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Issue 10

Table of Contents

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Lower re-rupture rates but higher complication rates following surgical versus conservative treatment of acute achilles tendon ruptures: a systematic review of overlapping meta-analyses.

Dr. Cody Misuraca PT, DPT

Key takeaways:
  1. Surgical management for Achilles tendon rupture results in lower re-rupture rates
  2. Non-surgical management carries lower risk of non-re-rupture complications
  3. “Early” non-surgical management doesn’t increase re-rupture risk compared to “late” non-surgical management
  4. “Early” and “late” non-surgical management seem similar for return to work and sport
  5. “Early” non-surgical management seems to result in higher satisfaction and QOL than “late”

 

Managing the rehabilitation process for Achilles tendon ruptures can be intimidating for many clinicians, especially students and new graduates. I remember working with my first case of Achilles tendon repair as a PT student during a second year clinical rotation and being nervous every week I saw them that I would push it too hard and cause the repair to fail.

The Achilles tendon is built to transmit loads up to 6-8 times bodyweight during running, so the thought of how a long-term deficit in Achilles function would hinder even basic leg function, let alone participation in any athletic pursuit, made me quite hesitant.I was intrigued a year later during a third year rotation when I worked with my first patient who had opted for non-operative “functional rehabilitation,” which in some cases involves beginning to partially weightbear in a boot with heel wedges as early as 2 weeks following the initial injury.

Can the Achilles really heal without surgery? Is it just being held together by scar tissue? Won’t it snap like an old crusty rubber band the second you go back to running on it? Fast forward to now, seven years into my career as an orthopedic and sports physical therapist, and I’ve worked with nearly every combination of operative approach and rehab pace you could think of for Achilles tendon rupture. Managing rehab for Achilles tendon ruptures doesn’t make me nervous like it did years ago, but the decision making process for choosing operative vs non-operative treatment for Achilles tendon ruptures remains interesting to me.

Enter this month’s Research Review article, a systematic review of meta-analyses comparing outcomes of surgical and non-surgical interventions for Achilles tendon rupture. Specifically, this review focused on complications such as re-ruptures, infections, nerve injuries, etc. This systematic review compiled an impressive amount of data, ultimately identifying 34 meta-analyses that were relevant to the topic, with the number of studies included in individual meta-analyses ranging from 2 to 29.

Because of the broad scope offered by including that many studies, it can be difficult to apply the overall results of this review to very specific patient populations, but the results probably do generalize pretty well to the overall group of “people with Achilles tendon ruptures.” Overall, the authors found that the rate of re-ruptures was significantly lower in surgically-treated Achilles tendon ruptures when compared to non-surgical interventions – the rate of re-rupture ranged from 2.3-5% for surgical treatment and 3.9-13% for non-surgical treatment. They also examined outcomes for “early” and “late” non-operative rehab. The definition of “early” vs “late” rehab in this review was somewhat vague, so I pulled the full-text versions of the included meta-analyses on non-operative interventions.

I found that the most aggressive “early” rehab group allowed immediate full weight-bearing in a plantar-flexion orthosis, which is probably slightly more aggressive that what you will see in common “functional rehab” protocols for Achilles tendon ruptures. Regarding “late” rehab, participants remained non-weightbearing for as long as 6-8 weeks in the included studies, which is not too uncommon to see in more conservative non-operative cases. On the flip side, complications not including re-rupture were found to be significantly lower for non-surgical intervention than surgical intervention. This makes sense as non-re-rupture complications include things like infections and nerve injuries.

Achilles tendon ruptures commonly occur due to overload of the tendon during deceleration and change of direction tasks, as opposed to a penetration injury that would break the skin or cause damage to other tissues in the vicinity of the tendon; infection and nerve injuries are more likely to occur secondary to surgical intervention which does involve tissue penetration. It may be tempting to think that the wider range of re-rupture rates in non-surgical management is due to the pooling of “early” and “late” rehabilitation as one group. However, this review also compared complication rates for “early” and “late” rehabilitation and found no significant differences in re-rupture rates.

This was somewhat unexpected to me as I would anticipate that very conservative “late” rehab protocols would result in more deconditioning of the calf/Achilles musculotendinous unit, and that deconditioning would increase re-rupture rates in “late” rehabilitation compared to “early.” That said, it could be true that this occurs in some cases, and at the same time some cases in more aggressive “early” rehab protocols end up loading the tendon more quickly than it was ready to handle, resulting in an overall similar re-rupture rates when large groups are pooled together.

 

 

As rehab professionals the other kind of outcome we’re likely very interested in is rate of return to prior level of function (PLOF) and sports. Unfortunately, since this review was published in a surgical journal and primarily concerned with complication rates, return to PLOF and sport was not a primary outcome of interest.

I pulled up the original meta-analyses comparing “early vs “late” rehab and found that 4 of the 9 reported no significant differences in time to return to work or rates of return to sport (Ghaddaf et al, Zhang et al, El-Akkawi et al, Coopmans et al), and one meta-analysis found a faster return to prior level of sport for “early” rehab in 5 of the 6 individual trials (McCormack & Bovard). Additionally, 3 of the 9 included meta-analyses found higher rates of satisfaction and quality of life (QOL) in the “early” rehab groups compared to “late” rehab (El-Akkawi et al, Coopmans et al, McCormack & Bovard).

Overall, based on the current data that we have, it seems that “early” rehab does not increase the risk of re-rupture compared to “late” rehab. Risk of re-rupture is a fair bit higher generally with non-operative management, but there is a lower risk of non-re-rupture complications. We can’t confidently say that non-operative rehab with earlier weightbearing and range of motion (ROM) results in better outcomes than non-operative rehab that delays weightbearing and ROM, but we do have a decent amount of data indicating higher satisfaction and QOL in those who are in the “early” rehab groups.

Taken together, this has led to the conclusion in some of the included meta-analyses that if non-operative management is pursued, “early” rehab should be recommended due to similar functional outcomes to “late” rehab but with higher satisfaction rates and QOL. As with many things rehab-related, there isn’t a clear-cut “right” answer for how to best manage an Achilles tendon rupture. As rehab clinicians, having an understanding of the pros and cons of various management options allows us to provide education to our patients so they can engage in an informed decision-making process.

If surgical management is pursued, the discussion of “if” and “what kind of” operation is appropriate for an individual will take a lot of individual factors into account and necessarily involves the patient having a discussion with a surgeon as well. Hopefully, this research review helps to increase your knowledge base regarding management of Achilles tendon ruptures.

 

References:
  1. Seow, D., Islam, W., Randall, G.W. et al. Lower re-rupture rates but higher complication rates following surgical versus conservative treatment of acute achilles tendon ruptures: a systematic review of overlapping meta-analyses. Knee Surg Sports Traumatol Arthrosc 31, 3528–3540 (2023). https://doi.org/10.1007/s00167-023-07411-1

 

Cody Misuraca is a physical therapist and strength coach in Seattle, WA. He works as a sports physical therapist for a community hospital system and also owns Waypoint Strength and Performance LLC, which offers strength coaching services. The views and opinions expressed in this review are those of the writer and do not necessarily reflect the views or positions of any institutions he is associated with.