You have a Ruptured Achilles Tendon – What options do you have for treatment?
There has been a debate in medicine lasting many decades about the benefits of surgery vs conservative treatment of a ruptured tendon. Initially the surgery required a large scar which posed risks of post-op infections. The alternative was plaster casting with pointed toes and allow the tendon to heal over a period of 3 months. This lead to a large lump in the tendon and quite often a not particularly strong repair. This also lead to very weak calf muscles and a stiff ankle. Both techniques have improved dramatically.
In this post I explain the healing process for a tendon and why this is important for an Achilles Rupture.
It is quite a technically complicated article but I have tried to make it easy to understand.
Basically you have two options:-
- NO SURGERY
There a several variations on the surgery and post-surgical care available see Surgical Repair of Achilles Tendon Rupture
There have been great advances in the non surgical treatment of ruptured Achilles over the past 30 years.
This extract is taken from a medical journal in 1979 “Twenty patients with total rupture of the Achilles tendon were treated by immobilisation in plaster in the gravitation-equinus position (foot down) for eight weeks. After removal of the plaster, seven patients had a re-rupture, four of whom were treated by operation, whilst two others sustained a deep vein thrombosis (blood clot).
At follow-up, 16 patients had no complaints and the remaining four had only minor problems. The range of motion in the ankle joint was normal in all patients and the strength in the affected calf was restored to normal in the majority. Because of the high complication rate we consider plaster treatment inferior to surgical treatment of Achilles tendon rupture.”
THAT WAS 30 YEARS AGO
However in 2009 this was published:
One hundred patients were randomly assigned to surgery with early mobilisation or to early mobilisation alone with the removable orthosis and without prior surgery.
In every other respect, all the patients in the study had the same treatment.
The thesis shows that there is no difference in the re-rupture rate.
A year after the injury, there was no difference in the patients’ own impression of symptoms and function,
but irrespective of which treatment the patient received, the function tests showed that there remained a substantial difference between the healthy and the injured foot.
“I have concluded that not everybody needs to have surgery, but it is important that those who suffer an Achilles tendon rupture discuss the treatment options with their orthopaedic
surgeon,” says surgeon Katarina Nilsson Helander
The key difference in the 30 years between the two articles is the phrase “early mobilisation alone with the removable orthosis”
There is a picture of one of these orthoses opposite.
This is a removable boot which is set to control the amount of ankle movement that can take place.
This allows the tendon to be protected as it heals but also allows it to be progressively stressed.
Stressing the repair site improves the quality of the scar which results in a better and more functional tendon.
For more on Tendon Healing click here
Relevance of Tendon Healing
It is the early mobility and then gradually stressing the healing tendon that has resulted in the dramatically reduced recovery times from a ruptured Achilles tendon. This applies to the surgically treated patients as well.
The secret of effective rehab is to apply the appropriate amount of stress – enough to encourage this alignment of the cells and fibres of the tendon. Applying too much stress at the wrong time results in re-rupture of the healing tendon.
Wearing the orthosis pictured above allows for the early application of these stresses which produce the excellent results now being achieved.
What Decision Do You Make?
That depends on your Doctor and their preferences although you should have input to the decision making. If you are serious about your sports then I would suggest that the Surgical approach is more likely to allow an earlier return to sport and probably with less calf muscle wasting. This is because you can start your rehab earlier after the surgery option.
However having said that, the results with non-surgical repairs are so good now that this option is becoming much better and there are none of the risks associated with surgery.
I just hope that you don’t have to make the decision!
If you do – good luck with whatever option you choose.
Other Achilles Related Posts
Anatomy of the Achilles Tendon
Achilles Tendon Rupture
Surgical Repair of Achilles Tendon Rupture
David Beckham's Achilles Tendon Rupture
Calf Exercises - Achilles Tendon Stretches
Function of the Achilles Heel Tendon