Achilles Tendinopathy

Mark Glazebrook, M.Sc., PhD, M.D., FRCSC, Dip Sports Med
Associate Professor, Dalhousie University Orthopaedics
Halifax, NS

Catastrophic rupture of the Achilles tendon (Figure 1) occurs when applied forces exceed the tensile limits of the tendon that are likely related to preexisting pathologic changes that may cause weakness. Recently, methods of EBM have been used in an attempt to clarify the treatment of Achilles tendon ruptures.

 

One of the more publicized examples of EBM techniques arises from the recent American Academy of Orthopaedic Surgery Diagnosis and Treatment of Acute Achilles Tendon Rupture1. This clinical practice guideline is based on a series of systematic reviews of published studies in the available literature on the diagnosis and treatment of acute Achilles tendon rupture. In this EBM review, 16 aspects of the diagnosis and treatment of Achilles tendon ruptures were examined. The studies identified were then assigned a LOE. The quality of treatment studies were assessed using a two-step process. First, a Level of Evidence was assigned to all results reported in a study based solely on that study's design. Accordingly, all data presented in randomized controlled trials were initially categorized as Level I evidence, all results presented in non-randomized controlled trials and other prospective comparative studies were initially categorized as Level II, all results presented in retrospective comparative and case-control studies were initially categorized as Level III, and all results presented in case-series reports were initially categorized as Level IV.

GLAZEBROOK_FIG1
Figure 1. Ruptured Achilles tendon.

To develop the strength of each recommendation, the quality and quantity of the available evidence was taken into account as well as the work group's evaluation of the applicability of the evidence. The final strength of the 16 recommendations for the Achilles AAOS were: Strong 0, Moderate 2, Weak 4, Inconclusive 8, and Consensus 2. The moderate recommendations included early (≤ 2 weeks) postoperative protected weight-bearing for patients with acute Achilles tendon rupture who have been treated operatively and use of a protective device that allows mobilization by 2-4 weeks postoperatively. It was interesting to note that the guideline provided equal weak recommendations for treatment of Achilles tendon rupture with and without surgery. This guideline clearly highlights the need for higher LOE studies on the diagnosis and treatment of acute Achilles tendon ruptures.

The most recent RCT attempt to provide a higher LOE study on treatment of Achilles tendon ruptures includes a RCT by Willits et al.2 in which 144 patients were randomized to operative or non-operative treatment. All patients underwent an accelerated rehabilitation protocol that featured early weight-bearing and early range of motion. The authors concluded that the application of an accelerated non-operative protocol avoids serious complications related to surgical management with no compromise in strength and re-ruptures rates. This was based on incidence of two and three re-ruptures in the operative and non-operative groups respectively, and no clinically important difference between groups for strength, range of motion, calf circumference and Leppilahti score. Complications were 13% in the operative group and 5% in the non-operative.

A recent meta-analysis of the literature on treatment of Achilles tendon ruptures provides insight into the efficacy and safety of non-operative treatment. Soroceanu et al.3 presented a paper that included eight RCTs that examined surgical treatment (open and minimally invasive) versus conservative treatment initiation within three weeks of 369 Achilles tendon ruptures. The analysis concluded that a combination functional rehabilitation with early range of motion and non-operative treatment should be preferred since surgical repair does not decrease re-rupture rates, and is associated with higher complication rates.

Thus, in conclusion, there is still no Grade A recommendations on the treatment of Achilles Tendon rupture. But, there does exist evidence to support both operative and non-operative treatments with a recent trend of reported success of non-operative treatment. Clearly, there is a need for new high Level of Evidence studies (Level I) on the treatment of Achilles tendon ruptures.

References

 

  1. Chiodo C.P., Glazebrook M., Bluman E.M., Cohen B.E., Femino J.E., Giza E., Watters W.C., 3rd, Goldberg M.J., Keith M., Haralson R.H., 3rd, Turkelson C.M., Wies J.L., Raymond L., Anderson S., Boyer K., Sluka P. Diagnosis and treatment of acute Achilles tendon rupture. J Am Acad Orthop Surg 2010;18-8:503-10.
  2. Willits K., Amendola A., Bryant D., Giffin R., Mohtadi N. Operative versus non-operative treatment of acute Achilles tendon ruptures: A multicentre randomized trial using accelerated functional rehabilitation. JBJS(A). Vol. Accepted for Publication, 2010.
  3. Soroceanu A., Feroze S., Shahram A., Kauffman A., Glazebrook M. Operative vs Non-Operative Treatment of Achilles Tendon Ruptures, a Meta-Analysis of Randomized Controlled Trials. Atlantic Provinces Orthopedic Society Annual Meeting. Halifax Nova Scotia, 2010.

 

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