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Three Part Question

In [a patient with suspected achilles tendon rupture in the last 24 days] is {Equinus plaster of paris backslab or cast better than functional brace/ splint/ CAM boot or equivalent] in [improving functional outcome at 6 months]

Clinical Scenario

A 32 year old gentleman presents to the Emergency Department after falling during his 5-a-side football match. He reports hearing a ‘pop’ and pain in his posterior ankle. His Simmonds-Thomson test is positive and you suspect an acute rupture of his achilles tendon. You wonder if this patient should be put in an equinus cast or heel-raised functional bracing prior to orthopaedic clinic review.

Search Strategy

Medline 1946-06/22 using the OVID interface
EMBASE 1974-06/22 using the OVID interface

{exp Achilles tendon rupture.mp} AND (exp {Cast.mp} OR {Equinus.mp} OR {Splint.mp} OR {Brace.mp} OR {Boot.mp}) limited to English language

Search Outcome

346 papers were identified and on review of paper title and abstract, 13 were found to be relevant to the three part question. A full text of one paper was not able to be accessed, 1 paper was a letter rather than clinical study and 1 paper was not relevant on review of the full-text leaving 10 papers for review.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Auija et al 2019 United Kingdom	Adults with acute achilles tendon rupture managed non-operatively	2b Prospective Cohort Study	Achilles Tendon Rupture Score (ATRS)	ATRS score 75.5/100 after 23 months following functional bracing treatment. Statistically significant reduced calf muscle girth and heel raise height in affected leg (compared with unaffected leg).	No control group or comparison. Main outcome of achilles tendon rupture score was never defined or elements described. High loss to follow up of almost 50%.
Philip Ellison, Lyndon William Mason 2017 United Kingdom	Case series of 10 patients managed conservatively with acute achilles rupture	4- Case Series	Tibiotalar angle(TAA) and Tibio-first metatarsal angle (1MTA) on X-Ray of patients in equinus cast and 2 different devices, a fixed angle walking boot into which wedges are inserted to position the foot in equinus (FAWW) and an adjustable external equinus system (EEB)	Equinas was being created by mid-foot flexion. TAA and 1MTA were greater in the EEB group.	No blinding of assessors or measuring of X-Ray angles. No clinical outcomes.
Maempel et al 2020 United Kingdom	Suspected achilles tendon rupture <2 weeks in 16-60yr old patients. Previous re-ruptures excluded. Randomised to conventional non-weight bearing equinus cast or functional walking boot with heel raise.	2b Randomised Control trial (single-center, unblinded	Main outcome - Short Musculoskeletal Functional Assessment Score (SMFA). Others included ATRS, Foot and Ankle Questionnaire (FAQ), calf circumference and ankle Range of motion.	There was a statistically significant reduction in all scores (SMFA/ ATRS/ FAQ) at 6 month follow up favoring the boot group over the cast group but no statistically significant difference between groups at 1 year follow up. For clinical outcomes (calf circumference, ankle range of motion and single/ double heel raise) there was no difference between cast and boot groups at 6 month and 1 year follow up	Lack of blinding and single center study make the trial prone to bias with higher loss to follow up in cast group potentially introducing error into results
Nash et al 2005 Australia	Patients with acute limb injuries treated with cast immobilisation or early mobilisation	3a Systematic Review of studies with significant heterogenecity in patient populations and interventions	Patient centered outcomes and functional outcomes in 49 trials comparing cast immobilsiation to early mobilsiation	Early mobilisation showed improved clinical outcomes (pain/ swelling) and improved functional outcome scoring in most trials	Large volume of heterogenecity in trials with lack of any statistical detail, not specifically applicable to any specific patient group with the wide variety in patient presentations/ pathology
David R W MacDonald, David Neilly , Joseph Littlechild, Fraser Harrold, Sam C Roberts 2018 United Kingdom	Conservative treatment: equinus cast vs rigid boot	1b- Randomised Control Trial	TTA, TMA and PCH angles in equinus vs heel raised rigid boot	Equinus cast provides greater degree of equinus than rigid boot and the two methods of immobilisaiton should not be used interchangeably	Small population (27 patients), did not give clear clinical recommendation as to which option is better for functional rehab protocols
Felix Neumayer, Elyazid Mouhsine, Yvan Arlettaz, Gérald Gremion, Michael Wettstein & Xavier Crevoisi 2009 Switzerland	Acute achilles tendon rupture within 10 days from rupture. 57 participants	2b (prospective non-randomised study)	5 year follow up using Leppilahti ankle score (+ 1st 30 patients had additional clinical examination and cybex muscle testing at 6 & 12 months - measuring speed, maximal and endurance power)	Average modified Leppilahti Ankle Score was 56.8 +/- 14.9. Dynamic cast is a good alternative to surgery, early ankle mobilisation equates to good functional results. Cybex muscle testing - 70% speed power, 75% maximal power, and 70% endurance power at 6 months, increasing to 92%, 90% and 90% at 12 months.	No direct comparison of alternative treatment.
Tobias M Hufner, Dirk B Brandes, Hajo Thermann, Martinus Richter, Karsten Knobloch, Christian Krette 2006 Germany	Functional non-operative treatment of 125 patients from 1990-96 who had an acute rupture and met specific US criteria	2b- Retrospective cohort study	Compilation of subjective (pain, strength & activity level pre and post injury) and objective (function – Range of movement in ankle joint and strength - active plantar flexion) measures scored on a 100 point scale.	65.6% had normal objective and subjective strength, 34.4% had reduced. 74% reported good or excellent outcomes, 6.4% re-ruptured.	Did not use a measurement device to evaluate strength. No comparisons were made in this study about functional vs equinus casting vs operative.
S Karkhanis, H Mumtaz, N Kurdy 2010 United Kingome	107 tendons (106 patients) undergoing non-operative management with air cast boot between Oct 03 & Mar 08	2b- Retrospective cohort study	ATRS for long term outcomes and review of case notes to establish report of clinical healing	Average ATRS of 21/100, 77% returned to pre-injury activity levels, 2 patients had non-healing tendons therefore were operated on, 2 cases of partial re-rupture, 4 patients had tendon lengthening. 98% of total cohort reported clinical healing.	Only 56/107 ATRS survey responses (via post), therefore significant loss to follow up.
Matthew L Costa, Juul Achten, Ioana R Marian, Susan J Dutton, Sarah E Lamb, Benjamin Ollivere, Mandy 2020 United Kingdom	540 acute first-time achilles tendon ruptures, 16 & over, <14 days from injury, only included patients opting for non-operative management	1b- Prospective, multicentre Randomised control trial	Primary outcome - ATRS at 9 months. Secondary outcomes - ATRS at other time points, health-related quality of living (EQ-5D-5L), complications (DVT, PE, re-rupture, fall +/- injury, pain under heel, numbness around foot, pressure sores)	No statistical difference in ATRS between groups at 9 months. Plaster cast = 74.4, Functional Brace = 72.8. Adjusted difference between groups -1.38. Tendon re-rupture of 6% (n=17) in cast group, 5% (n=13) in functional brace.	21 patients changed their random allocation (cast to brace).
Wenli Dai, Xi Leng, Jian Wang, Xiaoqing Hu, Yingfang Ao 2021 China	8 Randomised control trials, with a total of 978 patients	1a- sysetmatic review and meta-analysis	Primary outcome measure = rate of achilles tendon re-rupture. Secondary outcomes = functional and quality of life outcomes, return to sports and work, complications (excluding tendon re-rupture) and resource use.	Early weight-bearing (with and without) functional ankle motion had similar re-rupture rates compared to ankle immobilisation without weight bearing. No significant difference in return to work and sports, functional outcome or complication rate between the groups. Cost of £1087 in the early weight bearing group compared to £1181 in the immobilsation group.	Individual studies used different types of orthosis and casts. Studies lacked homogeneity regarding the type of work and type of sports measured. Studies used different definitions of early mobilisation. Some outcome measures (ATRS & EQ-5D-5L) were only used in a limited number of studies, therefore type 2 error may have occurred.

Comment(s)

Achilles tendon rupture is a debilitating injury affecting mostly young, active individuals. The traditional management of Equinus casting and immobilisation is disruptive to the typical lifestyle of those affected. The above papers demonstrate similar functional outcomes and re-rupture rates in both groups, with some suggesting that early mobilisation is beneficial. No papers reported worse outcomes in the functional bracing cohort.

Clinical Bottom Line

Both Equinus casting and functional bracing produce similar outcomes, therefore patient choice, comfort & impact on activities of daily living can be considered when choosing the appropriate treatment option.

References

1. Randeep S. Aujla, Shakil Patel, Annette Jones, Maneesh Bhatia Non-operative functional treatment for acute Achilles tendon ruptures: The Leicester Achilles Management Protocol (LAMP) Injury 995–999
2. Philip Ellison, Lyndon William Mason Early Protected Weightbearing for Acute Ruptures of the Achilles Tendon: Do Commonly Used Orthoses Produce the Required Equinus? The Journal of Foot & Ankle Surgery 2017; 960–963
3. Julian F. Maempel, Nick D. Clement, Andrew D. Duckworth, Oisin J.F. Keenan, Tim O. White A Randomized Controlled Trial Comparing Traditional Plaster Cast Rehabilitation With Functional Walking Boot Rehabilitation for Acute Achilles Tendon Ruptures The American Journal of Sports Medicine 2020; 2755–2764
4. Nash CE, Mickan SM, Del Mar CB, Glasziou PP. Injured Limbs Recover Better with Early Mobilization and Functional Bracing Than with Cast Immobilization Journal of Bone & Joint Surgery May 2005
5. David R W MacDonald, David Neilly , Joseph Littlechild, Fraser Harrold, Sam C Roberts Acute Achilles tendon rupture: Do cast boots produce adequate equinus when used for functional rehabilitation? Foot 2018; 1-4
6. Felix Neumayer, Elyazid Mouhsine, Yvan Arlettaz, Gérald Gremion, Michael Wettstein & Xavier Crevoisier A new conservative-dynamic treatment for the acute ruptured Achilles tendon Arthroscopy and Sports Medicine 2010; 363-368
7. Tobias M Hufner, Dirk B Brandes, Hajo Thermann, Martinus Richter, Karsten Knobloch, Christian Krettek Long-term results after functional nonoperative treatment of achilles tendon rupture Foot and Ankle International 2006; 167-171
8. S Karkhanis, H Mumtaz, N Kurdy Functional management of Achilles tendon rupture: A viable option for non-operative management Foot Ankle Surgery 2010; 81-86
9. Matthew L Costa, Juul Achten, Ioana R Marian, Susan J Dutton, Sarah E Lamb, Benjamin Ollivere, Mandy Maredza, Stavros Petrou, Rebecca S Kearney Plaster cast versus functional brace for non-surgical treatment of Achilles tendon rupture (UKSTAR): a multicentre randomised controlled trial and economic evaluation Lancet 2020; 441–448
10. Wenli Dai, Xi Leng, Jian Wang, Xiaoqing Hu, Yingfang Ao Rehabilitation regimen for non-surgical treatment of Achilles tendon rupture: A systematic review and meta-analysis of randomised controlled trials Journal of Science and Medicine in Sport 2021; 536-545