What are treatment options for an Achilles tendon rupture?
In general, for complete tear of the tendon, surgery is recommended. For partial tears, nonsurgical treatment is recommended. However, the selection of treatment depends on the patient, age, level of activity, and other risk factors.
Surgery for Achilles tendon rupture is now routine and well established. Surgery is generally suggested for the young, healthy and active individuals. For athletes, surgery is often the first choice of treatment. The Achilles tendon can be repaired surgically by either a closed or open technique. With the open technique, an incision is made to allow for better visualization and approximation of the tendon. With the closed technique, the surgeon makes several small skin incisions through which the tendon is repaired. Irrespective of type of treatment, a short leg cast or postoperative boot is applied on the operated ankle after completion of the procedure (picture 3).
Picture 3 shows the type of casts used to treat Achilles tendon injury.
The advantages of a surgical approach includes a decreased risk of re-rupture rate (0%-5%); the majority of individuals can return to their original sporting activities (within a short time), and most regain their strength and endurance.
Disadvantages of a surgical approach include hospital admission, wound complications (for example, skin sloughing, infection, sinus tract formation, sural nerve injury), higher costs, and hospital admission.
Nonsurgical method is generally undertaken in individuals who are old, inactive, and at high-risk for surgery. Other individuals who should not undergo surgery are those who have a wound infection/ulcer around the heel area. A large group of patients who may not be candidates for surgery include those with diabetes, those with poor blood supply to the foot, patients with nerve problems in the foot, and those who may not comply with rehabilitation.
Nonsurgical management involves application of a short leg cast to the affected leg, with the foot in a slightly downward flexed position. Maintaining the ankle in this position helps appose the tendons and improves healing. The leg is placed in a cast for six to 10 weeks and no movement of the ankle is allowed. Walking is allowed on the cast after a period of four to six weeks. When the cast is removed, a small heel lift is inserted in the shoe to decrease the stress on the Achilles tendon for an additional two to four weeks. Following this, physical therapy is recommended.
The advantages of a nonsurgical approach are no risk of a wound infection or breakdown of skin and no risk of nerve injury.
The disadvantages of the nonsurgical approach includes a slightly higher risk of Achilles tendon rupture and the surgery is much more complex if indeed a repair is necessary in future. In addition, the recuperative period after the nonsurgical approach is more prolonged.