TREATMENT OPTIONS

Achilles tendon rupture is treated with a cast regimen, functional bracing, or surgical repair, based on whether the rupture is a partial or complete tear. When discussing the treatment options with patients, clinicians should provide details about the healing process, including length of time and success and failure rates. The etiology of the injury and the patient's health status are factors to consider when deciding on a treatment method. For example, an athlete who wants to return to sports quickly may decide to undergo a surgical repair. However, a person with multiple comorbidities, recent MI, or poorly controlled diabetes or a person who is a poor candidate for anesthesia may favor the cast regimen. In most cases, the dilemma is in determining whether the injury is a partial or complete tear.

Unfortunately, some patients may refuse both surgical repair and the cast regimen; opting to allow the injury to heal on its own. This approach is neither medically advised nor endorsed because the ends of the Achilles tendon must be in close proximity to encourage reattachment. The patient who chooses this option is advised that a poor prognosis is to be expected. The patient is instructed to use crutches and not to walk on the injured leg.

Immobilization with a short-leg cast that holds the foot in a slight plantar flexion is effective. However, the patient must wear the cast for approximately 3 months before a determination can be made that a good connection has occurred at the rupture site. The cast is changed every 3 to 4 weeks, sooner if the patient experiences problems with the cast. Complications are variable and include skin irritation at the pressure points, itching, circulation compromise, cast laxity, neuritis, and cast breakdown. Patients are advised to remain nonweight-bearing on the affected leg for at least the first 6 weeks of the treatment period. A functional brace, also known as a boot brace, is used either alone or in postoperative treatment.

Surgical repair of the rupture is superior to nonsurgical treatment because the risk of rupture recurrence is less with surgery.8 Surgical repair is also indicated for tears that are older than 2 weeks. A randomized controlled clinical trial compared minimally invasive treatment (n = 42 patients) with nonoperative treatment (n = 41 patients). The results of this study showed that risk of complications other than rupture recurrence were approximately 21% with minimally invasive surgical treatment versus 37% with nonoperative treatment by bracing. However, the study also showed that functional bracing had fewer overall complications than minimally invasive surgery.9 In addition, percutaneous surgery on the Achilles tendon has fewer intraoperative risks than an open procedure.10

Fibrin glue has been used since the early 1980s to repair ruptured tendons. A long-term study in Switzerland followed patients for an average of 12.5 years after surgical repair with sutures and with fibrin glue.3 The researchers found that fibrin glue yielded a stronger tensile strength at the rupture site of an Achilles tendon than did suture material. An additional advantage of fibrin glue is that it is less likely to cause tissue ischemia and disproportionate approximation of the Achilles tendon.3

During open surgery, an incision is made on the posterior lower leg. The fascia is dissected to expose the Achilles tendon. The ends of the ruptured tendon are reattached. The decision about whether to use nonabsorbable or absorbable, monofilament or polyfilament suture material is most often based on the preference of the surgeon performing the procedure. Gentle dorsiflexion and plantar flexion are used to assess the reattachment before closing the wound. The foot is placed in a splint or cast at 20° of plantar flexion—a greater degree of plantar flexion decreases vascular perfusion, which can lead to a poorly healing wound and tendon.11

The affected leg must be kept in nonweight-bearing status for 2 weeks. Walking on the leg too soon increases the risk of rupture recurrence. At the first follow-up visit, the superficial sutures or staples are removed and the foot is placed in a new cast—a rigid orthosis or functional brace, such as a foam boot walker (Cam walker)—for 4 to 6 weeks with weight bearing as tolerated. The Achilles tendon is allowed increased dorsiflexion with each splint or cast change to allow for a gradual return to a neutral foot position.8,12 In general, casts and splinting materials are routinely changed every 2 to 4 weeks. A heel lift, which is a small foam pad placed inside the boot, is often used to offload the Achilles tendon during standing and walking.13 Patients are instructed to avoid walking without the boot walker until their physician expressly tells them they can walk without it. Most patients need to use crutches during the first 4 to 6 weeks of the healing phase. One group of researchers found that postoperative use of a rigid splint that allowed for active mobile plantar flexion but limited dorsiflexion of the ankle promoted early range of motion.14
Stretching, applying ice and/or heat, walking, bicycle riding, and swimming are therapeutic, low-impact activities that help rehabilitate the leg. Surgical repair of the Achilles tendon does not require formal postoperative physical therapy; however, some patients may require it to strengthen the tendon. Physical therapy is used more often as an adjunctive treatment. Until muscle strength in the repaired leg is regained, patients will use the unaffected leg to assist in performing a heel raise with the repaired tendon. Therefore, muscle strength is measured by the patient's ability to perform a single-heel raise with the repaired tendon. Patient strength progresses to a double-heel raise at 7.5 to 8 weeks after surgery, and a singleheel raise at 12 weeks after surgery.15

Surgeons in the United Kingdom developed a minimally invasive technique for repairing chronic ruptures of the Achilles tendon.16 They reconstructed the Achilles tendon using the semitendinosus tendon as the graft tissue. Study results showed that the semitendinosus is an effective graft for a large defect (6 cm or more) in the Achilles tendon.16 Another group of surgeons strengthened the Achilles tendon by grafting the flexor hallucis longus (FHL) tendon to it.17 In this study, the procedure is used to enhance a ruptured Achilles tendon or treat chronic Achilles tendinopathy. Follow-up was by MRI, and the FHL graft was found to be functioning well with the Achilles tendon.17

COMPLICATIONS

Adverse events from a rupture of the Achilles tendon include exacerbation of a preexisting condition, soft-tissue damage from the traumatic injury, infection, neuritis, poor wound healing at the incision site, and rupture recurrence.12 Preexisting conditions of greatest concern are Haglund's deformity, Achilles tendinosis, and a prior rupture on the affected leg. Patients experience soft-tissue swelling around the ankle, midfoot, and forefoot; neuritis around the ankle; and pain after an acute injury. Preoperative care includes elevating the foot and applying ice for 20 minutes three times per day, which can help reduce swelling. Patients who have excessive preoperative swelling will have more skin tension at the wound site when the wound is closed. This increases the risk of a poorly healing wound. Anti-inflammatories and/or pain medication may be prescribed for patient comfort. If immobilization therapy fails, surgery should be reconsidered.

Achilles tendon repair, as with all surgical procedures, has risks. Therefore, health care providers must take the time to explain to the patient the risks and benefits of surgery, especially the long recovery period. Infection is treated with antibiotics, rupture recurrence may warrant another surgical procedure, and most cases of postoperative neuritis resolve without interventions. Pressure sores and ulcers are prevented by moving regularly to avoid continuous pressure on one area for a prolonged period of time. Sural nerve deficits have been noted, and these may resolve over time.9 Most wound-related complications are caused by the anatomy of the skin at the posterior ankle. Specifically, skin tension is increased in the heel area. In addition, the skin is retracted for adequate visualization of the defect in an open surgical approach. Closing the wound can be problematic because the skin is delicate, and overstretching can compromise the vascular supply.

Patients must elevate the foot and apply ice to minimize swelling and reduce skin tension at the surgical site. Increased swelling in the ankle can leave small areas of the wound not fully approximated, which can delay wound healing and lead to infection and scarring, particularly after the sutures or staples are removed. Consequently, significantly fewer incisionrelated complications occur after a percutaneous procedure than occur after an open repair. If infection is a concern, oral antibiotics should be prescribed. Nevertheless, postoperative care of the surgical incision can be difficult, and patients must be educated on how to care for the wound and keep it clean in order to minimize the risk of infection.



PATIENT EDUCATION

Prevention of an Achilles tendon rupture is not always possible, especially in the case of a traumatic injury. Patient education is an essential part of preventing further injury, especially during the healing process. Stretching is an important factor when treating the Achilles tendon. Tight calf muscles, like other muscles in the body, are more susceptible to injury. Athletes and nonathletes should take the time to warm up and stretch. Sometimes injury occurs because a person resumed participation in a sport or exercise program after a long hiatus. In this case, the person should perform a runner's stretch against a wall. Unfortunately, some people will attempt to return to an original level of physical activity too soon and risk a rupture. Persons who cannot perform this stretch can use stretch bands or wrap a towel around the ankle and dorsiflex the foot from a sitting position to stretch the Achilles tendon. Although sometimes underrated as a treatment approach, nutrition is beneficial for bones and tendons as well. People should always consult their health care provider before beginning any exercise regimen.

Recovery from an Achilles tendon rupture is slow, and patients should be informed of the healing process. A detailed plan that meets the patient's expectations and goals can be worked out with the health care provider when the patient describes activities of daily life. With appropriate treatment, patients can have a positive outcome after repair of an Achilles tendon rupture. JAAPA

David Cary is an assistant professor in the physician assistant program at Nova Southeastern University, Orlando, Florida. He has indicated no relationships to disclose relating to the content of this article.

REFERENCES
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