 ANNOTATION
Current concepts in the rehabilitation of an
acute rupture of the tendo Achillis
R. S. Kearney,
M. L. Costa
From University of
Warwick, Coventry,
United Kingdom
 R. S. Kearney, MSc, BSc
Physiotherapy, Research
Physiotherapist
University of Warwick, Warwick
Orthopaedics, Division of
Health Sciences, Warwick
Medical School, Clinical
Sciences Research
Laboratories, University
Hospital, Clifford Bridge Road,
Coventry CV2 2DX, UK.
 M. L. Costa, PhD, FRCS(Tr &
Orth), Professor of Trauma and
Orthopaedic Surgery
University of Warwick, Warwick
Clinical Trials Unit, Division of
Health Sciences, Warwick
Medical School, Coventry CV4
7AL, UK.
Correspondence should be sent
to Mrs R. S. Kearney; e-mail:
r.s.kearney@warwick.ac.uk
©2012 British Editorial Society
of Bone and Joint Surgery
doi:10.1302/0301-620X.94B1.
28008 $2.00
J Bone Joint Surg Br
2012;94-B:28–31.
28
Rupture of the tendo Achillis is a common injury with a rising incidence. Traditionally the
key question following this injury has been whether or not to operate. However a
contemporary Cochrane review highlighted that the method of rehabilitation may also have
an important contribution to the outcome. Since this review, various early weight-bearing
rehabilitation protocols have been described. Currently evidence points to the use of early
functional rehabilitation, regardless of operative or non-operative management. However,
there is no consensus on which exact functional rehabilitation protocol should be used.
Future research should be directed towards improving our understanding of how the
different rehabilitative components interact in the tendo Achillis as it heals.
Rupture of the tendo Achillis is a common
injury and the incidence is rising.1 There is a
bimodal distribution according to age with the
first peak predominantly involving men aged
30 to 40 years and the second women aged
60 to 80 years.2 The first peak in incidence is
often associated with participation in sport,
such as football and racquet sports, whereas
the second peak often occurs during normal
daily activities such as climbing stairs.2 However, both often occur below the threshold of
‘macro-failure’ that might be expected in a
healthy tendon. Macro-failure is a term associated with the stress–strain curve that characterises the mechanical response of tendons, and
occurs beyond approximately 8% strain.3
It is widely accepted that spontaneous ruptures are the consequence of a pre-existing tendinopathy, which itself is attributed to failure in
the protective/regenerative function that
responds to repeated microscopic injury.4,5
Tendinopathy may develop in individuals with
no obvious predisposition, but it has been
linked to a number of external factors including
use of topical corticosteroids,6 fluoroquinolone
antibiotics7 and mechanical abnormalities of
the foot.8 Intrinsic factors have also been associated with a predisposition including autoimmune and neurological conditions.9
The most common mechanism of injury is
rapid eccentric contraction of the triceps surae,
which may occur during sports with activities
such as sprint starts, jumping and lunging or
after an unexpected dorsiflexion of the ankle,
which might occur when a patient stumbles.
The patient typically presents with a sudden
pain in the area of the tendo Achillis, often
reporting a feeling of having been kicked in the
back of the leg.10 Physical findings include a
positive calf squeeze test,11 decreased ankle
plantarflexion strength, presence of a palpable
gap and increased ankle dorsiflexion with gentle manipulation.12 Following a diagnosis of a
mid-substance rupture of the tendo Achillis the
clinician is faced with a range of management
options. This article will summarise the latest
developments in this area.
Management options
Traditionally the key question in relation to a
rupture of the tendo Achillis was simply
whether to operate or not. In 1981 Nistor13
designed and published the first randomised
control trial (RCT) to address this clinical
question, involving 105 patients, all of whom
underwent between six and nine weeks of
immobilisation in a cast, irrespective of
whether they were in the operative group. This
study was followed by a series of trials which
were pooled in a meta-analysis by the
Cochrane review group in 2004.14 The results
suggested a re-rupture rate of 3.5% in the
operatively treated group and 12.6% in the
non-operatively treated group. However, this
was alongside a pooled rate of ‘other’ complications of 34.1% in the operatively treated
group and 2.7% in the non-operatively treated
group. Therefore, operative repair seemed to
reduce the risk of re-rupture but came with an
increased risk of other complications, most of
which were associated with infection and
wound healing.
THE JOURNAL OF BONE AND JOINT SURGERY
CURRENT CONCEPTS IN THE REHABILITATION OF AN ACUTE RUPTURE OF THE TENDO ACHILLIS
In an attempt to reduce the number of wound complications associated with operative repair, clinicians have investigated percutaneous repair, as opposed to the traditional
open longitudinal approach. The percutaneous approach
involves small stab incisions along both borders of the tendon and then passing a suture through the tendon using
these incisions, as first described by Ma and Griffith.15 The
first RCT to examine the benefit of this approach was published by Schroeder, Lehmann and Steinbrueck16 in 1997,
followed by two further RCTs in 2001 and 2008.17,18 These
have all reported favourably towards the percutaneous
approach, regarding complication rates. However, it was
also noted that there is a higher rate of sural nerve injury
with percutaneous approaches. Consequently, a range of
surgical techniques, which sit between the open longitudinal and fully percutaneous techniques, have been developed
but there is currently no standard procedure amongst
surgeons.
The 2004 Cochrane review also evaluated two RCTs
published in 199219 and 2002,20 which compared cast immobilisation with functional bracing within patients managed
non-operatively. These suggested that there was a reduced rerupture rate of 2.4% in the functional bracing group,
compared with 12.2% in the casting group. This raised the
possibility that functional rehabilitation might reduce the
rate of re-rupture to that observed in operatively managed
patients, in which case the strength of the indication for surgical intervention was reduced. However, the authors of the
review also noted the considerable variation in functional
bracing protocols documented within the literature.
Functional rehabilitation
The term functional rehabilitation has been applied in various studies using a variety of orthotics and rehabilitation
regimes. However, the key components are weight-bearing
mobilisation, usually within an orthotic device with early,
but limited, range of movement being permitted. With
regard to the orthosis, there are two basic designs: rigid
rocker bottom style,21 or the more flexible carbon-fibre
dorsal orthoses.22 The flexible orthosis generally facilitates
a greater range of movement than the more rigid designs.
The choice of orthosis is just one consideration. There is
also the issue of what degree of plantarflexion should be
maintained within the orthosis. Some studies have advocated that the ankle should be positioned in neutral21
(plantar-grade) but with restricted dorsiflexion, while others have used three heel-wedge inserts such that the ankle
joint is initially maintained at near full plantarflexion.23
The latter protocol reproduces the more traditional use of
sequential plaster casts with gradually reducing plantarflexion. Finally, there is the consideration of when weightbearing should be permitted (day one or within first two
weeks), for how long the orthosis should be worn and
whether or not to permit active range of movement
exercises throughout the period when the orthosis is
worn.21,22,24-26 There is a trend towards immediate full
VOL. 94-B, No. 1, JANUARY 2012
29
weight-bearing and earlier removal of the orthosis with an
average of eight weeks reported in one study,26 but it would
be wrong to suggest that there is a consensus in this area.
This range of protocols exemplifies the complexity of
this early rehabilitative intervention. When developing an
intervention that has several interacting components the
clinician can reasonably refer to the growing number of
case series, documenting what has been tried and tested,
and implement a protocol into their practice accordingly.
An alternative approach, recommended by the Medical
Research Council,27 is to develop an understanding of the
underlying causal mechanisms why these different components may contribute to improved outcomes following a
rupture of the tendo Achillis.
The phases of tendon healing have been divided into
inflammation (first week), proliferation (weeks two to
eight) and remodelling (up to 12 months).28 Throughout
these phases the tendon’s tensile strength gradually
increases, but remains inferior to the uninjured tissue. The
biomechanical inferiority of the newly formed scar tissue is
due to its increased stiffness and subsequently decreased
visco-elastic properties.29 Animal models have shown that
early loaded movement improves the biomechanical properties of the scar tissue, decreases excessive adhesion formation and subsequently enhances the gliding function of the
tendon.30,31 Furthermore weight-bearing during the early
phases of healing stimulates fibroblast activity and type III
collagen synthesis.31 Consequently, there is both preliminary clinical evidence and underlying basic science research
to support early loading and early movement.
The RCT using functional rehabilitation involved early,
but not immediate weight-bearing.19 Subsequently, there
were RCTs to compare cast immobilisation with ‘immediate’ full weight-bearing functional bracing, firstly within
operatively managed patients and secondly within nonoperatively managed patients.22,32 These studies suggested
that immediate weight-bearing is safe, in terms of both risk
of re-rupture and the risk of tendon lengthening, for both
groups, and offer practical advantages for patients and
some evidence of improved functional outcomes.
Operative versus non-operative treatment with
functional rehabilitation
The next logical research question was therefore to compare
operative with non-operatively managed patients using
accelerated, functional rehabilitation methods for both
groups. The first RCT for this step was carried out by Metz
et al25 in 2008 and then more recently by Willits et al33 in
2010. Both studies used early functional bracing (within
two weeks of injury) and both found no statistically significant differences in outcome between operatively and nonoperatively managed patients. The primary outcome measures were complications other than re-rupture in one study25
and the rate of re-rupture in the other.33 Both RCTs had clear
inclusion and exclusion criteria and accountability for participant flow throughout the studies. They provide strong
30
R. S. KEARNEY, M. L. COSTA
evidence to suggest that there is no difference in the risk of rerupture whether the rupture is treated with operative repair
or managed non-operatively, provided functional rehabilitation is undertaken in the early phases of rehabilitation. However there are some unresolved issues. For example, Metz
et al25 managed the two groups using somewhat different
rehabilitation protocols. In contrast, Willits et al33 used an
identical rehabilitation protocol for both groups, but the
patient sample was recruited from two sports medical centres, bringing into question the external validity of the
results. Furthermore it is important to acknowledge that
both studies used complications as their primary measure of
treatment success. The most appropriate measure of the success of treatment, however, remains controversial.
Outcome measures
In order to ascertain superiority of one intervention over
another, the appropriate choice of primary outcome measure is imperative. Traditionally, within the musculoskeletal
field, published studies have focused on the technical outcomes of procedures, but more recently there has been a
move towards the assessment of effectiveness from the
patients’ perspective.34 A wide range of patient reported
functional measures have been developed over the last two
decades, such as the Victorian Institute of Sports Assessment questionnaire for patellar and Achilles tendinopathy,35,36 and in other areas assessments for both the upper
and lower limb.37-39 However, until recently there was no
validated, patient-reported outcome tool specifically for
patients with a rupture of the tendo Achillis. The Thermann
score40 and Leppilahti score41 have been used in some studies but neither tool has undergone in-depth validation,
being predominantly based on expert opinion.42 In 2007, a
research group addressed this gap publishing a new patient
reported outcome measure with supporting validation
data.42 This outcome measure was the Achilles tendon
Total Rupture Score (ATRS).
The ATRS contains ten items, for which patients are
asked to respond using an 11-grade Likert scale.43 This
scale ranges from a score of zero, which is equivalent to a
patient having major limitations or symptoms, to a score of
ten, which is equivalent to a patient having no limitations
or symptoms. The original validation paper is based on a
select population of patients aged 20 to 70 years, within a
Swedish sample.42
Conclusions and future research
In 2010, the first clinical guidelines on the treatment of
acute rupture of the tendo Achillis were published by the
American Academy of Orthopaedic Surgeons and endorsed
by the American Foot and Ankle Society.44 The guidelines
provided moderate recommendations in two areas: firstly
the use of early (two weeks or before) post-operative
weight-bearing and secondly the use of a protective/
orthotic device to allow mobilisation. However, this report
recognised that there were a range of protocols and
‘protective devices’ and there is a current lack of clinical
consensus regarding which devices should be used, the
degree of ankle plantarflexion they should facilitate and
how long they should be worn.
Over the past few years, the potential benefits of early
functional rehabilitation have increasingly been documented within randomised controlled trials, meta-analyses
and guideline development groups. Yet, despite this growing body of evidence, there are still reports of prolonged
cast immobilisation following this injury. This is particularly puzzling in light of the increased complications associated with prolonged immobilisation, including venous
thromboembolism, muscle atrophy from disuse and higher
rates of re-rupture.22,33,45,46
The literature to date has focused on three core areas.
Firstly, the question of whether to operate or not.47,48 Secondly, if operative repair is favoured, which technique is the
best, and finally whether to immobilise the patient in a plaster cast or to use accelerated rehabilitation with functional
bracing. However, new and emerging themes are developing as a result of advances in basic science and animalbased research. One such area is improving the ‘biology’
that governs tendon healing. Published animal studies have
investigated the use of bone morphogenetic proteins, autologous conditioned serum, fibroblast growth factor, vascular endothelial growth factor, platelet derived growth factor
and insulin-like growth factor-1.49-52 The findings are
increasingly being translated into clinical research. One
example specific to the tendo Achillis is an ongoing RCT
comparing the use of autologous platelet-rich plasma versus standard treatment for patients with an acute rupture
(trial registration: ISRCTN93608625), but there are likely
to be many more studies as our understanding of tendon
healing improves.
In conclusion, although current evidence points to the
use of early functional rehabilitation, regardless of operative or non-operative management, there is no consensus on
which exact functional rehabilitation protocols should be
used. Unanswered questions include: Which type of orthosis should be used? Is movement important or is early loading enough? What degree of plantarflexion provides the
best balance between tendon lengthening/re-rupture and
disuse atrophy in the calf muscles? The next few years of
research will no doubt improve our understanding of these
‘mechanical’ factors but perhaps the most exciting developments will come with a better knowledge of how the
mechanical and biological environment interacts in the
tendo Achillis as it heals.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
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