SLR - November 2014 - Derrick McKay
Reference: Barfod, K. W., Bencke, J., Lauridsen, H. B., Ban, I., Ebskov, L., & Troelsen, A.. Nonoperative Dynamic Treatment of Acute Achilles Tendon Rupture: The Influence of Early Weight-Bearing on Clinical Outcome. The Journal of Bone & Joint Surgery. 2014, 96(18): 1497-1503.Scientific Literature Review
Reviewed By: Derrick McKay, DPM
Residency Program: Steward-St. Elizabeth’s Medical Center
Podiatric Relevance: Acute Achilles tendon ruptures are a common problem that foot and ankle specialists face. Conservative treatments, including those with dynamic rehabilitation, have been shown to have functional outcomes and rerupture rates comparable with those of operative treatment. The role of early weight-bearing with controlled early motion exercises has yet to be determined. The authors’ goal is to compare immediate weight-bearing with non-weight-bearing in a nonoperative dynamic treatment protocol for Achilles tendon ruptures.
Methods: The study was conducted as a blinded, randomized, controlled, parallel superiority trial. Sixty patients between the ages of 18 – 60 with Achilles tendon ruptures less than four days old were randomized into two groups. Both groups went through the same treatment protocol except one was allowed to weight-bear from day one. Both groups were placed in a plantarflexed boot with three, 1.5cm heel wedges. At week two, a wedge was removed and the patient was instructed to perform 25 foot raises with the leg hanging off the edge of a table five times a day. The patient was instructed to only remove the boot when performing the exercises. At week four another wedge was removed and the patient was to continue with the exercise protocol. At week six, the last wedge was removed, the patient was to continue with the exercise protocol and may remove the boot to sleep. In weeks 9 – 16 the patient was rehabilitated by a team of physiotherapists with gradual return to activity with full return to contact sports after one year. Follow up consisted of 6 and 12 month clinical visits with all assessors being blinded to which treatment protocol the patient followed. The primary endpoint was the Achilles tendon Rupture Score (ATRS), with secondary endpoints of heel-rise work and height, rerupture, duration of sick leave and quality of life during treatment.
Results: One patient in the weight-bearing (WB) group and three patients in the control group were excluded from the one-year analysis due to various reasons. The ATRS did no differ significantly between the WB and control groups (73.4 and 74.4 respectively) but did improve significantly in both groups between the 6 and 12-month mark. Heel-rise work and height were slightly better in the WB with p values of 0.37 and 0.44 respectively. The WB group had three (10 percent) reruptures and the control group had two (7 percent). Duration of sick leave remained similar between the two groups at 52-days with the WB group and 58-days with the control group. The quality of life during treatment was significantly better in the WB group with a p value of 0.009.
Conclusions: While the quality of life during treatment was significantly better for the WB group, the ATRS scores, functional outcomes and rerupture rate did not differ significantly. Immediate weight-bearing with non-operative treatment of acute Achilles tendon ruptures can be used as a treatment option for conservative care with controlled dynamic range of motion exercise. A number of meta-analyses have shown significantly lower rate of rerupture and a significantly higher rate of other complications among surgically treated patients. Taking patient goals, co-morbidities and lifestyle remains paramount in determining the best possible treatment plan per individual patient. If treating acute Achilles tendon rupture conservatively, allowing early weightbearing with controlled dynamic range of motion can significantly improve the patient’s quality of life without undermining treatment goals.