The outcome of treating midsubstance Achilles tendon tears depends mainly on correct rehabilitation, and not the choice of surgical vs. non-surgical treatment!

The problem with all the results found with a Google search is that most historical research has the following main flaws:

• no standardisation of patient selection

• no standardisation of treatment regimens

• no standardisation of rehabilitation type or duration

• invalid outcome measures used to draw conclusions

The above represents bad science, and leads to incorrect guidelines.

There are only a handful of high-quality research studies using the only validated outcome measure (the ATRS = Achilles Tendon Rupture Score). 1 modern prospective series and 3 randomised controlled trials comparing surgical vs non-surgical outcomes (* listed at the bottom) have provided solid information with which which proper decisions can be made.

These studies have all shown that the magic in treating midsubstance Achilles ruptures depends on the correct implementation of a standardised protocol of Accelerated Functional Rehabilitation. This protocol combines:

• early progressive weightbearing, and

• early controlled range of motion in a hinged walker boot (not a cast, not a boot with wedges!)

The treatment protocol is as follows:

• 2 weeks non-weightbearing on crutches in an equinus front-slab, then

• 2 weeks in a hinged walker boot locked at 30 degrees equinus, partial weightbearing 50% body weight, then

• 2 weeks in the hinged walker boot, partially dynamised with 15-30 degrees plantar flexion range, full weight bearing (crutches still used for balance), then

• 2 weeks in the hinged walker boot, dynamised with 0-30 degrees plantar flexion range, full weight bearing, no crutches.

The boot is only removed for 1 hour per day for washing and cleaning, with care taken not to move the ankle beyond the range provided by the boot. It is important to sleep with the boot on!

After 8 weeks, the boot is removed completely, and the patient starts to walk in normal shoes, using silicone heel cups inside the shoes. Physiotherapy begins at this stage. It is important not to be too aggressive with stretching at any point until 10 weeks after the initial injury.

If patients with surgical and non-surgical treatment use the same rehabilitation protocol, then the following are the results:

• no difference in the validated outcome score ATRS at 1 year and 2 years after injury

• average results of ATRS >85/100 (good to excellent result) regardless of surgical vs. non-surgical – importantly, research proves that Achilles tendons are already show significant degeneration through their entire length by the time there is a rupture, and therefore patients sometimes describe the feeling of “running on a flat tyre” after healing, irrespective of surgical or non-surgical treatment!

• no statistically significant difference in re-rupture rates – note that the risk of re-rupture is never zero, however the risk of re-rupture is less than the risk of wound complications from surgery in this area of the body with fragile and tight skin

• no difference in patients <40 years old compared to >40 years old

• no statistically significant difference between males and females

• increased wound complications with surgical groups – these complications can be devastating!

Therefore, overall, non-surgical treatment is considered superior to surgical treatment for acute midsubstance Achilles tendon ruptures.

For the treatment to be successful, patient compliance is essential! A sobering consideration is that if someone is not compliant with non-operative rehabilitation, then the stakes of complications can be much higher in the same patient if surgery is offered. This makes non-compliance a particularly difficult problem to manage.

Please note that the following cases are exceptions, and require more individual decisions:

• cuts to the leg with open wound over a cut Achilles – always need surgery

• insertional Achilles tears or avulsions – almost always need surgery

• musculotendinous Achilles tears – almost never need surgery

• “tennis leg” (gastrocnemius tear) – never surgery, and different rehabilitation protocol

• delayed diagnosis – more likely to need surgery

• re-rupture – will likely need surgery

References:

• CS Lim, et al, FAI 2017, 38(12): 1331-1336

• M. Bhatia et al, Leicester Achilles Management Programme (LAMP), AOFAS Annual Meeting 2017

• A Soroceanu et al. Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials. J Bone Joint Surg Am. 2012;94(23):2136-2143.

• T. Mark-Christensen. Knee Surg Sports Traumatol Arthroscp. 2016 Jun;24(6)

• RS Kearney et al. A systematic review of patient-reported outcome measures used to assess Achilles tendon rupture management: what’s being used and should we be using it? Br J Sports Med. 2011:1102-1109.

• K Nilsson-Helander K, et al. Acute achilles tendon rupture: a randomized, controlled study comparing surgical and nonsurgical treatments using validated outcome measures. Am J Sports Med. 2010;38(11):2186-2193.

• Olsson N, Silbernagel KG, Eriksson BI, et al. Stable surgical repair with accelerated rehabilitation versus nonsurgical treatment for acute Achilles tendon ruptures: a randomized controlled study. Am J Sports Med. 2013;41(12):2867-2876.

• Willits K, Amendola A, Bryant D, et al. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation. J Bone Joint Surg Am. 2010;92(17):2767-2775.

• Hutchison AM, Topliss C, Beard D, Evans RM, Williams P. The treatment of a rupture of the Achilles tendon using a dedicated management programme. Bone Joint J. 2015;97:510-515.

• Grävare Silbernagel K, Brorsson A, Olsson N, Eriksson BI,

• Karlsson J, Nilsson-Helander K. Sex differences in outcome after an acute Achilles tendon rupture. Orthop J Sport Med. 2015;3(6):2325967115586768.

• Bergkvist D, Åström I, Josefsson P-O, Dahlberg LE. Acute

• Achilles tendon rupture: a questionnaire follow-up of 487 patients. J Bone Joint Surg Am. 2012;94(13):1229-1233.