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Review Article
14(1) 67–81

Acute Achilles tendon rupture ! The Author(s) 2011

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DOI: 10.1177/1460408611415909
Rajpal S Nandra, Gulraj S Matharu and Keith M Porter

Achilles tendon rupture is a common sports-related injury, with the incidence of acute ruptures continu-
ing to increase. Achilles ruptures can be missed, or presentation may be delayed. Clinical tests assist
diagnosis, with the Thompson and Matles tests being the most sensitive and specific. Ultrasound provides
a valuable adjunct for diagnosing acute Achilles tendon ruptures. Traditionally, operative management has
led to lower re-rupture rates than conservative treatment, but surgery increases the risk of complications
such as adhesions and wound infection. More recently, however, non-operative treatment consisting of
early mobilisation and rehabilitation, produces comparable re-rupture rates and functional outcomes to
surgery. Percutaneous surgery may reduce the risk of operative complications, but needs to be more
widely practised. In the present review we discuss the anatomy, aetiology, mechanism of injury, clinical
assessment and investigations for diagnosing acute Achilles tendon ruptures. The debate regarding oper-
ative versus non-operative management is also considered.

Achilles tendon, acute rupture, non-operative, early mobilisation, re-rupture, operative treatment,

assessment, investigation and management of

acute Achilles tendon ruptures.
The Achilles tendon attaches the gastrocne-
mius and soleus muscle to the calcaneum, facil-
itating plantarflexion of the ankle joint. The
tendon is a common site for injury with the The Achilles tendon is considered a machine
incidence of Achilles tendon-related morbidity with multiple moving parts (fibrils, fibres and
presently rising. The tendon is subject to the fascicles) that perform the basic function of
largest loads in the body, especially during
running and jumping. These repetitive forces
render the Achilles tendon susceptible to Department of Trauma and Orthopaedics, University Hospital
injury. Birmingham NHS Foundation Trust, Queen Elizabeth Hospital,
Birmingham, UK
Although acute Achilles tendon rupture is a
frequent form of injury, the management of this Corresponding author:
Rajpal S Nandra, Queen Elizabeth Hospital Birmingham,
condition remains a subject for debate. In the University Hospital Birmingham NHS Foundation Trust,
present review, we discuss the anatomy, inci- Mindelsohn Way, Birmingham B15 2WB, UK.
dence, aetiology, mechanism of injury, clinical Email:
68 Trauma 14(1)

force transfer to and from the skeleton during fossa (Rogers, 1992). Distal to the fossa, the
motion (Benjamin et al., 2006). It is the con- muscle lies superficially in the lower leg.
joined tendon of the gastrocnemius and the At mid-calf level, the muscle fibres converge
soleus muscle, which may have a small contribu- into a tough apneurosis, continuing distally as
tion from the plantaris muscle (O’Brien, 2005) the Achilles tendon and terminating at the pos-
and regarded as the largest and strongest tendon terior surface of the calcaneum. The tendon is
in the body. Direct measurement of force reveals approximately 15 cm long (O’Brien, 2005). Type
loading in the Achilles tendon as high as 9 KN I collagen formed by tenocytes, contributes up
during running, which is up to 12.5 times body to 80% of the tendon’s dry weight (Khan-
weight (Doral et al., 2010). Farooqui and Anderson, 2010), with an elastin,
The osteotendinous junction, or enthesis, con- proteoglycan and water amorphous ground sub-
centrates stress at a soft-tissue interface with stance (Kannus, 2000; O’Brien, 2005).
bone; this site is subsequently vulnerable to The vascular supply to the Achilles tendon is
injury (Benjamin et al., 2006). A variable insertion from the musculotendinous and osteotendinous
site of the Achilles tendon has been demonstrated junctions and adjacent connective tissue (Doral
on cadaveric specimens (Kim et al., 2010). et al., 2010). There are three separate vascular
Tendons insert on the superior 1/3 of the posterior territories. The mid-section of the tendon is sup-
calcaneum in 55% of specimens, 40% insert in plied by the peroneal artery, and the proximal
the middle of the posterior calcaneum and 5% and distal junctions by the posterior tibial artery
insert on the inferior 1/3. To dissipate stress, the (Chen et al., 2009). Intra-operatively, it is advan-
insertion is crescent shaped with medial and tageous to maintain the anterior tendon sheath
lateral projections, also referred to as fanning as it is the main access of the tendon’s blood
out (Doral et al., 2010). Biomechanically, the supply (Kelly and Stephens, 2000). At 2–6 cm
enthesis is a site for gradual change in properties. proximal to the enthesis is the least vascular
The progressive increase in stiffness and region, which is susceptible to degeneration
decreased elasticity from tendon to bone allows (Khan-Farooqui and Anderson, 2010). This
transfer of large forces without failure. watershed area is the commonest site for acute
Supplied by the tibial nerve (S1-2) the super- tendon rupture. To maintain vascularity surgical
ficial muscles in the posterior compartment of approach is via a longitudinal posteromedial
the lower leg (gastrocnemius, soleus, plantaris) incision. The skin, subcutaneous fat and parate-
facilitate plantarflexion of the ankle. Soleus lies non are incised longitudinally, avoiding the lat-
anterior and deep in the compartment, originat- erally placed sural nerve and short saphenous
ing from the soleal line. Figure 1 illustrates the vein (Kelly and Stephens, 2000).
origins, both the posterolateral aspect of the Sural nerve (S1 þ 2) injury incidence has
tibia and proximal 1/3 of the fibula with a been reported at 10–14% following percutane-
fibrous arch between the two bones (Rogers, ous repair (Webb et al., 2000) and thus repre-
1992) It is a postural muscle that is composed sents an important anatomical landmark. The
of slow twitch type I fibres (O’Brien, 2005), sural nerve is a cutaneous branch of the tibial
acting on the ankle joint to keep the body nerve. Its path has been illustrated in the
upright. As illustrated by the right knee model schematic Figure 2, with sensory fibres innervat-
in Figure 1, the two heads of gastrocnemius ing the lateral aspect of the calf and foot.
originate from the posterior surface of the Traditionally, the nerve descends lateral and ver-
distal femur, proximal to the medial and lateral tically. Webb et al. (2000), in an experimental
femoral condyles, deep to semimembranous and study, found the nerve to descend in the midline
biceps femoris fibres, respectively. The fibres proximally. At 16 cm proximal to the enthesis,
pass distally and converge, forming the infero- they report the nerve to be 10.4 mm medial to
medial and inferolateral borders of the popliteal the lateral border of the Achilles tendon. It
Nandra et al. 69

Figure 1. A model of the right knee joint, posterior view with the origins of the gastrocnemius, soleus and plantaris

meets the lateral border at a mean distance of The small saphenous vein ascends vertically
9.8 cm proximal to the enthesis and continues to adjacent to the sural nerve in a superficial, sub-
descend lateral to the tendon. At the enthesis cutaneous plane until perforating between the
itself, the nerve lies 18.7 mm laterally. After two heads of the gastrocnemius and draining
passing posterior and inferior to the lateral mal- into the popliteal vein. Majewski et al. (2006)
leolus, the sural nerve branches into the lateral performed a case control study of 84 patients,
dorsal cutaneous and lateral calcaneal nerves. concluding that primary exposure of the sural
70 Trauma 14(1)

Figure 2. Drawing of the lateral view right ankle and path of the Sural nerve. It initially descends vertically in the calf,
crossing the lateral border of the Achilles tendon proximally. It then passes posterior and inferior to the lateral

with a stab incision reduces the incidence of the tendon are possible, and stored energy can
injury during percutaneous surgery. be released during the appropriate phase of loco-
The Achilles tendon incorporates mechanical motion (Maffuli, 1999). The tendon also has a
enhancements to optimise its elasticity and deep retrocalcaneal bursa reducing friction
function. The fibres of the tendon spiral clock- between itself and the calcaneum, lying between
wise through 90 during its descent, such that the the tuberosity on the posterior surface of the cal-
fibres that lie medially in the proximal portion caneum and Achilles tendon. It is present at
become posterior distally (O’Brien, 2005). In birth, thick-walled sac, wedge-shaped, appearing
this way, elongation and elastic recoil within like a horseshoe on cross-section (O’Brien, 2005),
Nandra et al. 71

Between the Achilles tendon and the posterior plantarflexion or ‘push off’ are most susceptible
tibia and the upper calcaneum lies Karger’s tri- to sustaining this injury. Jozsa et al. (1989) stud-
angle, where the Achilles is separated from deep ied the role of recreational activity in 292 cases
flexors and many nutrient vessels lie (O’Brien, of acute Achilles tendon ruptures and reported a
2005). Encapsulating the tendon is a synovial- higher incidence in sports such as football, bad-
type membrane. This paratenon facilitates free minton, tennis, running and gymnastics. Acute
gliding movement against the epitenon and sup- Achilles tendon rupture is now increasingly
ports the metabolic demands of the tendon with affecting individuals participating in occasional
nutrient blood vessels. recreational sports and gym activities. It has
been estimated that 62.3% of acute ruptures
now occur in professional, white-collar workers
Incidence (Suchak et al., 2005) (Maffuli et al., 1999). Risk
The incidence of acute Achilles tendon rupture factors can be intrinsic, including deformities
has been estimated to be between 7 and such as tibia vara, an overly pronated foot,
13/100,000 per year (Levi, 1997; Cretnik et al., tight or underdeveloped hamstrings, a high
2010). In Finland, the incidence has increased arched (cavus) foot, or extrinsic such as inade-
6-fold between 1979 and 1994, with a peak inci- quate training shoes and training techniques
dence of 18/100,000 per year in 1994. (Leppilahti (McLauchlan and Handoll, 2001).
et al., 1996). Recent increases in recreational sport Studies from 1958 identified degenerative
and exercise participation has led to an increasing changes and collagen alteration in ruptured
incidence of this particular injury. The incidence is Achilles tendons (Arner et al., 1958; Davidson
highest in the 30–39-year age group (Leppilahti and Taunton, 1987). In the great majority of spon-
et al., 1996). Acute Achilles tendon rupture is taneous tendon ruptures, chronic degenerative
between 5.1 and 16.7 times more common in changes are seen at the rupture site of the tendon
males (Leppilahti et al., 1996) (Cretnik et al., (Jarvinen et al., 1997). In 1997, a histological anal-
2010). Up to 75% of acute injuries can be attrib- ysis of 1000 spontaneously ruptured Achilles ten-
uted to sports activity (Khan-Farooqui and dons was done which only estimated specific
Anderson, 2010). Thus, with an increasingly systemic conditions to attribute to 2% of patho-
ageing population which remains active in later logical alterations. Degenerative changes were
life, the incidence of acute Achilles tendon rupture responsible in the majority (Jarvinen et al.,
is likely to continue increasing. 1997). Jarvinen et al (1997) reported 865 of 891
(97%) tendons had signs of degeneration, com-
pared to 149 of 445 (33%) control tendons.
Aetiology and mechanism of injury Acute rupture has been demonstrated to be
The aetiology of acute Achilles tendon rupture is more common in abnormal tendons (Arner
multifactorial with biomechanical influences, et al., 1958).
degenerative changes and iatrogenic causes. Biomechanical properties, such as viscoelastic-
Achilles tendinitis is a recognised risk factor ity and tensile strength, are integral to tendon
for acute tendon rupture and one of the most function and attributable to elastin and collagen
common injuries in sports, accounting for fibres and their metabolism. Systemic conditions
6–17% of all running injuries (McLauchlan and local disease have been implicated here as
and Handoll, 2001). Over time, patient demo- contributing to acute ruptures. These ruptures
graphics for acute Achilles tendon rupture are seen more frequently in individuals
have changed. Previously, 80% of acute rup- with blood group O and in those with gout, syste-
tures were in high-level athletes (Jozsa et al., mic lupus erythematosus, rheumatoid arthritis
1989; Leppilahti et al., 1996). In particular, ath- and ankylosing spondylitis (McLauchlan and
letes participating in sports demanding forceful Handoll, 2001; Ufberg et al., 2004). The use of
72 Trauma 14(1)

fluoroquinolone or steroid therapy is also often tendon rupture. However, 25% of ruptures are
linked to Achilles tendon rupture, with a particu- missed due to insignificant injuries, vague symp-
larly high risk among individuals aged 60 years or toms and inadequate clinical assessment
older who are taking corticosteroid (Ufberg et al., (Mathieson et al., 1988; Ufberg et al., 2004). In
2004). The anti-inflammatory properties of corti- addition, patients self-diagnose ankle sprains
costeroids are beneficial for treating degenerative which delays presentation and may adversely
musculoskeletal disease; however, they have a affect treatment outcomes. Table 1 lists the
delayed healing effect and direct necrotic action common differentials, with key diagnostic
on tendons (Kennedy and Baxter Willis, 1976). indicators.
Similarly, Fluoroquinolones cause tendinopathy Patients commonly sustain the injury during
(Melhus, 2005) by altering the cytoarchitecture sporting activity, when jumping or pushing off.
of tendons. The British National Formulary They will describe a precipitating incident result-
2008 safety reporting authority advises patients ing in a feeling similar to being hit or kicked on
to stop medication when tendon pain or inflam- the back of the heel. Sometimes patients will
mation develops whilst taking Fluoroquinones. report hearing a popping or snapping sound
Their use triples an individual’s risk of Achilles as they fall onto the ground (Leppilahti and
tendon rupture, but the incidence among users is Orava, 1998). Patients cannot return to the
reportedly low (Sode et al., 2007). activity, often walk with a limp, with minimal
The gastro-soleus complex contracts in an symptoms and pain. On examination swelling,
eccentric manner, allowing the muscle fibres to tenderness and weak plantarflexion are usually
lengthen as they contract to overcome an external observed with increased passive dorsiflexion.
force, as opposed to concentric contraction These clinical signs are subjective and variable.
where fibres shorten on contracting. This mecha- Subsequently, a number of clinical tests are used
nism dissipates energy, advantageous when to assess patients presenting with this mecha-
decelerating a plantar-flexed ankle. The elasticity nism of injury. These specialist tests aid accurate
of the tendon however is dependent upon elas- diagnosis and initiate appropriate treatment.
tin and collagen fibres, which degenerate with The Thompson test (Thompson and Doherty,
age. Collagen density and maximum diameter 1962) (Calf squeeze test or Symmonds test) is the
reduce. At 30–50 years of age, the degenerative most commonly used and sensitive test, which
process plays a role in the aetiology of tendon assesses the function of the congruent Achilles
rupture, particularly in active individuals tendon. Figure 3 illustrates the positioning and
(Sargon et al., 2005). It has been suggested that technique to perform the Thompson test. The
overuse and eccentric contraction during infre- patient kneels on a chair with feet extending
quent exercise causes fatigue and microtrauma beyond the chair edge. As the patient’s calf mus-
(Jarvinen et al., 1997). Deranged healing, a possi- cles are squeezed, the foot will plantarflex.
ble consequence of poor vascularity, manifests as Matles (1975) described a knee flexion test,
altered collagen cross-linking, Types II and III where the patient lies prone. The knees are
collagen deposition and tissue hypoxia (Jarvinen actively flexed to 90 with close observation of
et al., 1997). It is now considered that rupture is the feet. The ipsilateral foot will remain in neural
an end-point of this degenerative process which position or dorsifelxed if the tendon is ruptured.
has been noted in patients after 30 years of age This test is useful in delayed presentations,
(Sargon et al., 2005). where a healing haematoma may give false neg-
ative results with Thompson test and gap palpa-
tion. Maffulli (1998) demonstrated that both the
Clinical assessment
Thompson and Matles tests are significantly
A focused history and clinical examination is more sensitive than other methods used (0.96
usually sufficient to diagnose an acute Achilles and 0.88, respectively).
Nandra et al. 73

Table 1. Common diagnosis to be considered when suspecting acute Achilles tendon rupture and the key differ-
entiating indicators

Differential diagnosis Symptoms Signs Investigation

Achilles tendinopathy Morning pain and Focal tenderness, Doppler

stiffness. Related thickening and nodularity ultrasound scan
to exercise of the tendon
Medial gastrocenemius Pain, swelling and Tender, palpable defect medial
tears (tennis leg) bruising medial calf gastrocnemius, ve
Thompsons test.
Calcaneal avulsion History of trauma Swelling, pain, difficulty Plain radiographs/
fracture weight-baring computer-assisted
Bursitis Pain on walking, Side to side compression Plain radiograph to
wearing shoes anterior to Achilles rule out fracture or
tendon causes pain rheumatic disorders
Ankle sprain Throbbing pain on Swelling, focal tenderness
weight baring
Source: Leppilahti (1998) and Jozsa (1989).

Figure 3. The Thompson test. Normal examination on the left with plantarflexion present. Absence of
plantarflexion on the right suggests acute Achilles tendon rupture.
74 Trauma 14(1)

When examining the posterior surface of the sharply demarcated from surrounding tissues by
ankle, a palpable gap, or loss of continuity, a paratenon, which is a thin echogenic band pre-
when compared to the contralateral tendon, is sent on either side of the tendon (Hollenberg
found, the majority 2–6 cm proximal to the et al., 1998). Complete tendon tear in the trans-
enthesis (Hollenberg et al, 1998). Maffulli verse plane produces complete absence of
(1998) studied 174 patients to determine the pre- tendon fibres due to tendon retraction with pos-
dictive value of individual diagnostic tests. sible hypoechoic fluid distention of the synovial
Palpation of the tendon, although easily per- sheath (Jacobson, 1999). Partial-thickness or
formed, was the least sensitive of tests (sensitiv- longitudinal tendon tears appear as abnormal
ity 0.73, specificity 0.89). Despite this, clinicians hypoechoic or anechoic clefts typically within
feel a palpable gap on examination and positive an enlarged tendon surrounded by anechoic or
Thompson test is enough to diagnose acute hypoechoic fluid (Jacobson, 1999).
Achilles tendon ruptures. The Achilles tendon gives low signal intensity
The O’Brien’s (1984) needle test and on MRI. Any increase in signal intensity is
Copeland (1990) sphygmomanometer examina- deemed abnormal. T1 weighted scans will differ-
tion are discussed in the literature. In practice, entiate fat from haemorrhage and give high sig-
their use is limited by pain and discomfort. In nals at the rupture site. More commonly used
addition, they have lower sensitivities than the are T2 weighted scans providing the orientation
other specialised tests. of fibres, their condition and the size of the gap
When diagnostic uncertainty remains, a fur- between tendon ends. Literature is lacking for
ther clinical test may be utilised. A unilateral acute Achilles rupture; however, studies have
heel raise provides valuable clinical information. reported similar efficacy for both modalities in
Informed this may cause discomfort, the patient diagnosing chronic tendinopathies. Ultrasound
is asked to plantarflex the ipsilateral ankle (sensitivity 0.80, specificity 0.49) and MRI (sen-
against gravity fully weight bearing. Eliminating sitivity 0.95, specificity 0.50) (Khan et al., 2003).
the function of the plantaris, tibialis posterior, A study of 37 patients by Kälebo et al. (1992)
flexor hallucis longus and flexor digitorum compared pre-operative ultrasound with intra-
longus, which biomechanically are weak, plan- operative findings in patients with partial tears.
tarflexors and may mask tendon injuries. The With safe technique and reliable results they
heel raise requires soleus and gastrocnemius recommended the use of ultrasonography, with
integrity. A functional deficit here, whilst single a reported sensitivity 0.94 and specificity 1.00.
heel raising against gravity, isolates an injury to Historically, proximal partial ruptures are
the Achilles tendon, and can be a useful adjunct difficult to distinguish from tendinopathies
to the other tests described. (Kayser et al., 2005). MRI is able to provide
an unequivocal diagnosis, especially with T2
weighted images enhanced by intravenous con-
trast medium. MRI provides excellent multi-
As most acute Achilles tendon ruptures are diag- planar tissue discrimination with a high degree
nosed following clinical assessment, the use of of sensitivity to injury and its use in this scenario
imaging in diagnosing this condition is limited. is advantageous (Khan et al., 2003).
However, when diagnostic uncertainty remains, The fundamental benefit of ultrasound is
ultrasound and magnetic resonance imaging real-time imaging, and its ability to dynamically
(MRI) can be useful, particularly in partial rup- examine a joint or soft-tissue structure (Jacobson,
tures or delayed presentations. 1999). Successful non-operative treatment relies
With ultrasound, the normal internal archi- on apposition of the ruptured tendon ends,
tecture of the Achilles tendon demonstrates which can be assessed during ultrasound
regular parallel echogenic bands. The tendon is in equinus and dorsiflexion. Kotnis et al. (2006)
Nandra et al. 75

successfully used dynamic ultrasound case sel- patient can be immobilised or rehabilitated in
ection of 125 patients; 58 patients with tendon a functional brace.
gaps <5 mm in equinus were treated non-
operatively and 67 with gaps greater than 5 mm
Treatment outcomes
treated operatively. The authors concluded that
patients with demonstrable apposition of rup- Treatment goals are to restore plantarflexion
tured ends will have similar re-rupture rates trea- strength and return to pre-injury levels of activity
ted conservatively to those managed operatively. in sports and work. Literature to date has failed
If ultrasound demonstrates a residual gap to demonstrate a superior treatment modality.
between the stumps when the ankle is in 15–20 A meta-analysis of 5 studies comprising 421
of plantarflexion, non-operative management will patients in 2002 (Bhandari et al., 2002) reported
not succeed (Khan-Farooqui and Anderson, no significant difference in surgical patients
2010). Additionally, Ultrasound can identify returning to normal function (71%) compared
a disruption in the integrity of the paratenon, to those managed non-operatively (63%). An
a situation where adhesions are likely to form earlier meta-analysis, with 2 randomised control
(Hollenberg et al., 1998) causing chronic pain. trials and 17 case series studies found 80% of
Traditionally, grey-scale sonography is opera- patients achieving greater than 80% of their con-
tor-dependent for tendinopathies; authors such tralateral leg strength using either form of treat-
as Kayser et al. (2005) report a 100% detection ment (Lo et al., 1997). They found no evidence to
rate in acute partial ruptures. The advent of support a difference in strength, return to work
colour or power Doppler, which is less operator- (average 10 weeks) or return to sporting activity
dependent than grey-scale may improve efficacy (73% vs. 69.5%). Leppilahti et al. (1998) evalu-
further (Khan et al., 2003). Overall sonography ated functional outcomes, satisfaction and prog-
is readily accessible, cost-effective and non- nostic factors in 101 operatively treated patients.
invasive (Hollenberg et al., 1998). Introducing an innovative scoring system consid-
Authors report little clinical significance ering pain, stiffness, weakness, range of motion,
when comparing MRI and ultrasound scanning. subjective outcome and isokinetic strength. They
It is accepted that MRI provides excellent concluded an overall result of excellent in 34%
detailed images, whilst sonagraphy provides cases, good in 46%, fair in 17% and poor in 4%.
dynamic assessment and valuable additional More recently, a study by Wallace et al. (2004)
clinical information. As ultrasound modalities using an identical functional scoring system
improve, the demand for MRI is likely to assessed non-operative treatment. Allowing
reduce in the future for the assessment of these direct comparison against Leppilahti et al.’s
injuries. data. The study included 140 patients with pri-
mary acute ruptures, treated with cast immobili-
sation for 4 weeks, followed by functional
bracing for 4 weeks with active exercises. The
The management of acute Achilles tendon rup- average patient age was was 45, followed up for
tures is under debate, despite an increasing body a mean of 2.9 years. The authors report a mean
of evidence on treating this injury. Treatment loss of work of 1 week, with 98% returning to pre-
can be inconsistent between centres, with no uni- employment levels. The mean return to sport was
versally accepted guidelines available. Clinicians 8 weeks with 54% at less than their previous
have traditionally balanced the benefits of oper- activity level and 9% not returning to sport. In
ative intervention against the potential compli- comparison to Leppilahti et al., excellent out-
cations and morbidity from surgery. Treatment come was found in 56%, good in 30%, fair in
is either conservative or operative. Surgery 12% and poor in 2% (Wallace et al., 2004). The
is open or percutaneous. Post-operatively, the authors concluding conservative management
76 Trauma 14(1)

has superior outcomes. Reviewing both studies rates and complication rates reported in meta-
(Leppilahti et al., 1998; Wallace et al., 2004), analysis from 1997 to 2005. Historically, sur-
when comparing the injured and uninjured legs geons have favoured operative intervention to
following recovery, we note a similar increase minimise re-rupture rates and enhance recovery.
in passive dorsiflexion. However, a greater deficit Lo et al. (1997) reviewed literature from 1959
in plantarflexion strength in non-operative to 1997; due to a lack of evidence at the time,
patients was observed. Wallace et al. (2004) they only included two randomised controlled
states that this may be due to different patient trials. The meta-analysis was weighted towards
demographics, with (Leppilahti et al., 1998) treat- 17 case series studies. Of the patients treated
ing competitive athletes. Despite this the authors non-operatively, cast immobilisation was used.
felt that tendon lengthening and weakness is a Similarly, Bhandari et al. (2002) compared out-
consequence of the injury, not the treatment comes for operative and conservative treat-
modality, and conclude that preventing tendon ments, with all patients immobilised in a
lengthening should not be an indication alone plaster cast for 6–8 weeks. The meta-analysis
for surgical treatment (Wallace et al., 2004). included 6 randomised controlled trials and
Prior to this, smaller studies have investigated 448 patients. Despite a significantly lower re-
the advent of functional bracing on patient out- rupture rate in operative patients, the authors
comes. McComis et al. (1997) reported no signif- failed to construct any strong recommendations.
icant difference in strength but an increase passive Subsequently, Khan et al. (2005) published
dorsiflexion, as described in the larger studies a more robust meta-analysis which concurred
above. The authors suggest functional bracing with previous literature. The overall compli-
as an alternative to surgery, avoiding the risks cation rates, excluding re-rupture, were 34.1%
of immobilisation, reducing rehabilitation time following surgery compared to 2.7% with con-
and facilitating return to work and sporting activ- servative treatment (Khan et al., 2005). The
ity. Non-operative treatment can reduce hospital most common complications following surgery
admission and minimise the economic impact on are adhesion formation, altered sensation,
both the health care service and patient. wound infection and thromboembolism (Khan
and Carey Smith, 2010).
Post-operative rehabilitation and early mobi-
Operative versus non-operative
lisation is increasingly important with numerous
This is perhaps the most debated subject with studies implementing similar regimens. Wong
respect to Achilles tendon injury and remains et al. (2002) demonstrated a three-fold reduction
controversial, Table 2 summarises the re-rupture in complications following open surgery and

Table 2. Summarises the meta-analyses between 1997 and 2005. The re-rupture rate is significantly lower in
operative cases. However, the infection risk is greater, with Lo (1997) reporting a 20-fold increase in morbidly
following surgery

Re-rupture Wound complications

Conservative Operative Conservative Operative

Lo (1997) 11.7 2.8 0.4 10.4

Immobilised (Wong et al., 2002) 9.8 2.2 0 14.6
Mobilised (Wong et al., 2002) Not applicable 1.4 Not applicable 5.3
Bhandari (2002) 13 3.1 0 4–20
Khan (2005) 12.6 3.5 0 4
Nandra et al. 77

Table 3. Complications of operative management

Minor Major

Wound Superficial infection, haematoma, adhesions, Deep infection, chronic fistula

suture granuloma and skin necrosis
General Pain, sensory disturbance, suture rupture DVT, PE, tendon lengthening, death
Source: Maayke and Van Sterkenburg (2008).

post-operative mobilisation. Common complica- significance from this finding. The study
tions excluding re-rupture are listed in Table 3, strongly advocates accelerated rehabilitation
categorised into wound and generalised compli- and non-operative treatment, avoiding the seri-
cations. In 2010, the largest study to date, a ous complications associated with surgery.
multicentre randomised controlled trial includ-
ing 144 patients primarily assessed re-rupture
Percutaneous surgery
rates in operative and non-operative patients,
with secondary outcomes including Leppilahti Percutaneous surgery was introduced as a
score, isokinetic strength and complications minimally invasive procedure to reduce the asso-
(Willits et al., 2010). The trial included patients ciated morbidity of open surgery. The percuta-
up to 14 days post-primary rupture, randomis- neous technique was first described for the
ing to operative or non-operative management. repair of Achilles tendon ruptures using
Following initial treatment, patients underwent six stab incisions, a proximal Bunnell suture
identical accelerated rehabilitation. The major- and a distal stump box suture (Ma and
ity of acute ruptures occurred following recrea- Griffith, 1977). Notable meta-analyses report
tional activity, with an average age of 40 years. re-rupture rates of 3.6% (Wong et al., 2002)
The trial excluded patients with insulin-depen- and 2.1% (Khan et al., 2005) with significantly
dent diabetes mellitus and neurological or vas- reduced complications. In the latter study there
cular disorders undergoing medical treatment. were no wound infections reported. Bhandari
Rehabilitation protocol permitted protected et al. (2002) published a meta-analysis including
weight bearing for 2 weeks progressing to 94 patients, a complication rate of 8.3% and no
weight bearing as tolerated at 4 weeks. infections in percutaneous-treated individuals.
Wearing a functional boot for 8 weeks in total Sural nerve entrapment associated with percu-
is recommended. The authors reported three taneous surgery has been estimated as high as
ruptures in non-operative patients and two in 16.7% in six stab incision techniques (Wong
operative, all within 3 months of initial treat- et al., 2002; Khan et al., 2003) with an estab-
ment. At 2-year review, mean Leppilahti scores lished incidence of 10–14% (Webb et al.,
in operative 82.6  11.1 and non-operative 2000). The original technique has been modified
82.2  12.3 were comparable. Isokinetic strength and the procedure can be performed under local
analysis using a dynamometer, with comparison anaesthesia. Additionally, the outcomes are
of the non-injured side at increasing velocities now comparable to open surgery when consider-
of 30–245 per second, was performed at 1 ing re-rupture rates, with lower complication
and 2 years. All patients achieved >80% plan- rates (Cretnik et al., 2005). In view of the ana-
tarflexor strength and 100% dorsiflexion. The tomical risk with lateral incisions, a technique
operative group performed marginally better utilising three midline stab incisions, away
throughout, with a small but statistically signif- from the laterally situated sural nerve, has
icant result at 240 per second at 1 and 2 years. been successfully trialled in 26 patients (Webb
Willits et al. (2010) do not draw any clinical and Bannister, 1999). This study reported no
78 Trauma 14(1)

sural nerve injuries or re-ruptures in 26 patients these theories with an increasing evidence base
treated within 5 days of presentation. supporting non-operative treatment in all ages,
The Achillon device evolved from an innova- lifestyles and co-morbidities.
tive technique by Kakiuchi, using bent K-Wires, The commonly used regime for non-operative
has become increasingly popular (Assal et al., management initially immobilises the patient in
2002). The device operates through a small inci- a below knee cast, non-weight bearing in equi-
sion over the rupture site, benefiting from direct nus for 4 weeks. They are cared for by a specia-
visualisation, and passes sutures percutaneously. lised multi-disciplinary team with weekly
In a large multi-centre trial using the Achillon assessment. In the second month, a custom fit
device, comprising 87 patients, there were no orthosis is applied, allowing weight-bearing and
infections or sural nerve injuries (Assal et al., restricting dorsiflexion. Patient compliance is
2002). Patients returned to previous employment required, with regular exercise when sitting and
levels and sports activity with the authors rec- strict guidance not to weight-bear without the
ommending its use in conjunction with rehabil- orthosis. A study published in 2004 using this
itation programmes. non-operative treatment protocol in 140 patients
found a re-rupture rate of 2% and complication
rate of 6%, which included two deep vein
Post-operative rehabilitation thrombosis, five partial ruptures due to non-
Since the introduction of rehabilitation following compliance and one case of temporary drop
injury and increasing use of orthosis, such as foot (Wallace et al., 2004).
functional braces, recent debate has focused Recently, two randomised controlled trials
away from operative or conservative manage- evaluated the benefits of early mobilisation
ment and concentrated on enhancing rehabilita- and rehabilitation. A Swedish trial comprising
tion. Functional bracing was introduced to 97 patients, randomised to surgical or nonsurgi-
reduce atrophic effects of immobilisation, expe- cal treatment had identical rehabilitation pro-
dite rehabilitation and facilitate return to activity tocols, with equinus cast immobilsation for
(McComis et al., 1997). In a study comparing 2 weeks, followed by an adjustable brace, non-
patients treated surgically, no significant differ- weight bearing with incremental graduation of
ences in re-rupture rates were identified using dorsiflexion for six weeks (Nilsson-Helander
cast immobilisation (7 of 140) or functional et al., 2010). The authors report similar Achilles
brace (3 of 133) were found. The meta-analysis tendon total rupture scores at 6 and 12 months,
included 273 patients (Khan et al., 2005). There with 2 (4%) re-ruptures in the surgical group
were half as many complications in patients using and 6 (12%) in the non-surgical group, where
the orthosis than in those immobilised in a cast compliance to weight bearing was an issue,
(Khan et al., 2005). Also, in the study, of signif- detrimentally affecting this primary outcome.
icance, patients treated non-operatively had a re- (Nilsson-Helander et al., 2009). No statistical
rupture rate comparable to operative treatment difference in re-rupture identified.
when rehabilitated with early mobilisation, 2.4% A supporting study by Willits et al. (2010)
(Khan et al., 2005). published findings from a multi-centred trial of
Conservative treatment has traditionally been 144 patients comparing the benefits of acceler-
reserved for the elderly patient deemed unfit for ated rehabilitation programmes using a pneu-
surgery. Specialists encouraged surgery, which matic walking brace, 2cm heel lifts and 20
benefited from direct visualisation and juxtapo- degrees plantarflexion. The primary outcome
sition of the ruptured ends allowing earlier of measuring re-rupture, occurred in two ope-
mobilisation and reporting lower re-rupture rative and three non-operative individuals.
rate as opposed to non-operative treatment. As Patients underwent identical rehabilitation pro-
treatment has evolved, articles have challenged grammes. Operative repair used Krakow suture
Nandra et al. 79

techniques and epitendinous suture. Importantly The evolving evidence base advocates the use
during analysis of secondary outcomes there was of non-operative treatment combined with early
no significant difference between the groups in mobilisation; alternatively, if percutaneous sur-
isokinetic strength, range of motion, calf circum- gery is more widely practised, individuals who
ference or Leppilahti score (Willits et al., 2010). necessitate surgery can do so with minimal
Recent literature advocates the implementa- complications.
tion of functional rehabilitation and early
mobilisation in patients treated operatively and
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