Acute Achilles Tendon Rupture

A Randomized, Controlled Study Comparing

Surgical and Nonsurgical Treatments Using
Validated Outcome Measures
Katarina Nilsson-Helander,*yz MD, PhD, Karin Grävare Silbernagel,z§ PT, PhD,
Roland Thomeé,z PT, PhD, Eva Faxén,z PT, Nicklas Olsson,z MD,
Bengt I. Eriksson,z MD, PhD, and Jon Karlsson,z MD, PhD
From the yDepartment of Orthopaedics, Kungsbacka Hospital, Kungsbacka, Sweden,
z
Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy,
University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden, and
§
University of Delaware, Newark, Delaware

Background: There is no consensus regarding the optimal treatment for patients with acute Achilles tendon rupture. Few randomized
controlled studies have compared outcomes after surgical or nonsurgical treatment with both groups receiving early mobilization.
Purpose: This study was undertaken to compare outcomes of patients with acute Achilles tendon rupture treated with or without
surgery using early mobilization and identical rehabilitation protocols.
Study Design: Randomized, controlled trial; Level of evidence, 1.
Methods: Ninety-seven patients (79 men, 18 women; mean age, 41 years) with acute Achilles tendon rupture were treated and
followed for 1 year. The primary end point was rerupturing. Patients were evaluated using the Achilles tendon Total Rupture Score
(ATRS), functional tests, and clinical examination at 6 and 12 months after injury.
Results: There were 6 (12%) reruptures in the nonsurgical group and 2 (4%) in the surgical group (P 5 .377). The mean 6- and 12-
month ATRS were 72 and 88 points in the surgical group and 71 and 86 points in the nonsurgical group, respectively. Improve-
ments in ATRS between 6 and 12 months were significant for both groups, with no significant between-group differences. At the
6-month evaluation, the surgical group had better results compared with the nonsurgically treated group in some of the muscle
function tests; however, at the 12-month evaluation there were no differences between the 2 groups except for the heel-rise work
test in favor of the surgical group. At the 12-month follow-up, the level of function of the injured leg remained significantly lower
than that of the uninjured leg in both groups.
Conclusion: The results of this study did not demonstrate any statistically significant difference between surgical and nonsurgical
treatment. Furthermore, the study suggests that early mobilization is beneficial for patients with acute Achilles tendon rupture
whether they are treated surgically or nonsurgically. The preferred treatment strategy for patients with acute Achilles tendon rup-
ture remains a subject of debate. Although the study met the sample size dictated by the authors’ a priori power calculation, the
difference in the rerupture rate might be considered clinically important by some.
Keywords: Achilles tendon rupture; movable brace; rerupture; ATRS; validated functional tests

Treatment protocols for patients with acute Achilles ten- in a cast or a movable brace. However, despite several
don rupture are constantly being modified. Both surgical randomized studies, there is no consensus regarding the
and nonsurgical therapies are followed by immobilization optimal treatment protocol.|| Meta-analyses generally
agree that the rerupture rate is higher in patients treated
nonsurgically (12.6%) than in patients treated surgically
*Address correspondence to Katarina Nilsson-Helander, MD, PhD, (3.5%), but the risk varies considerably in previous stud-
Department of Orthopaedics, Kungsbacka Hospital, SE-434 40 Kungs- ies.3,9,11,15,16,35 Surgically treated patients have an
backa, Sweden (e-mail: [email protected]).
The authors declared that they had no conflicts of interests in their
increased risk of other complications such as infections,
authorship and publication of this contribution. wound problems, and nerve injuries.26 Furthermore,
regardless of treatment type, patients often have residual
The American Journal of Sports Medicine, Vol. 38, No. 11
DOI: 10.1177/0363546510376052
||
Ó 2010 The Author(s) References 4-7, 14, 17, 19, 20, 27, 28, 32, 34.

2186
Vol. 38, No. 11, 2010 Acute Achilles Tendon Rupture 2187

weakness and decreased function after Achilles tendon TABLE 1

rupture.9,18,19,21,25 Patient Baseline Characteristicsa
There are large variations in the treatment protocols
used for patients with acute Achilles tendon rupture. The Surgical Nonsurgical P
Variable (n 5 49) (n 5 48) Value
initial decision is whether treatment should be surgical
or nonsurgical. If surgery is chosen, the literature Age 40.9 (8.8) 41.2 (9.5) .9367
describes many different techniques that include both 41.0 (24.0; 59.0) 39.0 (23.0; 63.0)
open and percutaneous repairs.35 The optimal approach n 5 49 n 5 48
is, however, still not clear. Gender
Furthermore, in the last few decades, postoperative Male 40 (81.6%) 39 (81.3%)
treatment and initial protocol for nonsurgically treated Female 9 (18.4%) 9 (18.8%) 1.0000
patients has changed from cast immobilization for 6 to 8 Height, cm 178.7 (9.2) 177.7 (8.8) .6362
180.0 180.0
weeks to the use of a functional brace that allows immedi-
(154.0; 197.5) (153.0; 192.0)
ate mobilization for both groups. The increased use of func- n 5 47 n 5 40
tional braces is associated with a decrease in rerupture Injured side
rates in both surgically and nonsurgically treated Right 23 (46.9%) 27 (56.3%)
patients.17,27,28,31,34 The rerupture rate decreases from Left 26 (53.1%) 21 (43.8%) .4753
approximately 5% to 2.3% when using a functional brace Work
instead of a cast in surgically treated patients, and from Sedentary 15 (30.6%) 15 (31.9%)
12.2% to 2.4% in nonsurgically treated patients.9 Studies Light but mobile 23 (46.9%) 27 (57.4%)
have also shown that the patients’ opinion of their quality Heavy 11 (22.4%) 5 (10.6%) .3708
of life was superior when a functional postoperative proto- a
For categorical variables, data are reported as n and (%). For
col was followed.17 However, it is difficult to draw defini-
continuous variables, data are reported as mean (standard devia-
tive conclusions because studies vary considerably in tion), median (min; max), and n. For comparisons between groups,
terms of the specific treatment protocols and methodology. the Fisher exact test was used for dichotomous variables, Mantel-
The present study is a continuation of a previous study19 Haenzsel x2 exact test was used for ordered categorical variables,
that reported a rerupture rate of 1.7% in patients treated and the Mann-Whitney U test was used for continuous variables.
with surgery and 20.8% in patients treated nonsurgically.
The nonsurgically treated group, however, underwent 8 patients who sought medical attention for acute Achilles
weeks of cast immobilization, whereas the surgically treated tendon rupture at the emergency wards.
group received a movable brace.19 Because the treatment Patients between 16 and 65 years of age with a unilat-
protocols for the 2 groups differed, it was difficult to judge eral Achilles tendon rupture were included in the study if
whether the surgery, the early range of motion, or the com- they were randomized and treated within 72 hours of the
bination of both was the reason for the superior outcomes in injury. Exclusion criteria were diabetes mellitus, previous
the surgically treated group. Validated outcome measures Achilles tendon rupture, other lower leg injuries, immuno-
are now available,23,30 making it possible to improve our suppressive therapy, and neurovascular diseases.
understanding of how various treatments affect outcomes Two patients who were randomized to receive nonsurgi-
after acute Achilles tendon rupture. cal treatment opted to receive surgical treatment. One
The purpose of the present study was to compare out- patient who was randomized to the surgical treatment
comes of patients with acute Achilles tendon rupture trea- group was treated nonsurgically because it was not possi-
ted with or without surgery using identical mobilization ble to perform the surgery within 72 hours. Therefore, 97
and rehabilitation protocols. patients (79 men and 18 women) were included in the
follow-up evaluations (Table 1).
METHODS All participants received oral and written information
about the purpose and procedures of the study and pro-
Patients vided written informed consent. Ethical approval was
obtained from the Regional Ethical Review Board in Goth-
One hundred patients with acute Achilles tendon rupture enburg, Sweden.
who sought medical attention at the emergency depart-
ment at the Sahlgrenska University Hospital, Gothenburg, Treatment Procedure
Sweden, were included in a prospective, randomized study
from 2004 to 2007. In all patients, the diagnosis was estab- Surgical Group. Forty-nine patients were treated surgi-
lished based on medical history and clinical examination cally. Surgery was performed with the patient in the prone
(tendon palpation and Thompson test33). Patients eligible position under local, spinal, or general anesthesia. A tour-
for the study were randomized to receive either surgical niquet was used for hemostasis in 27% of the patients.
treatment or nonsurgical treatment. Computer-generated After a longitudinal 5- to 8-cm medial skin and paratenon
sealed envelopes were used in the randomization proce- incision, an end-to-end suture was placed using a modified
dure that was administered by the study coordinator. Kessler suture technique8 and 1-0 polydioxanone (PDS)
Because of diversity in reporting, we do not know how sutures (PDS II, Ethicon, Somerville, New Jersey) (Figure 1).
many patients were included out of the total number of The paratenon was carefully repaired and the skin closed
2188 Nilsson-Helander et al The American Journal of Sports Medicine

TABLE 2
Rehabilitation Protocol

Weeks 8-11
Treatment: Shoe with a heel-lift (1.5 cm), crutches as needed for
another 1-3 weeks
Exercise program: Visit to physical therapist 2-3 times/wk and
home exercises daily
Exercise bike
Ankle range of motion
Sitting heel-rise
Standing heel-rise (2 legs)
Gait training
Balance exercises
Leg press
Leg extension and leg curl
Weeks 11-16
Treatment: Shoe with a heel-lift (1.5 cm) until week 16
Exercise program: Visit to physical therapist 2-3 times/wk and
home exercises daily
Exercises as above with increased weight
Standing heel-rise increase to hold at end range of
plantar flexion on 1 leg
Step
Walking on mattress
Weeks 16-20
Figure 1. A schematic view of the surgical technique used. Exercise program: Visit to physical therapist 2-3 times/wk and
home exercises
Exercises as above with increase in weights and intensity as
with interrupted nylon sutures. Surgery was performed by 1 tolerated
of 28 orthopaedic surgeons familiar with the technique. Slide
Postoperatively, the patients were placed in a below-the- Quick rebounding heel-rises
knee cast with the foot in 30° equinus position. From week 18
In the surgically treated group, thromboprophylaxis Heel-rise in stairs
consisting of 500 mL of high molecular-weight dextran Side jumps
was administered according to a specific protocol. No 2-legged jumps
Week 20-24
standard thromboprophylaxis was administered to the
Exercise program: Visit to physical therapist as needed
nonsurgically treated group.
Exercises as above with increase in weights and intensity as
Nonsurgical Group. Forty-eight patients composed the tolerated
nonsurgical group. The patients were treated immediately Jog
with a below-the-knee cast with the foot in equinus position. Side jumps forward
Surgical and Nonsurgical Groups. All patients in both Week 24 and onward
groups were treated with a below-the-knee cast with the Exercise program: Continued physical therapy if needed
foot in equinus position for 2 weeks, followed by an adjust- Start group exercise class (similar to aerobics)
able brace (DonJoy ROM Walker, DJO Nordic AB, Malmö, Gradual return to sports (dependent on patient ability)
Sweden) for the next 6 weeks. The brace was set at free plan-
tar flexion motion with dorsiflexion limited to 230° the first
by the first author (K.N.-H.), including such elements as
2 weeks, 210° the next 2 weeks, and 110° the last 2 weeks.
history, symptoms, general function, scar inspection, and
Weightbearing as tolerated was allowed after 6 to 8 weeks.
evaluation for loss of sensitivity of the foot. The patients
The brace was adjusted by a physiotherapist. The patients
were not examined for comorbidity.
were not allowed to remove the brace themselves.
Screening for deep vein thrombosis (DVT) was per-
formed by color duplex sonography 8 weeks after treat-
Rehabilitation ment was initiated.12
Evaluation of function, symptoms, and physical activity
All patients followed a standardized rehabilitation
level was performed at 6 and 12 months after the injury by
protocol (Table 2) under the supervision of 2 experienced
2 experienced independent physiotherapists.
physiotherapists.

Follow-up Evaluation Patient-Reported Outcome and Physical Activity

All patients received follow-up examinations at the ortho- The patients’ symptoms and physical activity levels were
paedic department at 2, 8, and 12 weeks and at 6 and 12 assessed using the Achilles tendon Total Rupture Score
months after injury. Examinations were performed mainly (ATRS) and a physical activity scale (PAS).23,29 The
Vol. 38, No. 11, 2010 Acute Achilles Tendon Rupture 2189

ATRS ranges from 0 to 100; a lower score indicates more Statistical Analysis
symptoms and greater limitation of physical activity. For
the PAS, a score of 1 equals no physical activity, whereas All data were analyzed using SPSS 15.0 for Windows
a score of 6 equals heavy physical exercise several times (SPSS, Chicago, Illinois). Descriptive data are reported as
per week. mean, median standard deviation, and range (minimum-
maximum).
The power calculation that was conducted before the study
started was based on a previous study from our hospital in
Functional Evaluations
which there was a rerupture rate of 1.7% (surgical treatment)
The MuscleLab (Ergotest Technology, Oslo, Norway) mea- versus 20.8% (nonsurgical treatment).19 For an 80% power,
surement system was used for functional evaluations. a sample size of 50 patients per group was needed.
MuscleLab is a data collection unit to which sensors of dif- Rerupture of the Achilles tendon was the primary end
ferent kinds can be connected. The test battery consisted of point in the study. The Fisher exact test was used for
2 different jump tests, 2 different strength tests, and 1 dichotomous variables. For comparison between the 2
muscular endurance test. The test battery has been shown groups, Mantel-Haenzsel x2 exact test was used for ordered
to be reliable and valid for evaluating lower leg function in categorical variables and Mann-Whitney for continuous
patients with Achilles tendinopathy and was performed as variables. The Wilcoxon signed rank test was used to eval-
described by Silbernagel et al.30 The tests were also used in uate differences between the injured and uninjured sides,
a recent study that evaluated outcomes of chronic rupture as well as differences before injury and after treatment.
and rerupture of the Achilles tendon.22 The jump tests The Mann-Whitney U test was used to compare the 2
were a drop counter-movement jump (drop CMJ) and hop- groups of patients. The level of significance was set at
ping. For the drop CMJ, the patients started by standing P \ .05. The limb symmetry index (LSI) was calculated
on 1 leg on a 20-cm-high wooden box. They were instructed to compare the 2 treatment groups. The LSI was defined
to ‘‘fall’’ down onto the floor and, directly on landing, per- as the ratio between the involved limb score and the unin-
form a maximum vertical 1-legged jump. The maximum volved limb score, expressed as a percentage (involved/
jumping height in centimeters was used for data analysis. uninvolved 3 100 5 LSI).
Hopping was a continuously rhythmical jump similar to
skipping. The patients performed 25 jumps, the average
RESULTS
air flight and floor contact times were documented, and
the plyometric quotient (flight time/contact time) was
Rerupture
used for data analysis. The strength tests were a concentric
heel rise and an eccentric-concentric heel rise. For the There were 6 (12%) reruptures in the nonsurgically trea-
strength tests, a linear encoder was used. A spring-loaded ted group and 2 (4%) in the surgically treated group (P 5
string was connected to a sensor inside the linear encoder .377). One patient in the surgically treated group suf-
unit. When the string was pulled, the sensor gave a series fered from a second rerupture.
of digital pulses proportional to the distance traveled. The
resolution is approximately 1 pulse every 0.07 mm. By
counting the number of pulses/time, the displacement as Patient-Reported Outcome and Physical Activity
a function of time can be recorded and thus allow calcula-
tion of time, length, velocity, force, and power (force 3 The patients in the surgically treated group had a mean
velocity). In this experiment, the spring-loaded string of ATRS of 72 points (median, 75; range, 31-100) at the 6-
the linear encoder was attached to the heel of the partici- month follow-up visit and 88 points (median, 93; range,
pant’s shoe and thus the height (in centimeters) and time 30-100) at the 12-month evaluation. The patients in the
(in seconds) of the heel displacement of the heel-rise could nonsurgically treated group had a mean ATRS of 71 points
be measured. The weight of the participant and the extra (median, 75; range, 32-100) at the 6-month evaluation and
external weight were entered into the MuscleLab software 86 points (median, 90; range, 31-100) at the 12-month eval-
and peak power in watts was calculated. The best trial (ie, uation. Both groups improved significantly (P \ .001) over
with the highest power in watts) for each weight was used time; however, there were no significant differences
for data analysis. between the 2 groups at either the 6-month or 12-month
The muscular endurance test was a standing heel-rise evaluations (P 5 .870 and P 5 .441, respectively).
test. The total amount of work performed (in joules) and Eighty-six percent of the ruptures in the present study
the maximum heel-rise height were used for data analysis. occurred during sports activities; racket sports accounted
All patients were given standardized instructions and the for 50%.
tests were then demonstrated by the physiotherapist. The mean PAS preinjury score was 4.31 for the surgical
The subjects also performed 3 to 5 practice trials prior to group and 4.39 for the nonsurgical group. The mean PAS
testing. Verbal encouragement was used and athletic foot- score for the surgical group was 3.4 (median, 3.0; range,
wear was standardized. Before testing, the patients 1-6) at the 6-month evaluation and 3.6 (median, 3.0; range,
warmed up by cycling for 5 minutes on a stationary bicycle, 1-6) at the 12-month evaluation. The mean PAS for the
followed by 3 sets of 10 two-legged toe raises. The unin- nonsurgical group was 3.3 (median, 3.0; range, 2-6) at
jured side was always tested first. the 6-month evaluation and 3.7 (median, 4.0; range, 2-6)
2190 Nilsson-Helander et al The American Journal of Sports Medicine

TABLE 3
Functional Test Performance Scores for Patients with Achilles Tendon Rupture at 6 and 12 Months Postinjurya

6-Month Evaluation 12-Month Evaluation

b
Test Nonsurgical Surgical P Value Nonsurgical Surgical P Valueb

Heel-rise work n 5 37 n 5 45 .013 n 5 40 n 5 45 .012

54% (20) 65% (17) 68% (20) 78% (20)
17-102 36-100 20-119 28-113
Heel-rise height n 5 38 n 5 45 .009 n 5 41 n 5 45 .053
68% (15) 75% (12) 77% (13) 81% (13)
42-121 46-103 49-113 47-103
Hopping n 5 38 n 5 45 .037 n 5 38 n 5 46 .222
75% (35) 90% (24) 90% (30) 101% (16)
0-109 0-126 0-133 68-144
Drop CMJ n 5 37 n 5 45 .379 n 5 40 n 5 44 .179
76% (18) 79% (16) 83% (16) 88% (17)
0-106 38-110 34-108 44-139
Concentric power n 5 38 n 5 45 .050 n 5 40 n 5 45 .295
71% (32) 82% (26) 82% (33) 87% (24)
21-161 26-140 29-180 42-151
Eccentric power n 5 38 n 5 45 .110 n 5 40 n 5 45 .193
60% (29) 70% (21) 72% (20) 79% (19)
0-116 26-119 24-133 49-135

a
For test variables: n 5 /mean (standard deviation)/ min-max. Mann-Whitney U test was used to evaluate differences between the non-
surgical and surgical groups. CMJ, counter-movement jump.
b
Boldface type indicates significant difference.

at the 12-month evaluation. There were no significant dif- respectively); however, there were no significant differences
ferences between the 2 groups at the 6- and 12-month eval- at the 12-month evaluation (P 5 .295, P 5 .053, and P 5
uations (P 5 .38 and P 5 .71, respectively); however, both .222, respectively). On the heel-rise work test, the surgical
groups had a significantly reduced PAS at the 6- and 12- group performed significantly better than the nonsurgical
month evaluations relative to their preinjury levels. group at both the 6-month and 12-month evaluations (P 5
.013 and P 5 .012, respectively). There were no between-
group differences in performance on the drop CMJ or eccen-
Complications tric strength test at either the 6- or 12-month evaluations.
Injured Versus Uninjured Side. Both groups had signif-
One patient in the surgically treated group sustained an
icantly lower values for the injured leg than the uninjured
Achilles tendon contracture, and even though reoperation
leg in all tests at both the 6- and 12-month evaluations,
was performed, the patient still reported severe symptoms
except for the hopping test at 12 months for which no dif-
and difficulties with normal gait and physical training.
ference was found. The injured leg improved significantly
Color duplex sonography screening showed a high incidence
over time in both groups (Table 4).
of DVT (34%).24 Two infections occurred in the surgical
group, 1 deep and 1 superficial. The patient with a deep
infection was treated with wound dressings and antibiotics; DISCUSSION
the other patient received local treatment. Two patients in
There were no significant differences in rerupture rate
the surgical group complained of nerve disturbances on
between the surgical and nonsurgical treatment groups.
the lateral side of the foot. Thirteen patients had complaints
Furthermore, there were no significant differences between
concerning the scar, with cosmetic complaints in 10 patients
the groups with regard to the patients’ own opinions about
and concerns about decreased ankle function attributable to
their symptoms and function or their physical activity
scar contracture and pain in 3 patients.
levels at the 6- and 12-month evaluations. The surgical
group achieved a greater improvement in function (con-
Functional Tests centric strength, heel-rise work/height, and hopping) at
the 6-month evaluation than did the nonsurgical group;
Nonsurgical Versus Surgical Group at 6 and 12 Months. however, there were no differences between groups at
Table 3 shows LSI at the 6- and 12-month evaluations for all the 12-month evaluation, except on the heel-rise work
functional tests. Performances on the concentric strength, test in which the surgical group performed significantly
heel-rise height, and hopping tests were significantly better better than the nonsurgical group. Both groups improved
in the surgical group than in the nonsurgical group at the in function during the 12 months of follow-up, but still
6-month evaluation (P 5 .05, P 5 .009, and P 5 .037, had significantly decreased function in the injured leg
Vol. 38, No. 11, 2010 Acute Achilles Tendon Rupture 2191

TABLE 4
Performance on Functional Tests for the Injured Versus Uninjured Leg at the 6- and 12-Month Evaluationsa

Comparison, 6- and 12-Month

6-Month Evaluation 12-Month Evaluation Evaluations

Test Injured Uninjured P Valueb Injured Uninjured P Valueb Injured P Valueb Uninjured P Valueb

Heel-rise work n 5 38 n 5 38 \.001 n 5 40 n 5 41 \.001 \.001 \.001

(nonsurgical) 1590 (984) 2926 (1097) 2078 (1095) 3101 (1440)
250-4903 1107-6377 342-5955 1199-8665
Heel-rise work n 5 45 n 5 45 \.001 n 5 45 n 5 45 \.001 \.001 .008
(surgical) 1919 (737) 2978 (938) 2373 (936) 3083 (1121)
891-4146 1001-4909 510-4683 1049-5519
Heel-rise height n 5 39 n 5 38 \.001 n 5 41 n 5 41 \.001 .001 .317
(nonsurgical) 9.6 (2.6) 14.0 (2.2) 10.7 (2.4) 14.0 (2.4)
5.0-17.9 10.3-21.6 7.3-16.9 9.5-21.6
Heel-rise height n 5 45 n 5 45 \.001 n 5 45 n 5 45 \.001 .007 .242
(surgical) 10.6 (2.2) 14.1 (2.1) 11.1 (2.2) 13.8 (2.0)
5.9-17.3 9.4-18.8 5.7-15.2 9.3-18.1
Hopping n 5 39 n 5 38 \.001 n 5 40 n 5 39 .083 .003 .613
(nonsurgical) 0.386 (0.194) 0.518 (0.127) 0.447 (0.182) 0.497 (0.145)
0.0-0.78 0.35-0.89 0.0-0.80 0.0-0.91
Hopping (surgical) n 5 45 n 5 45 .005 n 5 46 n 5 46 .764 .004 .407
0.465 (0.161) 0.513 (0.119) 0.536 (0.142) 0.536 (0.141)
0.0-0.84 0.29-0.85 0.31-0.91 0.32-0.91
Drop CMJ n 5 39 n 5 37 \.001 n 5 40 n 5 40 \.001 .001 .330
(nonsurgical) 10.2 (3.4) 13.5 (3.6) 11.6 (4.1) 14.0 (4.2)
0-18 6-23 3-20 4-23
Drop CMJ n 5 45 n 5 45 \.001 n 5 44 n 5 44 \.001 \.001 .536
(surgical) 10.5 (3.7) 13.3 (4.0) 11.8 (4.0) 13.4 (3.8)
4-21 6-22 6-22 7-23
Concentric power n 5 39 n 5 38 \.001 n 5 41 n 5 40 .001 .009 .881
(nonsurgical) 194 (115) 274 (99) 223 (96) 299 (136)
42-543 114-558 96-521 90-809
Concentric power n 5 45 n 5 45 \.001 n 5 46 n 5 45 \.001 .090 .210
(surgical) 238 (122) 302 (141) 258 (100) 311 (138)
73-732 117-929 87-664 113-869
Eccentric power n 5 39 n 5 38 \.001 n 5 41 n 5 40 \.001 \.001 .060
(nonsurgical) 226 (132) 381 (151) 292 (149) 418 (182)
0-575 210-762 107-884 176-946
Eccentric power n 5 45 n 5 45 \.001 n 5 45 n 5 46 \.001 \.001 .296
(surgical) 290 (106) 429 (141) 344 (132) 443 (158)
89-585 73-732 153-899 198-1074

a
For continuous variables: n 5 /mean (standard deviation)/ min-max. Wilcoxon signed rank test was used to evaluate differences between
the injured and uninjured side, as well as differences between 6-month and 12-month evaluations. CMJ, counter-movement jump.
b
Boldface type indicates significant difference.

relative to the uninjured leg. The importance of, and rea- meta-analyses of Bhandari et al3 and Khan et al.9 We
sons for, the seemingly better performance in some of enrolled 100 patients and, with the treatment protocol
the muscle function tests, unrelated to the patient’s own employed, the rerupture rate in nonsurgically treated
opinion, are unclear and thus further studies are needed. patients was dramatically lowered compared with a previous
Early mobilization was initiated in both the surgical and study.19 Although the study met the sample size dictated by
the nonsurgical group because evidence in the literature our a priori power calculation, the difference in the rerup-
indicates that early mobilization with mechanical loading ture rate might be considered clinically important by some.
of the tendon appears to improve the healing process.2,10 Our results strengthen previous recommendations to
Favorable results when using early mobilization have use a functional brace instead of rigid cast fixation. The
been reported for both surgically and nonsurgically treated fact that the number of patients included in the present
patients with acute Achilles tendon rupture.1,27,28,34 In the study was limited, as in most other studies, means that
present study, we attempted to use the exact same treat- the results of each patient have a substantial effect on
ment protocols for both groups, except for surgery. Surgi- the overall results. Therefore, larger studies are needed
cally treated patients had, in the present study, to evaluate the effect of functional bracing and early range
a rerupture rate of 4%, similar to that reported in the of motion training.
2192 Nilsson-Helander et al The American Journal of Sports Medicine

According to a meta-analysis by Bhandari et al,3 the significant deficits persisted for all tests except for the hop-
rerupture rate with surgical treatment (3.1%) was signifi- ping test, with deficits ranging from 12% to 32%. These
cantly lower than with nonsurgical treatment (13%). How- results underscore the importance of using several func-
ever, the authors pointed out that there were wide tional tests for evaluating treatment outcome, as in the
confidence intervals in the included studies. One major present study.
problem among the studies is the variation in methodologi- It is possible that patients treated nonsurgically require
cal quality. In a meta-analysis by Khan et al,9 the rerupture a longer recovery period and that this was reflected in the
rates were estimated at 3.5% and 12.6% in surgically and greater functional deficits at the 6-month evaluation. It is
nonsurgically treated patients, respectively. Other authors also possible that the nonsurgical group had been more cau-
have pointed out that surgical treatment is associated tious during rehabilitation than the nonsurgical group and
with a higher rate of other complications, such as infections, therefore their strength/endurance had not improved at
wound problems, nerve injuries, and adhesions after sur- the same pace. However, it remains that normalization of
gery.25,26 Early weightbearing and mobilization with or function of the injured leg relative to the uninjured leg
without surgical treatment is suggested to produce the was not achieved in either group at 12 months, which is in
best result, provided that the tendon ends are in contact.1 accordance with other studies.19,27 Further studies are
When following a large group of patients with acute needed to evaluate whether greater improvements could be
Achilles tendon rupture, it is important to consider that achieved with other types of treatment protocols. Further-
some patients experience rerupture because of accidents more, a follow-up time of 1 year is probably too short to
during normal activities of daily living, regardless of treat- determine whether normalization can be achieved over time.
ment type. The reasons for the accidents are many, but We have no explanation for the Achilles tendon contrac-
sometimes patients do sustain rerupture for no obvious ture sustained by 1 patient in the surgically treated group.
reason, as was the case for 3 of the patients in the present This patient reported being healthy overall. However, even
study. Six patients in the nonsurgical group sustained after reoperation, the patient reported severe symptoms
rerupture, 2 of whom were noncompliant with the study and difficulties with normal gait and physical activity 1
protocol. However, it is not known whether noncompliance year after the initial injury. The 2 cases of infection that
was the reason for rerupture. One patient sustained occurred in the surgical group, as well as the other wound
a rerupture because of a fall. All the patients with rerup- and nerve complications, are similar to that reported in the
ture underwent successful reoperation as described by literature. Thirteen patients complained about the scar,
Nilsson-Helander et al.22 Two reruptures occurred in the with 10 patients concerned about the aesthetics and 3
surgical group. One patient slipped on the floor 2 weeks reporting decreased ankle function attributable to scar
after injury and was successfully treated with extended contracture and pain. Although scar complications are gen-
immobilization with the brace locked; the other had erally minor, they can be troublesome for some patients.
a wound infection and sustained a rerupture 2 months Color duplex sonography revealed 32 patients with
after the infection had healed. This patient also suffered DVT, which coincides with results presented in a recent
from a second rerupture despite reoperation. study by Lapidus et al.13 Because DVT appears to be com-
With regard to the patients’ opinions of their own symp- mon after acute Achilles tendon rupture, a routine throm-
toms, function, and physical activity level, we found no sig- boprophylaxis protocol should be established for these
nificant differences between groups at the 6- or 12-month patients. These results are reported separately.24
evaluations. The ATRS for both groups improved signifi- The short-term results might favor the surgical group in
cantly over time, but neither group achieved full recovery terms of function, but this benefit does not translate to
as per the ATRS at the 12-month follow-up. In the future, patient-reported symptoms. Surgical treatment appears to
it would be helpful to evaluate whether the patients con- be associated with a lower rate of rerupture, but the abso-
tinue to improve over time or if their symptoms persist lute number of reruptures was low in both groups. Power
long term. Both groups also had significantly reduced calculation in the present study is based on clinically rele-
physical activity levels at the 6- and 12-month evaluations vant differences as commented upon above; however, type
relative to their preinjury levels. This could be explained II error cannot be excluded. The number of patients
by insufficient recovery, changes in their desired physical included in the present study could also be too low to detect
activity level, or fear of reinjury. a significant between-groups difference in this regard. Other
The surgical group had significantly better results in complications such as DVT, infection, and scar complaints
the heel-rise work, heel-rise height, concentric power, need to be considered when evaluating treatment options.
and hopping tests at the 6-month evaluation than did the Clinically, it is important to consider the type of treat-
nonsurgical group. However, at the 12-month evaluation, ment to use for each individual patient, weighing the risk
there was a significant between-groups difference only in of a rerupture against the risk of complications, the func-
the heel-rise work test. There were no significant differen- tional outcome in terms of muscle function, and the patients’
ces in performance on the drop CMJ or the eccentric own opinion about their symptoms and capacity.
strength tests between the 2 groups at the 6- or 12-month In conclusion, the results of this study did not demon-
evaluations. However, for both groups, there were signifi- strate any statistically significant difference between surgi-
cant differences between the injured and uninjured sides cal and nonsurgical treatment. Furthermore, the study
on all tests at the 6-month evaluation, with deficits indicates that early mobilization is beneficial for patients
ranging from 10% to 46%. At the 12-month evaluation, with acute Achilles tendon rupture whether they are treated
Vol. 38, No. 11, 2010 Acute Achilles Tendon Rupture 2193

surgically or nonsurgically. The preferred treatment strat- 15. Lo IK, Kirkley A, Nonweiler B, Kumbhare DA. Operative versus non-
egy for patients with acute Achilles tendon rupture remains operative treatment of acute Achilles tendon ruptures: a quantitative
review. Clin J Sport Med. 1997;7(3):207-211.
under debate. Larger, high-quality multicenter studies that
16. Lynch RM. Achilles tendon rupture: surgical versus non-surgical
evaluate both the occurrence of complications, including treatment. Accid Emerg Nurs. 2004;12(3):149-158.
rerupture, and patients’ symptoms and function are needed 17. Maffulli N, Tallon C, Wong J, Lim KP, Bleakney R. Early weightbear-
to determine the optimal course of treatment for the individ- ing and ankle mobilization after open repair of acute midsubstance
ual patient with acute Achilles tendon rupture. tears of the Achilles tendon. Am J Sports Med. 2003;31(5):692-700.
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Achilles tendon rupture: a prospective, randomised study comparing
surgical and non-surgical treatment. Scand J Med Sci Sports.
ACKNOWLEDGMENT 2002;12(1):9-16.
19. Möller M, Movin T, Granhed H, Lind K, Faxen E, Karlsson J. Acute
The authors thank Lotta Falkheden-Henning and Annelie rupture of tendon achillis: a prospective randomised study of com-
Brorsson for their help treating and evaluating the parison between surgical and non-surgical treatment. J Bone Joint
patients. They also thank the Swedish National Centre Surg Br. 2001;83(6):843-848.
for Research in Sports (CIF) and the local Research and 20. Mortensen HM, Skov O, Jensen PE. Early motion of the ankle after
operative treatment of a rupture of the Achilles tendon: a prospective,
Development Council of Halland, Sweden, for providing
randomized clinical and radiographic study. J Bone Joint Surg Am.
financial support. 1999;81(7):983-990.
21. Mullaney MJ, McHugh MP, Tyler TF, Nicholas SJ, Lee SJ. Weakness
in end-range plantar flexion after Achilles tendon repair. Am J Sports
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