Curr Rev Musculoskelet Med (2017) 10:72–80

DOI 10.1007/s12178-017-9386-7

FOOT AND ANKLE SPORTS MEDICINE (M DRAKOS, SECTION EDITOR)

Achilles tendon injuries

Anthony C. Egger 1 & Mark J. Berkowitz 1

Published online: 13 February 2017

# Springer Science+Business Media New York 2017

Abstract Introduction
Purpose of review The purpose of this study is to review the
current literature of Achilles tendon injuries, specifically The Achilles tendon is one of the most important and multi-
chronic tendinopathy and acute ruptures in regard to etiology, functional tendons in the body. A conjoining of the gastroc-
diagnosis, treatment options, and outcomes. nemius and soleus muscles, the tendon spans three different
Recent findings The incidence of Achilles tendon injuries is joints and is integral in knee flexion, foot plantar flexion, and
increasing, but the necessity for surgical intervention is de- hindfoot inversion. Given the broad array of critical functions
creasing due to improved conservative therapies, which may that it helps to provide, injury to the Achilles tendon can be
provide comparable outcomes without the implied surgical devastating. Pathology of the Achilles tendon can be acute or
risk. If surgery is undertaken, no difference has been noted chronic, ranging from tendinosis to frank tears, and can broad-
between open and minimally invasive techniques. The major- ly affect athletes and non-athletes alike.
ity of patients are able to return to pre-injury level of activity,
with the elite athlete as an unfortunate exception.
Summary Achilles injuries can be devastating injuries, but if Etiology
addressed early and appropriately, most patients have good
self-reported long-term outcomes regardless of the treatment Injury to the Achilles tendon is often multifactorial, with both
modality implemented. Further research is needed into the intrinsic and extrinsic forces recognized. Individual patient
etiology, potential preventative measures, and longer-term characteristics such as increasing age, male sex, and obesity
outcomes of the different treatment options for wide range have been shown to have positive correlation with Achilles
of Achilles pathology. tendon pathology [1]. Extrinsic factors such as the use of
fluoroquinolones and corticosteroids (both oral and
intrasubstance) have also been shown to lead to weakening
Keywords Chronic Achilles tendinopathy . Acute Achilles of the Achilles, with associated tendinitis and an increased risk
rupture of rupture [2, 3]. The risk for development of Achilles pathol-
ogy with these drugs is even higher in patients greater than
60 years old [4–6].
This article is part of the Topical Collection on Foot and Ankle Sports
The true etiology of Achilles tendon injuries is still un-
Medicine known, but two major theories have been proposed. The de-
generative theory postulates that chronic degeneration of the
* Anthony C. Egger tendon leads to a rupture without the need for excessive loads
[email protected] to be applied [7]. This theory was first postulated after Arner
et al. [8] found degenerative changes in all 74 of their patients
1
Department of Orthopaedic Surgery, The Cleveland Clinic
with acute Achilles ruptures. These degenerative changes
Foundation, 2049 E 100th St, Desk A40, Cleveland, OH 44195, have been seen in multiple other studies, including in tendons
USA operated on within 24 h of rupture, indicating preceding
Curr Rev Musculoskelet Med (2017) 10:72–80 73

chronic changes [9–11]. The exact mechanistic cause is un- defined as the presence of a hypoechogenic area within the
known, but it is hypothesized that impaired blood flow to the substance of the tendon [21].
tendon with resultant hypoxia and altered metabolism could Conservative management is the first line of treatment for
play a major role [12]. chronic Achilles tendinopathies. The most common modali-
Experimental findings of ruptures occurring in healthy ten- ties utilized are activity modification, eccentric exercises,
dons lead to development of the mechanical theory, which NSAIDs, injections, and shock wave therapy. Non-
states that different movements and forces exerted on the ten- insertional Achilles tendinopathies often respond quite well
don can lead to failure. In a biomechanical study of rat models, to these therapies, with Paavola et al. [22] showing only
Barfred et al. [13] noted that a tendon was at greatest risk of 29% of patients not returning to previous activities in an 8-
rupture when obliquely loaded at a short initial length with year follow-up. Moreover, there is an overall low rate of rup-
maximum muscle contraction, a very common occurrence in ture once an individual has advanced to the stage of a thick-
any push-off-type activity. This risk is exacerbated when there ened midsubstance tendinopathy.
is a dysfunction in the body’s ability to limit excessive and Though the mechanism of action is poorly understood,
uncoordinated muscle contractions [14]. This asynchrony is eccentric exercises have been shown in multiple studies to
more common in athletes who train less consistently, a major help in the early treatment of non-insertional Achilles
reason why Achilles ruptures are often seen in the “weekend tendinopathy. Ohberg et al. [23] showed that after a 12-week
warrior” population. course of eccentric calf muscle exercises, 36/41 patients had
no further tendon pain with activity, with the majority having a
more normalized tendon structure (34/36) and elimination of
neovascularity (32/36) at 2-year follow-up. All five patients
Chronic Achilles tendinopathy
who still reported a poor clinical outcome were found to have
remaining tendon neovascularity. In a randomized comparison
Chronic Achilles tendinopathies are painful conditions often
study, Alfredson et al. [24] found that 82% of patients were
found in athletes, particularly middle-aged male runners,
able to return to normal activities after 12 weeks of eccentric
though it can affect the sedentary population as well.
exercises compared with only 36% who performed concentric
Chronic tendinopathies are most commonly thought to be a
exercises. This difference was thought to be to due to the
result of repetitive overuse injuries, which explains a tenfold
increased load with eccentric exercises leading to structural
increase in Achilles tendon injuries in runners compared to
tendon change; however, Drew et al. [25] in a recent review
age-matched controls [15]. However, Rolf et al. [16] did show
have shown that the literature does not support this theory. The
that 31% of patients reviewed with Achilles tendinopathy did
authors thus propose the need for future research focusing on
not participate in vigorous physical activity. This finding in-
neural, biochemical, and myogenic changes as potential ex-
dicates that other etiologic factors, most likely related to met-
planations for the therapeutic response of eccentric exercise.
abolic or vascular imbalances, must also influence the devel-
Injections are utilized to produce local mechanical effects
opment of these conditions. Histological studies of Achilles
to alter the increased neovascularity seen in tendinosis and
tendinopathies have shown a disorganized collagen structure
provide pain relief through destruction of the surrounding
that this is indicative of this process being a primarily degen-
sensory nerves [26]. Injections have been effective with both
erative, non-inflammatory condition [17]. Achilles
local anesthetic and corticosteroids but need to be done under
tendinopathy can be divided mainly into disease of the
ultrasound guidance to ensure avoidance of potentially dele-
midportion of the tendon (55–65% of injuries) and the inser-
terious intratendinous placement [27]. Even with ultrasound
tion of the tendon (20–25%) [18].
guidance, there is still an inherent risk of rupture when
injecting around the Achilles, and it is the belief of the authors
Non-insertional Achilles tendinopathy to advise against injection of corticosteroids. The use of injec-
tions of platelet-rich plasma has yet to consistently demon-
Non-insertional Achilles tendinopathy in the acute phase is strate any greater improvement in pain or activity compared
due to an inflammatory cellular reaction in the tendon with to placebo [28]. The majority of patients, particularly those
circulatory impairment and edema, which can progress to fi- with insertional tendinopathies, respond to conservative man-
brinous exudates and adhesions in a more chronic condition agement [19]. However, about 20% of patients continue to
[19]. The main presenting symptom is pain, often occurring at have symptoms, and after 6 months without improvement,
the beginning of exercise and shortly after completion. potential surgical options should be evaluated [29].
Clinical exam can elicit pain on palpation (sensitivity 84%), Surgical intervention should address both the intratendinous
and pain is often located on average 2–6 cm above the inser- lesions and the pain transmitting neurogenic structures outside
tion site (sensitivity 78%) [20]. Though mainly a clinical di- of the tendon itself. Through either open or minimally invasive
agnosis, ultrasound or MRI can be utilized, with tendinopathy techniques, debridement and excision of the adhesions and
74 Curr Rev Musculoskelet Med (2017) 10:72–80

central tendinosis are performed with the goal of denervating

and devascularizing the paratenon while promoting a scarring
repair response within the tendon [30]. Lohrer et al. [31] in a
systematic review determined that there was no statistical dif-
ference between the two techniques in regard to success rates
(78.9 vs. 83.6%) or patient satisfaction (78.1 vs. 78.5%) but did
note a slightly higher complication rate (10.5 vs. 5.3%) with
open surgery. A majority of those patients who fail conservative
management do well after surgery, but the authors caution that
due to the paucity of well-done research in this field, these
success rates may be falsely elevated and recommend
discussing with patients the potential prolonged recovery time
and not insignificant rate of failure of these procedures.
A relatively novel surgical technique for Achilles tendinopathy
is a gastrocnemius recession, in which the gastrocnemius tendon Fig. 1 X-ray of a 56-year-old male with chronic posterior heel pain,
and soleus fascia are cut transversely and the soleus muscle is calcifications at insertion site indicative of chronic insertional
stretched by dorsiflexing the ankle to alleviate gastrocnemius- tendinopathy
soleus tightness that might be contributing to Achilles pain.
Often, this is done in combination with debridement, but
Labrode et al. [32] examined the results of this procedure alone
for patients with Achilles tendon pain. In this study, 18/24 patients commonly, a posterior central tendon approach for debride-
were available for follow-up, and all noted a marked improvement ment of the tendon along with removal of the prominent cal-
in their pain with no wound complications. Nawoczenski et al. caneal projection is utilized [37]. Augmentation of the tendon
[33] compared 13 patients undergoing gastrocnemius recession for repair with flexor hallucis longus may be required for older
Achilles tendinopathy compared to healthy controls and noted patients or revision cases in which greater than 50% of the
significant and sustained pain relief with good function for activ- tendon must be debrided. The augmentation with flexor
ities of daily living, but more limitations with power and endurance hallucis longus (FHL) was shown by Hunt et al. [38] to have
activities. These studies thus suggest that gastrocnemius recession little compromise in function or patient satisfaction compared
may be used as an alternative for Achilles surgery in non-athletic, to debridement alone. Hamstring tendon autograft can also be
high-risk patients. utilized to augment large defects with similar satisfactory
postoperative results [39, 40].

Insertional Achilles tendinopathy

Insertional tendinopathy is due to degeneration of the Achilles Acute Achilles tendon ruptures
tendon fibers at the insertion on the calcaneus and is often
associated with older age, steroid use, obesity, diabetes, and Despite being the strongest and thickest tendon in the body,
inflammatory arthropathies [34]. The pain is usually located at the Achilles tendon is the most common to rupture. Achilles
the midpoint of the calcaneus is worse in the morning and tendon ruptures most commonly occur in a healthy, active,
causes severe pain the day after exercising [35•]. It is often young- to middle-aged population, with a reported mean age
associated with a prominent calcaneal tuberosity (Haglund’s of patients from 37 to 43.5 years old [35•]. There is a male
deformity) and evidence of calcification at the insertion site on predilection for this injury with a M/F ratio in the literature
radiographs [36] (Fig. 1). ranging from 5.5:1 to 30:1 [7, 41, 42]. The most common
Non-operative management is also the initial treatment for ruptures are of the midsubstance Achilles, often occurring in
insertional tendinopathies. Activity modification, particularly a vascular watershed area 3–6 cm proximal to the insertion site
walking uphill, or other activities which place stress on the on the calcaneus [43]. Most patients with midsubstance tears
Achilles insertion should be avoided. Shoe lifts or a walker had no Achilles pain prior to rupture with ruptures occurring
boot may be utilized to avoid pressure on the posterior heel. in sports with abrupt repetitive jumping and sprinting activi-
Physical therapy must be used cautiously, as typical eccentric ties, which require a pushing-off type of force [44]. In con-
exercises utilized for non-insertional tendinopathies can often trast, those with insertional ruptures often did have preceding
aggravate and worsen insertional pathology [36]. Most pa- Achilles pain from insertional tendinopathies which ruptured
tients respond to conservative management, but 10–30% of at the site of chronic degeneration while performing activities
patients fail and require surgical intervention. Most of daily living [12].
Curr Rev Musculoskelet Med (2017) 10:72–80 75

Incidence regarding the routine use of MRI due to a lack of supporting

literature [50]. Garras et al. [51] sought to determine the ne-
The incidence of Achilles tendon ruptures has continuously cessity of MRI utilization in routine diagnosis of Achilles
increased in the last four decades. Leppilahti et al. [41] noted tendon ruptures. The study compared the sensitivity of phys-
an increase in a Finnish population from an annual incidence ical exam with that of MRI and found that in patients with a
of 2 (all numbers per 100,00) in 1979–1986 to 12 in 1987– positive Thompson’s test, palpable defect, and decreased rest-
1994, with a peak incidence of 18 in 1994. Houshian et al. ing ankle tension, the sensitivity was 100% for predicting a
[45] found a similar increase in Denmark with an annual in- complete tear. When MRI was utilized, the sensitivity was
cidence increase from 18.2 in 1984 to 37.3 in 1996. In more noted to be 90.9% for the interpretation of a complete tear
recent literature, Lantto et al. [46] investigated the epidemiol- compared to what was seen intraoperatively. It was also found
ogy of ruptures in Finland from 1979 to 2011. The overall that those undergoing MRI were delayed in their initial eval-
annual incidence increased from 2.1 in 1979 to 21.5 in 2011, uation by a surgeon (5.1 vs. 2.5 days) and time to operative
with the largest increase occurring in the 30–39-year-old age intervention (12.4 vs. 5.6 days) and required additional proce-
range. In reviewing the Swedish national registry for acute dures at the time of index repair (19/66 vs. 0/66), including 17
Achilles tendon ruptures between 2001 and 2012, Huttunen FHL transfers and 6 V-Y advancements (Fig. 2). Thus, the
et al. [47] found that in 2001, the sex-specific incidence of authors recommended MRI not be routinely utilized but re-
acute Achilles tendon ruptures was 47 for males and 12 for served for those patients with inconclusive clinical exam find-
females with it rising to 55.2 in men and 14.7 in females in ings and subacute or chronic tears occurring more than
2012, a 17 and 22% increase, respectively. Similar trends were 4 weeks prior to presentation and patients with prior tears with
noted by Ganestam et al. [48] in Denmark with a particularly concern for scar tissue in order to develop an appropriate
significant increase in those over 50 years old. These recent surgical plan.
studies indicate that the incidence of acute Achilles ruptures Ultrasound remains a cheaper and more readily available
continues to rise in the last decade, which has been theorized alternative to MRI. Margetic et al. [52] showed a high corre-
to be likely due to an increase in the number of older adults lation between the size of the rupture noted on ultrasound and
still participating in high-demand activities. that found in surgery. Kotnis et al. [53] recommended dynam-
ic ultrasound as a useful diagnostic tool, noting that if a >5-
Diagnosis mm gap is noted between tendon edges, that surgical interven-
tion is indicated. Ultrasound, however, does struggle with di-
The diagnosis of an acute Achilles tendon rupture is largely agnosis of partial ruptures, particularly at the intratendinous
reliant on history and physical exam. Patients usually com- junction with a sensitivity of only 50% [54]. Again, it is in
plain of a popping or giving way sensation in their posterior these ambiguous cases that MRI is the most effective imaging
heel after pushing off. Immediate pain is present but gradually modality.
dissipates, leaving a patient to complain of difficulty with
plantar flexion, weight bearing, or a limp [49]. The Non-operative treatment
American Academy of Orthopaedic Surgeons (AAOS)
Clinical Practice Guidelines note that a diagnosis can be made The two main options for non-operative management are cast
when two or more of the following exam findings are noted: a immobilization and functional bracing with early rehab. Non-
positive Thompson test (when compression of calf in supine
position does not elicit passive plantar flexion), decreased
plantar flexion strength, palpable defect distal to insertion site,
or increased passive ankle dorsiflexion at rest (Matles test)
[48]. Maffuli et al. [18] evaluated the accuracy of these diag-
nostic tests in both awake and anesthetized patients and found
that the Thompson (96%) and Matles (88%) tests were the two
most sensitive, with all four tests having a high positive pre-
dictive value.

Imaging

While clinical exam is the primary component of diagnosis,

imaging studies such as MRI and ultrasound are often utilized
to confirm physical exam findings. The AAOS Clinical Fig. 2 Repair of insertional Achilles rupture utilizing FHL tendon
Practice Guideline recommendations were inconclusive augmentation
76 Curr Rev Musculoskelet Med (2017) 10:72–80

weight-bearing cast immobilization for 4 weeks with transi- primary repair difficult. In these cases, the reconstruction may
tion to a walking cast for another 4 weeks was historically the require an augmentation with a flexor hallucis longus transfer.
method of treatment. Wallace et al. [55] assessed the results of Wong et al. [65] examined this technique in elderly patients
140 patients treated with cast immobilization and found that with insertional ruptures and found good pain relief and func-
86% of patients had an excellent or good result. tional recovery without any major surgical complications or
In the functional rehab protocol, patients are placed into a reruptures at 2 years.
boot with wedges with gradual reduction of plantar flexion to Given the tenuous tissue envelope surrounding the Achilles
neutral over 6 weeks, after which formal physical therapy is tendon, choosing the correct patient population on which to
started [49]. Functional bracing has been found to be preferred operate is paramount. Currently, the AAOS provides a con-
by patients to cast immobilization and is associated with in- sensus opinion that surgical intervention should be
creased dorsiflexion and an earlier return to activities [56]. approached cautiously in patients who are diabetics, smokers,
Functional bracing and earlier rehab are also associated with older than 65 years old, sedentary, obese, and neuropathic or
lower rerupture rates. These patients can be weight bearing as those with concern for wound healing [50].
tolerated immediately as there was no difference in outcome
scores or functional ability but was an increase in health-
related quality of life at 1 year compared to prior protocol of Non-operative versus surgical management
non-weight bearing for 6 weeks [57]. Porter et al. [58] found
that an accelerated functional rehab program, where patients For decades, open surgical intervention was considered the
were encouraged to begin active range of motion as soon as gold standard for acute Achilles ruptures due to a concern
possible instead of at 10 days, was also associated with less for an unacceptable rate of rerupture with conservative treat-
tendon lengthening and a more rapid return to running. ment. Khan et al. [66], in a meta-analysis of the literature prior
to 2002, noted a pooled rate of rerupture of 12.6% in the
Surgical management conservatively treated group compared to 3.5% in the opera-
tive group. Over the last 15 years though, the incidence of
Acute Achilles tendon ruptures can be treated surgically uti- surgical intervention has decreased despite the overall inci-
lizing either an open, a mini open, or a minimally invasive dence of ruptures increasing [47]. The paradigm shift to in-
approach. Several randomized control clinical trials compar- creased non-operative management is concurrent with multi-
ing these methods have been performed with conflicting re- ple well-designed randomized controlled trials comparing op-
sults regarding superiority and complications [59–61]. In a erative and non-operative treatments of acute Achilles rup-
systematic review of four meta-analyses, Li et al. [62] deemed tures with comparable results.
the review by McMahon et al. [63] as the best available evi- In a more recent meta-analysis of ten studies comparing
dence, demonstrating that minimally invasive surgery (MIS) surgical and conservative treatments, Soroceanu et al. [67]
and open repair had no difference in regard to rate of rerupture, similarly found that surgery reduced the risk of rerupture by
deep infection, deep vein thrombosis, adhesions, or sural 8.8% when compared against non-operative treatment without
nerve injury. The major difference occurred in MIS being functional rehab. However, if a functional rehab protocol with
superior in regard to lower rate of superficial infection (risk early range of motion was implemented as part of the conser-
difference = 0.17) and patients being nearly three times more vative treatment, the rates of rerupture were equivalent to
likely to report a good or excellent outcome. From a biome- those undergoing surgical intervention. There was also found
chanical standpoint, Clanton et al. [64] compared open repair to be a 15.8% risk reduction of other complications like infec-
versus three different percutaneous repair methods on cadaver tion, adhesion formation, and sural nerve injury in the non-
tendons, which were then subjected to cyclic loading proto- operative group. Surgical patients were able to return to work
cols indicative of progressive rehab. When compared to open 19.6 days earlier, but there was no difference noted in any
repairs, minimally invasive techniques demonstrated a greater functional outcome measures reported. These results were
susceptibility to early repair elongation, but the ultimate echoed by Erikson et al. [68•] in a broader 2015 review of
strength of all four repairs in terms of cycles to failure was nine meta-analyses comparing the two treatment options. In a
comparable. The authors concluded that MIS techniques can recent prospective randomized trial comparing surgical and
provide a biomechanically acceptable alternative but, due to nonsurgical treatment of acute ruptures, Lantto et al. [69]
early elongation, may require a longer protected period found similar results between the two options in Achilles ten-
postoperatively. don performance scores but found surgery restores calf muscle
Insertional ruptures occurring in patients with prior symp- strength earlier with maintained increased strength at
tomatic Achilles tendinopathies can present a unique surgical 18 months. The authors suggest that this should be taken into
challenge. Often, an extensive debridement of the diseased account particularly when treating physically active and de-
tissue is required, which can leave a substantial defect making manding patients.
Curr Rev Musculoskelet Med (2017) 10:72–80 77

Previously, non-surgical treatment for acute ruptures was still relatively high, suggesting that most patients have adjust-
mainly utilized in those patients who were poor surgical can- ed to their deficits.
didates. Recent literature though has consistently shown non- Horstmann et al. [79] found that even at 10 years after
surgical treatment with early functional rehab to result in ac- surgical repair for Achilles tendon rupture, long-term changes
ceptable outcomes and thus is a reasonable treatment option in were still noted compared to the contralateral leg. Ankle range
those centers equipped to provide it. of motion and calf circumference were noted to be less on the
injured leg, while gastrocnemius muscle activity was found to
Outcomes be greater, with the authors hypothesizing the increased acti-
vation served as a compensatory mechanism to protect the
Most athletes who suffer an Achilles rupture were participat- repaired Achilles tendon during plantar flexion movements.
ing in sports recreationally and mainly desire to return to this While these differences can be measured objectively, it is
same level of activity [70]. In a systematic review of 108 again seen that patients have adapted as most patients reported
studies, Zellers et al. [71] found that 80% of patients returned no reduction in subjective ankle range of motion, pain, or
to play after an acute Achilles tendon rupture (range 18.6– functional limitations in daily or physical activities.
100%). The mean time to return to play was found to be While the majority of recreational athletes are able to return
6.0 months, but this range was also quite varied (2.9 to to their prior level of sporting activity, the impact of an acute
10.4 months). This review noted numerous validated ques- Achilles rupture on a professional athlete can be much more
tionnaires measuring various aspects of return to play, but devastating. In a study of NFL players suffering Achilles ten-
the authors believed that none comprehensively captures re- don ruptures from 1997 to 2002 (n = 31), Parekh et al. [80]
turn to play in the Achilles tendon rupture population and found that nearly 32% of players with this injury were never
suggested the development of an improved questionnaire that able to return to play in the NFL, while those who did return
more thoroughly, consistently, and accurately assesses this had a greater than 50% reduction in performance. In a similar
metric [72–75]. study in NBA players, Amin et al. [81] found that 7/18 players
One of most commonly utilized current outcome question- (39%) who suffered an Achilles rupture and underwent surgi-
naires is the Achilles Tendon Total Rupture Score (ATRS). cal repair from 1988 to 2011 never returned to play in the
The ATRS is a patient-reported instrument developed by NBA. Those who did return to play were also found to have
Nilsson-Helander et al. [74] which asks patients to numerical- a significant decrease in both playing time and performance.
ly quantify their limitations with different activities after treat-
ment for an acute Achilles rupture. Olsson et al. [76•] utilized
the ATRS as a predictive model and noted that a ten-point Conclusions
increase in ATRS at 3 months predicted a 2% higher heel rise
at 6 and 12 months, where heel rise at 6 months was indepen- Achilles tendon pathology is a very common ailment af-
dently found to predict the degree of symptoms at 1 year. fecting a wide variety of the population. Given its vital
Hansen et al. [77] found that an increased ATRS at 3 months role in ambulation and activity, injury to the Achilles ten-
correlated with a significantly increased chance of return to don can be quite debilitating. Chronic tendinosis is most
sport at 1 year after injury. Thus, utilizing the simple ATRS often due to overuse and typically responds to conserva-
may help to identify patients not responding adequately to tive management. If no improvement is seen after
treatment within a time period where outcomes can still be 6 months though, surgical debridement should be consid-
altered. ered. The incidence of acute ruptures of the Achilles con-
Olsson et al. [76•] also attempted to identify potential pre- tinues to increase as the older population continues to stay
dictors of clinical outcomes after an acute Achilles tendon more active than past generations. The diagnosis is mainly
rupture. Increasing age and higher BMI were found to be clinical, but ambiguous presentations may require ad-
strong and significant predictors of decreased function and vanced imaging. The development of functional bracing
having a greater degree of symptoms respectively at 1 year. and early rehabilitation has provided another equal and
While a majority of patients are found to ultimately return potentially superior alternative to surgical fixation.
to play, Olsson et al. [78] noted that major functional deficits Overall, regardless of the method of fixation, most pa-
and decreased physical activity level persist for 2 years after tients ultimately return to their prior level of activity de-
acute Achilles rupture regardless of surgical or non-surgical spite slight persistent objective limitations. While the un-
treatment. The study also noted only minor improvements in derstanding of Achilles tendon pathology has grown ex-
function, symptoms, and activity level between the 1- and 2- ponentially, much more research is still required to more
year evaluations, indicating that the vital stages for improve- fully understand the multifaceted etiology, optimal treat-
ment occur mainly in the first year of recovery. Despite these ment modalities, and long-term outcomes of this common
persistent limitations though, patient-reported outcomes were and complex set of problems.
78 Curr Rev Musculoskelet Med (2017) 10:72–80

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