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Three Part Question

In [an adult patient presenting with an acute achilles tendon rupture that is for non-operative treatment] what is [the best method of treatment] to [facilitate an optimum outcome]?

Clinical Scenario

A fifty eight year old man, who is medically well but relatively inactive, presents to the emergency department after feeling a painful snap at the back of his left heel while running for a bus. On examination you note swelling and ecchymosis over the achilles tendon with a tender and palpable gap. He has weakness of plantar flexion and is Thompson's test / Simmonds' test positive. After being informed of the pros and cons of operative and non-operative treatment he opts to be managed non-operatively. You wonder how he can be best managed.

Search Strategy

OVID interface on the world wide web. 1966 – May 2010.
[({calcaneal tendon OR tendo-achilles OR tendoachilles OR tendo achilles OR achilles.mp} AND {rupture.mp}}]
LIMIT nil

Search Outcome

1741 papers found of which 1738 were either irrelevant or of insufficient quality for inclusion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Costa ML et al. 2006. UK.	48 adult patients with acute achilles tendon rupture who chose to have non-operative treatment. Randomised to either six weeks in an off-the-shelf, carbon-fibre orthosis with three 1.5cm heel raises that were encouraged to mobilise fully weight-bearing and move the ankle within the orthosis (trial group) or to six weeks in a below knee gravity equinus cast that were non weight-bearing (control group). This was followed by serial removal of heel raises or casting in increasing dorsiflexion over 6 further weeks. Immobilisation was discontinued at 12 weeks. Reviews at 3, 6 and 12 months.	PRCT.	Numbers returning to sport.	No significant difference found (p 1.0). 56% trial group vs. 52% control group.	Of the original 48 patients only 40 were available for review at one year. All patients who presented out of hours were initially placed in below-knee equinus plaster backslab.
			Time to return to normal activities.	No significant differences found. Sport- (p 0.631) 18 weeks trial group vs. 21 weeks control group. Walking- (p 0.765) 16 weeks trial group vs. 22 weeks control group. Stair climbing- (p 0.484 ) 16 weeks trial group vs. 22 weeks control group. Work- (p 0. 370) 13 weeks trial group vs. 17 weeks control group.
			EuroQol health status questionnaire- EQoL Domain.	No significant differences found. 3 months- (p 0.372) 80 trial group vs. 85 control group. 6 months (p 0.598) 89 trial group vs. 88 control group. 12 months- (p 0.122) 85 trial group vs. 91 control group.
			EuroQol health status questionnaire- E5D Domain.	No significant differences found. 3 months- (p 0.450) 0.73 trial group vs. 0.69 control group. 6 months- (p 0.810) 0.80 trial group vs. 0.80 control group. 12 months- (p 0.888) 0.85 trial group vs. 0.85 control group.
			Deficit in calf diameter in mm.	No significant difference found (p 0.634). 1.37 trial group vs. 1.11 control group.
			Loss of movement in degrees.	No significant differences found. Dorsiflexion (p 0.879) -0.7 trial group vs. 0.27 control group. Plantarflexion (p 0.248) 4.13 trial group vs. 7.27 control group.
			Deficit in total concentric and eccentric work.	No significant differences found.
			Complications.	1 re-rupture in trial group vs. 1 re-rupture, 1 failure of tendon healing and 1 PE in control group.
Petersen OF et al. 2002. Denmark.	50 adult patients with acute achilles tendon ruptures. Randomised to either a CAM walker and were encouraged to weight bear (trial group) or to a below knee full equinus cast and were non-weight bearing (control group). Both groups were immobilised for 8 weeks. Reviews at 4 and 12 months.	PRCT.	Re-rupture rate.	No significant difference found (p 0.066) but suggestive of a trend towards increased re-rupture in the control group. The risk of a type II error was 44% and it was thought likely that should the numbers of patients recruited have been larger this may have become a significant difference. 0% trial group, vs. 17% control group.	Number lost to follow-up: 8. Length of time between injury and treatment not stated although delayed presentations were excluded.
			Patient satisfaction.	No significant difference.
Saleh M et al. 1992. UK.	40 adult patients with acute achilles tendon ruptures. Randomised to either a below knee full equinus cast for 2 weeks followed by, a mid equinus cast for 1 week and then controlled early mobilisation in a Sheffield splint with full weight-bearing (trial group) or to a full-leg cast, with the ankle in full equinus, for four weeks, followed by two weeks in a below-knee cast with the ankle in mid-equinus, and then two more weeks with the ankle in the neutral position with weight-bearing allowed during the final two weeks only (control group). Review at 3, 6 and 12 months. The Sheffield splint is an ankle-foot orthosis which holds the ankle at 15 degrees of plantar flexion, but allows some movement at the metatarsophalangeal joints. The orthosis is used in conjunction with an insole within an extra-depth shoe. It is removed to allow controlled movement during physiotherapy.	PRCT.	Strength of plantar flexion.	No significant difference found at 3, 6 or 12 months.	Randomisation method not stated.
			Range of plantar flexion (degrees).	No significant difference found at 3, 6 or 12 months.
			Range of dorsiflexion (degrees).	Significantly more in trial group at 3, 6 and 12 months (p<0.001).
			Time to walking indoors.	Significantly quicker in trial group (p <0.001). 6 weeks trial group vs. 11 weeks control group.
			Time to walking outdoors.	Significantly quicker in trial group (p <0.001). 9 weeks trial group vs. 15 weeks control group.
			Complications.	1 re-rupture in each group.
			Patient preference.	All patients in the trial group preferred the time spent in the Sheffield splint to the time spent in the cast.

Comment(s)

Only three studies look at this common problem. These studies demonstrate that patients can be allowed to weight-bear early in an off-the-shelf orthosis / CAM walker / Sheffield splint with no detriment in any long term outcomes. This has obvious practical advantages compared to the traditional treatment of prolonged non weight-bearing in a below knee equinus cast. This is particularly true for frail or elderly patients where non-operative treatment tends to be preferred. Petersen et al also suggest that this may also actually decrease the risk of re-rupture although this was not found to be significant (p=0.066). Saleh M et al also suggested that their splint allowed patients to regain mobility significantly more quickly and that patients preferred the splint to the cast. These findings are in keeping with the literature on operatively managed acute achilles tendon ruptures which suggests that early weight bearing and mobilisation improve outcomes.

Clinical Bottom Line

Where facilities exist patients may be allowed to weight-bear in an off-the-shelf, carbon-fibre orthosis with three 1.5cm heel raises, CAM walker with heel raises or be non-weight bearing in a below knee full equinus cast for 2 weeks followed by, a mid eqinus cast for 1 week and then controlled early mobilisation in a Sheffield splint with full weight-bearing. Where these facilities do not exist patients should be initially managed in a below knee equinus cast.

References

1. Costa ML, MacMillan K, Halliday D, Chester R, Shepstone L, Robinson AH, Donell ST. Randomised controlled trials of immediate weight-bearing mobilisation for rupture of the tendo Achillis. J Bone Joint Surg Br. 2006; 69-77.
2. Petersen OF, Nielsen MB, Jensen KH, Solgaard S. Randomized comparison of CAM walker and light-weight plaster cast in the treatment of first-time Achilles tendon rupture Ugeskr Laeger. 2002; 3852-5.
3. Saleh M, Marshall PD, Senior R, MacFarlane A. The Sheffield splint for controlled early mobilisation after rupture of the calcaneal tendon. A prospective, randomised comparison with plaster treatment. J Bone Joint Surg Br. 1992; 206-9.