The Achilles tendon (also known as the heel cord or calcaneal tendon) is a strong, fibrous band of tissue that connects the calf muscles (gastrocnemius, soleus, and plantaris) to the heel bone (calcaneus). These muscles, acting via the tendon, cause plantar flexion of the foot at the ankle, and (except soleus) flexion of the knee. Rupture of the tendon can occur in anyone, but is commonly seen in landing athletes (ex. basketball players) and “weekend warriors”. If your Achilles tendon ruptures, you might hear a pop, followed by an immediate sharp pain in the back of your ankle and lower leg that is likely to affect your ability to walk properly.
It was previously believed that a rupture of the Achilles was best treated surgically. However, more recently, the management of Achilles tendon ruptures has fallen under the spotlight with multiple studies comparing the effectiveness of non-operative management to surgery, with conservative management coming out either on top or equivalent to surgery in many cases.
Of particular note, a revolutionary study by Willitis et al. from the University of Western Ontario (JBJS 2010) – Dr. Dold’s alma mater – looked specifically at operative versus non-operative treatment of acute Achilles tendon ruptures, while following a strict accelerated functional rehabilitation protocol to manage the non-operative group. This was a level 1, prospective, randomized trial comparing the two treatment options. The result of this study showed that all measured outcomes of non-operative treatment (re-rupture rate, post-operative strength, the Leppilahti score, range of motion, and calf circumference) were acceptable and were clinically similar to those for operative treatment.
Furthermore, all of the potentially serious adverse effects of surgery were avoided by treating the injuries non-operatively. Various other studies have been published since this trial. Some show an increased re-rupture rate with non-operative treatment, while others show no difference in the majority of outcome measures.
If you’re interested in listening to Dr. Dold discuss the management of Achilles tendon ruptures, find it here:
Recover With Purpose Podcast – Dr. Andrew Dold – Achilles Tendon Rupture.
- Sudden onset of sharp pain in the heel and back of the calf.
- Patient usually reports a audible “pop” after landing on the affected leg.
- Weakness and difficulty walking after the injury.
- Pain and swelling in the heel area after the injury
- Non-operative management options:
- Accelerated functional rehabilitation protocol
- Platelet-Rich Plasma (PRP)
- Bone Marrow Aspirate Concentrate (BMAC)
The decision on whether to manage an acute Achilles tendon rupture conservatively or with surgery depends on a number of important factors. These include:
- Patient factors (age, activity level, medical comorbidities, etc.)
- Injury factors (open vs. closed injury, gap between tendon ends, complete vs. partial tear)
Many studies have emerged recently trying to predict factors associated with positive outcomes after conservative management of these injuries. One important factor to consider is the gap between tendon ends, as elongation of the repaired tendon and muscle length is reported to produce inferior functional results, as illustrated by this study. The gap between tendon ends after a rupture can be broadly assessed on physical exam, but is best appreciated with an MRI or ultrasound with the ankle in a plantar flexed position. Dr. Dold will generally order one of these studies for patients with an acute rupture to better assess the injury and predict the likelihood of successful non-operative management.