Diagnosis and Treatment of Acute Achilles Tendon Rupture
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: (1) Clinical Thompson test (Simmonds squeeze test) (2) Decreased ankle plantar flexion strength (3) Presence of a palpable gap (defect, loss of contour) (4) Increased passive ankle dorsiflexion with gentle manipulationA 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.
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.
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.
Non-operative treatment is an option for all patients with acute Achilles tendon ruptureA 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.
For all 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.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
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.
Operative treatment is an option in patients with acute achilles tendon rupture.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, 32that 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. After twelve months, 92% of patients reported they had no pain.
All studies relevant to this Recommendation were Level IV because this is non comparative data.
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.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.
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.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.
Open, limited open and percutaneous techniques are options for treating patients with acute Achilles tendon rupture.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 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 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.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.
We cannot recommend for or against the use of antithrombotic treatment for patients with acute Achilles tendon ruptures.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.
We suggest early (= 2 weeks) post-operative protected weight bearing for patients with acute Achilles tendon rupture who have been treated operativelyA 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. 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.
We suggest the use of a protective device that allows mobilization by 2- 4 weeks post operatively.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.
We are unable to recommend for or against post-operative physiotherapy for patients with acute Achilles tendon rupture.A systematic review did not identify any studies that met the inclusion criteria.
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.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).
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.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.
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.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.
Guideline Work Group:
Christopher P. Chiodo, MD, Chair
Mark Glazebrook, MD, Vice-Chair
Eric Michael Bluman, MD. PhD
Bruce E. Cohen, MD
John E. Femino, MD
Eric Giza, MD
AAOS Guidelines and Technology Oversight Chairs:
William C. Watters, III, MD, Chair
Michael J. Goldberg, MD, Vice-Chair
AAOS Evidence Based Practice Committee:
Michael Warren Keith, MD, Chair
Robert H. Haralson III, MD, MBA, AAOS Medical Director
Charles M. Turkelson, PhD, Director of Research and Scientific Affairs
Janet L. Wies, MPH, Manager, Clinical Practice Guidelines
Laura Raymond, MA, Lead Research Analyst
Sara Anderson, MPH, Lead Research Analyst
Kevin Boyer, BS, Research Analyst
Patrick Sluka, MPH, Research Analyst