little clear advantage to one approach versus
another.
Implications: Practitioners should be cautious in deciding whether to follow a recommendation

classified as Limited, and should exercise judgment and be alert to emerging publications that
report evidence. Patient preference should have a substantial influencing role.
Rationale:
A systematic review of non-operative treatment compared to operative treatment of acute
Achilles tendon ruptures identified four level II studies including all operative
techniques.18-21 Three studies included standard open treatment and one included a
minimally invasive technique. Increased complications were noted in the open operative
group.
When the outcomes of open and minimally invasive techniques were considered
separately, the preliminary strength of recommendation was moderate. The group agreed
that it was important to evaluate both functional outcomes and complications comparing
non-operative and all operative treatment groups. When these heterogeneous groups were
separated into non-operative and operative (including minimally invasive) treatments, the
strength of recommendation was downgraded to limited.
The functional outcomes were favorable in the operative group in 1 of 2 level II studies
and the return to activity and sport in 1 of 3 level II studies. Only 1 of 4 studies
demonstrated improvement in the rerupture rate in the operative group. The remainder of
the studies demonstrated no difference between the groups.
Higher complication rates, primarily due to impaired wound healing in the operative
group, demonstrate the importance of awareness of surgical risk factors in the decision
making of operative versus non-operative treatment (see Recommendation 6).
With acceptable functional results and lower complication rates than operative treatment,
non-operative treatment of acute Achilles tendon ruptures is an option in all patients,
especially those with increased surgical risk factors.
To address this recommendation, we analyzed studies that made two different

comparisons. Three level II studies compared patients treated non-operatively (with
21 v1.0 12.04.09
casting) to patients treated with open repair and one level II study compared casting to
minimally invasive open repair.18-21
Two studies examined functional outcomes and both found non-significant results (Table
9). Based on AAOS calculations, one of these studies did have significant results at two,
three, and six months measured by the Musculoskeletal Functional Assessment Index
(MFAI) in which patients with operative treatment had better functional ability than those
treated non-operatively; our results differ from the authors because a higher powered
statistical test was used. Two studies reported no significant difference in the number of
patients with pain (see Table 10).
Three studies reported patients treated non-operatively did not significantly differ in the
amount of time to return to work (see Table 11). Three studies examined return to sports
and one reported significant results in favor of patients treated with operative repair (see
Table 12). One study reported significantly less reruptures in patients treated operatively
(see Table 13).The occurrence of extreme residual tendon lengthening, DVT, and
“major” complications were not significantly different between patients treated
operatively or non-operatively. Minor complications reported in the included studies
were related to the surgical intervention and therefore occurred less in patients treated
non-operatively (see Table 15).
SUMMARY OF EVIDENCE
Table 9. Operative vs. Cast – Function
Duration (Months)
Author Comparison Outcome LOE N 2
2 3 6 12
weeks
Twaddle Open vs. Cast MFAI‡ II 42 ○ ●Op ●Op ●Op ○
Cetti Open vs. Cast Function II 111 ○

‡Musculoskeletal Functional Assessment Index
●Op: Statistically Significant in Favor of Operative Repair
●Non-Op: Favors Non-Operative treatment with Cast
○ No statistical significance
Table 10. Operative vs. Cast – Pain

Duration (Months)
Author Comparison Outcome LOE N
2 3 12
Möller Open vs. Cast % w/ Pain‡ III 85 ○
Metz Minimally Invasive vs. Cast Pain (VAS) II 83 ○ ○ ○

‡Level III evidence due to less than 80% of patients at follow-up
22 v1.0 12.04.09
Table 11. Operative vs. Cast – Return to Work

Duration
(Months)
12 24
Cetti Open vs. Cast Sick Leave II 111 ○
Möller Open vs. Cast Sick Leave II 112 ○

Minimally
Metz Invasive vs. Return to Work II 78 ○
Cast
Table 12. Operative vs. Cast - Return to Sport
Duration
Author Comparison Outcome LOE N (Months)
12 24
Return to
Cetti Open vs. Cast II 111 ●Op
Sport
Return to
Möller Open vs. Cast II 112 ○
Sport
Minimally
Return to
Metz Invasive vs. II 69 ○
Sport (%)
Cast
Table 13. Operative vs. Cast - Rerupture

Duration
Author Outcome LOE N (Months)
12
Twaddle Rerupture II 42 ○
Cetti Rerupture II 111 ○
Möller Rerupture II 112 ●Op
23 v1.0 12.04.09
Metz Rerupture II 83 ○
Table 14. Operative vs. Cast - Satisfaction

Duration (Months)
2 3 6 12 24
Satisfaction‡
Möller Open Repair vs. Cast III 85 ●Op ●Op ●Op ●Op
(VAS)
Minimally Invasive Satisfaction
Metz II 83 ○ ○ ○
vs. Cast (VAS)
‡Level III evidence due to less than 80% of patients at follow-up
Table 15. Operative vs. Cast – Complications

Duration
Adverse event/ (Months)
Author LOE N
Complication
12
Major Complications -
Cetti II 111 ○
(not including rerupture)
Metz Total Complications II 83 ○

Extreme Residual Tendon
Möller II 112 ○
Lengthening
Möller DVT II 112 ○
Total - Minor
Cetti II 111 ●Non-Op
Complications‡
Metz Partial Sensibility II 83 ●Non-Op
Cetti Disturbances of Sensibility II 111 ○
Möller Disturbance of Sensitivity II 112 ○
Metz Scar Adhesions II 83 ●Non-Op
Möller Scar Adhesions II 112 ●Non-Op
24 v1.0 12.04.09
Cetti Suture granuloma II 111 ○
Möller Superficial infection II 112 ○

‡As defined by the author: “Differences between major/minor complications is that major
complications give functional discomfort.” Minor Complications include: Scar adhesions,
superficial infection, disturbances of sensibility, suture granuloma, delayed wound healing.
●Non-Op: Statistically Significant in Favor of Non-Operative treatment with Cast
Summary of Systematic Reviews
Table 16. Systematic Review Summary

Author Conclusion
Bhandari, M et al. "Deep venous thrombosis is more common after
2002 nonoperative treatment of Achilles tendon ruptures" (p. 195).
"…The current group of randomized trials suggests a benefit
Bhandari, M et al.
to surgical repair of acute Achilles tendon ruptures in
2002
younger, active patients" (p. 199).
"Pooled analysis of studies did not reveal any difference in
Bhandari, M et al. the risk of minor complaints or return to normal function
2002 between surgical repair and conservatively treated groups"
(p. 190).
"Surgical treatment significantly reduces the risk of Achilles
Bhandari, M et al.
tendon re-ruptures, but increases the risk of infection, when
2002
compared with conservative therapy" (p. 190).
"In conclusion, open operative treatment of acute Achilles
tendon ruptures significantly reduces the risk of re-rupture
Khan, RJK, et al.
compared with nonoperative treatment but has the drawback
2005
of a significantly higher risk of other complications,
including wound infection" (p.2209).
"Although operative treatment provides a reduced re-rupture
rate over nonoperative treatment, the rate of moderate and
Lo, IKY, et al. 1997
mild complications in operative treatment is 20 times
greater" (p. 211).
"Presently, we favor non-operative treatment in patients with
Lo, IKY, et al. 1997 poor healing potential (i.e., smokers, diabetics, and patients
with peripheral vascular disease)" (p. 211).
"For healthy active individuals, we offer both forms of
Lo, IKY, et al. 1997 treatment, providing the patients with the estimates of
treatment success and complication rates" (p. 211).
"Surgical treatment is preferable to non-surgical treatment,
Lynch, RM 2004 produces better functional outcomes, and therefore appears
to be the treatment of choice" (p. 156).
25 v1.0 12.04.09
Author Conclusion
"The incidence of re-rupture following non-surgical
Lynch, RM 2004 treatment is significantly higher than for surgical treatment"
(p. 156).
"The number of patients that need to be treated surgically to
Lynch, RM 2004 prevent one re-rupture if these patients were treated non-
surgically is 5 (3-13, 95% confidence intervals)" (p.156).
"The incidence of minor complications following surgical
Lynch, RM 2004 treatment is large, but these do not appear to affect
functional outcome" (p. 156).
"Non-surgical treatment should be reserved for patients who
Lynch, RM 2004
refuse or who are unfit for operative repair" (p. 156).
EXCLUDED ARTICLES
Doral, et al. Percutaneous suturing of the ruptured Not best available evidence - not
2009 Achilles tendon with endoscopic control comparative
Neumayer,
A new conservative-dynamic treatment for Not best available evidence - not
et al.
the acute ruptured Achilles tendon comparative
2009
Ebinesan, et
Conservative, open or percutaneous repair Not best available evidence -
al.
for acute rupture of the Achilles tendon retrospective comparative
2008
Lorkowski,
Evaluation of long term therapy outcomes Combines operative and non-
et al.
for Achilles tendon ruptures operative patients
2007
Kotnis, et al. Dynamic ultrasound as a selection tool for
Not best available evidence
2006 reducing Achilles tendon re-ruptures
van, et al. Results of surgical versus non-surgical
Not best available evidence
2004 treatment of Achilles tendon rupture
Non-operative treatment of acute rupture of
Weber, et al. the Achilles tendon. results of a new Not best available evidence -
2003 protocol and comparison with operative retrospective comparative
treatment
The utility of gait analysis in the
Follak, et al. Not best available evidence - not
rehabilitation of patients after surgical
2002 comparative
treatment of Achilles tendon rupture
Calf muscle function after Achilles tendon
Moller, et al. rupture. A prospective, randomised study Duplicate - Data reported in prior
2002 comparing surgical and non-surgical study
treatment
Rumian, et
Surgical repair of the Achilles tendon. The Not best available evidence - not
al.
lateral approach comparative
2001
Horstmann, Isokinetic strength and strength endurance of Not best available evidence - not
et al. the lower limb musculature ten years after comparative
26 v1.0 12.04.09
2000 Achilles tendon repair
Rowley, et
Rupture of the Achilles tendon treated by a
al. No patient oriented outcome
simple operative procedure
1982
Ruptures of the tendo achillis. An objective
Inglis, et al.
assessment of surgical and non-surgical Less than 10 patients per group
1976
treatment
Surgical and non-surgical treatment of
Nistor, et al.
Achilles Tendon rupture. A prospective Not best available evidence
1981
randomized study
Combines acute and
Jacobs, et al. A new conservative-dynamic treatment for
neglected/chronic Achilles
1978 the acute ruptured Achilles tendon
tendon tear patients
STUDY QUALITY
outcome performance at entry

Those rating outcome Blinded
Stochastic Randomization
Follow Up - 80% or more

● = Yes ○ = No
Allocation Concealment
All groups have similar

× = Not Reported
Patients Blinded
Level of
Author Outcome N Treatment(s)
Evidence
Operative vs.
Twaddle MFAI 42 Cast Level II ● ● ○ ● ● ×
Operative vs.
Twaddle Re-rupture 42 Cast Level II ● ● ○ ● ● ×
Operative vs.
Moller Re-rupture 112 Cast Level II ● ● ○ ● ● ●
Operative vs.
Moller Return to work 112 Cast Level II ● ● ○ ● ● ●
Quality of Life Operative vs.
Moller (VAS) 112 Cast Level II ● ● ○ ● ● ●
Treatment Operative vs.
Moller Results (VAS) 112 Cast Level II ● ● ○ ● ● ●
Operative vs.
Pain
Moller 85 Cast Level III ● ● ○ ● ○ ●
Operative vs.
Cetti Return to Work
111 Cast Level II × × ○ ● ● ●
Operative vs.
Cetti Return to Sports
111 Cast Level II × × ○ ● ● ●
Cetti Hospitalization 111 Operative vs. Level II × × ○ ● ● ●
27 v1.0 12.04.09

● = Yes ○ = No

× = Not Reported
Patients Blinded
Level of
Evidence
Cast
Operative vs.
Metz Re-rupture 83 Cast Level II ○ ○ × × ● ×
Operative vs.
Metz Return to work 83 Cast Level II ● ● ○ ● ● ●
Operative vs.
Metz Return to sport 83 Cast Level II ● ● ○ ● ● ●
Operative vs.
Metz Pain- VAS 83 Cast Level II ● ● ○ ● ● ×
Satisfaction - Operative vs.
Metz VAS 83 Cast Level II ● ● ○ ● ● ×
STUDY RESULTS
Table 19. Open vs. Cast - Function
Open
Durati Cast
Repair
Author Comparison Outcome LOE N on Results
mean (SD) mean (SD)
% %
2
Twaddle Open vs. Cast MFAI II 42 42.4 (2.7)‡ 43 (2.7)‡ p = 0.48‡
weeks
2
Twaddle Open vs. Cast MFAI II 42 23.7 (2.6)‡ 27.6 (3.4)‡ p = 0.002‡
months
3
Twaddle Open vs. Cast MFAI II 42 15.2 (2.1)‡ 17 (2.6)‡ p = 0.02‡
months
6
months
12
months
Function -
12
Cetti Open vs. Cast Abnormal II 111 5.4% 3.6% NS
months
Gait
Function –
12
months
Run
Function -
12
months
Toe Stand
28 v1.0 12.04.09
NS: No statistical significance; authors do not report p-value.
Table 20. Cast vs. Open Repair - Pain

Open Minimally
Cast
Repair Invasive
Author Comparison Outcome LOE N Duration mean Results
mean (SD) mean (SD)
(SD)
% %
%
Open vs. Pain - 12
Möller III 85 92% n/a 88% p = .69‡
Cast None months
Open vs. Pain - 12
Möller III 85 6% n/a 3% p = .55‡
Cast Moderate months
Pain -
Open vs. 12
Möller During III 85 2% n/a 9% p = .129‡
Cast months
Walking
Minimally
Pain 1.80 1.56 p=
Metz Invasive II 83 2 months n/a
(VAS)‡ (1.40)‡ (1.25)‡ 0.20‡
vs. Cast
Minimally
1.53 1.80
Metz Invasive Pain (VAS) II 83 3 months n/a p = 0.78‡
(1.71)‡ (1.40)‡
vs. Cast
Minimally
12 0.40 p=
Metz Invasive Pain (VAS) II 83 n/a 0.78(1.40)‡
months (0.93)‡ 0.92‡
vs. Cast
n/a: not applicable
29 v1.0 12.04.09
Table 21. Operative vs. Cast - Return to Work
Open Minimally
Cast
Repair Invasive
Author Comparison Outcome LOE N Duration Results
mean (SD) mean (SD) mean (SD)
12 43.4
Cetti Open vs. Cast Return to Work (days) II 111 n/a 56 (25.2) NS
months (15.05)
24 p=
Möller Open vs. Cast Sick Leave (days) II 111 54.9 (47.9) n/a 73.4 (56.5)
months 0.06
Return to heavy work 24 102.2
Möller Open vs. Cast II 24 n/a 108.1(34.7) NS
(days) months (52.7)
24 p=
Möller Open vs. Cast Return to light work (days) II 54 35.7 (38) n/a 67.2 (65.9)
months 0.03
Return to Work – Sedentary 24

Möller Open vs. Cast II 34 30.8 (36.5) n/a 33.2 (54.7) NS
(days) months
Minimally Invasive vs. 12 p<

Metz Return to Work (days) II 78 n/a 59 (82) 108 (115)
Cast months 0.05
n/a: not applicable
30 v1.0 12.04.09
Table 22. Operative vs. Cast - Return to Sport
Open Minimally
Cast
Author Comparison Outcome LOE N Duration Repair Invasive Results
%
% %
Return to
Open vs. 12 p=
Cetti Sports- II 111 79% n/a 64%
Cast months .21‡
Total
Return to
Open vs. Sport - 12
Cetti II 111 57% n/a 29% p =.005
Cast Same months
Level
Return to
Open vs. Sport - 12
Möller II 112 54% n/a 54% NS
Cast Same months
Level
Return to
Open vs. 12
Cetti Sport - II 111 21% n/a 35% NS
Cast months
Diminished
Return to
Open vs. 12
Cetti Sport - II 111 14% n/a 22% NS
Cast months
Stopped
Return to
Open vs. 12 p=
Möller Sport - II 112 16% n/a 14%
Cast months .620‡
Stopped
Minimally
Return to 12 p=
Metz Invasive II 69 n/a 67% 81%
Sport months 0.16
vs. Cast
n/a: not applicable
Table 23. Operative vs. Cast - Rerupture

Open Minimally
Cast
Author Complication LOE N Duration Repair Invasive Results
% % %
12
Cetti Rerupture II 111 5.4% n/a 12.7% p = .167‡
months
12
Möller Rerupture II 112 1.7% n/a 20.8% p = < .001
months
Twaddle Rerupture II 42 6 months 10.0% n/a 4.5% p = .49‡
12
Metz Rerupture II 83 n/a 7.1% 12.2% p = 0.44‡
months
Second 12
Cetti II 111 0.0% n/a 1.8% p = .154‡
Rerupture months
n/a: not applicable
31 v1.0 12.04.09
Table 24 Cast vs. Open - Complications
Open Minimally
Cast
Repair Invasive
Author Complications LOE N Duration Results
% % %
Total 12
Metz II 83 n/a 28.6% 48.8% p = 0.06
Complications months
Major
Complications 12
Cetti II 111 9.0% n/a 16.3% NS
(not including months
rerupture)
Total
Complications 12
Metz II 83 n/a 21.4% 36.6% p = 0.13
Other Than months
Rerupture
12
Metz Sural Nerve Injury II 83 n/a 7.1% 2.4% p = 0.30‡
months
12
Cetti Deep Infection II 111 3.6% n/a 0% p = 0.05
months
Deep Wound 12
Metz II 83 n/a 0 0.0% NS
Infection months
Delayed Wound 12
Cetti II 111 1.8% n/a 0% p = 0.158‡
Healing months
Disturbances of 12
Cetti II 111 12.5% n/a 1.8% p = 0.017‡
Sensibility months
Disturbance of 24
Möller II 112 1.7% n/a 0% p = 0.16‡
Sensitivity months
12
Metz Partial Sensibility II 83 n/a 9.5% 0.0% p = 0.01‡
months
12
Metz DVT - lower leg II 83 n/a 0.0% 2.4% p = 0.15‡
months
24
Möller DVT II 112 0.0% n/a 1.9% p = 0.14‡
months
Necrosis of the 12
Cetti II 112 0.0% n/a 0% NS
Skin months
Extreme Residual
12
Cetti Tendon II 111 0.0% n/a 1.8% p = 0.15‡
months
Lengthening
Extreme Residual
24
Möller Tendon II 112 0.0% n/a 1.9% p = 0.14‡
months
Lengthening
Total - Minor 12
Cetti II 111 26.8% n/a 5.4% p = 0.004
Skin Related 12
Metz II 83 n/a 4.8% 31.7% p = .001‡
12
Cetti Scar Adhesions II 111 10.7% n/a 3.6% p = 0.136‡
months
12
Metz Scar Adhesions II 83 n/a 7.1% 0.0% p = 0.01‡
months
32 v1.0 12.04.09
Open Minimally
Cast
Repair Invasive
% % %
24
Möller Scar Adhesions II 112 13.6% n/a 0% p = <.001‡
months
12
Cetti Suture Granuloma II 111 1.8% n/a 0% p = 0.158‡
months
Superficial 24
Möller II 112 1.7% n/a 0% p = 0.16‡
Infection months
n/a: not applicable
33 v1.0 12.04.09
RECOMMENDATION 4
For patients treated non-operatively, we are unable to recommend for or against the use
of immediate functional bracing for patients with acute Achilles tendon rupture.
AAOS Strength of Recommendation: Inconclusive
potential harm.

Rationale:
Non-operative treatment for Achilles tendon ruptures was evaluated by comparing the
use of immediate functional bracing or a combination of casting with functional bracing
(for a period of 0-12 weeks) to casting alone. One level II and one level IV comparative
study were analyzed. The only outcome that could be adequately determined in these
studies was rerupture rate which was not significantly different. 22, 22
Functional outcomes of the functional bracing group were analyzed with three studies
(level IV and V) and no case series of cast treatment alone was identified. 23-25
With the lack of functional data demonstrating improved outcomes with functional
bracing and the lack of demonstrable difference in rerupture rates, we are unable to
recommend for or against the use of immediate functional bracing for patients treated
non-operatively for acute Achilles tendon rupture.
We analyzed one level II and one level IV study that compared patients treated with cast
plus a functional brace vs. patients treated with a cast only. 26 22 We reported the
rerupture rates of both comparative studies but other outcomes were considered due to
the reliability of the evidence reported in both studies (See Methods Section – Outcomes
considered). We then examined three studies (Level IV and V) that reported results for
patients treated with functional bracing. 23-25
In both comparative studies, rerupture rates did not significantly differ between patients
treated with cast plus orthosis vs. cast (see Table 25). See Table 36 for case series re-
rupture rates.
Seventy-eight percent of patients treated with a functional brace had no pain, 55%
reported no stiffness, 56% had no weakness, 98% of patients returned to full level of
employment and 37% returned to the same level of sports at 2.9 years. The average time
to return to work was 7 days (range 21 – 52) (see Table 26).
34 v1.0 12.04.09
One study reported 2% of patients had a pulmonary embolism and another study reported
1% of patients with a DVT and “temporary drop foot” (see Table 35).
SUMMARY OF EVIDENCE
Table 25. Cast + Functional Brace vs. Cast - Rerupture
Cast +
Cast orthosis
Author Outcome LOE N Duration (%) (%) Results
Saleh, et 12
al. 1992 Rerupture II 31 months 6% 7% p=.96‡
Ingvar, et
al. 2005 Rerupture IV 194 4 years 7% 10% p=.51‡
‡ AAOS calculation
Table 26. Summary of Results - Case Series
Results
Author Outcome LOE N Duration (%)
Wallace Pain - none IV 140 2.9 years 78%
Stiffness –
Wallace none IV 140 2.9 years 55%
Weakness –
Wallace none IV 140 2.9 years 56%
Return to Full
Preinjury Level
Wallace of Employment IV 122 2.9 years 98%
Wallace, Return to
et al. Sports - same
2004 or better level IV 101 2.9 years 37%
Table 27. Summary of Systematic Reviews

Author Conclusion
"Early functional mobilisation is more acceptable to
Lynch, RM 2004 patients than plaster cast immobilisation and results in
improved functional outcomes" (p. 156).
35 v1.0 12.04.09
Table 28. Functional Bracing – Satisfaction (VAS)
Results
Author Outcome LOE N Duration
(mean ± SD)
Neumayer, Satisfaction
IV 46 5 years 8.1 ± 2
et al. 2009 (VAS)
Table 29. Functional Bracing - Satisfaction (%)
Results
(%)
Wallace, Satisfaction – very

IV 140 2.9 years 83%
et al. 2004 satisfied
Satisfaction –
Wallace,
satisfied with IV 140 2.9 years 15%
et al. 2004
minor reservations
Satisfaction –
Wallace,
satisfied with IV 140 2.9 years 1%
et al. 2004
major reservations
Wallace, Satisfaction –
IV 140 2.9 years 1%
et al. 2004 dissatisfied
Table 30. Functional Bracing - Pain
Results
(%)
Wallace,
Pain - none IV 140 2.9 years 78%
et al. 2004
Wallace,
Pain - mild IV 140 2.9 years 13%
et al. 2004
Wallace,
Pain - moderate IV 140 2.9 years 8%
et al. 2004
Wallace,
Pain – severe IV 140 2.9 years 1%
et al. 2004
Table 31. Functional Bracing - Function
Results
(%)
Wallace,
Stiffness – none IV 140 2.9 years 55%
et al. 2004
36 v1.0 12.04.09
Wallace,
Stiffness – mild IV 140 2.9 years 41%
et al. 2004
Wallace, Stiffness –
IV 140 2.9 years 3%
et al. 2004 moderate
Wallace,
Stiffness – severe IV 140 2.9 years 1%
et al. 2004
Table 32. Functional Bracing - Strength
Results
(%)
Wallace,
Weakness – none IV 140 2.9 years 56%
et al. 2004
Wallace,
Weakness - mild IV 140 2.9 years 33%
et al. 2004
Wallace, Weakness -
IV 140 2.9 years 10%
et al. 2004 moderate
Wallace,
Weakness -severe IV 140 2.9 years 1%
et al. 2004
Table 33. Functional Bracing - Return to Work and Sports

Results
(%)
Return to Full
Wallace,
Preinjury Level of IV 122 2.9 years 98%
et al. 2004
Employment
Return to Sports -
Wallace,
same or better IV 101 2.9 years 37%
et al. 2004
level
Return to Sports -
Wallace,
diminished or IV 101 2.9 years 63%
et al. 2004
none
McComis, Return to Sports -
V 15 26 weeks 67%
et al. 1997 same level
McComis, Return to Sports -
V 15 26 weeks 33%
et al. 1997 diminished
Table 34. Functional Bracing - Return to Work and Sports (days)

Results
Author Outcome LOE N
(mean)
37 v1.0 12.04.09
Wallace, Time to Return to 7 days
IV 122
et al. 2004 Work (max: 52 days)
McComis, Time to Return to 4 days
V 15
et al. 1997 Work (max: 3 weeks)
8 weeks
Wallace, Time to Return to
IV 101 (range 2 weeks
et al. 2004 Sports
- 6 months)
Table 35. Functional Bracing - Complications

Cast Cast +
orthosis
Author Outcome LOE N Duration (%) (%) Results
Neumayer, Pulmonary 12
et al. 2009 embolism IV 57 months n/a 2% n/a
Wallace, 2.9 years

et al. 2004 DVT IV 140 (0.4-8.2) n/a 1% n/a
Wallace, Temporary 2.9 years

et al. 2004 Drop foot IV 140 (0.4-8.2) n/a 1% n/a
n/a: not applicable
Table 36. Functional Bracing - Rerupture

Cast +
Cast
Author Outcome LOE N Duration orthosis Results
(%)
(%)
Neumayer, Complete
IV 57 12 months n/a 9% n/a
et al. 2009 rerupture
Wallace, et Complete 2.9 years
IV 140 n/a 2% n/a
al. 2004 rerupture (0.4-8.2)
Neumayer,
Partial rerupture IV 57 12 months n/a 4% n/a
et al. 2009
Wallace, et 2.9 years
Partial rerupture IV 140 n/a 4% n/a
al. 2004 (0.4-8.2)
n/a: not applicable
EXCLUDED ARTICLES
Table 37. Functional Bracing - Excluded Studies
Edna TH; Non-operative treatment of Achilles tendon ruptures case series cast only
Fruensgaard S, et Conservative treatment for acute rupture of the Achilles
casting only
al. tendon
38 v1.0 12.04.09
Long-term results after functional non-operative
Hufner TM, et al. cast only case series
Ruptures of the tendo achillis. An objective assessment
Inglis AE, et al. Less than 10 patients per arm
of surgical and non-surgical treatment
Immediate, full weight bearing cast treatment of acute
Josey RA, et al. cast only case series
Achilles tendon ruptures: a long-term follow-up study
Keller J, et al Closed treatment of Achilles tendon rupture case series cast only
Lea RB; Smith L; Non-surgical treatment of tendo achillis rupture casting only
Conservative treatment to Achilles tendon rupture. A
Lildholdt T, et al cast only case series
follow-up study of 14 cases
Conservative treatment of fresh subcutaneous rupture
Nistor L; casting only case series
of the Achilles tendon
Residual functional problems after non-operative
Pendleton H, et al. cast only case series
The treatment of total ruptures of the Achilles tendon
Persson A, et al. cast only case series
by plaster immobilisation
Dynamised cast management of Achilles tendon
Roberts CP, et al retrospective case series
ruptures
STUDY QUALITY
Table 38. Study Quality - Randomized Control Trials



Patients Blinded
● = Yes ○ = No
× = Not Reported
Level of
Evidence
Saleh, et Cast vs. Cast +

Rerupture 31 Level II × × ○ ○ ● ●
al. 1992 Orthosis
Table 39. Study Quality - Non-Randomized Comparative Study

approximately
outcome
characteristics
on outcome at
comparable at
80% or more
experimental
receive same
concurrently
performance
Follow Up -
equal follow
and control
All groups
groups
difference
evaluated
than 20%
treatment
treated
using
samehave
for
● = Yes ○ = No
All
× = Not Reported
39 v1.0 12.04.09
Level of
Author Outcome N Treatment(s) Evidence
Ingvar,
et al. Cast vs. Cast
2005 Re-rupture 194 + Orthosis Level IV × ○ ● ● × ● ● ● ×
Table 40. Study Quality - Case Series
All patients have approximately equal

All patients receive same treatment
All patients evaluated using
same outcome measures

Consecutive enrollment
follow-up times
of patients
● = Yes ○ = No
× = Not Reported
Level of
Neumayer, et al.
2009 Satisfaction (VAS) 46 Cast + Orthosis Level IV ● ● ● ● ●
Wallace, et al.
2004 Satisfaction 140 Cast + Orthosis Level IV ● ● ● ● ●
Wallace, et al.
2004 Pain 140 Cast + Orthosis Level IV ● ● ● ● ●
Wallace, et al.
2004 Stiffness 140 Cast + Orthosis Level IV ● ● ● ● ●
Wallace, et al.
2004 Weakness 140 Cast + Orthosis Level IV ● ● ● ● ●
Return to Full
Wallace, et al. Preinjury Level of
2004 Employment 122 Cast + Orthosis Level IV ● ● ● ● ●
Wallace, et al. Return to Sports -
2004 same or better level 101 Cast + Orthosis Level IV ● ● ● ● ●
Wallace, et al. Return to Sports -
2004 diminished or none 101 Cast + Orthosis Level IV ● ● ● ● ●
McComis, et al. Return to Sports -
1997 same level 15 Cast + Orthosis Level V ● ○ ● ● ●
McComis, et al. Return to Sports -
1997 diminished 15 Cast + Orthosis Level V ● ○ ● ● ●
40 v1.0 12.04.09
All patients have approximately equal

follow-up times
of patients
● = Yes ○ = No
× = Not Reported
Level of
Wallace, et al. Time to Return to
2004 Work 122 Cast + Orthosis Level IV ● ● ● ● ●
McComis, et al. Time to Return to
1997 Work 15 Cast + Orthosis Level V ● ○ ● ● ●
Wallace, et al. Time to Return to
2004 Sports 140 Cast + Orthosis Level IV ● ● ● ● ●
Neumayer, et al. Complete re-
2009 rupture 57 Cast + Orthosis Level IV ● ● ● ● ●
Wallace, et al. Complete re-
2004 rupture 140 Cast + Orthosis Level IV ● ● ● ● ●
Neumayer, et al.
2009 Partial rerupture 57 Cast + Orthosis Level IV ● ● ● ● ●
Wallace, et al.
2004 Partial rerupture 140 Cast + Orthosis Level IV ● ● ● ● ●
Neumayer, et al. Pulmonary
2009 embolism 57 Cast + Orthosis Level IV ● ● ● ● ●
Wallace, et al.
2004 DVT 140 Cast + Orthosis Level IV ● ● ● ● ●
Wallace, et al. Temporary Drop
2004 foot 140 Cast + Orthosis Level IV ● ● ● ● ●
41 v1.0 12.04.09
RECOMMENDATION 5
Operative treatment is an option in patients with acute Achilles tendon rupture.
another.

Rationale:
To answer this recommendation, we reviewed studies addressing the efficacy of operative
treatment. A systematic review of the literature included eight studies20, 19, 27, 28, 29, 30,31,
32
that addressed the efficacy of open repair and six studies33, 29, 34, 21, 27, 31, addressing the
efficacy of minimally invasive techniques. This systematic review addressed only the
efficacy of operative treatment and therefore did not consider the comparisons made in
the studies. Please refer to Recommendation 3 and its rationale for a comparison of non-
operative and operative treatment of acute Achilles tendon ruptures. In addition, relevant
comparative information about operative techniques can be found in Recommendation 8
and its rationale.
A systematic review of the literature included eight studies20, 19, 27, 28, 29, 30,31, 32 that
addressed the efficacy of open repair and six studies33, 29, 34, 21, 27, 31 addressing the
efficacy of minimally invasive techniques. By six months the return to activity ranged
from 73% to 100% after operative treatment (see Table 42 through Table 58). After
twelve months, 92% of patients reported they had no pain (see Table 48).
All studies relevant to this Recommendation were Level IV (see Table 60) because this is
non comparative data.
To determine the efficacy of open repair and/or minimally invasive repair we need a
study with preoperative and postoperative data. However, the data we identified only
provides postoperative measures and is therefore unreliable. We have tabled the
postoperative data from eight studies20, 19, 27, 28, 29, 30,31,32 that address efficacy of open
repair and six studies 33, 29, 34, 21, 27, 31 that address minimally invasive techniques. Table 42
through Table 58 demonstrate the wide variety of patient-oriented outcome measures and
duration to follow-up used to evaluate patients receiving operative treatment for Achilles
tendon rupture. The inconsistency of these outcome measures makes comparisons
between studies difficult. Because the body of evidence is limited, it does not allow for
additional statistical analysis.
42 v1.0 12.04.09
Please see Recommendation 7 for results of operative treatment comparisons.
43 v1.0 12.04.09
SUMMARY OF EVIDENCE
Table 41. Open Repair – All Outcomes
Result
Outcome (Efficacy)
Time until Return to Work ?
Time until Return to Stair Climbing ?
Time until Return to Walking ?
Time until Return to Sports ?
Return to work (%) ?
Return to ADL (%) ?
Return to Final Functional Activities (%) ?
Pain (%) ?
Function- Abnormal ankle movement (%) ?
Abnormal Run (%) ?
Abnormal toe stand (%) ?
Satisfaction (%) ?
Table 42. Open Repair - Return to work

Mean time
Author LOE N Outcome Mean (SD)
Moller, et al. 2001 IV 59 Return to work (days) 54.9 (nr)
Cetti, et al. 1993 IV 56 Return to work (weeks) 6.2 (SD 2.15)
Moller, et al. 2001 IV 59 Return to heavy work (days) 102.2 (nr)
Moller, et al. 2001 IV 59 Return to sedentary work (days) 30.8 (nr)

Return to light, mobile work
Moller, et al. 2001 IV 59 35.7 (nr)
(days)
nr: not reported
44 v1.0 12.04.09
Table 43. Open Repair - Activities of daily living
Mean time
Mean
Author LOE N Outcome (SD)/(range)
Bhattacharyya, et al. Return to Normal Stair Climbing
IV 53 19 (3.5)‡
2009 (weeks)
Bhattacharyya, et al. Return to Normal Walking
IV 53 17 (3)‡
2009 (weeks)
Return to same level of sports
Uchiyama, et al. 2007 IV 84 5 (17-26 weeks)
(months) (high level athletes)
12.3 (range 8-
Uchiyama, et al. 2007 IV 84 Return to jogging (weeks)
21)
‡AAOS Calculation
Table 44. Open Repair- Mean time until return to athletic activity
Mean time
Author LOE N Outcome Mean (range)
Return to same level of sports
Uchiyama, et al. 2007 IV 84 5 (17-26 weeks)
(months) (high level athletes)
Uchiyama, et al. 2007 IV 84 Return to jogging (weeks) 12.3 (8-21)
45 v1.0 12.04.09
Table 45. Open Repair- Percent of patients able to return to activities of daily living
Follow- % of
Author LOE N Outcome
up Patients
2
Lim, et al. 2001 IV 33 Return to ADL 6%
months
3
months
6
months
Return to final functional 3
Lim, et al. 2001 IV 33 36%
activity‡ months
Return to final functional 6
Lim, et al. 2001 IV 33 64%
activity‡ months
‡ Final functional activity defined as “patient is unhindered in all his or her activities apart from
active sports”
Table 46. Open Repair- Percent of patients able to return to work

Follow- % of
up Patients
Moller, et al. 2001 IV 59 Return to work (days) nr 100%
Moller, et al. 2001 IV 59 Return to sedentary work (days) nr 22%

Moller, et al. 2001 IV 59 nr 54%
(days)
Moller, et al. 2001 IV 59 Return to heavy work (days) nr 24%
Nr: not reported
Table 47. Open Repair- Percent of patients able to return to sports

Follow- % of
up Patients
Return to pre-injury sporting
Coutts, et al 2002 IV 22 nr 91%
level
12
Moller, et al. 2001 IV 47 Return to sports - same level 54%
months
12
Cetti, et al. 1993 IV 52 Return to sports - same level 62%
months
Return to active sporting/outdoor 3
Lim, et al. 2001 IV 33 9%
activities months
Return to active sporting/outdoor 6
Lim, et al. 2001 IV 33 48%
activities months
12
Moller, et al. 2001 IV 47 Return to sports - stopped 16%
months
46 v1.0 12.04.09
Follow- % of
up Patients
12
Cetti, et al. 1993 IV 52 Return to sports - stopped 15%
months
Return to sports - diminished 12
Cetti, et al. 1993 IV 52 23%
level months
Table 48: Open Repair- Percent of patients with pain

Author LOE N Outcome Follow-up % of Patients
Aktas, et al. 2007 IV 30 Pain - Mild w/ maximal exertion 6 months 14%
Aktas, et al. 2007 IV 30 Pain - Absent 6 months 86%
Moller, et al. 2001 IV 52 Pain-during walking 12 months 2%
Moller, et al. 2001 IV 52 Pain-moderate 12 months 6%
Moller, et al. 2001 IV 52 Pain-none 12 months 92%
Aktas, et al. 2009 IV 23 Pain- mild during exertion 22 months 13%
Table 49. Open Repair- Percent of patients able to complete functional activities
Function-Abnormal ankle
Cetti, et al. 1993 IV 56 4 months 52%
movement
Cetti, et al. 1993 IV 56 12 months 18%
movement
Cetti, et al. 1993 IV 56 Function-Abnormal gait 4 months 27%
Cetti, et al. 1993 IV 56 Function-Abnormal gait 12 months 5%
Cetti, et al. 1993 IV 56 Function-Abnormal run 4 months 52%
Cetti, et al. 1993 IV 56 Function-Abnormal run 12 months 13%
Cetti, et al. 1993 IV 56 Function-Abnormal toe stand 4 months 21%
Cetti, et al. 1993 IV 56 Function-Abnormal toe stand 12 months 9%
Table 50. Open Repair- Percent of patients with excellent satisfaction

Lim, et al. 2001 IV 33 Satisfaction - Excellent 6 months 42%
47 v1.0 12.04.09
Table 51. Minimally Invasive Repair- All outcomes
Result
Outcome (Efficacy)
Return to Work (%) ?
Return to Stair Climbing (%) ?
Return to Walking (%) ?
Return to Sports (%) ?
Return to work (%) ?
Return to ADL (%) ?
Return to Final Functional Activities (%) ?
Satisfaction (%) ?
Function- Abnormal ankle movement (%) ?
Return to same level of activity (%) ?
Able to walk without limitations (%) ?
Return to sports (%) ?
Pain (%) ?
Table 52. Minimally Invasive Repair- Percent of Patients able to return to activity
% of
Author LOE N Treatment Outcome Follow-up
Patients
ES Ng, et al. Return to activity - 65.5
IV 25 percutaneous 96%
2007 same level months
Lim, et al.
IV 33 percutaneous Return to ADL 2 months 6%
2001
Lim, et al.
2001
Lim, et al.
2001
Lim, et al. Return to final
IV 33 percutaneous 3 months 27%
2001 functional activity
Lim, et al. Return to final
2001 functional activity
Chillemi, et Able to walk
al. 2002 without limitation
48 v1.0 12.04.09
Table 53. Minimally Invasive Repair - Percent of patients able to return to sports
% of
Author LOE N Treatment Outcome Follow-up
Patients
Return to active
Lim, et al.
IV 33 percutaneous sporting/outdoor 3 months 0%
2001
activities
Return to active
Lim, et al.
IV 33 percutaneous sporting/outdoor 6 months 67%
2001
activities
Return to sports
Chillemi, et activity (frequent
IV 14 percutaneous nr 57%
al. 2002 participant 2-3
times per week)
nr: not reported
Table 54. Minimally Invasive Repair - Satisfaction
Author LOE Treatment N Outcome Follow-up %

Lim, et al. IV Satisfaction -
percutaneous 33 6 months 52%
2001 Excellent
Table 55. Minimally Invasive Repair - Mean time until return to activity
Mean Time (Days)
Author LOE Treatment N Outcome
Mean (SD)
Metz, et al.
IV minimally-invasive 40 Return to work 59 (82)
2008
Bhattacharyya, Return to Normal
IV minimally-invasive 53 12.5 (3)‡
et al. 2009 Walking (weeks)
Return to Normal
Bhattacharyya,
IV minimally-invasive 53 Stair Climbing 14 (3)‡
et al. 2009
(weeks)
‡= AAOS Calculation
Table 56. Minimally Invasive Repair-Percent of patients able to return to sports

% of
Author LOE Treatment N Outcome Follow-up Patients
Metz, et al.
IV minimally-invasive 36 Return to sports 12 months 67%
2008
Metz, et al. IV
minimally-invasive 36 Change sports 12 months 11%
2008
Metz, et al. IV
minimally-invasive 36 Stop sports 12 months 22%
2008
Metz, et al. IV
minimally-invasive 40 Return to work nr 98%
2008
nr: not reported
49 v1.0 12.04.09
Table 57. Minimally Invasive Repair-Percent of patients able to return to work
% of
Metz, et al. IV
minimally-invasive 40 Return to work nr 98%
2008
nr: not reported
Table 58. Minimally Invasive Repair-Pain
% of
IV Percent of patient
Aktas, et
minimally-invasive 23 with mild pain 22 months 4.5%
al.2009
during exertion
EXCLUDED ARTICLES
Exclusion
Author Title
Reason
Not best
Leppilahti J;Forsman Outcome and prognostic factors of Achilles rupture
available
K;Puranen J;Orava S; repair using a new scoring method
evidence
Not best
Chiodo CP;Wilson Current concepts review: acute ruptures of the
available
MG; Achilles tendon
evidence
Nonoperative treatment of acute rupture of the
Weber M;Niemann
Achilles tendon: results of a new protocol and Retrospective
M;Lanz R;Muller T;
comparison with operative treatment
Maffulli N;Tallon Early weightbearing and ankle mobilization after open
C;Wong J;Lim repair of acute midsubstance tears of the Achilles Not Relevant
KP;Bleakney R; tendon
Halasi T;Tallay Percutaneous Achilles tendon repair with and without
Retrospective
A;Berkes I; endoscopic control
Costa ML;Shepstone Not best
Immediate full-weight bearing mobilisation for
L;Darrah C;Marshall available
repaired Achilles tendon ruptures: a pilot study
T;Donell ST; evidence
Not relevant-
looks at effect
Maffulli N;Tallon
No adverse effect of early weight bearing following of weight
C;Wong J;Peng
open repair of acute tears of the Achilles tendon bearing
LK;Bleakney R;
following
surgery
van der Linden-van der Not best
Results of surgical versus non-surgical treatment of
Zwaag HM;Nelissen available
RG;Sintenie JB; evidence
50 v1.0 12.04.09
Exclusion
Author Title
Reason
Comparison of functional ability following No patient-
Steele GJ;Harter
percutaneous and open surgical repairs of acutely oriented
RA;Ting AJ;
ruptured Achilles tendons outcome
Not best
Cretnik A;Kosanovic Percutaneous versus open repair of the ruptured
available
M;Smrkolj V; Achilles tendon: a comparative study
evidence
No patient -
Goren D;Ayalon Isokinetic strength and endurance after percutaneous
oriented
M;Nyska M; and open surgical repair of Achilles tendon ruptures
outcome
The Webb-Bannister percutaneous technique for acute Not best
Wagnon R;Akayi M; Achilles' tendon ruptures: a functional and MRI available
assessment evidence
Early motion of the ankle after operative treatment of Not best
Mortensen HM;Skov
a rupture of the Achilles tendon. A prospective, available
O;Jensen PE;
randomized clinical and radiographic study evidence
Hufner TM;Brandes
Not best
DB;Thermann Long-term results after functional nonoperative
available
H;Richter M;Knobloch treatment of Achilles tendon rupture
evidence
K;Krettek C;
Recovering motor performance of the foot after
No patient
Kauranen K;Kangas Achilles rupture repair: a randomized clinical study
oriented
J;Leppilahti J; about early functional treatment vs. early
outcome
immobilization of Achilles tendon in tension
Not best
Majewski M;Rohrbach Avoiding sural nerve injuries during percutaneous
available
M;Czaja S;Ochsner P; Achilles tendon repair
evidence
Attinger CE;Ducic
Outcome of skin graft versus flap surgery in the
I;Hess CL;Basil
salvage of the exposed Achilles tendon in diabetics Not relevant
A;Abbruzzesse
versus nondiabetics
M;Cooper P;
Combines open
Kotnis R;David
Dynamic ultrasound as a selection tool for reducing and
S;Handley R;Willett
Achilles tendon re-ruptures percutaneous
K;Ostlere S;
repair
Schonberger TJ;Janzing Operative treatment of acute Achilles tendon rupture:
Retrospective
HM;Morrenhof JW;de Open end-to-end-reconstruction versus reconstruction
case series
Visser AC;Muitjens P; with Mitek-anchors
Metz R;Verleisdonk
EJ;van der Heijden
Acute Achilles tendon rupture: minimally invasive
GJ;Clevers
surgery versus nonoperative treatment with immediate Not Relevant
GJ;Hammacher
full weightbearing--a randomized controlled trial
ER;Verhofstad MH;van
der WC;
Suchak AA;Bostick
The influence of early weight bearing compared with All patients do
GP;Beaupre
non-weight bearing after surgical repair of the Achilles not receive same
LA;Durand DC;Jomha
tendon treatment
NM;
51 v1.0 12.04.09
Exclusion
Author Title
Reason
Blankstein A;Israeli No patient
Percutaneous Achilles tendon repair combined with
A;Dudkiewicz oriented
real-time sonography
I;Chechik A;Ganel A; outcome
Maffulli N;Longo Not best
Favorable Outcome of Percutaneous Repair of
UG;Ronga M;Khanna available
Achilles Tendon Ruptures in the Elderly
A;Denaro V; evidence
Early motion for Achilles tendon ruptures: is surgery No relevant
Twaddle BC;Poon P;
important? A randomized, prospective study outcomes
Fujikawa A;Kyoto No patient
Achilles tendon after percutaneous surgical repair:
Y;Kawaguchi M;Naoi oriented
serial MRI observation of uncomplicated healing
Y;Ukegawa Y; outcome
Costa ML;MacMillan
K;Halliday D;Chester
Randomised controlled trials of immediate weight
R;Shepstone Not Relevant
bearing mobilisation for rupture of the tendo Achillis
L;Robinson AH;Donell
ST;
Carter TR;Fowler Functional postoperative treatment of Achilles tendon
Retrospective
PJ;Blokker C; repair
Traumatic rupture of the Achilles Tendon. Insufficient
Perez TA; Reconstruction by transplant and graft using the lateral Quantitative
peroneus brevis Data
Not best
Martinelli B; Percutaneous repair of the Achilles tendon in athletes available
evidence
Gorschewsky O;Pitzl Insufficient
M;Putz A;Klakow Percutaneous repair of acute Achilles tendon rupture Quantitative
A;Neumann W; Data
Mullaney MJ;McHugh No patient
Weakness in end-range plantar flexion after Achilles
MP;Tyler TF;Nicholas oriented
tendon repair
SJ;Lee SJ; outcome
Rumian AP;Molloy Not best
Surgical repair of the Achilles tendon: The lateral
S;Solan M;Newman available
approach
KJ;Elliott D; evidence
Ebinesan AD;Sarai
Conservative, open or percutaneous repair for acute Retrospective
BS;Walley GD;Maffulli
rupture of the Achilles tendon comparative
N;
Chan SK;Chung SC;Ho
Minimally invasive repair of ruptured Achilles tendon Retrospective
YF;
Lildholdt T;Munch- Conservative treatment to Achilles tendon rupture. A No description

Jorgensen T; follow-up study of 14 cases of surgery
52 v1.0 12.04.09
Exclusion
Author Title
Reason
Not best
Surgical and non-surgical treatment of Achilles
Nistor L; available
Tendon rupture. A prospective randomized study
evidence
Haggmark T;Liedberg Calf muscle atrophy and muscle function after non- No patient
H;Eriksson operative vs operative treatment of Achilles tendon oriented
E;Wredmark T; ruptures outcome
Early functional treatment versus early immobilization
Kangas J;Pajala A;Siira
in tension of the musculotendinous unit after Achilles
P;Hamalainen Not Relevant
rupture repair: a prospective, randomized, clinical
M;Leppilahti J;
study
Insufficient
Synder Post-operative results in fresh injuries the Achilles
Quantitative
M;Zwierzchowski H; tendon
Data
Therbo M;Petersen No patient
Loss of bone mineral of the hip and proximal tibia
MM;Nielsen PK;Lund oriented
following rupture of the Achilles tendon
B; outcome
Surgeons did
Solveborn SA;Moberg Immediate free ankle motion after surgical repair of
not follow same
A; acute Achilles tendon ruptures
technique
Not best
A combined open and percutaneous technique for
Kakiuchi M; available
repair of tendo Achillis. Comparison with open repair
evidence
Percutaneous repair of Achilles tendon rupture.
Buchgraber A;Passler
Immobilization versus functional postoperative No baseline data
HH;
treatment
Early full weightbearing and functional treatment after
Speck M;Klaue K; No baseline data
surgical repair of acute Achilles tendon rupture
Aoki M;Ogiwara Early active motion and weightbearing after cross- Insufficient
N;Ohta T;Nabeta Y; stitch Achilles tendon repair Data
Dargel J;Ninck
J;Koebke J;Appell Influence of knee flexion on plantarflexion moments Retrospective
HJ;Pennig D;Hillekamp after open or percutaneous Achilles tendon repair comparative
J;
The utility of gait analysis in the rehabilitation of No relevant
Follak N;Ganzer
patients after surgical treatment of Achilles tendon patient oriented
D;Merk H;
rupture outcomes
Horstmann T;Lukas
C;Mayer F;Winter All patients did
Isokinetic strength and strength endurance of the lower
E;Ambacher not receive
limb musculature ten years after Achilles tendon repair
T;Heitkamp exact surgery
H;Dickhuth H;
Kerkhoffs GM;Struijs
Functional treatment after surgical repair of acute
PA;Raaymakers Not Relevant
Achilles tendon rupture: wrap vs walking cast
EL;Marti RK;
53 v1.0 12.04.09
Exclusion
Author Title
Reason
Soldatis JJ;Goodfellow
End-to-end operative repair of Achilles tendon rupture Retrospective
DB;Wilber JH;
Ruptured Achilles tendon--preliminary results of a

Cetti R; No baseline data
new treatment
Cetti R;Henriksen A new treatment of ruptured Achilles tendons. A

Not Relevant
LO;Jacobsen KS; prospective randomized study
54 v1.0 12.04.09
STUDY QUALITY
● = Yes ○ = No
× = Not Reported
Same Treatments
Follow up <80%
Equal Follow up
Same Outcomes
Consecutive
Enrollment
Outcome
Author N Treatment LoE
Measure
Time
Pain - Mild w/
Aktas, et al. 2007 maximal 30 Open Repair IV ● ● ● ● ●
exertion‡
Aktas, et al. 2007 Pain - Absent‡ 30 Open Repair IV ● ● ● ● ●
Bhattacharyya, et Return to Normal

53 Open Repair IV ● ● ● ● ●
al. 2009 Walking (weeks)
Return to Normal
Bhattacharyya, et
Stair Climbing 53 Open Repair IV ● ● ● ● ●
al. 2009
(weeks)
Bhattacharyya, et Return to Normal Minimally
53 IV ● ● ● ● ●
al. 2009 Walking (weeks) Invasive Repair
Return to Normal
Bhattacharyya, et Minimally
Stair Climbing 53 IV ● ● ● ● ●
al. 2009 Invasive Repair
(weeks)
Return to work
Cetti, et al. 1993 56 Open Repair IV ● ● ● ● ●
(weeks)
Return to sports -
diminished level
Return to sports -
same level
Return to sports -
stopped
Function-
Cetti, et al. 1993 Abnormal ankle 56 Open Repair IV ● ● ● ● ●
movement
Function-
Cetti, et al. 1993 Abnormal ankle 56 Open Repair IV ● ● ● ● ●
movement
Function-
Abnormal gait
Function-
Abnormal gait
Function-
Abnormal run
55 v1.0 12.04.09
● = Yes ○ = No
× = Not Reported
Same Treatments
Follow up <80%
Equal Follow up
Same Outcomes
Consecutive
Enrollment
Outcome
Measure
Time
Function-
Abnormal run
Function-
Cetti, et al. 1993 Abnormal toe 56 Open Repair IV ● ● ● ● ●
stand
Function-
Cetti, et al. 1993 Abnormal toe 56 Open Repair IV ● ● ● ● ●
stand
Chillemi, et al. Able to walk Percutaneous
38 IV ● ● ● ● ●
2002 without limitation Repair
Return to sports
Chillemi, et al. activity (frequent Percutaneous
14 IV ● ● ● ● ●
2002 participant 2-3 Repair
times per week)
Return to pre-
Coutts, et al 2002 injury sporting 22 Open Repair IV ○ ● ● ● ●
level
Return to activity Percutaneous
ES Ng, et al. 2007 25 IV ● ● ● ● ●
- same level Repair
Gigante, et al. SF-12 - Physical Percutaneous
19 IV ● ● ● ● ●
2008 Component Score Repair
Gigante, et al. SF-12 - Mental Percutaneous
19 IV ● ● ● ● ●
2008 Component Score Repair
Return to active
Lim, et al. 2001 sporting/outdoor 33 Open Repair IV ● ● ● ● ●
activities
Return to active
Percutaneous
Lim, et al. 2001 sporting/outdoor 33 IV ● ● ● ● ●
Repair
activities
Open Repair
Lim, et al. 2001 Return to ADL 33 IV ● ● ● ● ●
Return to final Open Repair
Lim, et al. 2001 functional 33 IV ● ● ● ● ●
activity
Satisfaction - Open Repair
Lim, et al. 2001 33 IV ● ● ● ● ●
Excellent
Return to final Percutaneous
Lim, et al. 2001 functional 33 Repair IV ● ● ● ● ●
activity
56 v1.0 12.04.09
● = Yes ○ = No
× = Not Reported
Same Treatments
Follow up <80%
Equal Follow up
Same Outcomes
Consecutive
Enrollment
Outcome
Measure
Time
Return to active Percutaneous
Lim, et al. 2001 sporting/outdoor 33 Repair IV ● ● ● ● ●
activities
Return to active Percutaneous
Lim, et al. 2001 sporting/outdoor 33 Repair IV ● ● ● ● ●
activities
Satisfaction - Percutaneous
Lim, et al. 2001 33 IV ● ● ● ● ●
Excellent Repair
Minimally
Metz, et al. 2008 Return to work 40 IV ● ● ● ● ●
Invasive Repair
Minimally
Metz, et al. 2008 Return to sports 40 IV ● ● ● ● ●
Invasive Repair
Minimally
Metz, et al. 2008 Change sports 40 IV ● ● ● ● ●
Invasive Repair
Minimally
Metz, et al. 2008 Stop sports 40 IV ● ● ● ● ●
Invasive Repair
Return to
Moller, et al. 2001 sedentary work 59 Open Repair IV ● ● ● ● ●
(days)
Return to light,
Moller, et al. 2001 mobile work 59 Open Repair IV ● ● ● ● ●
(days)
Return to work
Moller, et al. 2001 59 Open Repair IV ● ● ● ● ●
(days)
Return to heavy
work (days)
Return to sports -
same level
Return to sports -
stopped
Return to
Moller, et al. 2001 sedentary work 59 Open Repair IV ● ● ● ● ●
(days)
Return to light,
Moller, et al. 2001 mobile work 59 Open Repair IV ● ● ● ● ●
(days)
Return to work
(days)
Return to heavy
work (days)
57 v1.0 12.04.09
● = Yes ○ = No
× = Not Reported
Same Treatments
Follow up <80%
Equal Follow up
Same Outcomes
Consecutive
Enrollment
Outcome
Measure
Time
Pain-during
walking
Moller, et al. 2001 Pain-moderate 59 Open Repair IV ● ● ● ● ●
Moller, et al. 2001 Pain-none 59 Open Repair IV ● ● ● ● ●
Uchiyama, et al. Return to jogging
84 Open Repair IV ○ ● ● ● ●
2007 (weeks)
Return to same
Uchiyama, et al. level of sports
84 Open Repair IV ○ ● ● ● ●
2007 (months) (high
level athletes)
Aktas, et al.Aktas, Minimally
Pain 46 IV ● ● ● ● ●
et al.2009 Invasive Repair
Aktas, et al.Aktas,
Pain 46 Open Repair IV ● ● ● ● ●
et al.2009
58 v1.0 12.04.09
RECOMMENDATION 6
In the absence of reliable evidence, it is the opinion of the work group that although
operative treatment is an option , it should be approached more cautiously in patients
with diabetes, neuropathy, immunocompromised states, age above 65, tobacco use,
sedentary lifestyle, obesity (BMI >30), peripheral vascular disease or local/systemic
dermatologic disorders.
AAOS Strength of Recommendation: Consensus
recommendation based on expert opinion by considering the known potential harm and benefits
associated with the treatment. A Consensus recommendation means that expert opinion supports
the guideline recommendation even though there is no available empirical evidence that meets the
inclusion criteria of the guideline’s systematic review.
Implications: Practitioners should be flexible in deciding whether to follow a recommendation

classified as Consensus, although they may set boundaries on alternatives. Patient preference
should have a substantial influencing role.
Rationale:
Rupture of the Achilles tendon occurs not only in healthy active individuals, but also in
those with substantial medical histories. We were unable to find any published studies
that addressed the effects of co-morbid conditions on the success of operative repair.
Therefore, this recommendation is based on expert opinion, and is consistent with current
clinical practice.
The consensus of the work group is that consideration of non-operative treatment should
occur before performing operative repair of Achilles tendon ruptures in those individuals
with conditions that may impair wound healing. These individuals may be at increased
risk for wound problems and infection with subsequent detrimental effect on outcome.
We did not identify any studies to address this recommendation.
59 v1.0 12.04.09
RECOMMENDATION 7
For patients who will be treated operatively for an acute Achilles tendon rupture, we are
unable to recommend for or against preoperative immobilization or restricted weight
bearing.
potential harm.

Rationale:
We were unable to find any published studies that addressed the effects of preoperative
immobilization or restricted weight bearing on the success of operative repair of acute
rupture of this tendon.
We did not identify any studies to address this recommendation.
60 v1.0 12.04.09
RECOMMENDATION 8
Open, limited open and percutaneous techniques are options for treating patients with
acute Achilles tendon rupture.
another.

Rationale:
We defined the following operative repairs:
Open – procedure utilizing an extended incision for exposure allowing

visualization of the rupture and tendon to allow direct placement of sutures for the
repair.
Limited-Open – procedure utilizing a small incision for exposure allowing direct
visualization of the ruptured ends.
Percutaneous – procedure without direct exposure of the tendon rupture site.
A systematic review identified three level II comparative trials29, 33, 35 investigating

percutaneous repair and one level II and two level III comparative trials studying limited-
open repairs.27, 36, 31 In both these comparisons, there was no significant difference in
reruptures between open and minimally invasive techniques.
Two studies 29, 33 that compared percutaneous to open repairs found no statistically
significant difference in return to activity. Two studies27, 36 comparing limited open to
open repair found that patients treated with a limited open technique returned to activity
sooner than those treated with an open repair.
There is no statistically significant difference in satisfaction in patients treated with

percutaneous or open repairs.29 Patients treated with limited open repair techniques have
statistically significantly fewer symptoms than those treated with open technique but no
statistically significant differences in pain.
One study33 showed a statistically significant difference in the short term in favor of the
percutaneous group for wound breakdown/delayed healing. Two studies29, 33 showed
statistically significantly less scar adhesion in the percutaneous repair group compared
with the open repair. Similarly, patients treated with limited open groups had statistically
61 v1.0 12.04.09
significantly fewer minor surgical site infections leading to delayed wound healing and in
one study fewer severe wound infections.27
Beyond short term wound complications, there is no identified added benefit when
comparing long term adverse events between open repair and minimally invasive repair.
While in some studies33, 31 there were an increased number of superficial infections in the
open repair group, there was no statistically significant difference between groups for
deep infections31. One study29 reported a statistically significant difference in superficial
infections between the open group and percutaneous groups, however, the authors29 did
not administer IV antibiotics to the open control group. Based on these considerations,
we downgraded this body of evidence to limited.
The literature reviewed refers primarily to non insertional ruptures in which there is
sufficient distal tendon for repair. It is acknowledged that a small subset of ACTR consist
of purely insertional injuries, often with a segment of bone attached. The latter group is
beyond the scope of this GL. However, the reader should be aware of the fact that the
repair techniques reviewed may not be compatible with these distal ruptures.
Consideration should also be given to the location of the tear when performing a repair in
a percutaneous or limited-open fashion. Tears located at the proximal or distal ends of
the tendon may compromise the ability to successfully complete a limited open repair.
The orthopaedic surgeon performing the repair may need to extend the incision,
converting it to an open technique if unable to obtain good suture fixation with a limited-
open or percutaneous technique.
We examined studies that made two different comparisons. Two level II studies
compared percutaneous repair to open repair.29, 35 Two level II studies and two level III
studies compared limited open to open repair.31,33 27, 36
PERCUTANEOUS VS OPEN REPAIR

Patients treated with percutaneous repair scored significantly higher on the SF-12
physical and mental component scores (see Table 61). There was no significant
difference in the amount of patients who returned to functional activities, activities of
daily living, (see Table 62) or patient satisfaction (see Table 63). The amount of
reruptures did not significantly differ between treatment groups (see Table 65)
Studies29, 33 reported no significant difference in the number of sural nerve injuries,

superficial infection with staphalococcus, hypertonic scars, or keloid formation (Table
64). Patients treated with percutaneous repair had significantly less wound
breakdown/delay of healing as well as less scar adhesions (see Table 64). No significant
difference in the amount of deep infections was reported. One study29 reported a
statistically significant difference in superficial infection, while another study33 did not
report a difference(see Table 64). However, the study which did report more superficial
infections in the open repair group, did not administer IV antibiotics. Wound puckering
occurred significantly more in patients treated with percutaneous repair (see Table 64).
62 v1.0 12.04.09
SUMMARY OF EVIDENCE- PERCUTANEOUS VS. OPEN
Table 61. Percutaneous and Limited Open vs. Open - Global Outcomes
Duration
24 months
SF-12 - Physical
Gigante II 39 ●P
Component Score
SF-12 - Mental
Gigante II 39 ●P
Component Score
● P: Statistically Significant in Favor of Percutaneous Repair
● Op: Statistically Significant in Favor of Open Repair
Table 62. Percutaneous vs. Open - Return to Activities and Function

Duration
Outcome
Author LOE N (months)
% 6 65.5
ES Ng Return to Activity II 68 ○
Return to Activities of
Lim II 66 ○
Daily Living
Returned to Final
Lim II 66 ○
Functional Activity‡
● L: Statistically Significant in Favor of Limited Open Repair
‡ Final Functional Activity: “When patient was unhindered in all his or her activities apart from
sports.”
Table 63. Percutaneous vs. Open - Satisfaction

Outcome Duration
Author LOE N
% 6 months
Lim Satisfaction II 66 ○
Table 64. Percutaneous vs. Open- Complications

Duration
Author Adverse Event LOE N (months)
6 65.5
63 v1.0 12.04.09
Duration
6 65.5
Wound breakdown/
Ng II 68 ●P
delay healing
Ng Sural Nerve Injury II 68 ○
Lim Sural Nerve Problems II 66 ○
Deep Infection with
Lim II 66 ○
staphalococcus
Lim Adhesions II 66 ●P
Ng Scar Adhesion II 68 ●P
Ng Superficial Infection II 68 ○
Lim Superficial Infection II 66 ●P
Superficial Infection
Lim ○
with staphalococcus
Ng Hypertrophic Scar II 68 ○
Lim Keloid Formation II 66 ○
Lim Wound Puckering II 66 ● Op
Table 65. Percutaneous vs. Open- Rerupture

Duration
6 65.5
Lim et al 2001 Rerupture II 66 ○
Ng, et al 2006 Rerupture II 68 ○
LIMITED OPEN VS OPEN REPAIR

Patients treated with limited open repair did not have less pain or score higher on the
AOFAS scale than patients treated with open repair (see Table 66 and Table 67).
Patients treated with limited open repair returned to normal walking, stair climbing, and
sports in significantly less time than patients treated with standard open repair (seeTable
68). A significantly larger percentage of patients treated with limited open repair had
fewer symptoms compared to patients treated with open repair (seeTable 69).
There was no significant difference in the number of reruptures between treatment groups
(see Table 71). There was no statistically significant difference in DVT, large hematoma,
64 v1.0 12.04.09
stiffness of ankle, insertional tendinopathy, or deep infection between the open and
limited repair groups (see Table 70). However, patients treated with limited open repair
had significantly fewer severe wound infections, superficial infections, and minor
surgical site infections than patients treated with open repair (see Table 70).
SUMMARY OF EVIDENCE- LIMITED OPEN VS. OPEN

Table 66. Minimally Invasive vs. Open- Pain
Outcome Duration
Author LOE N
% 6 months
Aktas Pain II 46 ○
Table 67. Minimally Invasive vs. Open- Global Outcomes

Duration
24 months
Aktas AOFAS II 40 ○
Table 68. Limited Open vs. Open- Return to Activity

Outcome Duration
Author LOE N 12 63.5
(weeks) months
months
Return to Normal
Bhattacharyya III 53 ●Mini
Walking
Return to Normal
Bhattacharyya III 53 ●Mini
Stair Climbing
Kakiuchi Return to Sports III 22 ● Mini

● Mini: Statistically Significant in Favor of Minimally Invasive (mini-open) Repair
Table 69. Mini-Open vs. Open- Symptoms

Outcome Duration
Author LOE N
(%) 63.5 months
Kakiuchi Symptoms III 22 ● Mini
● Mini: Statistically Significant in Favor of Minimally Invasive Repair
65 v1.0 12.04.09
Table 70. Limited Open Repair vs. Open - Complications

Duration
Author Complication LOE N 6 12
Months months
Minor Surgical Site
Infection with
Bhattacharyya III 53 ● Mini
Delayed Wound
Healing
Severe Wound
Bhattacharyya Infection and III 53 ● Mini
Dehiscence
Aktas, 2009 Deep Infection II 40 ○
Aktas, 2009 Superficial Infection II 40 ● Mini

Insertional
Aktas, 2009 II 40 ○
Tendinopathy
Aktas, 2009 Stiffness of the ankle II 40 ○
Aktas, 2009 Large Hematoma II 40 ○
Aktas, 2009 DVT II 40 ○

Table 71. Mini-Open vs. Open – Rerupture

Duration
Author Adverse Events LOE N
63.5 months
Kakiuchi Rerupture III 22 ○
66 v1.0 12.04.09
EXCLUDED ARTICLES
Table 72. Excluded Studies - All Operative Techniques
Percutaneous versus open repair of the ruptured Achilles Not best available
Cretnik A, et al
tendon. a comparative study evidence
The Webb-Bannister percutaneous technique for acute
Not best available
Wagnon R, et al Achilles' tendon ruptures. a functional and MRI
evidence
assessment
Limited open repair of Achilles tendon ruptures. a Not best available
Assal M, et al technique with a new instrument and findings of a evidence - not
prospective multicenter study comparative
Not best available
Percutaneous Achilles tendon repair with and without
Halasi T, et al evidence - not
endoscopic control
comparative
Not best available
Percutaneous suturing of the ruptured Achilles tendon
Cretnik A, et al evidence - not
under local anesthesia
comparative
Not best available
Clinical and functional results of open operative repair for
Coutts A, et al evidence - not
Achilles tendon rupture in a non-specialist surgical unit
comparative
Not best available
Independent evaluation of a recently described Achilles
Calder JD, et al evidence - not
tendon repair technique
comparative
Not best available
Uchiyama E, et al A modified operation for Achilles tendon ruptures evidence - not
comparative
Not best available
Is percutaneous repair of the Achilles tendon a safe
Maes R, et al; evidence - not
technique? A study of 124 cases
comparative
Not best available
The percutaneous suture of the Achilles tendon with the
Amlang MH, et al evidence - not
Dresden instrument
comparative
Not best available
Arthroscopically assisted percutaneous repair of fresh
Tang KL, et al evidence - not
closed Achilles tendon rupture by Kessler's suture
comparative
Not best available
Repair of Achilles tendon rupture under endoscopic
Fortis AP, et al evidence - not
control
comparative
Operative treatment of acute Achilles tendon rupture.
Schonberger TJ, et
Open end-to-end-reconstruction versus reconstruction with Retrospective case series
al
Mitek-anchors
Long-term results after operatively treated Achilles tendon
Hohendorff B, et al suture technique
rupture. fibrin glue versus suture
Not best available
Critical analysis of tendo Achillis repair using Achilles
Kuwada GT; evidence - not
tendon rupture classification system and repair
comparative
67 v1.0 12.04.09
The results of 163 Achilles tendon ruptures treated by a Not best available
Lansdaal JR, et al minimally invasive surgical technique and functional after evidence - not
treatment comparative
Not best available
Percutaneous Achilles tendon repair combined with real-
Blankstein A, et al evidence - not
time sonography
comparative
Not best available
Avoiding sural nerve injuries during percutaneous Achilles
Majewski M, et al evidence - not
tendon repair
comparative
Not best available
Outcome of Achilles tendon ruptures treated by a limited
Jung HG, et al evidence - not
open technique
comparative
Not best available
Scarfi G, et al Percutaneous repair of Achilles tendon evidence - not
comparative
Not best available
Follow-up results of Achilles tendon rupture treatment by
Crnica S, et al evidence - not
the method of modified percutaneous suture
comparative
Not best available
Traumatic rupture of the Achilles Tendon. Reconstruction
Perez TA; evidence - not
by transplant and graft using the lateral peroneus brevis
comparative
Not best available
Ma GW;Griffith Percutaneous repair of acute closed ruptured Achilles
evidence - not
TG; tendon. a new technique
comparative
Not best available
Late versus early repair of Achilles tendon rupture.
Boyden EM, et al; evidence - not
Clinical and biomechanical evaluation
comparative
Not best available
Soldatis JJ, et al End-to-end operative repair of Achilles tendon rupture evidence - not
comparative
Not best available
Martinelli B; Percutaneous repair of the Achilles tendon in athletes evidence - not
comparative
Not best available
Mellor SJ;Patterson
Tendo Achillis rupture; surgical repair is a safe option evidence - not
MH;
comparative
Not best available
Bruggeman NB, et Wound complications after open Achilles tendon repair. an
evidence - not
al analysis of risk factors
comparative
Not best available
Webb JM;Bannister
Percutaneous repair of the ruptured tendo Achillis evidence - not
GC;
comparative
Not best available
Gillespie HS;George Results of surgical repair of spontaneous rupture of the
evidence - not
EA; Achilles tendon
comparative
Not best available
Surgical treatment of 102 tendo achillis ruptures-- suture
Jessing P;Hansen E; evidence - not
or tenontoplasty?
comparative
68 v1.0 12.04.09
Not best available
Surgical repair of subcutaneous rupture of the Achilles
Kiviluoto O, et al evidence - not
tendon
comparative
Calf muscle atrophy and muscle function after non- Not best available
Haggmark T, et al operative vs. operative treatment of Achilles tendon evidence - not
ruptures comparative
Not best available
Bomler J;Sturup J; Achilles tendon rupture. An 8-year follow up evidence - not
comparative
Not best available
Hogsaa B, et al Surgical treatment of Achilles tendon ruptures evidence - not
comparative
Not best available
FitzGibbons RE, et
Percutaneous Achilles tendon repair evidence - not
al
comparative
Not best available
Chillemi C, et al evidence - not
Ultrasonographical and isokinetic evaluation
comparative
Not best available
Gorschewsky O, et
Percutaneous repair of acute Achilles tendon rupture evidence - not
al
comparative
STUDY QUALITY
Table 73. Study Quality - RCTs
outcome performance at

Those rating outcome
Patients Blinded
Randomization
Stochastic
Blinded
entry
● = Yes ○ = No
× = Not Reported
Level of
Evidence
Open Repair
Gigante, SF-12.
vs.
et al. Physical 39 Level II ● × × ● ● ×
Percutaneous
2008 Component
Repair
Open Repair
Gigante,
SF-12. Mental vs.
et al. 39 Level II ● × × ● ● ×
Component Percutaneous
2008
Repair
Open Repair
Lim, et
vs.
al. Complications 66 Level II ○ ● ● × ● ×
Percutaneous
2001
Repair
Lim, et Duration of Open Repair
66 Level II ○ ● ● × ● ×
al. Immobilization vs.
69 v1.0 12.04.09

Patients Blinded
Randomization
Stochastic
Blinded
entry
● = Yes ○ = No
× = Not Reported
Level of
Evidence
2001 Percutaneous
Repair
Open Repair
Lim, et Return to
vs.
al. activities of 66 Level II ○ ● ● × ● ×
Percutaneous
2001 daily living
Repair
Open Repair
Lim, et Return to
vs.
al. functional 66 Level II ○ ● ● × ● ×
Percutaneous
2001 activity
Repair
Aktas, Minimally
et al. AOFAS 40 Invasive vs. Level II × × × ○ ● ●
2009 Open
70 v1.0 12.04.09
Table 74. Quality of Studies - Comparative Studies
experimental and control

All groups concurrently


characteristics at entry
Same center for
group data
treated
entry
● = Yes ○ = No
× = Not Reported
Level of
Evidence
Percutaneous
Kakiuchi, et Return to and Minimally
22 Level III × × ● ○ ●
al. 1995 Sports Invasive vs.
Open Repair
Percutaneous
Kakiuchi, et Symptoms - and Minimally
22 Level III × × ● ○ ●
al. 1995 None Invasive vs.
Open Repair
Percutaneous
22 Level III × × ● ○ ●
al. 1995 Stiffness Invasive vs.
Open Repair
Percutaneous
22 Level III × × ● ○ ●
al. 1995 Discomfort Invasive vs.
Open Repair
Percutaneous
22 Level III × × ● ○ ●
al. 1995 Pain Invasive vs.
Open Repair
Percutaneous
Kakiuchi, et and Minimally
Re-rupture 22 Level III × × ● ○ ●
al. 1995 Invasive vs.
Open Repair
Return to Percutaneous
Ng, et al. 2006 Activity - 68 vs. Open Level II ● × ● ● ●
Same Level Repair
Percutaneous
Ng, et al. 2006 Complications 68 vs. Open Level II ● × ● ● ●
Repair
Return to Minimally
Bhattacharyya,
Normal 53 Invasive vs. Level III ○ × ● ● ●
et al. 2009
Walking Open Repair
Return to Minimally
Bhattacharyya,
Normal Stair 53 Invasive vs. Level III ○ × ● ● ●
et al. 2009
Climbing Open Repair
Severe Minimally
Bhattacharyya,
Wound 53 Invasive vs. Level III ○ × ● ● ●
et al. 2009
Infection and Open Repair
71 v1.0 12.04.09
experimental and control



characteristics at entry
Same center for
group data
treated
entry
● = Yes ○ = No
× = Not Reported
Level of
Evidence
Dehiscence
Minor Minimally
Bhattacharyya,
Surgical Site 53 Invasive vs. Level III ○ × ● ● ●
et al. 2009
Infection Open Repair
Delayed Minimally
Bhattacharyya,
Wound 53 Invasive vs. Level III ○ × ● ● ●
et al. 2009
Healing Open Repair
72 v1.0 12.04.09
STUDY RESULTS
Table 75. Limited open vs. Open - Global Outcomes
Minimally
Open
Author Outcome LOE N Duration Invasive Results
mean (SD) mean (SD)
SF-12 - Physical
II 39 24 months 52.6 (2.31) 50.7 (2.57) p = 0.02‡
Gigante, et al. Component Score
2008 SF-12- Mental
II 39 24 months 52.2 (1.91) 50.4 (2.75) p = 0.02‡
Component Score
Table 76. Percutaneous vs. Open - Return to Activities

Percutaneous Open
Author Outcome LOE N Duration Results
(%) (%)
Return to
Lim, et al. 2001 Activities of Daily II 66 6 months 100% 100% NS
Living
Returned to Final
Lim, et al. 2001 Functional II 66 6 months 100% 100% NS
Activity
NS: not significant; authors do not report p-value
Table 77. Percutaneous vs. Open - Satisfaction

Percutaneous Open
(%) (%)
Satisfaction -
Lim, et al. 2001 II 66 6 months 52% 42% NS
Excellent
Table 78. Percutaneous vs. Open - Complications

Percutaneous Open
(%) (%)
Lim, et al
Re-rupture II 66 6 months 3% 6% p = .55‡
2001
Lim, et al. Sural Nerve
II 66 6 months 3% 0% p = .15‡
2001 Problems
Deep infection
with wound
Lim, et al. p = 0.155‡
breakdown and II 66 6 months 0% 3%
2001
staphalococcus
infection
Superficial
Lim, et al. Infection with p = 0.155‡
II 66 6 months 0% 3%
2001 staphalococcus
infection
73 v1.0 12.04.09
Percutaneous Open
(%) (%)
Lim, et al. Superficial
II 66 6 months 0% 15% p=0.001‡
2001 Infection
Lim, et al. Keloid
II 66 6 months 0% 3% p = .15‡
2001 Formation
Lim, et al.
Adhesions II 66 6 months 0% 6% p = .043
2001
Lim, et al. Wound
II 66 6 months 9% 0% p = .013‡
2001 Puckering
Aktas, et al. Post
Deep Infection II 40 0% 5% p=0.15‡
2009 operative
Aktas, et al. Superficial Post

II 40 0% 15% p=0.011‡
2009 Infection operative
Aktas, et al. Insertional Post
II 40 5% 0 p=0.15‡
2009 Tendinopathy operative
Aktas, et al. Stiffness of the Post
II 40 0% 5% p=0.15‡
2009 ankle operative
Aktas, et al. Large Post
II 40 0% 5% p=0.15‡
2009 Hematoma operative
Aktas, et al. Post
DVT II 40 0% 5% p=0.15‡
2009 operative
Table 79. Minimally Invasive vs. Open- Pain
Percutaneous Open
(%) (%)
Aktas, et al.
Pain II 46 22 months 4.5% 13% P=0.3
2009
Table 80. Minimally Invasive vs. Open- Global Outcomes

Percutaneous Open
(%) (%)
Aktas, et al.
Pain II 46 22 months 4.5% 13% P=0.3
2009
Table 81. Minimally Invasive vs. Open - Function
Minimally Open
Author Outcome LOE N Duration Invasive Repair Results
mean (SD) mean (SD)
Return to Normal
III 53 12 months 12.5 (3)‡ 17 (3)‡ p ≤ .001‡
Walking (weeks)
Bhattacharyya,
Return to Normal
et al. 2009
Stair Climbing III 53 12 months 14 (3)‡ 19 (3.5)‡ p ≤ .001‡
(weeks)
74 v1.0 12.04.09
Minimally Open
Author Outcome LOE N Duration Invasive Repair Results
mean (SD) mean (SD)
Return to
65.5
Ng, et al 2006 Activity - Same II 68 96% 88% p = 0.244
months
Level
Table 82. Minimally Invasive vs. Open - Complications
Minimally
Invasive Open Open
Repair (%)
(%)
Minor Surgical
Bhattacharyya, Site Infection p <.001‡
III 53 12 months 0% 17%
et al. 2009 with Delayed
Wound Healing
Severe Wound
Bhattacharyya,
Infection and III 53 12 months 0% 7% p =.034‡
et al. 2009
Dehiscence
Ng, et al. 65.5
Re-rupture II 68 0% 2% p = .223‡
2006 months
Ng, et al. Sural Nerve 65.5
II 68 0% 2% p = .22‡
2006 Injury months
Ng, et al. Superficial 65.5
II 68 8% 5% p = .58‡
2006 Infection months
Ng, et al. Hypertrophic 65.5
II 68 4% 19% p = .052‡
2006 Scar months
Ng, et al. 65.5
Scar Adhesion II 68 0% 9% p = .014‡
2006 months
Ng, et al. Wound 65.5
II 68 0% 12% p = .005‡
2006 Breakdown/delay months
Table 83. Minimally Invasive vs. Open - Symptoms
Minimally Open
Invasive (%) (%)
Kakiuchi, et al. 63.5
Symptoms - Pain III 22 0% 20% p = .05‡
1995 months
Symptoms- None III 22 83% 40% p <.001‡
1995 months
Kakiuchi, et al. Symptoms - 63.5
III 22 17% 30% p =.78‡
1995 Stiffness months
Kakiuchi, et al. Symptoms - 63.5
III 22 0% 10% p = .17‡
1995 Discomfort months
75 v1.0 12.04.09
Table 84. Minimally Invasive vs. Open - Return to Sport
Open
Author Outcome LOE N Duration Minimally Results
(%)
Invasive (%)
Return to Sport -
63.5
Same or III 22 75% 10% p < .001‡
months
increased level
Kakiuchi, et al. Return to Sport - 63.5
III 22 8% 40% p = .17‡
1995 Decreased months
Return to Sport -
63.5
No participation III 22 17% 50% p = .27‡
months
for other reasons
Table 85. Minimally Invasive vs. Open - Complications
Minimally
Open
Author Complications LOE N Duration Invasive (%) Results
% %
Rerupture III 22 0% 0% NS
1995 months
76 v1.0 12.04.09
RECOMMENDATION 9
We cannot recommend for or against the use of allograft, autograft, xenograft, synthetic
tissue, or biologic adjuncts in acute Achilles tendon ruptures that are treated operatively.
potential harm.

Rationale
A systematic review failed to identify adequate evidence to make a recommendation for

or against the use of allograft, autograft, xenograft, synthetic tissue, or biologic adjuncts
in acute Achilles tendon ruptures that are treated operatively.
No studies addressed adjunctive augmentation with allograft, xenograft, or biologic

adjuncts.
Three level II studies32, 37, 38 compared open repair alone and autograft augmentation.
One level IV study39 compared patients treated with synthetic tissue augmentation to
open repair alone. All four of these studies failed to demonstrate significant improvement
in outcomes or complications.
No studies were identified that address adjunctive augmentation with allograft (see Table
92), xenograft, or biologic adjuncts (see Table 95). We examined three level II studies
that compared patients given adjunctive augmentation with autograft tissue vs. open
repair.32, 37, 38 One Level IV study that compared patients given adjunctive augmentation
with synthetic tissue vs. open repair.39
AUTOGRAFT TISSUE VS OPEN REPAIR

Three studies reported that patients given adjunctive augmentation did not significantly
differ in pain, stiffness, satisfaction, return to daily activities, return to sport, or footwear
restrictions (see Table 86 - Table 89).
One study reported one patient given adjunct augmentation had a pulmonary embolism;
no significant difference was found between treatment groups (see Table 91). In two
studies, DVT rates did not significantly differ in patients given augmentation with
autograft tissue vs. open repair. Two studies reported patients with deep infection. One
study found patients treated with open repair had significantly less deep infections and
77 v1.0 12.04.09
the other study reported no significant difference. No significant differences were found
in patients given augmentation with superficial infections, dysesthesia, Keloid, and
dehiscence (see Table 91).
AUGMENTATION WITH SYNTHETIC TISSUE VS OPEN REPAIR

We analyzed one non-comparative study that analyzed patients treated with synthetic
tissue (polypropylene braid). All patients reported excellent results and all patients
returned to previous activity (see Table 106). There were no reruptures and no healing
impairment (see Table 106). One patient underwent a PB removal procedure 1 year after
surgery because of the distal heat-sealed end of the PB device stuck out of the tendon,
causing an impingement on the shoe (see Table 106).
SUMMARY OF EVIDENCE
Table 86. Autograft vs. Open - Pain and Stiffness
Duration (months)
6 12 42
Pajala II 59 Pain ○
Aktas II 30 Pain ○
Taglialavoro II 46 Pain ○
Pajala II 59 Stiffness ○
●Op: Statistically Significant in Favor of Open Operative Repair
●A: Statistically Significant in Favor of Open Repair with Adjunctive Augmentation
Table 87. Autograft vs. Open - Satisfaction

Duration
Author LOE N Outcome (months)
12 42
Taglialavoro II 46 Satisfaction ○
Pajala II 59 Satisfaction ○
Table 88. Autograft - Return to Activities and Sports

Duration (months)
Author LOE N Outcome 6 42
Recovery of Daily
Taglialavoro II 46 Activities (days) ○
78 v1.0 12.04.09
Duration (months)
Author LOE N Outcome 6 42
Return to Sports –
Complaints during normal
Taglialavoro II 46 activity ○
Return to Sports – Same
Aktas, et al II 30 Level / Pre-injury ○
Taglialavoro II 46 Return to Sports ○

Table 89. Autograft vs. Open - Footwear Restrictions
Duration
Author LOE N Outcome (months)
12 42
Footwear
Pajala II 59 ○
Restrictions
Taglialavoro II 46 Conflict with shoes ○
Table 90. Autograft vs. Open - Hospitalization and Immobilization

Outcome Duration
Author LOE N
(Days) 42 months
Taglialavoro Hospitalization II 46 ●Op
Taglialavoro Immobilization II 46 ●Op

Table 91. Autograft vs. Open - Complications

Duration (months)
6 12 42
Taglialavoro II 46 PE ○
Taglialavoro II 46 DVT ○
Pajala II 60 DVT ○
Aktas II 30 Deep Infection ○
Pajala II 60 Deep Infection ●Op
Pajala II 60 Superficial ○
79 v1.0 12.04.09
Duration (months)
6 12 42
Infection
Pajala II 60 Re-rupture ○
Aktas II 30 Re-rupture ○
Taglialavoro II 46 Dysesthesia ○
Taglialavoro II 46 Keloid ○
Taglialavoro II 46 Dehiscence ○
EXCLUDED ARTICLES
Table 92. Excluded Studies - Allograft
Bleakney, et al.
Imaging of the Achilles tendon Commentary
2005
Lee, et al. Achilles tendon repair with acellular tissue graft Neglected/chronic
2007 augmentation in neglected ruptures Achilles tear patients
Table 93. Excluded Studies - Autograft

Bradley, et al. Percutaneous and open surgical repairs of Achilles tendon Not best available
1990 ruptures. A comparative study evidence
Coull, et al. Flexor hallucis longus tendon transfer: evaluation of Not best available
2003 postoperative morbidity evidence
Cretnik, et al. Not best available
Incidence and outcome of rupture of the Achilles tendon
2004 evidence
Dekker, et al. Results of surgical treatment of rupture of the Achilles Not best available
1977 tendon with use of the plantaris tendon evidence
Reconstruction for missed or neglected Achilles tendon
Elias, et al. Neglected/chronic
rupture with V-Y lengthening and flexor hallucis longus
2007 Achilles tear patients
tendon transfer through one incision
Garabito, et al. Augmented repair of acute Achilles tendon ruptures using Not best available
2005 gastrocnemius-soleus fascia evidence
Treatment of chronic Achilles tendinopathy and ruptures
Hahn, et al. Less than 10 patients
with flexor hallucis tendon transfer: clinical outcome and
2008 per group
MRI findings
Jessing, et al. Surgical treatment of 102 tendo achillis ruptures-- suture or Not best available
1975 tenontoplasty? evidence
80 v1.0 12.04.09
Kiviluoto, et al. Surgical repair of subcutaneous rupture of the Achilles
cast only
1985 tendon
Leppilahti, et al. Outcome and prognostic factors of Achilles rupture repair Not best available
1998 using a new scoring method evidence
Lynn, et al. Repair of the torn Achilles tendon, using the plantaris tendon Less than 50% follow-
1966 as a reinforcing membrane up
Maffulli, et al. Free gracilis tendon graft in neglected tears of the Achilles Neglected/chronic
2005 tendon Achilles tear patients
Roberts, et al. Team physician #6. Surgical treatment of Achilles tendon Not best available
1989 rupture evidence
Schedl, et al. Achilles tendon repair with the plantaris tendon compared Not best available
1979 with repair using polyglycol threads evidence
Stein, et al. Insufficient
Duthie's biological repair of ruptured Achilles tendons
2005 Quantitative Data
Winter, et al. Surgical repair of Achilles tendon rupture. Comparison of Retrospective case
1998 surgical with conservative treatment series
Wong, et al. Modified flexor hallucis longus transfer for Achilles Less than 10 patients
2005 insertional rupture in elderly patients per group
Table 94. Excluded Studies - Synthetic Tissue

Fernandez-Fairen, et
Retrospective case
al. Augmented repair of Achilles tendon ruptures
series
1997
Hohendorff, et al. Long-term results after operatively treated Achilles tendon
Suture Technique
2008 rupture: fibrin glue versus suture
Combines acute and
Parsons, et al. Achilles tendon repair with an absorbable polymer-carbon neglected/chronic
1984 fiber composite Achilles tendon tear
patients
Patients had prior
Parsons, et al. Long-term follow-up of Achilles tendon repair with an
surgical or
1989 absorbable polymer carbon fiber composite
conservative treatment
Table 95- Biologic Adjuncts

Aspenberg, et al. Stimulation of tendon repair: mechanical loading, GDFs and
Review
2007 platelets. A mini-review
Sanchez, et al. Comparison of surgically repaired Achilles tendon tears Less than 10 patients
2007 using platelet-rich fibrin matrices per group
81 v1.0 12.04.09
STUDY QUALITY
Table 96. Study Quality – Autograft RCTs
All groups have similar outcome


performance at entry
Patients Blinded
● = Yes ○ = No
× = Not Reported
Level of
Evidence
Pajala, et
Open vs. Autograft
al. Stiffness 60 Level II ● ● ● ○ ● ×
Augmentation
2009
Pajala, et
Footwear Open vs. Autograft
al. 60 Level II ● ● ● ○ ● ×
Restrictions Augmentation
2009
Pajala, et
Open vs. Autograft
al. Pain 60 Level II ● ● ● ○ ● ×
Augmentation
2009
Pajala, et
Open vs. Autograft
al. Satisfaction 60 Level II ● ● ● ○ ● ×
Augmentation
2009
Pajala, et
Open vs. Autograft
al. Re-rupture 60 Level II ● ● ● ○ ● ×
Augmentation
2009
Pajala, et
Open vs. Autograft
al. Deep Infection 60 Level II ● ● ● ○ ● ×
Augmentation
2009
Pajala, et
Open vs. Autograft
al. DVT 60 Level II ● ● ● ○ ● ×
Augmentation
2009
Pajala, et
Superficial Open vs. Autograft
al. 60 Level II ● ● ● ○ ● ×
Infection Augmentation
2009
Aktas, et
Open vs. Autograft
al. Return to sport 30 Level II × × ● ○ ● ×
Augmentation
2007
Aktas, et
Open vs. Autograft
al. Pain 30 Level II ○ ● ● ○ ● ×
Augmentation
2007
82 v1.0 12.04.09

Patients Blinded
● = Yes ○ = No
× = Not Reported
Level of
Evidence
Aktas, et
Open vs. Autograft
al. Deep Infection 30 Level II ○ ● ● ○ ● ×
Augmentation
2007
Aktas, et
Open vs. Autograft
al. Re-rupture 30 Level II ○ ● ● ○ ● ×
Augmentation
2007
Table 97. Study Quality - Autograft Comparative Studies
All groups have similar characteristics
Same center for experimental and


control group data

● = Yes ○ = No
at entry
treated
× = Not Reported
Level of
Evidence
Taglialavoro, Open vs. Autograft
Pain 46 Level II ● ● ● ● ●
et al 2004 Augmentation
Taglialavoro, Recovery of Open vs. Autograft
46 Level II ● ● ● ● ●
et al 2004 Daily Activities Augmentation
Return to Sports 46 Level II ● ● ● ● ●
Satisfaction 46 Level II ● ● ● ● ●
Hospitalization 46 Level II ● ● ● ● ●
83 v1.0 12.04.09
All groups have similar characteristics
Same center for experimental and


control group data

● = Yes ○ = No
at entry
treated
× = Not Reported
Level of
Evidence
Immobilization 46 Level II ● ● ● ● ●
DVT 46 Level II ● ● ● ● ●
PE 46 Level II ● ● ● ● ●
Dysesthesia 46 Level II ● ● ● ● ●
Shoe conflict 46 Level II ● ● ● ● ●
Keloid 46 Level II ● ● ● ● ●
Dehiscence 46 Level II ● ● ● ● ●
84 v1.0 12.04.09
Table 98. Study Quality - Synthetic Tissue Case Series
All patients have approximately


equal follow-up times

● = Yes ○ = No
of patients
× = Not Reported
Level of
Evidence
Giannini et Synthetic Adjunctive
Return to Sports 15 Level IV ● ● ● ● ●
al, 1994 Augmentation
Return to
Previous 15 Level IV ● ● ● ● ●
Activity
Subjective
Results- 15 Level IV ● ● ● ● ●
Excellent
Giannini et Full weight Synthetic Adjunctive
15 Level IV ● ● ● ● ●
al, 1994 bearing (weeks) Augmentation
Rerupture 15 Level IV ● ● ● ● ●
Giannini et Healing Synthetic Adjunctive
15 Level IV ● ● ● ● ●
al, 1994 Impairment Augmentation
Giannini et Return to Synthetic Adjunctive
15 Level IV ● ● ● ● ●
al, 1994 Swimming Augmentation
85 v1.0 12.04.09
STUDY RESULTS
Table 99 Autograft vs. Open Pain and Stiffness
Adjunctive
Open
Author Outcome LOE N Duration Augmentation Results
% %
Pajala, et al. 12
No Pain vs. Pain II 59 79% (4%) 90% (0%) p = 0.35
2009 months
Aktas, et al.
Pain - Absent‡ II 30 6 months 94% 86% NS
2007
Aktas, et al. Pain - Mild w/ maximal
II 30 6 months 6% 14% NS
2007 exertion‡
Taglialavoro, 42
Pain - Absentª II 46 83% 73% NS
et al 2004 months
Taglialavoro, Pain - During Intense 42
II 46 17% 18% NS
et al 2004 Trainingª months
Taglialavoro, Pain - During Moderate 42
II 46 0% 5% NS
et al 2004 Trainingª months
Taglialavoro, 42
Pain - Continuousª II 46 0% 5% NS
et al 2004 months
Pajala, et al. 12
No stiffness vs. stiffness II 59 46% (36% 72% (16%) p = .10
2009 months
‡American Orthopaedic Foot and Ankle Score
Table 100. Autograft vs. Open - Satisfaction

Adjunctive
Author Outcome LOE N Duration Augmentation Open (%) Results
(%)
Pajala, et al. Very satisfied vs. all other 12
II 59 71% (11%) 71% (19%) p = 0.55
2009 satisfaction levels months
Taglialavoro, 42
Satisfaction - Very Goodª II 46 46% 46% p = .98‡
et al 2004 months
Taglialavoro, 42
Satisfaction - Goodª II 46 42% 46% p = .8‡
et al 2004 months
Taglialavoro, 42
Satisfaction - Fairª II 46 13% 0% p = .01‡
et al 2004 months
Taglialavoro, 42
Satisfaction - Poorª II 46 0% 9% p = .04‡
et al 2004 months
ª Modified McComis Score
86 v1.0 12.04.09
Table 101. Autograft vs. Open - Return to Sports
Adjunctive
Open
(%)
(%)
Aktas, et al. Return to Sports - Same
II 30 6 months 85% 89% p = .620‡
2007 Level / Pre-injury
Taglialavoro, Return to Sports - 42
II 46 38% 32% NS
et al 2004 Complete months
Taglialavoro, Return to Sports - Low 42
II 46 50% 55% NS
et al 2004 Loss months
Taglialavoro, Return to Sports - 42
II 46 8% 9% NS
et al 2004 Decreased months
Taglialavoro, Return to Sports - Not 42
II 46 4% 0% NS
et al 2004 Recovered months
Return to Sports -
Taglialavoro, 42
Complaints during II 46 0% 5% NS
et al 2004 months
normal activity
Table 102. Autograft vs. Open - Return to Activities

Adjunctive
Open
Outcome LOE N Duration Augmentation Results
Author mean(SD)
mean (SD)
Taglialavoro, Recovery of Daily 42
II 46 128 (39) 106 (66) p = .17‡
et al 2004 Activities(days) months
Table 103. Autograft vs. Open - Footwear Restrictions

Adjunctive
Author Outcome LOE N Duration Augmentation Open (%) Results
(%)
Pajala, et al. No footwear restrictions 12
II 60 79% (4%) 90% (0%) p = 0.35
2009 vs. footwear restrictions months
Taglialavoro, 42
Shoe conflict II 46 38% 23% NS
et al 2004 months
87 v1.0 12.04.09
Table 104. Autograft vs. Open - Hospitalization vs. Immobilization
Adjunctive
Open
mean(SD)
mean (SD)
Taglialavoro, 42
Hospitalization (days) II 46 8.2 (2.3) 5.0 (1.9) p <.001‡
et al 2004 months
Taglialavoro, 42 49.5
Immobilization (days) II 46 63.9 (15.8) p <.001‡
et al 2004 months (10.6)
Table 105. Autograft vs. Open - Complications

Adjunctive Open
Author Complication LOE N Duration Augmentation Repair
% % Results
Taglialavoro,
PE II 46 42 months 4% 0% NS
et al 2004
Taglialavoro,
DVT II 46 42 months 4% 14% NS
et al 2004
Pajala, et al.
DVT II 60 3 weeks 4% 0% NS
2009
Pajala, et al.
Deep Infection II 60 12 months 7% 0% p = .04‡
2009
Aktas et al.
Deep Infection II 30 6 months 6% 0% NS
2007
Pajala, et al. Superficial
II 60 12 months 4% 13% NS
2009 Infection
Pajala, et al.
Re-rupture‡ II 60 12 months 11% 9% NS
2009
Aktas et al.
Re-rupture II 30 6 months 0% 0% NS
2007
Taglialavoro,
Dysesthesia II 46 42 months 13% 14% NS
et al 2004
Taglialavoro,
Keloid II 46 42 months 8% 5% NS
et al 2004
Taglialavoro,
Dehiscence II 46 42 months 13% 9% NS
et al 2004
‡ Three of the patients with reruptures had obvious new injury during recovery period. One re-rupture
occurred at ten weeks when patient was cycling up a steep hill. Two re-ruptures occurred at twelve weeks
with minimum trauma; these patients were in the Open repair group and recalled having sustained a slight
injury during the first three weeks.
NS: Non-Significant; Authors did not report p-value
88 v1.0 12.04.09
Table 106. Synthetic Tissue - Results
Adjunctive
Author Outcome LOE N Duration Augmentation
mean (SD) %
Giannini et al, 18
Subjective Results- Excellent IV 15 100%
1994 months
Giannini et al, 18
Return to Previous Activity IV 15 100%
1994 months
Giannini et al, 18
Rerupture IV 15 0%
1994 months
Giannini et al, 18
Healing Impairment IV 15 0%
1994 months
89 v1.0 12.04.09
RECOMMENDATION 10
We cannot recommend for or against the use of antithrombotic treatment for patients with
acute Achilles tendon ruptures.
potential harm.

Rationale:
A systematic review was conducted to determine if prophylaxis for thromboembolic
events is warranted for patients with acute Achilles tendon rupture. No studies were
identified that address this issue.
EXCLUDED STUDIES
Table 107. Antithrombotic Treatment - Excluded Studies

Not Relevant; Does
Nilsson-Helander, High Incidence of deep venous thrombosis after Achilles tendon
not answer the
et al. 2009 rupture: a prospective study
recommendation.
Lapidus, et al. Prolonged thromboprophylaxis with dalteparin after surgical treatment Less than 50%
2007 of Achilles tendon rupture: a randomized, placebo-controlled study follow up
Less than 80%
Lassen, et al. Use of the low-molecular-weight heparin reviparin to prevent deep-
Achilles tendon tear
2002 vein thrombosis after leg injury requiring immobilization
patients
90 v1.0 12.04.09
RECOMMENDATION 11
We suggest early (≤ 2 weeks) post-operative protected weight bearing (including limiting
dorsiflexion) for patients with acute Achilles tendon rupture who have been treated
operatively.
AAOS Strength of Recommendation: Moderate
Description: Evidence from two or more “Moderate” strength studies with consistent findings, or
evidence from a single “High” quality study for recommending for or against the intervention. A
Moderate recommendation means that the benefits exceed the potential harm (or that the
potential harm clearly exceeds the benefits in the case of a negative recommendation), but the
strength of the supporting evidence is not as strong.
Implications: Practitioners should generally follow a Moderate recommendation but remain alert
to new information and be sensitive to patient preferences.
Rationale:
A systematic review identified four Level II studies40, 5, 41,42 that compared early
postoperative weight bearing to non-weight bearing following surgical repair of the
Achilles tendon. All studies compared patients with either six weeks of non-weight
bearing in a cast to early weight bearing. Two studies40, 42 permitted immediate weight
bearing starting the day of surgery in a cast, defined as toe-touch weight bearing in one
study.40 The second study5 allowed the weight bearing group to begin immediate
rehabilitation on the first post-operative day in a modified splint. The patients in the third
study41 began weight bearing two weeks after surgery. By two weeks, three
investigators40, 5, 41 used a splint device that limited dorsiflexion to prevent compromise
of the repair. After four weeks, Maffulli et al.40, 42 allowed the non-weight bearing group
to begin full weight bearing in a cast, while the other two studies5, 41 kept the non-weight
bearing group on crutches for six weeks.
One study,5 found a significantly higher re-rupture rate in the early postoperative weight
bearing group (2 of 23 patients) compared to non-weight bearing group (0 of 25 patients).
Both patients had documented non-compliance with the use of their postoperative splint
and fell during the first four weeks after surgery.
Three studies40, 5, 42 found that the weight bearing group had statistical improvement in
the time to return to activities including work, sports, and normal walking. Suchak et
al.41 found significantly better scores in physical functioning and reported fewer
limitations of daily living six weeks after the operation. By 12 months, all four studies
found that there was no significant difference between the two groups in outcomes such
as pain and function.
Although the ultimate level of function achieved after operative repair of an Achilles
rupture is similar regardless of the post-operative weight bearing protocol, early post-
operative weight bearing allows the patient to achieve a quicker return to activities during
the first six months than those patients treated with traditional postoperative casting.
Treatment decisions should be made in light of all circumstances presented by the patient.
91 v1.0 12.04.09
Mutual communication between patient and physician should include a discussion of the
importance of patient compliance when a program is prescribed for the use of early
weight bearing. Patient compliance to protocol is important to prevent re-rupture.
Four Level II studies 40, 5, 41, 42 compare early postoperative weight bearing to non-weight
bearing following surgical repair of the Achilles tendon. The post-operative regimes in
the three studies are detailed in Table 108. For results of early weight bearing versus
non-weight bearing see Table 109 through Table 115.
Of forty-nine outcome measures comparing early weight bearing to non-weight bearing,

seventeen were statistically significant in favor of early weight bearing, while one was in
favor of non-weight bearing. Eleven of the seventeen results in favor of early weight
bearing measured time until returning to activity (return to sports, return to normal
walking, return to stair climbing, return to work, return to full weight bearing, number of
physical therapy visits, and time until release from physical therapy) (see Table 109). A
third study5 that measured time until return to work did not find a statistically significant
difference between groups. At one and a half months, the early weight bearing group had
no limitation and scored statistically significantly higher on the physical function, social
function, vitality, and emotion components of the Rand-36 scale. One study reported that
statistically significantly more patients returned to sports at 12 months (see Table 109)..
However, two other studies reported no statistically significant difference in return to
sports at six or twelve months. There was no statistically significant difference in pain,
satisfaction, return to work, or footwear restrictions at twelve months (see Table 110
through Table 113).
One study5, reported significantly more reruptures in the early weight bearing group. Of
the two patients with re-ruptures, one patient did not follow the written rehabilitation
protocol and the second patient suffered a fall on ice and forcibly dorsiflexed his ankle.
There were no statistically significant differences between groups in complications.
Table 108: Description of treatment groups

Author Post operative Instructions
Early weight bearing group: Bear weight on the tiptoes of the
operated leg as tolerated but keep leg elevated for the first two weeks.
Maffulli, et al.(a) Begin weight bearing as tolerated.
Non-weight bearing group: No weight bearing and keep leg elevated
for first two weeks. Increase weight bearing at 4 weeks.
Early weight bearing group: Bear weight on the operated leg as
tolerated but keep leg elevated for the first two weeks. Begin weight
Maffulli, et al (b) bearing as tolerated.
Non-weight bearing group: No weight bearing and keep leg elevated
for first two weeks. Increase weight bearing at 4 weeks.
Costa, et al. Early weight bearing group: Immediate weight bearing and
92 v1.0 12.04.09
mobilization using carbon fibre orthosis with 1.5 cm heal raises.
Non-weight bearing group: Traditional plaster cast.
Early weight bearing group: Two weeks of non-weight bearing
followed by weight bearing.
Suchak, et al.
Non-weight bearing group: 6 weeks of non-weight bearing using
auxiliary crutches.
93 v1.0 12.04.09
SUMMARY OF EVIDENCE
Table 109 Time until return to activity
Time to
Author Outcome LoE N Return to
Activity
Maffulli, et al 2003 (a) Return to Sports (months) II 53 ●wb
Maffulli, et al 2003 (b) Return to Sports (months) II 56‡ ●wb
Costa, et al 2006 Return to Normal Walking (weeks) II 48‡‡ ●wb
Costa, et al 2006 Return to Normal Stair Climbing (weeks) II 48‡‡ ●wb
Costa, et al 2006 Return to Work (weeks) II 48‡‡ ○
Maffulli, et al 2003 (a) Return to Work (weeks) II 53 ●wb
Maffulli, et al 2003 (a) Full weight bearing (wks) II 53 ●wb
Maffulli, et al 2003 (b) Full weight bearing (wks) II 56‡ ●wb
Maffulli, et al 2003 (a) Physiotherapy sessions (visits) II 53 ●wb
Maffulli, et al 2003 (b) Physiotherapy sessions (visits) II 56‡ ●wb
Maffulli, et al 2003 (a) Discharged from Physiotherapy (months) II 53 ●wb
Maffulli, et al 2003 (b) Discharged from Physiotherapy (months) II 56‡ ●wb

Wb= weight bearing
○= no statistically significant difference
●= statistically significant difference
‡ AAOS calculations
‡‡= Number of patients is unclear. The authors state both 56 and 53 as the number of patients
enrolled
Table 110 Pain

Result (months)
Author Outcome LoE N 1.5 2 3 6 12
Maffulli, et al 2003 (a) Pain- None II 53 ○‡
Maffulli, et al 2003 (a) Pain- Mild, Occasional II 53 ○‡
Maffulli, et al 2003 (a) Pain- Moderate II 53 ○‡
Maffulli, et al 2003 (b) Pain- None II 53 ○‡
94 v1.0 12.04.09
Result (months)
Author Outcome LoE N 1.5 2 3 6 12
Maffulli, et al 2003 (b) Pain- Mild, Occasional II 53 ○‡
Maffulli, et al 2003 (b) Pain- Moderate II 53 ○‡

Wb= weight bearing
‡‡= Open cast group converted to orthosis at 3 weeks
95 v1.0 12.04.09
Table 111 Function
Author Outcome
Result (months)
LoE N 1.5 6 12
Suchak, et al No Limitations or Limitations only in
II 110 ●wb
2008 recreation
Maffulli, et al
No Limitations II 53 ○‡
2003 (a)
Maffulli, et al 53
No Limitations II ○
2003 (b)
Maffulli, et al Activity Limitation - Limited
II 53 ○‡
2003 (a) Recreational but not Daily Activities
Maffulli, et al Activity Limitation - Limited 53
II ○‡
2003 (b) Recreational but not Daily Activities
Suchak, et al
Return to at least partial sports II 38 ○‡
2008 (a)
Maffulli, et al
Return to Sports II 48 ○‡
2003 (a)
Maffulli, et al 53
Return to Sports II ○‡
2003 (b)
Costa, et al 2006 Return to Sports II 48‡‡ ●wb
Maffulli, et al
Return to Work II 49 ○‡
2003 (a)
Maffulli, et al 53
Return to Work II ○‡
2003 (b)
Maffulli, et al
Changed Jobs II 49 ○‡
2003 (a)
Maffulli, et al
Changed Jobs ○‡
2003 (b)
Maffulli, et al Experience Problems at work due to
II 49 ○‡
2003 (a) injury
Maffulli, et al Experience Problems at work due to 53
II ○‡
2003 (b) injury
Maffulli, et al Footwear restrictions- None, mild
II 53 ○‡
2003 (a) (most shoes tolerated)
Maffulli, et al Footwear restrictions- None, mild
II 53 ○‡
2003 (b) (most shoes tolerated)
Footwear restrictions- Moderate 53
Maffulli, et al
(unable to tolerate fashionable shoes, II ○‡
2003 (a)
with or without insert)
Footwear restrictions- Moderate
Maffulli, et al
(unable to tolerate fashionable shoes, II 53 ○‡
2003 (b)
with or without insert)
Wb= weight bearing
96 v1.0 12.04.09
Table 112 EuroQoL, Rand-36

Results (Months)
Author Outcome LoE N
1.5 2 6 12
Costa, et al EuroQoL - Health
II 48‡‡ ○ ○ ○
2006 Score
Costa, et al
EuroQoL - E5D II 48‡‡ ○ ○ ○
2006
Suchak, et al Rand-36 Physical
II 110 ●wb
2008 Functioning
Suchak, et al Rand-36 Social
II 110 ●wb
2008 Functioning
Suchak, et al
Rand-36 Vitality II 110 ●wb
2008
Suchak, et al Rand-36 Role-
II 110 ●wb
2008 Emotional
Wb= weight bearing
Table 113 Patient Subjective Results

Results
(Months)
Author Outcome LoE N 12 months
Patient opinion
Maffulli, et al
of results- II 53 ○‡
2003 (a)
Excellent
Percent satisfied
Maffulli, et al
with results of II 53 ○‡
2003 (a)
surgery
Patient opinion
Maffulli, et al
of results- II 53 ○‡
2003 (a)
Excellent
Percent satisfied
Maffulli, et al
with results of II 53 ○‡
2003 (a)
surgery
Wb= weight bearing
97 v1.0 12.04.09
Table 114 Reruptures
Weight Non-Weight Statistically
Author LoE Duration N
Bearing Bearing Significant Difference
Costa,
et al II 1 year 48‡‡ 8.69% 0% ●‡ nwb
2006
‡‡= Open cast group converted to orthosis at 3 weeks;
●‡ nwb= statistically significant difference in favor of non-weight bearing
98 v1.0 12.04.09
SUMMARY OF COMPLICATIONS
Table 115 Reported Complications
Non- Statistically
Weight
Author Complication LoE Duration N Weight Significant
Bearing
Bearing Difference
Suchak,
et al DVT II 6 months 110 0% 2% ○‡
2008
Suchak,
Necrosis of the
et al II 6 months 110 0% 2% ○‡
skin
2008
Sural nerve
dysesthesias,
Suchak, superficial
et al infections, II 6 months 110 15% 16% ○‡
2008 delayed wound
healing, scar
adhesions.
Maffulli,
Superficial
et al II 12 months 53 7.69% 7.40% ○‡
Infection
2003 (a)
Maffulli, Hypersensitivity
et al of surgical II 10-12 wks 53 15.38% 18.51% ○‡
2003 (a) wounds
Maffulli,
Hypertrophic
et al II 10-12 weeks 53 3.84% 0% ○‡
Scar
2003 (a)
Costa, et Minor wound
II Nr 48‡‡ 26% 21% ○‡
al 2006 complications
Costa, et Persistent
II Nr 48‡‡ 0% 4.3% ○‡
al 2006 paraethesiae
Maffulli, Hypersensitivity
et al of surgical II 10-12 wks 53‡‡‡ 12% 4% ○‡
2003 (b) wounds
Maffulli,
Hypertrophic
et al II 10-12 weeks 53‡‡‡ 4% 4% ○‡
Scar
2003 (b)
Wb= weight bearing
Nwb= non-weight bearing
‡‡‡= Number of patients is unclear. The authors state both 56 and 53 as the number of patients
enrolled
99 v1.0 12.04.09
Table 116 Systematic Reviews
Author Conclusion
"Postoperative splinting in a cast followed by a functional brace
Khan, RJK, et al. 2005 rather than a cast alone reduces the overall complication rate" (p.
2209).
"Early functional mobilisation is more acceptable to patients than
Lynch, RM 2004 plaster cast immobilisation and results in improved functional
outcomes" (p. 156).
"An early functional rehabilitation protocol for Achilles tendon
Suchak, AA et al. 2006 ruptures improves patient satisfaction with reduction in minor
complications and no increase in rerupture rate or infection rate"
(p. 220).
100 v1.0 12.04.09

EXCLUDED ARTICLES
Table 117 Article Inclusion List- Early weight bearing vs. non-weight bearing
Costa, et al. Immediate full-weight bearing mobilisation for Less than 10 patients per
2003 repaired Achilles tendon ruptures: a pilot study group
Wagnon, et The Webb-Bannister percutaneous technique for
No patient-oriented
al. acute Achilles' tendon ruptures: a functional and MRI
outcome
2005 assessment
Not best available
Aoki, et al. Early active motion and weight bearing after cross-
evidence - not
1998 stitch Achilles tendon repair
comparative
Not best available
Speck, et al. Early full weight bearing and functional treatment
evidence - not
1998 after surgical repair of acute Achilles tendon rupture
comparative
Solveborn, Not best available
Immediate free ankle motion after surgical repair of
et al. evidence - not
acute Achilles tendon ruptures
1994 comparative
101 v1.0 12.04.09

STUDY QUALITY
Table 118. Quality- Weight bearing vs. non-weight bearing- RCT
All groups have similar outcome performance

● = Yes ○ = No × = Not Reported


Patients Blinded
at baseline
Author Outcome N Treatment(s) LoE
Costa, et Weight bearing

al. Return to Sports 43 vs. Non-weight II ● ● × × ● ●
2006 bearing

Return to Sport
al. 43 vs. Non-weight II ● ● × × ● ●
(weeks) ‡‡
2006 bearing

Return to Normal
Walking (weeks)
2006 bearing
Costa, et Return to Normal Weight bearing

al. Stair Climbing 43 vs. Non-weight II ● ● × × ● ●
2006 (weeks) bearing

Return to Work
(weeks)
2006 bearing

EuroQoL - Health
al. 43 vs. Non-weight II ● ● × × ● ×
Score‡‡
2006 bearing

al. EuroQoL - E5D‡ 43 vs. Non-weight II ● ● × × ● ×
2006 bearing
102 v1.0 12.04.09



Patients Blinded
at baseline
Suchak, et Weight bearing

RAND-36:
Physical Function
2008 bearing

RAND-36: Mental
health
2008 bearing

al. Complications 110 vs. Non-weight II ● ● × × ● ×
2008 bearing

RAND-36: Social
Functioning
2008 bearing

RAND-36: Role-
physical
2008 bearing

RAND-36: Bodily
pain
2008 bearing

RAND-36:
General health
2008 bearing

RAND-36:
Vitality
2008 bearing
103 v1.0 12.04.09



Patients Blinded
at baseline

RAND-36: Role-
emotional
2008 bearing
104 v1.0 12.04.09

Table 119. Quality- Weight bearing vs. non-weight bearing- Comparative
All groups have similar outcome performance at entry
Same center for experimental and control group data

All groups have similar characteristics at entry
All groups concurrently treated

Weight
Maffulli,
Bearing vs.
et al. Pain- None 53 II ● ● x ● ●
Non-Weight
2003 (a)
Bearing
Weight
Maffulli,
Pain- Mild, Bearing vs.
et al. 53 II ● ● x ● ●
Occasional Non-Weight
2003 (a)
Bearing
Weight
Maffulli,
Bearing vs.
et al. Pain- Moderate 53 II ● ● x ● ●
Non-weight
2003 (a)
bearing
Weight
Maffulli,
Bearing vs.
et al. Return to Sports 53 II ● ● x ● ●
Non-weight
2003 (a)
bearing
Weight
Maffulli,
Return to Sports Bearing vs.
et al. 53 II ● ● x ● ●
(months) Non-weight
2003 (a)
bearing
Weight
Maffulli,
Return to Work Bearing vs.
et al. 53 II ● ● x ● ●
(weeks) Non-weight
2003 (a)
bearing
105 v1.0 12.04.09



Weight
Maffulli,
Bearing vs.
et al. Return to Work 53 II ● ● x ● ●
Non-weight
2003 (a)
bearing
Weight
Maffulli,
Bearing vs.
et al. Changed Jobs 53 II ● ● x ● ●
Non-weight
2003(a)
bearing
Weight
Maffulli, Experience
Bearing vs.
et al. Problems at work 53 II ● ● x ● ●
Non-weight
2003 (a) due to injury
bearing
Weight
Maffulli,
Full weight Bearing vs.
et al. 53 II ● ● x ● ●
bearing (wks) Non-weight
2003 (a)
bearing
Weight
Maffulli,
Activity Limitation Bearing vs.
et al. 53 II ● ● x ● ●
- None Non-weight
2003 (a)
bearing
Activity Limitation
Maffulli, - Limited Weight
et al. Recreational but 53 Bearing vs. II ● ● x ● ●
2003(a) not Daily Non Weight
Activities
Weight
Maffulli, Discharged from
Bearing vs.
et al. Physiotherapy 53 II ● ● x ● ●
Non-weight
2003 (a) (months)
bearing
106 v1.0 12.04.09



Weight
Maffulli,
Physiotherapy Bearing vs.
et al. 53 II ● ● x ● ●
sessions (visits) Non-weight
2003 (a)
bearing
Footwear Weight
Maffulli,
restrictions- None, Bearing vs.
et al. 53 II ● ● x ● ●
mild (most shoes Non Weight
2003 (a)
tolerated) Bearing
Footwear
restrictions-
Weight
Maffulli, Moderate (unable
Bearing vs.
et al. to tolerate 53 II ● ● x ● ●
Non-weight
2003 (a) fashionable shoes,
bearing
with or without
insert)
Weight
Maffulli, Percent satisfied
Bearing vs.
et al. with results of 53 II ● ● x ● ●
Non-weight
2003 (a) surgery
bearing
Weight
Maffulli,
Patient opinion of Bearing vs.
et al. 53 II ● ● x ● ●
results- Excellent Non-weight
2003 (a)
bearing
Weight
Maffulli,
Bearing vs.
et al. Pain- None 53 II ● ● x ● ●
Non-Weight
2003 (b)
Bearing
107 v1.0 12.04.09



Weight
Maffulli,
Pain- Mild, Bearing vs.
et al. 53 II ● ● x ● ●
Occasional Non-Weight
2003 (b)
Bearing
Weight
Maffulli,
Bearing vs.
et al. Pain- Moderate 53 II ● ● x ● ●
Non-weight
2003 (b)
bearing
Weight
Maffulli,
Bearing vs.
et al. Return to Sports 53 II ● ● x ● ●
Non-weight
2003 (b)
bearing
Weight
Maffulli,
Return to Sports Bearing vs.
et al. 53 II ● ● x ● ●
(months) Non-weight
2003 (b)
bearing
Weight
Maffulli,
Return to Work Bearing vs.
et al. 51 II ● ● x ● ●
(weeks) Non-weight
2003 (b)
bearing
Weight
Maffulli,
Bearing vs.
et al. Return to Work 51 II ● ● x ● ●
Non-weight
2003 (b)
bearing
Weight
Maffulli,
Bearing vs.
et al. Changed Jobs 51 II ● ● x ● ●
Non-weight
2003(b)
bearing
108 v1.0 12.04.09



Weight
Maffulli, Experience
Bearing vs.
et al. Problems at work 51 II ● ● x ● ●
Non-weight
2003 (b) due to injury
bearing
Weight
Maffulli,
Full weight Bearing vs.
et al. 56‡‡ II ● ● x ● ●
bearing (wks) Non-weight
2003 (b)
bearing
Weight
Maffulli,
Activity Limitation Bearing vs.
et al. 53 II ● ● x ● ●
- None Non-weight
2003 (b)
bearing
Activity Limitation
Maffulli, - Limited Weight
et al. Recreational but 53 Bearing vs. II ● ● x ● ●
2003(b) not Daily Non Weight
Activities
Weight
Maffulli, Discharged from
Bearing vs.
et al. Physiotherapy 56‡‡ II ● ● x ● ●
Non-weight
2003 (b) (months)
bearing
Weight
Maffulli,
Physiotherapy Bearing vs.
et al. 56‡‡ II ● ● x ● ●
sessions (visits) Non-weight
2003 (b)
bearing
Footwear Weight
Maffulli,
restrictions- None, Bearing vs.
et al. 53 II ● ● x ● ●
mild (most shoes Non Weight
2003 (b)
tolerated) Bearing
109 v1.0 12.04.09



Footwear
restrictions-
Weight
Maffulli, Moderate (unable
Bearing vs.
et al. to tolerate 53 II ● ● x ● ●
Non-weight
2003 (b) fashionable shoes,
bearing
with or without
insert)
Weight
Maffulli, Percent satisfied
Bearing vs.
et al. with results of 53 II ● ● x ● ●
Non-weight
2003 (b) surgery
bearing
Weight
Maffulli,
Patient opinion of Bearing vs.
et al. 53 II ● ● x ● ●
results- Excellent Non-weight
2003 (b)
bearing
110 v1.0 12.04.09

STUDY RESULTS
Table 120 Study Data: Weight Bearing vs. Non-Weight Bearing
Weight Non-Weight
Author Outcome LoE Duration N Result
Bearing Bearing
Suchak, et al Rand-36 Physical 61.4 (SD 47.6 (SD

II 6 week 110 p = 0.03
2008 Functioning 29.4) 34.4)
Suchak, et al Rand-36 Social 72.7 (SD 60.7 (SD

II 6 week 110 p = 0.03
2008 Functioning 28.5) 26.8)
Suchak, et al 69.4 (SD 60.6 (SD

Rand-36 Vitality II 6 week 110 p = 0.04
2008 23.7) 21.1)
Suchak, et al Rand-36 Role- 84.6 (SD 67.3 (SD

II 6 week 110 p = 0.02
2008 Emotional 32.0) 43.1)
No Limitations or
Suchak, et al
Limitations only in II 6 week 110 43% 9% p = <.001
2008
recreation
Suchak, et al Return to at least
II 6 months 110 67% 63% p=0.68
2008 partial sports
Maffulli, et al Full weight bearing 12 2.5 (SD

II 53 5.5 (SD 2.2) p = 0.021
2003(a) (wks) months 0.4)
Maffulli, et al Physiotherapy 12 6.1 (SD

II 53 13.6 (SD 4.8) p = 0.03
2003(a) sessions (visits) months 3.1)
Discharged from
Maffulli, et al 12 2.1 (SD
Physiotherapy II 53 4.6 (SD 2) p = <.0001
2003(a) months 1.1)
(months)
Maffulli, et al 12
Pain- None II 53 88% 89% p= 0.96 ‡
2003(a) months
Maffulli, et al Pain- Mild, 12

II 53 8% 7% p=0.97‡
2003(a) Occasional months
Maffulli, et al 12
Pain- Moderate II 53 4% 4% p=0.98 ‡
2003(a) months
Maffulli, et al Activity Limitation - 12

II 53 92% 93% p=0.97‡
2003(a) None months
Activity Limitation -
Maffulli, et al Limited Recreational 12
II 53 8% 7% p=0.97
2003(a) but not Daily months
Activities
111 v1.0 12.04.09

Weight Non-Weight
Bearing Bearing
Maffulli, et al 12
Return to Sports II 38 89% 89% p=0.99 ‡
2003(a) months
Maffulli, et al Return to Sports 12 5.1 (SD

II 53 6 (SD 3) p= 0.04
2003(a) (months) months 2.8)
Footwear restrictions-
Maffulli, et al 12
None, mild (most II 53 96% 93% p=0.57‡
2003(a) months
shoes tolerated)
Moderate (unable to
Maffulli, et al 12
tolerate fashionable II 53 4% 7% p=0.57‡
2003(a) months
shoes, with or without
insert)
Maffulli, et al Percent satisfied with 12

II 53 88% 85% p=0.51‡
2003(a) results of surgery months
Maffulli, et al 12
Excellent II 53 88% 81% p=0.47‡
2003(a) months
Maffulli, et al Return to Work 12 9.2 (SD

II 53 13.2 (SD 3) p= 0.05
2003(a) (weeks) months 2.5)
Maffulli, et al 12
Return to Work II 49 100% 100% 1
2003(a) months
Maffulli, et al 12
Changed Jobs II 49 1 2 p=0.51‡
2003(a) months
Maffulli, et al Experience Problems 12

II 49 2 4 .p=0.41‡
2003(a) at work due to injury months
Maffulli, et al Full weight bearing 53‡‡ 2.5 (SD

II 6 weeks 5.7 (SD 2.2) P=0.013
2003 (b) (wks) ‡ 0.4)
Maffulli, et al Physiotherapy 12 53‡‡ 8.3 (SD

II 14.6 (SD 5.3) p = 0.008
2003 (b) sessions (visits) months ‡ 4.1)
Discharged from
Maffulli, et al 12 2.7 (SD
Physiotherapy II 53‡ 4.7 (SD 2) <.08
2003(b) months 1.1)
(months)
Maffulli, et al 12
Pain- None II 53 92% 86% P=0.46‡
2003(b) months
Costa, et al
Return to Sports II 1 year 48‡‡ 83% 68% p= 0.04
2006
112 v1.0 12.04.09

Weight Non-Weight
Bearing Bearing
Costa, et al Return to Normal 12.5 (CI

II 1 year 48‡‡ 18 (CI 18-22) p= 0.03
2006 Walking (weeks) 10-18)
Return to Normal
Costa, et al 13 (CI 10-
Stair Climbing II 1 year 48‡‡ 22 (CI 18-22) p= 0.02
2006 18)
(weeks)
Costa, et al Return to Work
II 1 year 48‡‡ 8 (CI 2-13) 4(CI 1-13) p= 0.59
2006 (weeks)
Costa, et al EuroQoL - Health 75 (IQR 75 (IQR 65-

II 2 months 48‡‡ p= 0.85
2006 Score 70-85) 80)

II 6 months 48‡‡ p= 0.96
2006 Score 80-90) 95)

II 1 year 48‡‡ p= 0.14
2006 Score‡‡ 75-95) 95)
Costa, et al 0.69 (IQR 0.69 (IQR

EuroQoL - E5D II 2 months 48‡‡ p= 0.45
2006 0.6-0.9) 0.6-0.7)
Costa, et al 0.8 (IQR 0.8 (IQR 0.8-

EuroQoL - E5D II 6 months 48‡‡ p= 0.96
2006 0.7-1.0) 1.0)
Costa, et al 1 (IQR 1(IQR 0.8-

EuroQoL - E5D II 1 year 48‡‡ p= 0.15
2006 0.9-1.0) 1.0)
Costa, et al
Re-rupture II 1 year 48‡‡ 8.69% 0 p= 0.03‡
2006
Suchak, et al
DVT II 6 months 110 0 2% p= 0.14‡
2008
Suchak, et al
Necrosis of the skin II 6 months 110 0 2% p= 0.14‡
2008
Sural nerve
dysesthesias,
Suchak, et al superficial infections,
II 6 months 110 15% 16% p= 0.89‡
2008 delayed wound
healing, scar
adhesions.
Maffulli, et al 12
Superficial Infection II 53 7.69% 7.40% p= 0.97‡
2003(a) months
Costa, et al
2006 Minor wound
II Nr 48‡‡ 26% 21% p=0.17‡
complications
113 v1.0 12.04.09

Weight Non-Weight
Bearing Bearing
Costa, et al Persistent
2006 II Nr 48‡‡ 0% 4.3% p= 0.60‡
paraethesiae
Maffulli, et al Hypersensitivity of 10-12

II 53 15.38% 18.51% p= 0.76‡
2003(a) surgical wounds wks
Maffulli, et al 10-12
Hypertrophic Scar II 53 3.84% 0% p= 0.15‡
2003(a) weeks
Maffulli, et al Pain- Mild, 12

II 53 8% 8% p=0.93
2003 (b) Occasional months
Maffulli, et al 12
Pain- Moderate II 53 0% 7% p=0.95
2003 (b) months
Maffulli, et al Activity Limitation - 12

II 53 0.96 89% p=0.37
2003 (b) None months
Activity Limitation -
Maffulli, et al Limited Recreational 12
II 53 4% 11% p=0.91
2003 (b) but not Daily months
Activities
Maffulli, et al 12
Return to Sports II 53‡ 89% 89% p=0.93
2003 (b) months
Maffulli, et al Time until Return to 12 53‡‡

II 5.2 (SD 3) 6.1 (SD 2.8) p=0.45
2003 (b) Sports (months) months ‡
Maffulli, et al 12
None, mild (most II 53 96% 96% p=0.33
2003 (b) months
shoes tolerated)
Moderate (unable to
Maffulli, et al 12
tolerate fashionable II 53 4% 4% p=0.97
2003 (b) months
shoes, with or without
insert)
Maffulli, et al Percent satisfied with 12
II 53 84% 89% p=0.37
2003 (b) results of surgery months
Maffulli, et al 12
Excellent II 53 84% 89% p=0.37
2003 (b) months
Maffulli, et al 12
Return to Work II 51 100% 100% 1
2003 (b) months
Maffulli, et al 12
Changed Jobs II 49 1 2 p=0.61
2003 (b) months
114 v1.0 12.04.09

Weight Non-Weight
Bearing Bearing
Maffulli, et al Experience Problems 12

II 49 20% 11% p=0.91
2003 (b) at work due to injury months
Maffulli, et al Hypersensitivity of
II 6 weeks 53 12% 4% p=0.97
2003 (b) the surgical wound
Maffulli, et al
Hypertrophic scar II 6 weeks 53 4% 4% p=0.97
2003 (b)
‡= AAOS calculations
115 v1.0 12.04.09

RECOMMENDATION 12
We suggest the use of a protective device that allows mobilization by 2- 4 weeks post
operatively.
AAOS Strength of Recommendation: Moderate
Description: Evidence from two or more “Moderate” strength studies with consistent findings, or
evidence from a single “High” quality study for recommending for or against the intervention. A
Moderate recommendation means that the benefits exceed the potential harm (or that the
potential harm clearly exceeds the benefits in the case of a negative recommendation), but the
strength of the supporting evidence is not as strong.
Implications: Practitioners should generally follow a Moderate recommendation but remain alert
to new information and be sensitive to patient preferences.
Rationale:
A systematic review identified five Level II 40, 43-45 studies comparing postoperative
immobilization to postoperative mobilization following surgical repair of the Achilles
tendon. All five studies randomized the patients into two groups with either six weeks in
a cast or early motion with a modified splint device. For all studies, patients in the
mobilization group had a splint or modified cast device that limited dorsiflexion to
protect the repair.
All five studies40, 5, 43-45 found that the weight bearing group had statistical improvement
in the mean time to return to activities such as work and normal walking. One44 of three
studies found a significantly higher rate in return to sport activities at twelve months,
while two40, 39 found no difference. One study 5 found a significantly higher re-rupture
rate in the postoperative mobilization group (2 of 23 patients) compared to the
immobilization group (0 of 25 patients). Both patients had documented non-compliance
with the use of their postoperative splint and fell during the first 4 weeks after surgery.
By 12 to 18 months, all five studies40, 5, 43-45 found that there was no significant difference
between the two groups in outcomes such as pain and function.
Although the ultimate level of function achieved after operative repair of an Achilles
rupture is similar regardless of the postoperative immobilization protocol, early
postoperative mobilization allows the patient to achieve a quicker return to activities
during the first six months than those patients treated with immobilization. However,
treatment decisions should be made in light of all circumstances presented by the patient.
Mutual communication between patient and physician should include a discussion of the
importance of patient compliance when a program is prescribed for early mobilization.
Patient compliance to protocol is important to aid in protection of the incision during the
early post-operative period and is also important to prevent wound healing complications.
Supporting Evidence
Five Level II studies40, 5, 43-45 compare postoperative immobilization to postoperative

mobilization. The post operative mobilization and immobilization regimes are detailed in
116 v1.0 12.04.09

Table 121. Please see Table 122 through Table 129 for results of mobilization versus
immobilization.
Of the forty outcomes reported, seventeen were statistically significant in favor of early
motion. Nine of the seventeen statistically significant results measured time until return
to activity, sports, walking, stair climbing, work, weight bearing, discharge from
physiotherapy, number of physiotherapy sessions, and sick leave (see Table 122).
However, another study that reported time until return to sport and work did statistically
significantly differ between groups (see Table 122). Patients in the early motion group
reported statistically significantly less pain at one month but no statistically significant
difference in pain at three, six, or twelve months (see Table 123). One of seven outcome
measures found a statistically significant difference in the percent of patients able to
return to sports in favor of the motion group. Statistically significantly more patients were
able to stand on their toes and walk as far as they could before surgery in the early motion
group at three and six months. Patients in the early motion group were more satisfied
with their cast at one year. There was no statistically significant difference between
groups in regard to: patient opinion of results, footwear restrictions, EuroQoL, E5D, or
Ankle Performance Score (see Table 124).
Costa, et al5, reported significantly more re-ruptures in the early weight bearing group.
Of the two patients with re-ruptures, one patient did not follow the written rehabilitation
protocol and the second patients suffered a fall on ice and forcibly dorsiflexed his ankle.
Abnormal sensibility was significantly more prevalent in the immobilized group than in
the motion group. There were no other statistically significant differences between
groups in complications.
Table 121. Description of Treatment Groups

Author Post operative Instructions
Mobilization group: Immediate weight bearing and mobilization
Costa, et al. using carbon fibre orthosis with 1.5 cm heal raises.
Immobilization group: Traditional plaster cast.
Mobilization group: Below the knee dorsal plaster splint followed by
Mortensen, et al. walker brace.
Immobilization group: Below the knee plaster cast
Mobilization group. Mobile cast
Cetti, et al.
Immobilization group. Rigid below the knee cast
Mobilization group. Below the knee dorsal cast for 6 weeks, this
Kangas, et al allowed for free plantar flexion.
Immobilization group. Below the knee plaster cast
Mobilization group: Removable splint and mobilization at 2 weeks.
Maffulli, et al. (a)
Immobilization group: Below the knee plaster cast.
SUMMARY OF EVIDENCE
Table 122. Time to Return to Activity
117 v1.0 12.04.09

Time to
Author Outcome LoE Comparison N return
Maffulli, Return to Early Motion
et al Sports II vs. 53 ●em
2003(a) (months) Immobilization
Time in
Early Motion
Costa, et al weeks taken
II vs. 48‡‡ ○
2005 to return to
Cast
sport
Return to
Early Motion
Cetti, et al. same level of
II vs. 60 ●em
1994 sports
Cast
activities
Time in
Early Motion
Costa, et al weeks until
II vs. 48‡‡ ●em
2005 return to stair
Cast
climbing
Time in
Early Motion
II vs. 48‡‡ ●em
2005 to return to
Cast
walking
Time in
Early Motion
II vs. 48‡‡ ○
2005 to return to
Cast
work.
Early Motion
Cetti, et al. Mean Sick
II vs. 60 ●em
1994 leave (days)
Cast
Maffulli, Early Motion
Return to
et al II Vs. 53 ●em
Work (weeks)
2003(a) Immobilization
Full weight
et al II Vs. 53 ●em
bearing (wks)
2003(a) Immobilization
Physiotherapy Early Motion
Maffulli,
sessions II Vs. 53 ●em
et al 2003
(visits) Immobilization
Discharged
Early Motion
Maffulli, from
II Vs. 53 ●em
et al 2003 Physiotherapy
Immobilization
(months)
em= early motion
118 v1.0 12.04.09

Table 123. Pain
Duration
Author Outcome LoE Comparison N (Months)
1 3 6 12
Early Motion
Kangas, et al
Vas Pain II vs. 50 ●em ○ ○
2002
Cast
Early Motion
Maffulli, et al
Pain- None II vs. 53 ○
2003
Immobilization
Early Motion
Maffulli, et al Pain- Mild,
II Vs. 53 ○
2003 Occasional
Immobilization
Early Motion
Maffulli, et al
Pain- Moderate II Vs. 53 ○
2003
Immobilization
em= early motion
Table 124. Function

Duration
3 6 12 18
Early Motion
Costa, et al Return to 48
II vs. ○
2005 sports ‡‡
Cast
Mortensen, Early Motion
Return to
et al II vs. 61 ○
sports
1999 Cast
Maffulli, et Return to Early Motion vs.
II 38 ○
al 2003 Sports Immobilization
Return Early Motion
Cetti, et al. ●e
sports II vs. 60
1994 m
activities Cast
Mortensen, Reached Early Motion
et al pre-injury II vs. 61 ○
1999 level Cast
Return to
Early Motion
Cetti, et al. lesser level
II vs. 60 ○
1994 of sports
Cast
activities
Stopped Early Motion
Cetti, et al.
sports II vs. 60 ○
1994
activities Cast
119 v1.0 12.04.09

Duration
3 6 12 18
Early Motion
Maffulli, et No
II Vs. 53 ○
al 2003 Limitations
Immobilization
Activity
Limitation
- Limited Early Motion
Maffulli, et
Recreation II Vs. 53 ○
al 2003
al but not Immobilization
Daily
Activities
Able to
walk as far
et al II vs. 71 ●em
before
1999 Cast
surgery
Able to Early Motion
Cetti, et al.
stand on II vs. 60 ●em ●em ○
1994
toes Cast
Sick Leave
et al II vs. ●em
(days)
1999 Cast
Maffulli, et Return to
II 49 ○
al 2003 Work
Maffulli, et Changed
II 49 ○
al 2003 Jobs
em= early motion
Table 125. EuroQoL, E5D, Ankle Performance Score
Duration
(Months)
Author Outcome LoE Comparison N 3.5 4 12 15

Early
Costa, EuroQoL -
Motion
et al Health II 48‡‡ ○ ○ ○
vs.
2006 Score‡‡
Cast
Costa, E5D Early
et al (Dimension II Motion 48‡‡ ○ ○ ○
2006 of Health vs.
120 v1.0 12.04.09

Score) Cast
Ankle Early
Kangas,
Performance Motion
et al II 50 ○
Score - vs.
2002
Excellent Cast
em= early motion
Table 126. Patient opinion of results
Author Outcome LoE 3m 6m 12m 16m

Patient opinion
Cetti, et al.
of cast- II
1994
excellent ●em
Subjective
Mortensen,
Result- II ●em
et al. 1999
Excellent
Cetti, et al.
Complaints II ●em ○ ●em
1994
Patient opinion
Maffulli, et
of results- II ○
al 2003
Excellent
Percent satisfied
Maffulli, et
with results of II ○
al 2003
surgery
em= early motion
121 v1.0 12.04.09

Table 127. Footwear restrictions
Duration
(Months)
Author Outcome LoE Comparison N 12 16

Kangas, Early Motion
Footwear
et al II vs. 50 ○
Restrictions
2002 Cast
Footwear
Maffulli, restrictions- Early Motion
et al None, mild II vs. 53 ○
2003 (most shoes Cast
tolerated)
Footwear
restrictions-
Moderate
(unable to
et al II vs. 53 ○
tolerate
2003 Cast
fashionable
shoes, with or
without insert)
em= early motion
Table 128. Rerupture

Statistically
Early Immobilizatio
Author LoE Duration N Significant
Motion n
Difference
Cetti, et al. Re-
II 3% 7% ○
1994 rupture
Costa, et al 48
II 1 year 8.69% 0% ●‡ nwb
2006 ‡‡
em= early motion
122 v1.0 12.04.09

SUMMARY OF COMPLICATIONS
Table 129. Early Motion vs. Cast - Complications
Statistically
Early Rigid Cast
Author Complication LoE N Significant
Motion Group
Difference
Cetti, et al.
Infection II 60 0% 3% ○
1994
Cetti, et al.
Scar Adhesion II 60 3% 13% ○
1994
Cetti, et al.
Suture Granuloma II 60 3% 0% ○
1994
Cetti, et al. Abnormal
II 60 3% 17% ●em
1994 Sensibility
Cetti, et al.
Keloid Scar II 60 10% 23% ○
1994
Cetti, et al.
Re-rupture II 60 3% 7% ○
1994
Mortensen Deep Infection II 61 3% 0% ○
Mortensen Failed Repair II 61 3% 7% ○
Costa, et al Minor Wound

II 60 23% 20% ○
2006 Complications
Maffulli, et al Superficial
II 53 7.69% 7.40% ○
2003 Infection
Maffulli, et al Hypersensitivity
II 53 15.38% 18.51% ○
2003 of surgical wounds
Maffulli, et al
Hypertrophic Scar II 53 3.84% 0% ○
2003
em= early motion
nem= not early motion
‡ AAOS calculated
123 v1.0 12.04.09

Table 130. Systematic Reviews
Author Conclusion
"Postoperative splinting in a cast followed by a
Khan, RJK, et al.
functional brace rather than a cast alone reduces the
2005
overall complication rate" (p. 2209).
"Early functional mobilisation is more acceptable to
Lynch, RM 2004 patients than plaster cast immobilisation and results in
improved functional outcomes" (p. 156).
"An early functional rehabilitation protocol for Achilles
Suchak, AA et al. tendon ruptures improves patient satisfaction with
2006 reduction in minor complications and no increase in
rerupture rate or infection rate" (p. 220).
124 v1.0 12.04.09

EXCLUDED ARTICLES
Table 131. Mobilization vs. Immobilization Included Articles
Achilles tendon rupture: effect of early
Sorrenti SJ; Not relevant
mobilization in rehabilitation after surgical repair
Buchgraber A;Passler Not best available
Immobilization versus functional postoperative
HH; evidence
treatment
Kerkhoffs GM;Struijs Functional treatment after surgical repair of
PA;Raaymakers acute Achilles tendon rupture: wrap vs. walking Not relevant
EL;Marti RK; cast
Recovering motor performance of the foot after
Kauranen K;Kangas Achilles rupture repair: a randomized clinical No patient
J;Leppilahti J; study about early functional treatment vs. early oriented outcome
immobilization of Achilles tendon in tension
Maffulli N;Tallon Early weight bearing and ankle mobilization
C;Wong J;Lim after open repair of acute midsubstance tears of Not relevant
KP;Bleakney R; the Achilles tendon
Kangas J;Pajala Achilles tendon elongation after rupture repair: a Duplicate - Data
A;Ohtonen randomized comparison of 2 postoperative reported in prior
P;Leppilahti J; regimens study
Majewski M;Schaeren Postoperative rehabilitation after percutaneous
Not best available
S;Kohlhaas U;Ochsner Achilles tendon repair: Early functional therapy
evidence
PE; versus cast immobilization
Not best available
Solveborn SA;Moberg Immediate free ankle motion after surgical repair
evidence - not
A; of acute Achilles tendon ruptures
comparative
125 v1.0 12.04.09

STUDY QUALITY
Table 132. Mobilization vs. Immobilization Quality

Patients Blinded
Blinded
entry
Costa, et Mobilization
al. Sport 43 vs. II ● ● × × ● ×
2006 Immobilization
al. Walking 43 vs. II ● ● × × ● ×
2006 Immobilization
Stair
al. 43 vs. II ● ● × × ● ×
Climbing
2006 Immobilization
al. Work 43 vs. II ● ● × × ● ×
2006 Immobilization
Kangas, et Mobilization
VAS
al. 50 vs. II × ● ○ ○ ● ●
Pain
2003 Immobilization
VAS
al. 50 vs. II × ● ○ ○ ● ●
Pain
2003 Immobilization
VAS
al. 50 vs. II × ● ○ ○ ● ●
Pain
2003 Immobilization
VAS
al. 50 vs. II × ● ○ ○ ● ●
Pain
2003 Immobilization
VAS
al. 50 vs. II × ● ○ ○ ● ●
Pain
2003 Immobilization
126 v1.0 12.04.09


Patients Blinded
Blinded
entry
al. Stiffness 50 vs. II × ● ○ ○ ● ●
2003 Immobilization
Kangas, et subjective Mobilization

al. calf muscle 50 vs. II × ● ○ ○ ● ●
2003 weakness Immobilization
footwear
al. 50 vs. II × ● ○ ○ ● ●
restrictions
2003 Immobilization
Kangas, et Ankle Mobilization
al. performance 50 vs. II × ● ○ ○ ● ●
2003 score Immobilization
Mortensen, Mobilization
et al. Sick Leave 61 vs. II ● ○ ○ ○ ○ ●
1999 Immobilization
Subjective
et al. 61 vs. II ● ○ ○ ○ ○ ●
assessment
1999 Immobilization
Sports
et al. 61 vs. II ● ○ ○ ○ ○ ●
Activity
1999 Immobilization
et al. Pain 61 vs. II ● ○ ○ ○ ○ ●
1999 Immobilization
127 v1.0 12.04.09


Patients Blinded
Blinded
entry
Mobilization
Mortense
vs.
n, et al. Stiffness 61 II ● ○ ○ ○ ○ ●
Immobilizatio
1999
n
Mobilization
Mortense Able to walk as
vs.
n, et al. far as pre 61 II ● ○ ○ ○ ○ ●
Immobilizatio
1999 surgery
n
Mobilization
Cetti, et
Resumption of vs.
al. 111 II × × × × × ○
sports activity Immobilizatio
1994
n
Mobilization
Cetti, et
vs.
al. Return to sport 111 II × × ○ ● ● ●
Immobilizatio
1993
n
Mobilization
Cetti, et
vs.
al. Return to work 111 II × × ○ ● ● ●
Immobilizatio
1993
n
Mobilization
Cetti, et
vs.
al. Re-rupture 111 II × × ○ ● ● ●
Immobilizatio
1993
n
Mobilization
Maffulli,
vs.
et al. Pain- None 53 II ○ ○ ○ ● ● ×
Immobilizatio
2003
n
Maffulli, Mobilization
Pain- Mild,
et al. 53 vs. II ○ ○ ○ ● ● ×
Occasional
2003 Immobilization
et al. Pain- Moderate 53 vs. II ○ ○ × × ● ×
2003 Immobilization
Return to
et al. 53 vs. II ○ ○ × × ● ×
Sports
2003 Immobilization
128 v1.0 12.04.09


Patients Blinded
Blinded
entry
Return to
et al. 53 vs. II ○ ○ × × ● ●
Sports (months)
2003 Immobilization
Mobilization
Maffulli,
Return to Work vs.
et al. 53 II ○ ○ × × ● ●
(weeks) Immobilizatio
2003
n
et al. Return to Work 53 vs. II ○ ○ × × ● ●
2003 Immobilization
et al. Changed Jobs 53 vs. II ○ ○ × × ● ●
2003 Immobilization
Experience
Problems at
et al. 53 vs. II ○ ○ × × ● ●
work due to
2003 Immobilization
injury
Full weight
et al. 53 vs. II ○ ○ × × ● ●
bearing (wks)
2003 Immobilization
Maffulli, Activity Mobilization
et al. Limitation - 53 vs. II ○ ○ × × ● ●
2003 None Immobilization
Activity
Limitation -
Limited
et al. 53 vs. II ○ ○ × × ● ●
Recreational
2003 Immobilization
but not Daily
Activities
Discharged
from
et al. 53 vs. II ○ ○ × × ● ●
Physiotherapy
2003 Immobilization
(months)
Physiotherapy
et al. 53 vs. II ○ ○ × × ● ●
sessions (visits)
2003 Immobilization
Maffulli, Footwear Mobilization
et al. restrictions- 53 vs. II ○ ○ × × ● ●
2003 None, mild Immobilization
129 v1.0 12.04.09


Patients Blinded
Blinded
entry
Footwear
restrictions-
Maffulli, Moderate Mobilization
et al. (unable to 53 vs. II ○ ○ × × ● ●
2003 tolerate Immobilization
fashionable
shoes)
Percent Weight
Maffulli,
satisfied with Bearing vs.
et al. 53 II ○ ○ × × ● ●
results of Non-weight
2003
surgery bearing
Weight
Maffulli, Patient opinion
Bearing vs.
et al. of results- 53 II ○ ○ × × ● ●
Non-weight
2003 Excellent
bearing
130 v1.0 12.04.09

STUDY RESULTS
Table 133. Mobilization vs. Immobilization Study Data
Results
Author Outcome LoE Duration N Early Motion Cast Results
Return to same
Cetti, et al. p=
level of sports II 1 year 60 80% 50%
1994 0.0292
activities
Return to lesser
Cetti, et al.
level of sports II 1 year 60 7% 13% p= 0.616
1994
activities
Cetti, et al. Stopped sports
II 1 year 60 3% 13% p= 0.141
1994 activities
Cetti, et al. Patient opinion of p=
II 1 year 60 77% 20%
1994 cast- excellent 0.0005
53.4
Cetti, et al. Mean Sick leave 20.2 p=
II NA 60 (Range
1994 (days) (Range 3-75) 0.0009
1-182)
Cetti, et al. Able to stand on
II 3 months 60 83% 53% p= 0.025
1994 toes
Cetti, et al. Able to stand on
II 6 months 60 100% 77% p= 0.011
1994 toes
Cetti, et al. Able to stand on 12
II 60 100% 97% p= 0.15‡
1994 toes months
Cetti, et al.
Re-rupture II NA 60 3% 7% p= 0.55‡
1994
Cetti, et al.
Complaints II 3 months 60 17.0 25.00 p= 0.047
1994
Cetti, et al. p=
Complaints II 6 months 60 10.00 14.00
1994 0.290‡
Cetti, et al. 12
Complaints II 60 3.00 11.00 p= 0.03
1994 months
Mortensen, Able to walk as far
et al as they could II 12 weeks 61 19% 40% p= 0.06
1999 before surgery
Mortensen,
Subjective Result - 16
et al II 61 84% 63% p=0.06‡
excellent months
1999
Mortensen,
16
et al Returned to sports II 61 73% 76% OR =1
months
1999
131 v1.0 12.04.09

Results
Mortensen,
Reached pre-
et al II 16 months 61 57% 55% 1
injury level
1999
Time until pre-
Mortensen,
injury level 6 9
et al II NA 61 P <0.01
reached (2.5-13) (6-14)
1999
(months)
Kangas, et
2.02 ±
al Vas Pain II 1 week 50 2.17± 2.7 p= 0.08
1.7
2002
Kangas, et
.82 ±
al Vas Pain II 3 weeks 50 .83 ± 1.2 p= 0.797
1.3
2003
Kangas, et
.60 ±
al Vas Pain II 6 weeks 50 .65 ± 1.4 p= 0.9
.09
2003
Kangas, et
al No Stiffness II 60 weeks 50 44% 68% p>0.08
2003
Kangas, et
al Mild Stiffness II 60 weeks 50 56% 32% p>0.08
2003
Kangas, et
No footwear
al II 60 weeks 50 68% 92% p>0.08
restrictions
2003
Kangas, et Ankle
al Performance II 60 weeks 50 88% 92% p>0.08
2003 Score - Excellent
Kangas, et
al Re-rupture II 5 months 50 4% 8% 1.000
2003
18
Return to
Costa, et al Time 18 (95% CI 12- (95%
Normal II 48 p= 0.027
2006 measurement 22) CI 18-
Walking‡‡
22)
18
Return to
Costa, et al Time 17 (95% CI 11- (95%
Normal Stair II 48 p= 0.023
2006 measurement 18) CI 14-
Climbing‡‡
22)
Cetti, et al.
Infection II Not Reported 60 0 3.3 p= 0.155‡
1994
Cetti, et al.
Scar Adhesion II Not Reported 60 3.3 13.3 0.141‡
1994
132 v1.0 12.04.09

Results
Cetti, et al. Suture
II Not Reported 60 3.3 0 0.155‡
1994 Granuloma
Maffulli, et Full weight 5.5 (SD

II 12 months 53 2.5 (SD 0.4) p= 0.021
al 2003 bearing (wks) 2.2)
13.6
Maffulli, et Physiotherapy
II 12 months 53 6.1 (SD 3.1) (SD p= 0.03
al 2003 sessions (visits)
4.8)
Discharged from
Maffulli, et 4.6 (SD
Physiotherapy II 12 months 53 2.1 (SD 1.1) p<.0001
al 2003 2)
(months)
Maffulli, et
Pain- None II 12 months 53 88% 89% p= 0.96 ‡
al 2003
Maffulli, et Pain- Mild,

II 12 months 53 8% 7% p=0.97‡
al 2003 Occasional
Maffulli, et
Pain- Moderate II 12 months 53 4% 4% p=0.98 ‡
al 2003
Activity
Maffulli, et
Limitation - II 12 months 53 92% 93% p=0.97‡
al 2003
None
Activity
Limitation -
Maffulli, et Limited
II 12 months 53 8% 7% p=0.97
al 2003 Recreational but
not Daily
Activities
Maffulli, et
Return to Sports II 12 months 38 89% 89% p=0.99 ‡
al 2003
Maffulli, et Return to Sports 6 (SD

II 12 months 53 5.1 (SD 2.8) 0.04
al 2003 (months) 3)
Footwear
Maffulli, et
restrictions- II 12 months 53 96% 93% p=0.57‡
al 2003
None, mild
Footwear
restrictions-
Moderate
Maffulli, et (unable to
II 12 months 53 4% 7% p=0.57‡
al 2003 tolerate
fashionable
shoes, with or
without insert)
133 v1.0 12.04.09

Results
Percent satisfied
Maffulli, et
with results of II 12 months 53 88% 85% p=0.51‡
al 2003
surgery
Maffulli, et
Excellent II 12 months 53 88% 81% p=0.47‡
al 2003
Maffulli, et Return to Work 13.2

II 12 months 53 9.2 (SD 2.5) p= 0.05
al 2003 (weeks) (SD 3)
Maffulli, et
Return to Work II 12 months 49 100% 100% 1
al 2003
Maffulli, et
Changed Jobs II 12 months 49 1 2 p=0.51‡
al 2003
Hypersensitivity
Maffulli, et
of surgical II 10-12 wks 53 15.38% 18.51% p= 0.76‡
al 2003
wounds
Maffulli, et Hypertrophic
II 10-12 weeks 53 3.84% 0% p= 0.15‡
al 2003 Scar
134 v1.0 12.04.09

Results
Cetti, et
Abnormal Not p=
al. II 60 3.3 16.7
Sensibility Reported 0.066‡
1994
Cetti, et
Not p=
al. Keloid Scar II 60 10 23.3
Reported 0.157‡
1994
Deep p=
Mortensen II 6 weeks 3% 0%
Infection 0.154‡
p=
Mortensen Failed Repair II 6 weeks 3% 7%
0.52‡
Minor Wound p=
Costa II Varying Tie 23% 20%
Complications 0.79‡
Kangas, et
p=
al Re-rupture II 5 months 4% 8%
0.545‡
2002
Time in
Costa, et
weeks taken Time p=
al II 48 22 26
to return to measurement 0.593‡
2005
work.
EuroQoL -
Costa, et p=
Health II 10 weeks 48 75 (IQR 70-85) 75 (IQR 65-80)
al 2006 0.854
Score‡‡
EuroQoL -
Costa, et p=
Health II 6months 48 85 (IQR 80-90) 81 (IQR 75-95)
al 2006 0.956
Score‡‡
EuroQoL -
Costa, et p=
Health II 12 months 48 84 (IQR 75-95) 90 (IQR 85-95)
al 2006 .138
Score‡‡
E5D
Costa, et p=
(Dimension of II 10 weeks 48 0.69 (IQR 0.6-0.9) 0.69 (IQR 0.6-0.7)
al 2006 0.450
Health Score)
E5D
Costa, et p=
(Dimension of II 6months 48 0.8 (IQR 0.7-1.0) 0.8 (IQR 0.8-1.0)
al 2006 0.956
Health Score)
E5D
Costa, et p=
(Dimension of II 12 months 48 1 (IQR 0.9-1.0) 1(IQR 0.8-1.0)
al 2006 0.146
Health Score)
135 v1.0 12.04.09

RECOMMENDATION 13
We are unable to recommend for or against post-operative physiotherapy for patients
with acute Achilles tendon rupture.
potential harm.

Rationale:
A systematic review did not identify any studies that met the inclusion criteria.
We searched for any studies addressing post operative physical therapy including
supervised and unsupervised physical therapy. The only studies that we identified did not
specifically study whether physical therapy was effective. Therefore, it is not possible to
draw evidence-based conclusions for this recommendation.
SUMMARY OF EVIDENCE
Table 134. Post Operative Physiotherapy Regiments
Post
Author LOE Treatment N PT Regimen
Treatment
Cast followed
15 by walking
Percutaneous Both groups received same PT at 8
Majewski III cast
Repair weeks
Combination
88
splint and shoe
Mini-Open Functional "Active physiotherapy programme"
Calder IV 46
Repair Brace at 2 weeks
Cast (5) All had supervised PT. Authors do
Troop IV Open Repair 13
Splint (8) not report details of PT regimen.
All patients began supervised active
ankle dorsiflexion at 1 week. Neutral
Cast followed
position of the ankle at 2 weeks.
Saw IV Open Repair 19 by walking
Active non-weight bearing exercises
boot
at 6 weeks. Normal walking allowed
at 8 weeks.
136 v1.0 12.04.09

Post
Author LOE Treatment N PT Regimen
Treatment
Immediate free ankle joint
Operative Mobile plaster
Moberg IV 17 movement. Free weightbearing and
Repair cast
mobilization at 6 weeks.
Dorsal rigid Both groups performed "standard
II Open Repair 25 splint at 6 rehabilitation program;" Authors do
weeks not specify details of PT program
Kangas
Both groups performed "standard
II Open Repair 25 Plaster splint rehabilitation program;" Authors do
not specify details of PT program
EXCLUDED ARTICLES
Postoperative rehabilitation after percutaneous Achilles
Majewski Does not answer the
tendon repair: Early functional therapy versus cast
M, et al recommendation
immobilization
Calder JD, Early, active rehabilitation following mini-open repair of Does not answer the
et al. Achilles tendon rupture: a prospective study recommendation
Troop RL, Does not answer the
Early motion after repair of Achilles tendon ruptures
et al. recommendation
Saw Y, et Early mobilization after operative repair of ruptured Does not answer the
al. Achilles tendon recommendation
Surgically repaired Achilles tendon ruptures with
Moberg A, postoperative mobile ankle cast: A 12-month follow-up Does not answer the
et al. study with an isokinetic and a dynamic muscle function recommendation
test
Kangas J, et Achilles tendon elongation after rupture repair: a Does not answer the
al. randomized comparison of 2 postoperative regimens recommendation
137 v1.0 12.04.09

RECOMMENDATION 14
In patients with acute Achilles tendon rupture, irrespective of treatment type, we are
unable to recommend a specific time at which patients can return to activities of daily
living.
potential harm.

Rationale:
A systematic review identified 18 studies that reported on return to low impact activities.
Our meta-analysis suggested the results of these studies were very different from each
other and this is confirmed by examining their individual results (See supporting
evidence below).
Eighteen studies5, 46, 47, 48, 49, 50, 20,41, 51, 30,21,52,53, 25,48, 19, 40 are included that report data on
return to low impact activity. We have tabled the mean length of time to return to
activity and the percent of patients able to return after either non-operative or operative
treatments (see Table 136 through Table 143). We attempted meta-analysis for the
following patient groups and outcomes: mean time for non-operative patients to return to
work (I^2 95%), mean time for operative patients to return to work (I^2 >90%), and the
percent of operative patients able to return to work at three months (I^2 at 3 months >75%).
The results of these studies are so different from each other, as demonstrated by the high
heterogeneity, that it is difficult to draw any conclusions about the time to return to
recreational or athletic activity. There were too few studies included for each outcome to
investigate the reasons for heterogeneity.
SUMMARY OF EVIDENCE
Table 136. Non-Operative treatment - Percent of patients able to return to work
Duration % of
(months) Patients
immediate weight
Costa, et al.
IV bearing 22 Return to work 12 59%
2006
mobilization
Costa, et al. plaster cast
IV 26 Return to work 12 65%
2006 immobilization
Hufner, et al. IV cast and boot 125 Return to work 0.6 45%
138 v1.0 12.04.09

2006
Table 137. Non-Operative Treatment -Percent of patients able to return to ADL

Duration % of
(months) Patients
immediate weight
Costa, et al. Return to normal
IV bearing 22 12 73%
2006 walking
mobilization
Costa, et al. plaster cast Return to normal
IV 26 12 85%
2006 immobilization walking
Table 138. Operative Treatment - Percent of patients returning to ADL

Duration
Author LOE Treatment N Outcome %
(months)
Scarfi, et
IV percutaneous repair 20 Return to ADL 2 100%
al. 2002
Tang, et arthroscopically assisted
IV 20 Resume walking 3 100%
al. 2007 percutaneous
open end-to-end
Costa, et Return to normal
IV (immediate weight 23 12 96%
al. 2006 walking
bearing mobilisation)
Costa, et open end-to-end (plaster Return to normal
IV 25 12 100%
al. 2006 cast immobilisation) walking
open end-to-end
Costa, et Return to stair
IV (immediate weight 23 12 96%
al. 2006 climbing
Costa, et open end-to-end (plaster Return to stair
IV 25 12 96%
al. 2006 cast immobilisation) climbing (months)
139 v1.0 12.04.09

Table 139. Operative Treatment - Percent of patients able to return to work
Duration
(months)
Kiviluoto,
et al. IV open repair 70 Return to work 1-3 70%
1985
Hogsaa, Return to work -
et al. IV open repair 68 same employment 1.5-3 35%
1990 (weeks)
Moller, et end-to-end suture w/o Return to light,

IV 32 1 100%
al. 2001 augmentation mobile work
Moller, et end-to-end suture w/o Return to sedentary

IV 13 1 100%
al. 2001 augmentation work

et al. IV open repair 68 same employment <1 29%
1990 (weeks)
Suchak,
et al. IV open repair 103 Return to work 1.7 65%
2008
Jung, et
IV limited open 27 Return to work 2 100%
al. 2008
et al. IV open repair 68 same employment >3 15%
1990 (weeks)
Suchak,
et al. IV open repair 103 Return to work 3 82%
2011
Moller, et end-to-end suture w/o Return to heavy
IV 14 3.5 100%
Kuskucu,
Return to daily
et al. IV fibrin sealant 32 6 97%
work
2005
et al. IV open repair 68 same employment <6 18%
1990 (weeks)
Suchak,
et al. IV open repair 103 Return to work 6 97%
2008
Lansdaal,
Return to work -
et al. IV minimally-invasive 150 12 98%
same work
2007
140 v1.0 12.04.09

Duration
(months)
open end-to-end
Costa, et
IV (immediate weight 23 Return to work 12 87%
al. 2006
Costa, et open end-to-end (plaster
IV 25 Return to work 12 100%
al. 2006 cast immobilisation)
Maffulli,
open repair (non-weight Return to work -
et al. IV 26 12 92%
bearing) same job
2003
Maffulli,
open repair (non-weight
et al. IV 26 Return to work 12 100%
bearing)
2003
Maffulli,
open repair (weight Return to work -
et al. IV 23 12 96%
bearing) same job
2003
Maffulli,
open repair (weight
et al. IV 23 Return to work 12 100%
bearing)
2003
141 v1.0 12.04.09

Table 140. Non-Operative Treatment - Mean time until return to work
Author LOE Treatment N Outcome Duration (weeks)
Metz, et al.
IV functional brace 33 Return to work 15.4 (SD 16.42)
2008
Costa, et al. immediate weight
IV 22 Return to work 1 (95% CI 1-13) ‡
2006 bearing mobilisation
Costa, et al. immediate weight Return to normal
IV 22 18 (95% CI 12-22) ‡
2006 bearing mobilisation walking
Moller, et al. Below the knee plaster
IV 53 Return to work 10.48 (SD 8.07)
2001 cast
Wallace, et al.
IV cast 122 Return to work 2.36 (SD 1.19)
2004
Cetti, et al.
IV below-knee plaster cast 55 Return to work 8 (SD 3.6)
1993
Costa, et al. plaster cast
IV 26 Return to work 10 (95% CI 2-22) ‡
2006 immobilisation
Moller, et al. Below the knee plaster Return to light,
IV 22 9.6 (SD 9.4)
2001 cast mobile work
Moller, et al. Below the knee plaster Return to sedentary
IV 22 4.7 (SD7.8)
2001 cast work
IV 26 18 (95% CI 18-22) ‡
2006 immobilisation walking
Table 141. Non-Operative Treatment - Mean time until return to walking

Author LOE Treatment N Outcome Duration (weeks)
Costa, et al. immediate weight Return to normal
IV 22 18 (95% CI 12-22) ‡
2006 bearing mobilisation walking
IV 26 18 (95% CI 18-22) ‡
2006 immobilisation walking
142 v1.0 12.04.09

Table 142. Operative Treatment - Mean time to return to ADL
Author LOE Treatment N Outcome Duration (Weeks)
open end-to-end
Costa, et al. Return to normal 12.5 (95% CI 10-
IV (immediate weight 23
2006 walking 18) ‡
Costa, et al. open end-to-end (plaster Return to normal 18 (95% CI 18-22)
IV 25
2006 cast immobilisation) walking ‡
Maffulli, et open repair (non-weight 5.5 (SD 2.2; range
IV 27 Walk w/o crutches
al. 2003 bearing) 4.6-8.1)
Maffulli, et open repair (weight 2.5 (SD 0.4; range
IV 26 Walk w/o crutches
al. 2003 bearing) 1.2-3.1)
open end-to-end
Costa, et al. Return to stair 13 (95% CI 10-18)
IV (immediate weight 23
2006 climbing ‡
Costa, et al. open end-to-end (plaster Return to stair 22 (95% CI 18-22)
IV 25
2006 cast immobilisation) climbing ‡
Calder, et
IV percutaneous repair 25 Return to driving 4.14 (range .7-9)
al. 2006
143 v1.0 12.04.09

Table 143. Operative Treatment - Mean time until return to work
Author LOE Treatment N Outcome Duration (Weeks)
Moller, et end-to-end suture w/o Return to heavy
IV 14 14.6 (SD 7.5)
Coutts, et Return to work -
IV open repair 15 11.1 (range 8-24)
al. 2002 manual
Moller, et end-to-end suture w/o Return to light,
IV 32 5.1 (SD 5.4)
al. 2001 augmentation mobile work
Moller, et end-to-end suture w/o Return to sedentary
IV 13 4.4(SD 5.2)
Moller, et end-to-end suture w/o
IV 59 Return to work 7.8(SD 68.4)
al. 2001 augmentation
Cetti, et al.
IV end-to-end suture 56 Return to work 6.2 (SD 2.15)
1993
Metz, et al.
IV minimally-invasive 40 Return to work 8.4 (SD 11.71)
2008
Lansdaal, 15 4 (range .14-52.57)
IV minimally-invasive Return to work
et al. 2007 0 ‡
mini-open repair w/
Calder, et
IV early active 46 Return to work 3.12 (range .57-11)
al. 2005
rehabilitation
open end-to-end
Costa, et al.
IV (immediate weight 23 Return to work 8 (95% CI 2-13) ‡
2006
open end-to-end
Costa, et al.
IV (plaster cast 25 Return to work 4 (95% CI 1-13) ‡
2006
immobilisation)
Calder, et
IV percutaneous repair 25 Return to work 2.7 (range .85-11)
al. 2006
Majewski,
IV percutaneous w/ shoe 14 Return to work 5.2 (range .7-18.85)
et al. 2008
Wagnon, et percutaneous repair Return to work
IV 22 1.07
al. 2005 (Webb-Bannister) (months)
Doral, et al. endoscopy assisted
IV 62 Return to work 11.7 (range 10-13)
2009 percutaneous
144 v1.0 12.04.09

EXCLUDED ARTICLES
Author Title Reason for Exclusion
Costa ML;Shepstone Immediate full-weight bearing
Less than 80% follow
L;Darrah C;Marshall mobilisation for repaired Achilles
up
T;Donell ST; tendon ruptures: a pilot study
Isokinetic strength and endurance
Goren D;Ayalon No patient oriented
after percutaneous and open surgical
M;Nyska M; outcome
repair of Achilles tendon ruptures
van der Linden-van der Results of surgical versus non-
Zwaag HM;Nelissen surgical treatment of Achilles tendon Not 80% follow
RG;Sintenie JB; rupture
A combined open and percutaneous
Not 80% time follow
Kakiuchi M; technique for repair of tendo Achilles.
up
Comparison with open repair
Hufner TM;Brandes
Long-term results after functional
DB;Thermann H;Richter Not best available
nonoperative treatment of Achilles
M;Knobloch K;Krettek evidence
tendon rupture
C;
Roberts C;Rosenblum Team physician #6. Surgical Not best available
S;Uhl R;Fetto J; treatment of Achilles tendon rupture evidence
Early motion of the ankle after
operative treatment of a rupture of the
Mortensen HM;Skov Not best available
Achilles tendon. A prospective,
O;Jensen PE; evidence
randomized clinical and radiographic
study
Is percutaneous repair of the Achilles
Maes R;Copin Not best available
tendon a safe technique? A study of
G;Averous C; evidence
124 cases
Percutaneous versus open repair of
Cretnik A;Kosanovic Not best available
the ruptured Achilles tendon: a
M;Smrkolj V; evidence
comparative study
Current concepts review: acute Not best available
Chiodo CP;Wilson MG;
ruptures of the Achilles tendon evidence
Fernandez-Fairen Augmented repair of Achilles tendon Not best available
M;Gimeno C; ruptures evidence
The Webb-Bannister percutaneous
technique for acute Achilles' tendon Not best available
Wagnon R;Akayi M;
ruptures: a functional and MRI evidence
assessment
Percutaneous repair of the Achilles Not best available
Martinelli B;
tendon in athletes evidence
Limited open repair of ruptured
Park HG;Moon Not best available
Achilles tendons with Bunnel-type
DH;Yoon JM; evidence
sutures
Non-operative treatment of Achilles Not best available
Edna TH;
tendon ruptures evidence
145 v1.0 12.04.09

Author Title Reason for Exclusion
Surgical treatment of 102 tendo
Not best available
Jessing P;Hansen E; achillis ruptures-- suture or
evidence
tenontoplasty?
Closed treatment of Achilles tendon Not best available
Keller J;Rasmussen TB;
rupture evidence
Majewski M;Rohrbach Avoiding sural nerve injuries during Not best available
M;Czaja S;Ochsner P; percutaneous Achilles tendon repair evidence
Repair of acute rupture of the
Jennings AG;Sefton Achilles tendon: a new technique Not best available
GK;Newman RJ; using polyester tape without external evidence
splintage
The influence of early weight bearing
Suchak AA;Bostick
compared with non-weight bearing Does not report
GP;Beaupre LA;Durand
after surgical repair of the Achilles relevant outcomes
DC;Jomha NM;
tendon
Residual functional problems after
Pendleton H;Resch
non-operative treatment of Achilles Retrospective
S;Stenstrom A;Astrom I;
tendon rupture
Nonoperative treatment of acute
Weber M;Niemann rupture of the Achilles tendon: results
Retrospective
M;Lanz R;Muller T; of a new protocol and comparison
with operative treatment
146 v1.0 12.04.09

STUDY QUALITY
Table 145. Patient return to activities of daily living
Same Treatment
Equal Follow up
Same Outcomes
●= yes ○= no x= not reported
Follow up 80
Consecutive
Time
Author Outcome Measure N LoE
Return to previous sporting

Calder, et al. 2005 46 IV ● ● ● ● x
activities
Calder, et al. 2006 25 IV ● ● ● ● x
activities
Cetti, et al. 1993 Return to sports - same level 47 IV ● ● ● ● ●
Chillemi, et al. Return to sports - frequent‡‡

14 IV ● ● ● ● ●
2002 (months)
Costa, et al. 2006 Return to sports 23 IV x ● ● ● ●
Return to stair climbing x
Costa, et al. 2006 26 IV ● ● ● ●
(weeks)
Return to stair climbing x
Costa, et al. 2006 22 IV ● ● ● ●
(weeks)
Costa, et al. 2006 Return to sports (weeks) 23 IV x ● ● ● ●
Return to pre-injury level of x
Coutts, et al. 2002 22 IV ● ● ● ●
sporting participation
Coutts, et al. 2002 Return to sports 20 IV x ● ● ● ●
Doral, et al. 2009 62 IV ● ● ● ● ●
activities
Doral, et al. 2009 Rehabilitation training 62 IV ● ● ● ● ●
Return to previous activity
Fortis, et al. 2008 20 IV x ● ● ● ●
levels
Garabito, et al. Return to sports - pre-injury
54 IV ● ● ● ● ●
2004 level
Giannini, et al. Return to pre-injury level of
15 IV ● ● ● ● ●
1994 activity
Resumption of recreational
Hogsaa, et al. 1990 63 IV ● ● ● ● ●
activities
Hogsaa, et al. 1990 63 IV ● ● ● ● x
activities
Hogsaa, et al. 1990 63 IV ● ● ● ● ●
activities
147 v1.0 12.04.09

Same Treatment
Equal Follow up
Same Outcomes
Follow up 80
Consecutive
Time
Jung, et al. 2008 Resume light exercise 27 IV x ● ● ● ●

Jung, et al. 2008 27 IV x ● ● ● ●
activities
Kuskucu, et al. Return to amateur sports
32 IV x ● ● ● ●
2005 activity
Lansdaal, et al.
Return to sports - same level 152 IV x ● ● ● ●
2007
Lansdaal, et al.
Return to sports 152 IV x ● ● ● ●
2007
Maffulli, et al.
Activity limitations - none 27 IV ● ● ● ● ●
2003
Maffulli, et al.
2003
Maffulli, et al.
Return to sports 19 IV ● ● ● ● ●
2003
Maffulli, et al.
2003
Maffulli, et al.
2003
Maffulli, et al.
2003
Maffulli, et al.
2009
Moller, et al. 2001 Return to sports - same level 47 IV ● ● ● ● ●
Scarfi, et al. 2002 Return to sports activities 20 IV x ● ● ● ●

Solveborn, et al. Return to previous sports
16 IV ● ● ● ● ●
1994 activity w/o any difficulty
Solveborn, et al.
1994
Taglialavoro, et al.
Return to sports - complete 24 IV ● ● ● ● ●
2004
2004
Tang, et al. 2007 Return to sports level 6 IV x ● ● ● ●
Troop, et al. 1995 Resume jogging/running 13 IV ● ● ● ● ●
148 v1.0 12.04.09

Same Treatment
Equal Follow up
Same Outcomes
Follow up 80
Consecutive
Time
Uchiyama, et al.
Resume jogging (weeks) 84 IV x ● ● ● ●
2007
Uchiyama, et al. Return to sports for high-level
21 IV x ● ● ● ●
2007 athletes - original game level
Wallace, et al.
Return to sports (weeks) 101 IV ● ● ● ● x
2004
149 v1.0 12.04.09

RECOMMENDATION 15
In patients who participate in sports it is an option to return them to sports within 3-6
months after operative treatment for acute Achilles tendon rupture.
another.

Rationale:
A systematic review identified 23 level IV studies providing data on return to sports after
operative treatment. Two studies54, 51 reported return to jogging at three months. One
study 47 reported return to sport at four months. Five studies55, 32,54, 51,56 reported that
83%-100% of patient returned to sports at six months. Ten studies19,57, 58, 53, 56, 54 , 40, 5, 21,
20
reported that 32-100% of patients returned to sports at 12 months or more.
Twenty-three21,5,20, 19, 50,39, 59,54,51,47,32,57, 58,38,25, 60,53,28,30,34, 55, 40studies are included that
report data on return to athletic activity. We have tabled the percent of patients able to
return to recreational and sports activities after operative treatments and the mean length
of time to return to athletic activity (see Table 146 through Table 148 ). We attempted
meta-analysis for the following patient groups and outcomes: percent operative patients
able to return to activity at ≥ 12 months (I2>80%) (see Table 146 ) percent of operative
patients able to return to sports at 6 and at 12 months (I2>90%) (see Table 147), and mean
time for operative patients to return to sports (I2>95%) (see Table 148). The results of
these studies are so different from each other, as demonstrated by the high heterogeneity,
that it is difficult to draw any conclusions about the time to return to recreational or
athletic activity. There were too few studies included for each outcome to investigate the
reasons for heterogeneity. The remainder of outcomes and patient groups do not include
enough studies to attempt meta-analysis.
150 v1.0 12.04.09

SUMMARY OF EVIDENCE
Table 146. Operative Treatment - Return to Recreational Activity
Author LOE Treatment N Outcome Duration (months) %

Hogsaa, et al. Resumption of recreational
IV open repair 63 6-12 30%
1990 activities
IV open repair 63 3-6 33%
1990 activities
IV open repair 63 <3 10%
1990 activities
Maffulli, et al. open repair (non-
IV 27 Activity limitations - none 12 93%
2003 weight bearing)
Maffulli, et al. open repair
IV 26 Activity limitations - none 12 92%
2003 (weight bearing)
IV open repair 63 > 12 51%
1990 activities
adjunctive
Giannini, et al. Return to pre-injury level
IV augmentation 15 18 100%
1994 of activity
(synthetic graft)
endoscopically
Fortis, et al. Return to previous activity
IV assisted 20 30 100%
2008 levels
percutaneous
Table 147. Operative Treatment - Return to sports

Duration
Author LOE Treatment N Outcome (months) %
Troop, et al. end-to-end w/
IV 13 Resume jogging/running 3 92%
1995 early motion
Jung, et al.
IV limited open 27 Resume light exercise 3 100%
2008
Troop, et al. end-to-end w/
IV 13 Resume jogging/running 3 92%
1995 early motion
Scarfi, et al. percutaneous
IV 20 Return to sports activities 4 100%
2002 repair
IV fibrin sealant 32 6 97%
2005 activity
adjunctive
Aktas, et al. Return to sports - pre-injury
2007 level of activity
(autograft)
arthroscopically
Tang, et al.
IV assisted 6 Return to sports level 6 83%
2007
percutaneous
Jung, et al. Return to previous sporting
IV limited open 27 6 100%
2008 activities
151 v1.0 12.04.09

Duration
Author LOE Treatment N Outcome (months) %
mini-open repair
Calder, et al. Return to previous sporting
IV w/ early active 46 6 100%
2005 activities
rehabilitation
Aktas, et al. Return to sports - pre-injury
IV open repair 14 6 89%
2008 level of activity
Calder, et al. percutaneous Return to previous sporting
IV 25 6 100%
2006 repair activities
Cetti, et al.
IV end-to-end suture 52 Return to sports - same level 12 62%
1993
end-to-end suture
Solveborn, et w/ below-knee Return to previous sports
IV 16 12 81%
al. 1994 transport splint activity w/o any difficulty
cast
end-to-end suture
Solveborn, et w/ below-knee
IV 16 Return to sports 12 100%
al. 1994 transport splint
cast
Moller, et al. end-to-end suture
IV 47 Return to sports - same level 12 54%
2001 w/o augmentation
Metz, et al. minimally-
2008 invasive
Lansdaal, et al. minimally-
IV 152 Return to sports - same level 12 64%
2007 invasive
open end-to-end
Costa, et al. (immediate
2006 weight bearing
mobilisation)
open end-to-end
Costa, et al.
IV (plaster cast 25 Return to sports 12 68%
2006
immobilisation)
Maffulli, et al. open repair (non-
2003 weight bearing)
Maffulli, et al. open repair
2003 (weight bearing)
adjunctive
Taglialavoro,
IV augmentation 24 Return to sports - complete 42 38%
et al. 2004
(autograft)
Taglialavoro,
IV open repair 22 Return to sports - complete 42 32%
et al. 2004
endoscopy
Doral, et al. Return to previous sporting
IV assisted 62 46 95%
2009 activities
percutaneous
adjunctive
2004 level
(autograft)
152 v1.0 12.04.09

Table 148. Operative Treatment - Mean time to return to athletic activity
Duration
(months)
Doral, et al. endoscopy assisted Rehabilitation
IV 62 11.7 (SD 0.75)
2009 percutaneous training
Troop, et al. end-to-end w/ early Resume
IV 13 3 (SD 0.75)
1995 motion jogging/running
Lansdaal, et
IV minimally-invasive 152 Return to sports 7.1 (SD 3.8)
al. 2007
open end-to-end
Costa, et al. (immediate weight Return to sports 11.14 (95% CI
IV 23
2006 bearing (weeks) 5-17) ‡
mobilisation)
Uchiyama, et Resume jogging
IV open repair 84 3.5(SD .9)
al. 2007 (weeks)
Return to pre-injury
Coutts, et al.
IV open repair 22 level of sporting 40.8 (SD 25.2)
2002
participation
Coutts, et al.
IV open repair 20 Return to sports 4.5 (SD 2.14)
2002
Return to sports for
Uchiyama, et
IV open repair 21 high-level athletes - 5 (SD .35)
al. 2007
original game level
Maffulli, et open repair (non-
IV 19 Return to sports 6 (SD 3)
al. 2003 weight bearing)
Maffulli, et open repair (weight
IV 19 Return to sports 5.1 (SD 2.8)
al. 2003 bearing)
Gorschewsky, Return to original
IV percutaneous repair 66 5.46 (SD 1.5)
et al. 2004 sport
Maffulli, et
IV percutaneous repair 24 Return to sports 88 (SD 14.5)
al. 2009
Chillemi, et Return to sports -
IV percutaneous repair 14 8 (SD 1.5)
al. 2002 frequent‡ (months)
EXCLUDED ARTICLES
Reason for
Author Title
Exclusion
Suchak AA;Bostick The influence of early weight bearing compared
No relevant
GP;Beaupre LA;Durand with non-weight bearing after surgical repair of the
outcomes
DC;Jomha NM; Achilles tendon
Majewski M;Rohrbach Avoiding sural nerve injuries during percutaneous Not best available
M;Czaja S;Ochsner P; Achilles tendon repair evidence
153 v1.0 12.04.09

Reason for
Author Title
Exclusion
The Webb-Bannister percutaneous technique for Time of return to
Wagnon R;Akayi M; acute Achilles' tendon ruptures: a functional and sports not
MRI assessment reported
Isokinetic strength and endurance after
Goren D;Ayalon M;Nyska No patient-
percutaneous and open surgical repair of Achilles
M; oriented outcome
tendon ruptures
Current concepts review: acute ruptures of the Not best available
Achilles tendon evidence
Cretnik A;Kosanovic Percutaneous versus open repair of the ruptured Not best available
M;Smrkolj V; Achilles tendon: a comparative study evidence
Repair of acute rupture of the Achilles tendon: a
Jennings AG;Sefton Not best available
new technique using polyester tape without external
GK;Newman RJ; evidence
splintage
van der Linden-van der
Results of surgical versus non-surgical treatment of Less than 80%
Zwaag HM;Nelissen
Achilles tendon rupture follow up
RG;Sintenie JB;
Costa ML;Shepstone
Immediate full-weight bearing mobilisation for Less than 80%
L;Darrah C;Marshall
repaired Achilles tendon ruptures: a pilot study follow up
T;Donell ST;
Early motion of the ankle after operative treatment
Mortensen HM;Skov Not best available
of a rupture of the Achilles tendon. A prospective,
O;Jensen PE; evidence
randomized clinical and radiographic study
A combined open and percutaneous technique for
Less than 80%
Kakiuchi M; repair of tendo Achillis. Comparison with open
follow up
repair
Roberts C;Rosenblum S;Uhl Team physician #6. Surgical treatment of Achilles Not best available
R;Fetto J; tendon rupture evidence
Not best available
Keller J;Rasmussen TB; Closed treatment of Achilles tendon rupture
evidence
Percutaneous repair of the Achilles tendon in Not best available
Martinelli B;
athletes evidence
Fernandez-Fairen Not best available
Augmented repair of Achilles tendon ruptures
M;Gimeno C; evidence
Park HG;Moon DH;Yoon Limited open repair of ruptured Achilles tendons Not best available
JM; with Bunnel-type sutures evidence
154 v1.0 12.04.09

STUDY QUALITY
Table 150. Return to sports
Equal Follow up Time

Same Treatment
Same Outcomes
Follow up 80
Consecutive
Return to sports - pre-injury

Aktas, et al. 2007 16 IV ● ● ● ● ●
level of activity
Return to sports - pre-injury
Aktas, et al. 2008 14 IV ● ● ● ● ●
level of activity
Calder, et al. 2005 46 IV ● ● ● ● x
activities
Calder, et al. 2006 25 IV ● ● ● ● x
activities
Chillemi, et al. Return to sports - frequent‡

14 IV ● ● ● ● ●
2002 (months)
Return to stair climbing

Costa, et al. 2006 26 IV x ● ● ● ●
(weeks)
Costa, et al. 2006 22 IV x ● ● ● ●
(weeks)
Costa, et al. 2006 Return to sports (weeks) 23 IV x ● ● ● ●
Return to pre-injury level of

Coutts, et al. 2002 22 IV x ● ● ● ●
sporting participation
Coutts, et al. 2002 Return to sports 20 IV x ● ● ● ●

Doral, et al. 2009 62 IV ● ● ● ● ●
activities
Doral, et al. 2009 Rehabilitation training 62 IV ● ● ● ● ●
155 v1.0 12.04.09

Same Treatment
Same Outcomes
Follow up 80
Consecutive
Return to previous activity

Fortis, et al. 2008 20 IV x ● ● ● ●
levels
54 IV ● ● ● ● ●
2004 level
Giannini, et al. Return to pre-injury level of
15 IV ● ● ● ● ●
1994 activity
Hogsaa, et al. 1990 63 IV ● ● ● ● ●
activities
Hogsaa, et al. 1990 63 IV ● ● ● ● ●
activities
Hogsaa, et al. 1990 63 IV ● ● ● ● ●
activities
Hogsaa, et al. 1990 63 IV ● ● ● ● ●
activities
Jung, et al. 2008 Resume light exercise 27 IV x ● ● ● ●

Jung, et al. 2008 27 IV x ● ● ● ●
activities
32 IV ● ● ● ● ●
2005 activity
Lansdaal, et al.
Return to sports - same level 152 IV x ● ● ● ●
2007
Lansdaal, et al.
Return to sports 152 IV x ● ● ● ●
2007
Re-rupture 33 IV ● ● ● ● ●
Metz, et al. 2008
Absence from work 33 IV ● ● ● ● ●
Metz, et al. 2008
Return to sport 33 IV ● ● ● ● ●
Metz, et al. 2008
Pain - VAS 33 IV ● ● ● ● ●
Metz, et al. 2008
Pain - VAS 33 IV ● ● ● ● ●
Metz, et al. 2008
156 v1.0 12.04.09

Same Treatment
Same Outcomes
Follow up 80
Consecutive
Pain - VAS 33 IV ● ● ● ● ●
Metz, et al. 2008
Satisfaction - VAS 33 IV ● ● ● ● ●
Metz, et al. 2008
Metz, et al. 2008
Metz, et al. 2008
Return to sedentary work
59 IV ● ● ● ● ●
Metz, et al. 2008 (days)
Moller, et al. 2001 59 IV ● ● ● ● ●
(days)
Moller, et al. 2001 Return to work (days) 59 IV ● ● ● ● ●
Moller, et al. 2001 Return to heavy work (days) 59 IV ● ● ● ● ●
Moller, et al. 2001 Return to sports - stopped 59 IV ● ● ● ● ●

Moller, et al. 2001 59 IV ● ● ● ● ●
(days)
Moller, et al. 2001 59 IV ● ● ● ● ●
(days)
Scarfi, et al. 2002 Return to sports activities 20 IV x ● ● ● ●
Solveborn, et al. Return to previous sports

16 IV ● ● ● ● ●
1994 activity w/o any difficulty
Solveborn, et al.
1994
2004
2004
157 v1.0 12.04.09

Same Treatment
Same Outcomes
Follow up 80
Consecutive
Uchiyama, et al. Return to sports for high-level

21 IV ● ● ● ● ●
2007 athletes - original game level
Cetti, et al. 1993 Return to work (weeks) 56 IV ● ● ● ● ●
Return to sports - diminished

Cetti, et al. 1993 56 IV ● ● ● ● ●
level
Cetti, et al. 1993 Return to sports - stopped 56 IV ● ● ● ● ●
Cetti, et al. 1993 56 IV ● ● ● ● ●
movement
Cetti, et al. 1993 56 IV ● ● ● ● ●
movement
Cetti, et al. 1993 Function-Abnormal gait 56 IV ● ● ● ● ●
Cetti, et al. 1993 Function-Abnormal run 56 IV ● ● ● ● ●
Cetti, et al. 1993 Function-Abnormal toe stand 56 IV ● ● ● ● ●
Chillemi, et al. Able to walk without

38 IV ● ● ● ● ●
2002 limitation
Return to sports activity
Chillemi, et al.
(frequent participant 2-3 times 14 IV ● ● ● ● ●
2002
per week)
158 v1.0 12.04.09

Same Treatment
Same Outcomes
Follow up 80
Consecutive
Return to pre-injury sporting

Coutts, et al 2002 22 IV x ● ● ● ●
level
Maffulli, et al.
2003
Maffulli, et al.
2003
Maffulli, et al.
2003
Maffulli, et al.
2003
Maffulli, et al.
2003
Maffulli, et al.
2003
Maffulli, et al.
2009
Tang, et al. 2007 Return to sports level 6 IV x ● ● ● ●
159 v1.0 12.04.09

RECOMMENDATION 16
In patients with acute Achilles tendon rupture treated non-operatively, we are unable to
recommend a specific time at which patients can return to athletic activity.
potential harm.

Rationale:
A systematic review identified 5 level IV studies21,5,20, 19,25 providing data on return to

sports after non-operative treatment. These studies did not provide adequate evidence to
make a recommendation for the specific time patients can return to athletic activity
following non-operative treatment for Achilles tendon rupture.
Five Level IV studies21,5,20, 19,25 that provided data on return to sports after non-operative
treatment were identified. We have tabled the percent of patients and the mean length of
time to return to athletic activity reported by the authors of these studies (see Table 151
and Table 152). The lack of studies, variation in treatments and variation in reported
outcomes makes it difficult to draw any conclusions about the time to return to athletic
activity following non-operative treatment.
SUMMARY OF EVIDENCE
Table 151. Non-Operative Treatment - Percent of patients returning to athletic
activity
Duration
(months)
Metz, et al.
IV functional brace 33 Return to sports 12 82%
2008
Costa, et al. immediate weight Return to sports
IV 18 12 56%
2006 bearing mobilisation (months)
Costa, et al. plaster cast Return to sports
IV 21 12 52%
2006 immobilisation (months)
Moller, et al. below the knee Return to sports - same
IV 38 12 54%
2001 plaster cast level (months)
Cetti, et al. below-knee plaster Return to sports-same
IV 47 12 34 %
1993 cast level
160 v1.0 12.04.09

161 v1.0 12.04.09
Table 152. Non-Operative Treatment - Mean time until patients return to athletic
activity
Duration
Author LOE Treatment N Outcome (weeks)
Wallace, et al.
IV cast 101 Return to sports (weeks) 10 (SD 4.9)
2004
plaster cast Return to stair climbing 18 (95% CI
Costa, et al. 2006 IV 26
immobilisation (weeks) 14-22) ‡
immediate weight
Return to stair climbing 17 (95% CI
Costa, et al. 2006 IV bearing 22
(weeks) 11-18) ‡
mobilisation
162 v1.0 12.04.09

EXCLUDED ARTICLES
Table 153. Excluded studies
Reason for
Author Title
Exclusion
Current concepts review: acute ruptures of the Not best available
Achilles tendon evidence
van der Linden-van der
Results of surgical versus non-surgical treatment Less than 80%
Zwaag HM;Nelissen
of Achilles tendon rupture follow up
RG;Sintenie JB;
Costa ML;Shepstone
Immediate full-weight bearing mobilisation for Less than 80%
L;Darrah C;Marshall
repaired Achilles tendon ruptures: a pilot study follow up
T;Donell ST;
Nonoperative treatment of acute rupture of the
Weber M;Niemann M;Lanz
Achilles tendon: results of a new protocol and Retrospective
R;Muller T;
comparison with operative treatment
Pendleton H;Resch Residual functional problems after non-operative
Retrospective
S;Stenstrom A;Astrom I; treatment of Achilles tendon rupture
STUDY QUALITY

Same Treatment
Same Outcomes
Follow up 80
Consecutive

Costa, et al. 2006 26 IV x ● ● ● ●
(weeks)
Costa, et al. 2006 22 IV x ● ● ● ●
(weeks)
Re-rupture 33 IV ● ● ● ● ●
Metz, et al. 2008
163 v1.0 12.04.09


Same Treatment
Same Outcomes
Follow up 80
Consecutive
Absence from work 33 IV ● ● ● ● ●

Metz, et al. 2008
Return to sport 33 IV ● ● ● ● ●
Metz, et al. 2008
Pain - VAS 33 IV ● ● ● ● ●
Metz, et al. 2008
Pain - VAS 33 IV ● ● ● ● ●
Metz, et al. 2008
Pain - VAS 33 IV ● ● ● ● ●
Metz, et al. 2008
Metz, et al. 2008
Metz, et al. 2008
Metz, et al. 2008
59 IV ● ● ● ● ●
Metz, et al. 2008 (days)
Moller, et al. 2001 59 IV ● ● ● ● ●
(days)
Moller, et al. 2001 Return to work (days) 59 IV ● ● ● ● ●
Moller, et al. 2001 Return to heavy work (days) 59 IV ● ● ● ● ●
Moller, et al. 2001 Return to sports - stopped 59 IV ● ● ● ● ●

Moller, et al. 2001 59 IV ● ● ● ● ●
(days)
Moller, et al. 2001 59 IV ● ● ● ● ●
(days)
Wallace, et al.
Return to sports (weeks) 101 IV x ● ● ● ●
2004
164 v1.0 12.04.09


Same Treatment
Same Outcomes
Follow up 80
Consecutive
Cetti, et al. 1993 Return to sports - stopped 56 IV ● ● ● ● ●
Cetti, et al. 1993 56 IV ● ● ● ● ●
movement
Cetti, et al. 1993 56 IV ● ● ● ● ●
movement
165 v1.0 12.04.09

FUTURE RESEARCH
While the current guideline is instructive in many ways, it also demonstrates a substantial
need for future research. Wherever the strength of a specific Recommendation is limited
or inconclusive, there exists a need for well-designed studies and high-level evidence.
As such, the most obvious need is for further, high-level investigations into the
fundamental question of whether or not surgical management is superior to non-operative
management of acute Achilles ruptures. There are hundreds of studies that are centered
on this question, but too few are high-level randomized control trials.
Beyond this, there are several other areas of needed research. Does the clinician
routinely need MRI or an ultrasound for the diagnosis of an Achilles rupture? Probably
not. However, there are no high-level studies to help answer this question. For non-
operative treatment, low-level evidence supports the use of immediate functional bracing,
but again more randomized trials are necessary. Post-operatively, is DVT prophylaxis
necessary? Does the patient really need physical therapy? These are very important
questions that so far remain unanswered.
166 v1.0 12.04.09

IV. APPENDIXES
167 v1.0 12.04.09

APPENDIX I
WORK GROUP Guidelines and Technology Oversight
Chair:
Christopher P Chiodo MD, Chair William C. Watters, III, MD
Brigham Orthopedic Associates 6624 Fannin #2600
75 Francis Street Houston, TX 77030
Boston MA 02115
Guidelines and Technology Oversight Vice-
Mark Glazebrook MD, Vice-Chair Chair:
Queen Elizabeth Health Sciences Center Michael J. Goldberg, MD
Halifax Infirmary Suite 4867 Department of Orthopaedics
1796 Summer Street Seattle Children’s Hospital
Halifax NS B3H 3A7 Canada 4800 Sand Point Way NE
Seattle, WA 98105
Eric Michael Bluman MD PhD
Madigan Army Medical Center Evidence Based Practice Committee Chair:
ATTN: MCHJ-SOP (Ortho Clinic) Michael Keith, MD
9040 A Reid Street 2500 Metro Health Drive
Tacoma WA 98431-1100 Cleveland, OH 44109-1900
Bruce E Cohen MD AAOS Staff:
1783 Sterling Road Robert H. Haralson III, MD, MBA
Charlotte NC 28209 AAOS Medical Director
6300 N River Road
John E Femino MD Rosemont, IL 60018
Department of Orthopedics
University of Iowa Hospital and Clinics Charles M. Turkelson, PhD
JPP 01022 Director of Research and Scientific Affairs
200 Hawkins Drive
Iowa City IA 52242 Janet L. Wies MPH
AAOS Clinical Practice Guideline Mgr
Eric Giza MD
UC Davis Dept of Orthopaedics AAOS Research Analysts
Ambulatory Care Services Bldg Laura Raymond MA - Lead Analyst
4860 Y St #3800 Sara Anderson MPH
Sacramento, CA 95817 Kevin Boyer BS
Patrick Sluka MPH
168 v1.0 12.04.09

APPENDIX II
TIME FROM RUPTURE TO TREATMENT
Table 155. Time from injury to treatment
Author Time from Injury to treatment
0-3 days, 45 patients
Maffulli, et al. 4-7 days, 14 patients
1998 8-14 days, 7 patients
Attended hospital within 3 days

Moller, et al
Non-op group treated immediately
2001
Surgery performed within 2 days in 95% of cases
Metz, et al.
Within 3 days of rupture
2008
Cetti, et al
Mean 0.6 days (range 0-7 days)
1993
Twaddle, et al Presented within 10 days of injury

2007 Operated within 48 hours
1 day after injury, 25 patients

Ingvar, et al.
2-7 days after injury, 10 patients
2005
8-31 days after injury, 11 patients
Saleh, et al.
Presented within 48 hours of injury
1992
Neumayer, et al.
Less than ten days
2009
Wallace, et al.
Mean 22 hours (range 1 hour, 17.5 days)
2004
Bhattacharyya, et
al 7 days
2008
Uchiyama, et al.
Acute not defined
2007
169 v1.0 12.04.09

Lim, et al.
Presented less than 7 days
2001
Time to presentation: 24 hours, 13 patients

Coutts, et al.
4-18 weeks, 5 patients
2002
Operated on within an average of 3 days (range 24 hours -10 days) from
presentation
Aktas, et al
1.5 days (range 2-56 hours)
2007
Aktas, et al
2009
Ng et al.
within 7 days (85% treated within one day)
2006
Chellemi, et al.
Within 4 days
2002
Gigante, et al.
Acute not defined
2007
Kakiuchi, et al
Range 1-9 days
1995
Giannini, et al
6 days
1994
Taglialavoro, et al
Not Reported
2004
Suchak, et al.
Within 2 weeks of injury
2008
Maffulli, et al.
0-7 days
2003 (a)
170 v1.0 12.04.09

Maffulli, et al.
0-7 days
2003 (b)
Costa, et al.
0-7 days
2005
Mortensen, et al.
0-48 hours to presentation
1999
Cetti, et al
7-112 hours
1993
Kangas, et al
0-7 days
2002
Scarfi, et al
2 days (range 1-5 days)
2002
Hogsaa, et al Less than 3 days, 96% of patients

1990 More than 3 days, 4% of patients
Doral, et al
0-10 days
2009
Troop, et al
0-2 weeks
1995
Kuskucu, et al
Average 4 days (range, 3-8 days)
2005
Solveborn, et al.
Average 1.8 days (range, 0-5 days)
1994
Lansdaal, et al.
0-2 weeks
2007
171 v1.0 12.04.09

Garbito, et al.
Within 24 hours of injury
2004
Gorschewsky, et
al Average within 24 hours
2004
Hufner, et al.
Within one week
2006
Tang, et al
6 hours- 18 days
2007
Jung, et al Mean 5.4 days ( range 1-23 days)

2008 87% of patients were operated in less than 2 weeks
Wagnon, et al
Less than 2 weeks to presentation
2005
Aktas, et al
2009
Margetic, et al
Not Reported
2007
McComis, et al.
Not Reported
1997
Fortis, et al.
Not Reported
2008
172 v1.0 12.04.09

APPENDIX III
AAOS BODIES THAT APPROVED THIS CLINICAL PRACTICE GUIDELINE
Guidelines and Technology Oversight Committee

The AAOS Guidelines and Technology Oversight Committee (GTOC) consist of sixteen
AAOS members. The overall purpose of this Committee is to oversee the development of
the clinical practice guidelines, performance measures, health technology assessments
and utilization guidelines.
Evidence Based Practice Committee

The AAOS Evidence Based Practice Committee (EBPC) consists of ten AAOS members.
This Committee provides review, planning and oversight for all activities related to
quality improvement in orthopaedic practice, including, but not limited to evidence-based
guidelines, performance measures, and outcomes.
Council on Research, Quality Assessment, and Technology

To enhance the mission of the AAOS, the Council on Research, Quality Assessment, and
Technology promotes the most ethically and scientifically sound basic, clinical, and
translational research possible to ensure the future care for patients with musculoskeletal
disorders. The Council also serves as the primary resource to educate its members, the
public, and public policy makers regarding evidenced-based medical practice,
orthopaedic devices and biologics, regulatory pathways and standards development,
patient safety, occupational health, technology assessment, and other related areas of
importance.
The Council is comprised of the chairs of the AAOS Biological Implants, Biomedical
Engineering, Evidence Based Practice, Guidelines and Technology Oversight,
Occupational Health and Workers’ Compensation, Patient Safety, Research
Development, and US Bone and Joint Decade committees. Also on the Council are the
AAOS second vice-president, representatives of the Diversity Advisory Board, the
Women's Health Issues Advisory Board, the Board of Specialty Societies (BOS), the
Board of Councilors (BOC), the Communications Cabinet, the Orthopaedic Research
Society (ORS), the Orthopedic Research and Education Foundation (OREF), and three
members at large.
Board of Directors
The 17 member AAOS Board of Directors manages the affairs of the AAOS, sets policy,
and determines and continually reassesses the Strategic Plan.
173 v1.0 12.04.09

DOCUMENTATION OF APPROVAL
AAOS Work Group Draft Completed August 18, 2009
Peer Review Completed September 18, 2009
Public Commentary Completed November 12, 2009
AAOS Guidelines and Technology Oversight Committee December 2, 2009
AAOS Evidence Based Practice Committee December 2, 2009
AAOS Council on Research, Quality Assessment, December 2, 2009

and Technology
AAOS Board of Directors December 4, 2009
174 v1.0 12.04.09

APPENDIX IV
LITERATURE SEARCHES FOR PRIMARY STUDIES
The literature searches were performed using the following databases. The full search
strategies are listed below:
• PubMed
• EMBASE
• CINAHL
• The Cochrane Library
• The National Guidelines Clearinghouse
• TRIP Database - Guidelines
All literature searches were supplemented with manual screening of bibliographies in

publications accepted for inclusion into the evidence base. In addition, the bibliographies
of recent review articles were searched for potentially relevant citations.
PubMed was searched using the following strategy:
(("Achilles Tendon"[mh] OR Achilles[tw]) AND ((("Tendon Injuries"[mh] OR

injuries[sh] OR injur*[tiab] OR ruptur*[tiab] OR re-ruptur*[tiab] OR tears[tiab] OR
torn[tiab] OR tear[tiab]) AND (diagnosis[sh] OR diagnos*[tw] OR "Magnetic Resonance
Imaging"[mh] OR MRI[tiab] OR Ultrasonography[mh] OR sonograph*[tiab] OR
ultrasound[tiab] OR radiograph*[tiab] OR Radiography[mh] OR x-ray[tiab] OR
imaging[tiab] OR gap[tiab] OR "Thompson test"[tw] OR therapy[sh] OR treated[tiab]
OR treatment*[tiab] OR brace[tiab] OR bracing[tiab] OR cast[tiab] OR casting[tiab] OR
casts[tw] OR "Casts, Surgical"[mh] OR immobiliz*[tiab] OR surgery[tiab] OR
surgical*[tiab] OR operati*[tiab] OR repair*[tiab] OR reconstruct*[tiab] OR non-
operativ*[tiab] OR nonoperativ*[tiab] OR "weight bearing"[tiab] OR "Recovery of
Function"[mh] OR "Physical Therapy Modalities"[mh] OR physiotherapy[tiab] OR
Anticoagulants[pa])) OR ((repair*[tiab] OR surgery[tiab] OR surgery[sh] OR
surgical*[tiab] OR operati*[tiab] OR repair*[tiab] OR reconstruct*[tiab] OR post-
operative*[tiab] OR postoperative*[tiab]) AND ("Physical Therapy Modalities"[mh] OR
physiotherapy[tiab] OR brace[tiab] OR bracing[tiab] OR cast[tiab] OR casting[tiab] OR
casts[tw] OR "Casts, Surgical"[mh] OR immobiliz*[tiab] OR low-impact[tiab] OR
activity[tiab] OR activities[tiab] OR "weight bearing"[tiab] OR weight bearing[tiab] OR
"Recovery of Function"[mh])))) AND "1966"[PDat]:"2008"[PDat] AND
“1”[EDat]:”2008/12/21”[EDAT] AND English[lang] AND (human[mh] OR in
process[sb] OR publisher[sb]) NOT (comment[pt] OR editorial[pt] OR letter[pt] OR
addresses[pt] OR news[pt] OR "newspaper article"[pt] OR “historical article”[pt] OR
"case reports"[pt] OR "retrospective case study"[tw])
EMBASE was searched using the following strategy:
('Achilles tendon rupture'/de OR (('Achilles tendon'/de OR Achilles) AND ('tendon

reconstruction'/de OR ((('tendon injury'/de OR injur* OR ruptur* OR reruptur* OR tears
OR torn OR tear) AND (diagnos* OR 'nuclear magnetic resonance imaging'/exp OR mri
OR 'ultrasound'/de OR ultrasound OR sonograph* OR radiograph* OR 'radiography'/de
175 v1.0 12.04.09

OR imaging OR gap OR 'thompson test' OR treated OR treatment* OR brace OR bracing
OR cast OR casts OR 'plaster cast'/de OR 'walking aid'/de OR immobiliz* OR surgery
OR surgical* OR operati* OR repair* OR reconstruct* OR nonoperativ* OR 'weight
bearing'/de OR 'weight bearing' OR 'convalescence'/de OR 'physiotherapy'/exp OR
physiotherapy OR 'anticoagulant agent'/exp)) OR ((repair* OR surgery OR surgical* OR
operti* OR reconstruct* OR postoperative*) AND ('physiotherapy'/de OR physiotherapy
OR brace OR bracing OR case OR casting OR casts OR 'plaster cast'/de OR 'walking
aid'/de OR immobiliz* OR 'low impact' OR activity OR activities OR 'weight bearing'/de
OR 'weight bearing' OR convalescence/de)))))) AND ([article]/lim OR [conference
paper]/lim OR [review]/lim) AND [english]/lim AND [humans]/lim AND [embase]/lim
NOT [22-12-2008]/sd
CINAHL was searched using the following strategy:
MM "Achilles Tendon" or Achilles and MM "tendon injuries" or ruptur* and ( PT

“research” and LA English and PY 1966-2008 ) not (PT “editorial” or PT “letter” or PT
“case study” or MM “case studies”)
The Cochrane Library was searched using the following strategy:
Achilles AND (injur* OR ruptur* OR re-ruptur* OR tears OR torn OR tear)
The National Guidelines Clearinghouse was searched using the following strategy:
The TRIP Database - Guidelines was searched using the following strategy:
176 v1.0 12.04.09

APPENDIX V
STUDY ATTRITION FLOWCHART
4247 citations identified
by literature search
1766 citations excluded
2481 abstracts screened

for inclusion
2200 abstracts excluded
281 articles recalled for

full text review
235 articles excluded
46 articles included
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APPENDIX VI
DATA EXTRACTION ELEMENTS
The data elements below were extracted into electronic forms in Microsoft® Access and
Microsoft® Excel. The extracted information includes:
Study Characteristics (for all relevant outcomes in a study)
• methods of randomization and allocation

• use of blinding (patient, caregiver, evaluator)
• funding source/conflict of interest
• duration of the study
• number of subjects and follow-up percentage
• experimental and control groups
Patient Characteristics (for all treatment groups in a study)
• patient inclusion/exclusion criteria

• co-interventions (if used) and co-morbidities (if present)
• measures of disease severity
• Complications
Results (for all relevant outcomes in a study)
• outcome measure
• is the outcome measure patient-oriented? validated? objective/subjective?
• duration at which outcome measure was evaluated
• statistic reported (for dichotomous results)
• mean value and measure and value of dispersion (continuous results)
• statistical test used, value of test statistic, and p-value
• verification of calculations
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APPENDIX VII
JUDGING THE QUALITY OF DIAGNOSTIC STUDIES
The QUADAS tool is used to identify sources of bias, variability, and the quality of
reporting in studies of diagnostic accuracy. Fourteen questions answered “yes”, “no”, or
“unclear” contribute to the QUADAS tool. There is no score derived from the use of the
QUADAS tool.
Was the spectrum of patient’s representative of the patients who will receive the test in
practice?
Were selection criteria clearly described?
Is the reference standard likely to correctly classify the target condition?
Is the time period between ref. standard and index test short enough to be reasonably sure
that the target condition did not change between the two tests?
Did the whole sample or a random selection of the sample, receive verification using a
reference standard of diagnosis?
Did patients receive the same reference standard regardless of the index test result?
Was the reference standard independent of the index test (i.e. the index test did not form
part of the reference standard)?
Was the execution of the index test described in sufficient detail to permit replication of
the test?
Was the execution of the reference standard described in sufficient detail to permit its
replication?
Were the index test results interpreted without knowledge of the results of the reference
standard?
Were the reference standard results interpreted without knowledge of the results of the
index test?
Were the same clinical data available when test results were interpreted as would be
available when the test is used in practice?
Were uninterpretable/intermediate test results reported?
Were withdrawals from the study explained?
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JUDGING THE QUALITY OF TREATMENT STUDIES
RANDOMIZED CONTROLLED TRIALS
Did the study employ stochastic randomization?
Was there concealment of allocation?
Were subjects blinded to the treatment they received?
Were those who assessed/rated the patient’s outcomes blinded to the group to which the
patients were assigned?
Was there more than 80% follow-up for all patients in the control group and the
experimental group on the outcome of interest?
Did patients in the different study groups have similar levels of performance on ALL of
the outcome variables at the time they were assigned to groups?
For randomized crossover studies, was there evidence that the results obtained in the
study’s two experimental groups (in period 1 and 2) did not differ?
For randomized crossover studies, was there evidence that the results of the two control
groups (in period 1 and 2) did not differ?
PROSPECTIVE NON- RANDOMIZED CONTROLLED STUDIES
Were the characteristics of patients in the different study groups comparable at the
beginning of the study?
the outcome variables at baseline?
Were all of the study’s groups concurrently treated?
Did the study avoid collecting control group data from one center and experimental group
data from another?
For crossover studies, was there evidence that the results obtained in the study’s two
experimental groups (in period 1 and 2) did not differ?
For crossover studies, was there evidence that the results of the two control groups (in
period 1 and 2) did not differ?
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RETROSPECTIVE COMPARATIVE STUDIES
Was there less than 20% difference in completion rates in the study’s groups?
Were all of the study’s groups concurrently treated?
Was the same treatment given to all patients enrolled in the experimental and
Were the same laboratory tests, clinical findings, psychological instruments, etc. used to
measure the outcomes in all of the study’s groups?
Were the follow-up times in all of the study’s relevant groups approximately equal?
Did the study avoid collecting control group data from one center and experimental group
data from another?
the outcome variables at the time they were assigned to groups?
Were the characteristics of patients in the different study groups comparable at the
beginning of the study?
CASE SERIES
Was enrollment in the study consecutive?
Was there more than 80% follow-up for all patients on the outcome of interest?
Were the same laboratory tests, clinical findings, psychological instruments, etc. used to
measure the outcomes in all patients?
Were the patients instructed/not given concomitant or adjuvant treatments?
Were the follow-up times for all patients approximately equal?
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APPENDIX VIII
FORM FOR ASSIGNING STRENGTH OF RECOMMENDATION
(INTERVENTIONS)
GUIDELINE RECOMMENDATION___________________________________
PRELIMINARY STRENGTH OF
RECOMMENDATION:________________________________________
STEP 1: LIST BENEFITS AND HARMS
Please list the benefits (as demonstrated by the systematic review) of the intervention
Please list the harms (as demonstrated by the systematic review) of the intervention
Please list the benefits for which the systematic review is not definitive
Please list the harms for which the systematic review is not definitive
STEP 2: IDENTIFY CRITICAL OUTCOMES
Please circle the above outcomes that are critical for determining whether the intervention
is beneficial and whether it is harmful
Are data about critical outcomes lacking to such a degree that you would lower the
preliminary strength of the recommendation?
What is the resulting strength of recommendation?
STEP 3: EVALUATE APPLICABILITY OF THE EVIDENCE
Is the applicability of the evidence for any of the critical outcomes so low that
substantially worse results are likely to be obtained in actual clinical practice?
Please list the critical outcomes backed by evidence of doubtful applicability:
Should the strength of recommendation be lowered because of low applicability?
STEP 4: BALANCE BENEFITS AND HARMS
Are there trade-offs between benefits and harms that alter the strength of
recommendation obtained in STEP 3?
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STEP 5 CONSIDER STRENGTH OF EVIDENCE
Does the strength of the existing evidence alter the strength of recommendation obtained
in STEP 4?
NOTE: Because we are not performing a formal cost analyses, you should only consider
costs if their impact is substantial.
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APPENDIX IX
VOTING BY THE NOMINAL GROUP TECHNIQUE
Voting on guideline recommendations will be conducted using a modification of the

nominal group technique (NGT), a method previously used in guideline development.12
Briefly each member of the guideline work group ranks his or her agreement with a
guideline recommendation on a scale ranging from 1 to 9 (where 1 is “extremely
inappropriate” and 9 is “extremely appropriate”). Consensus is obtained if the number of
individuals who do not rate a measure as 7, 8, or 9 is statistically non-significant (as
determined using the binomial distribution). Because the number of work group members
who are allowed to dissent with the recommendation depends on statistical significance,
the number of permissible dissenters varies with the size of the work group. The number
of permissible dissenters for several work group sizes is given in the table below:
Number of Permissible
Work group Size Dissenters
Not allowed, statistical
≤3 significance cannot be
obtained
4-5 0
6-8 1
9 1 or 2
The NGT is conducted by first having members vote on a given recommendation without
discussion. If the number of dissenters is “permissible”, the recommendation is adopted
without further discussion. If the number of dissenters is not permissible, there is further
discussion to see whether the disagreement(s) can be resolved. Three rounds of voting are
held to attempt to resolve disagreements. If disagreements are not resolved after three
voting rounds, no recommendation is adopted.
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APPENDIX X
STRUCTURED PEER REVIEW FORM
Review of any AAOS confidential draft allows us to improve the overall guideline but does
not imply endorsement by any given individual or any specialty society who participates in
our review processes. The AAOS review process may result in changes to the
documents; therefore, endorsement cannot be solicited until the AAOS Board of Directors
officially approves the final guideline.
Reviewer Information:
Name of Reviewer_________________________________________
Address_________________________________________________
City___________________ State_________________ Zip Code___________
Phone _____________________Fax ________________________
E-mail_______________________
Specialty Area/Discipline: _______________________________________

Work setting: _________________________________________________
Credentials: _________________________________________________
May we list you as a Peer Reviewer in the final Guidelines? Yes No
Are you reviewing this guideline as Yes No

a representative of a professional society?
If yes, may we list your society as a reviewer Yes No

of this guideline?
Reviewer Instructions
Please read and review this Draft Clinical Practice Guideline and its associated
Technical Report with particular focus on your area of expertise. Your responses
are confidential and will be used only to assess the validity, clarity, and accuracy
of the interpretation of the evidence. If applicable, please specify the draft page
and line numbers in your comments. Please feel free to also comment on the
overall structure and content of the guideline and Technical Report.
If you need more space than is provided, please attach additional pages.
Please complete and return this form electronically to wies@aaos.org or fax the
form back to Jan Weis at (847) 823-9769.
Thank you in advance for your time in completing this form and giving us your
feedback. We value your input and greatly appreciate your efforts. Please send
the completed form and comments by Month, Day, Year
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186 v1.0 12.04.09
COMMENTS
Please provide a brief explanation of both your positive and negative answers in the
preceding section. If applicable, please specify the draft page and line numbers in your
comments. Please feel free to also comment on the overall structure and content of the
guideline and Technical Report
OVERALL ASSESSMENT
Would you recommend these guidelines for use in practice? (check one)
Strongly recommend _______
Recommend (with provisions or alterations) _______
Would not recommend _______
Unsure _______
COMMENTS:
Please provide the reason(s) for your recommendation.
187 v1.0 12.04.09

APPENDIX XI
PEER REVIEW PANEL
Participation in the AAOS peer review process does not constitute an
endorsement of this guideline by the participating organization.
Peer review of the draft guideline is completed by an outside Peer Review Panel. Outside
peer reviewers are solicited for each AAOS guideline and consist of experts in the
guideline’s topic area. These experts represent professional societies other than AAOS
and are nominated by the guideline Work group prior to beginning work on the guideline.
For this guideline, eleven outside peer review organizations were invited to review the
draft guideline and all supporting documentation. Seven societies participated in the
review of this guideline draft and explicitly consented to be listed as a peer review
organization in this appendix. The organizations that reviewed the document and gave
written consent to publication are listed below:
American Academy of Family Practitioners

American Academy of Physical Medicine and Rehabilitation
American College of Foot and Ankle Surgeons
American Orthopaedic Foot and Ankle Society
American Orthopaedic Society for Sports Medicine
American Physical Therapy Association
American Podiatric Medical Association
Individuals who participated in the peer review of this document and gave their explicit
written consent to be listed as reviewers of this document are:
Avrill Roy Berkman, MD

Christopher R. Carcia, MD
Michael Heggeness, MD
Harvey Insler, MD
John Kirkpatrick, MD
Michael S. Lee, DPM, FACFA
Angus McBryde Jr., MD
Ariz R. Mehta, MD
Lawrence Oloff, DPM
Steven Raikin, MD
Charles Reitman, MD
John Richmond, MD
Kevin Shea, MD
Naomi Sheilds, MD
Nelson F. Soohoo, MD
Glenn Weinraub, DPM, FACFAS
188 v1.0 12.04.09

Again, participation in the AAOS guideline peer review process does not
constitute an endorsement of the guideline by the participating
organizations or the individuals listed above.
PUBLIC COMMENTARY
A period of public commentary follows the peer review of the draft guideline. If
significant non-editorial changes are made to the document as a result of public
commentary, these changes are also documented and forwarded to the AAOS bodies that
approve the final guideline. The organizations that reviewed the document and consented
to publication are listed below:
German Society for Foot and Ankle Surgery (GFFC)
Public commentators who gave explicit written consent to be listed in this document
include the following:
Laura Gehrig, MD
Kurt F. Konkel, MD
John McGraw COL, USAR, MC
David Thordarson, MD
Mathew Walther, MD
Kristy Weber, MD
For this guideline, outside specialty societies could post the confidential draft of the
guideline to their “member only” website. The only society that submitted a compiled
response as a result of this posting was the American Orthopaedic Foot and Ankle
Society. Responses garnered from this posting were compiled by the specialty society
and submitted as one succinct public commentary by a member of the AOFAS evidence-
based medicine committee. Please contact the AOFAS for these member names since we
do not have explicit written consent to publish the names of these members.
Participation in the AAOS guideline public commentary review process

does not constitute an endorsement of the guideline by the participating
organizations or the individual listed nor does it is any way imply the
reviewer supports this document.
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APPENDIX XII
DESCRIPTION OF SYMBOLS USED IN TABLES
Symbol Description
Odds Ratio = The odds in Group B divided by the odds in Group A, where the odds is
OR the probability of the outcome occurring divided by the probability of the outcome not
occurring.
95% Confidence Interval = A measure of uncertainty of the point estimate: if the trial
95% CI were repeated an infinite number of times, then the 95% CI calculated for each trial
would contain the true effect 95% of the time.
An open circle in a Summary of Evidence Table indicates that the result is not
○
statistically significant.
A filled-in circle in a Summary of Evidence Table indicates that the result is
● op statistically significant in favor of the listed treatment (in this example, in favor of op
= operative treatment)
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APPENDIX XIII
CONFLICT OF INTEREST
Eric Michael Bluman, MD (Tacoma, WA): 4 (DePuy, A Johnson & Johnson Company).
Submitted on: 08/23/2008 and last confirmed as accurate on 10/09/2008.
Christopher P Chiodo, MD (Boston, MA): 1 (American Orthopaedic Foot and Ankle

Society; Mass Ortho Association); 2 (Foot and Ankle International); 3 (Aircast(DJ);
Arthrex, Inc); 4 (DePuy, A Johnson & Johnson Company); 5A (Smith & Nephew;
Zimmer); 7 (DJ Orthopaedics; EBI; Carticept); 8 (Johnson & Johnson; Zimmer).
Submitted on: 10/24/2008.
Bruce E Cohen, MD (Charlotte, NC): 2 (Foot and Ankle International; Techniques in

Foot and Ankle Surgery); 3 (DJ Orthopaedics; Wright Medical Technology, Inc); 4
(Arthrex, Inc); 5A (Wright Medical Technology, Inc.; Smith & Nephew); 7 (DJ
Orthopaedics; Wright Medical Technology, Inc.); 9 (Lippincott). Submitted on:
05/18/2008.
John E Femino, MD (Iowa City, IA): (n). Submitted on: 10/30/2008.
Eric Giza, MD (Sacramento, CA): 5A (Arthrex, Inc). Submitted on: 02/13/2008.
Mark Glazebrook, MD (Halifax,NS Canada): 2 (Foot and Ankle International); 5A

(DePuy, A Johnson & Johnson Company; Linvatec); 7 (Arthrex, Inc; Biomimetic;
DePuy, A Johnson & Johnson Company); 8 (Smith & Nephew; Stryker; Wright Medical
Technology, Inc.). Submitted on: 11/04/2008.
William Charles Watters III, MD: 1 (North American Spine Society; Work Loss Data
Institute); 2 (The Spine Journal); 5A (Stryker; Intrinsic Therapeutics; MeKessen Health
Care Solutions). Submitted on: 10/09/2007 at 08:09 PM and last confirmed as accurate on
04/23/2008.
Disclosure Items: (n) = Respondent answered 'No' to all items indicating no conflicts.
1=Board member/owner/officer/committee appointments; 2= Medical/Orthopaedic
Publications; 3= Royalties; 4= Speakers bureau/paid presentations;5A= Paid consultant;
5B= Unpaid consultant; 6= Research or institutional support from a publisher; 7=
Research or institutional support from a company or supplier; 8= Stock or Stock Options;
9= Other financial/material support from a publisher; 10= Other financial/material
support from a company or supplier.
191 v1.0 12.04.09

APPENDIX XIV
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Management of Acute Achilles Tendon Rupture

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Management of Acute Achilles Tendon Rupture

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THE DIAGNOSIS AND TREATMENT OF ACUTE

ACHILLES TENDON RUPTURE

Adopted by the American Academy of Orthopaedic Surgeons

Published 2009 by the American Academy of Orthopaedic Surgeons

o Clinical Thompson test (Simmonds squeeze test)

Strength of Recommendation – Consensus*

Implications: Practitioners should be flexible in deciding whether to follow a

Strength of Recommendation – Inconclusive

Implications: Practitioners should feel little constraint in deciding whether to follow a

Strength of Recommendation: Limited

Implications: Practitioners should be cautious in deciding whether to follow a

4. For patients treated non-operatively, we are unable to recommend for or against

Strength of Recommendation: Inconclusive

Implications: Practitioners should feel little constraint in deciding whether to follow a

Strength of Recommendation: Limited

Implications: Practitioners should be cautious in deciding whether to follow a

Strength of Recommendation: Consensus

Implications: Practitioners should be flexible in deciding whether to follow a

Strength of Recommendation: Inconclusive

Implications: Practitioners should feel little constraint in deciding whether to follow a

Strength of Recommendation: Limited

Implications: Practitioners should be cautious in deciding whether to follow a

9. We cannot recommend for or against the use of allograft, autograft, xenograft,

Strength of Recommendation: Inconclusive

Implications: Practitioners should feel little constraint in deciding whether to follow a

Strength of Recommendation: Inconclusive

Implications: Practitioners should feel little constraint in deciding whether to follow a

Strength of Recommendation: Moderate

Implications: Practitioners should generally follow a Moderate recommendation but

Strength of Recommendation: Moderate

Implications: Practitioners should generally follow a Moderate recommendation but

13. We are unable to recommend for or against post-operative physiotherapy for

Strength of Recommendation: Inconclusive

Implications: Practitioners should feel little constraint in deciding whether to follow a

Strength of Recommendation: Inconclusive

Implications: Practitioners should feel little constraint in deciding whether to follow a

Strength of Recommendation: Limited

Implications: Practitioners should be cautious in deciding whether to follow a

Strength of Recommendation: Inconclusive

Implications: Practitioners should feel little constraint in deciding whether to follow

Eric Giza MD Janet L. Wies MPH

American Academy of Family Practitioners

Avrill Roy Berkman, MD

SUMMARY OF RECOMMENDATIONS .............................................................. III

WORK GROUP ................................................................................................... X

PEER REVIEW ................................................................................................... XI

TABLE OF CONTENTS .................................................................................... XII

LIST OF TABLES ............................................................................................. XVI

Goals and Rationale ..................................................................................................................................... 1

Intended Users .............................................................................................................................................. 1

Patient Population ........................................................................................................................................ 2

Burden of Disease ......................................................................................................................................... 2

Risk Factors .................................................................................................................................................. 2

Emotional and Physical Impact of Achilles Tendon Rupture .................................................................. 2

Potential Benefits, Harms, and Contraindications .................................................................................... 2

II. METHODS ..................................................................................................... 3

Formulating Preliminary Recommendations ............................................................................................. 3

Study Inclusion Criteria ............................................................................................................................... 4

Outcomes Considered .................................................................................................................................. 4

Literature Searches ...................................................................................................................................... 5

Judging the Quality of Evidence ................................................................................................................. 6

Consensus Development ..............................................................................................................................10

Statistical Methods ......................................................................................................................................10

Peer Review ..................................................................................................................................................11