Foot and Ankle Conditions
We Treat the Following Issues:
Achilles Tendon Rupture
The Achilles tendon (also known as the heel cord or calcaneal tendon) is a strong, fibrous band of tissue that connects the calf muscles (gastrocnemius, soleus, and plantaris) to the heel bone (calcaneus). These muscles, acting via the tendon, cause plantar flexion of the foot at the ankle, and (except soleus) flexion of the knee. Rupture of the tendon can occur in anyone, but is commonly seen in landing athletes (ex. basketball players) and "weekend warriors". If your Achilles tendon ruptures, you might hear a pop, followed by an immediate sharp pain in the back of your ankle and lower leg that is likely to affect your ability to walk properly.
It was previously believed that a rupture of the Achilles was best treated surgically. However, more recently, the management of Achilles tendon ruptures has fallen under the spotlight with multiple studies comparing the effectiveness of non-operative management to surgery, with conservative management coming out either on top or equivalent to surgery in many cases.
Of particular note, a revolutionary study by Willitis et al. from the University of Western Ontario (JBJS 2010) - Dr. Dold's alma mater - looked specifically at operative versus non-operative treatment of acute Achilles tendon ruptures, while following a strict accelerated functional rehabilitation protocol to manage the non-operative group. This was a level 1, prospective, randomized trial comparing the two treatment options. The result of this study showed that all measured outcomes of non-operative treatment (re-rupture rate, post-operative strength, the Leppilahti score, range of motion, and calf circumference) were acceptable and were clinically similar to those for operative treatment.
Furthermore, all of the potentially serious adverse effects of surgery were avoided by treating the injuries non-operatively. Various other studies have been published since this trial. Some show an increased re-rupture rate with non-operative treatment, while others show no difference in the majority of outcome measures.
If you're interested in listening to Dr. Dold discuss the management of Achilles tendon ruptures, find it here:
- Sudden onset of sharp pain in the heel and back of the calf.
- Patient usually reports a audible "pop" after landing on the affected leg.
- Weakness and difficulty walking after the injury.
- Pain and swelling in the heel area after the injury
- Non-operative management options:
- Accelerated functional rehabilitation protocol
- Platelet-Rich Plasma (PRP)
- Bone Marrow Aspirate Concentrate (BMAC)
The decision on whether to manage an acute Achilles tendon rupture conservatively or with surgery depends on a number of important factors. These include:
- Patient factors (age, activity level, medical comorbidities, etc.)
- Injury factors (open vs. closed injury, gap between tendon ends, complete vs. partial tear)
Many studies have emerged recently trying to predict factors associated with positive outcomes after conservative management of these injuries. One important factor to consider is the gap between tendon ends, as elongation of the repaired tendon and muscle length is reported to produce inferior functional results, as illustrated by this study. The gap between tendon ends after a rupture can be broadly assessed on physical exam, but is best appreciated with an MRI or ultrasound with the ankle in a plantar flexed position. Dr. Dold will generally order one of these studies for patients with an acute rupture to better assess the injury and predict the likelihood of successful non-operative management.
- Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation. JBJS (2010).
- A Prospective Randomized Trial Comparing Surgical and Nonsurgical Treatments of Acute Achilles Tendon Ruptures. AJSM (2016).
- Early functional treatment versus cast immobilization in tension after achilles rupture repair: results of a prospective randomized trial with 10 or more years of follow-up. AJSM (2015).
- Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials. JBJS (2012).
- Tendon Length, Calf Muscle Atrophy, and Strength Deficit After Acute Achilles Tendon Rupture: Long-Term Follow-up of Patients in a Previous Study. JBJS (2017).
- Augmented Compared with Nonaugmented Surgical Repair After Total Achilles Rupture: Results of a Prospective Randomized Trial with Thirteen or More Years of Follow-up. JBJS (2016).
- Accelerated rehabilitation following Achilles tendon repair after acute rupture - Development of an evidence-based treatment protocol. Injury (2014).
- Functional Outcome of Acute Achilles Tendon Rupture With and Without Operative Treatment Using Identical Functional Bracing Protocol. Foot Ankle Int (2017).
- Cost-effectiveness analysis of surgical versus non-surgical management of acute Achilles tendon ruptures. KSSTA (2018).
- Practice patterns in the care of acute Achilles tendon ruptures : is there an association with level I evidence? Bone Joint J (2017).
- Patients with an Achilles tendon re-rupture have long-term functional deficits in function and worse patient-reported outcome than primary ruptures. KSSTA (2018).
- Stable surgical repair with accelerated rehabilitation versus nonsurgical treatment for acute Achilles tendon ruptures: a randomized controlled study. AJSM (2013).
- Predictors of functional outcome in non-operatively managed Achilles tendon ruptures. Foot Ankle Surg (2017).
- Outcome after operative treatment for chronic versus acute Achilles tendon rupture - A comparative analysis. Foot Ankle Surg (2018).
- Operative versus nonoperative management of acute Achilles tendon ruptures: a quantitative systematic review of randomized controlled trials. AJSM (2012).
- Outcomes of open surgery versus nonoperative management of acute achilles tendon rupture. Clin J Sport Med (2014).
- Achillon versus open surgery in acute Achilles tendon repair. Foot Ankle Surg (2017).
- Risk Factors for Failed Nonoperative Treatment and Rerupture in Acute Achilles Tendon Rupture. Foot Ankle Int (2018).
- Platelet rich Plasma in Achilles Tendon Healing 2 (PATH-2) trial: protocol for a multicentre, participant and assessor-blinded, parallel-group randomised clinical trial comparing platelet-rich plasma (PRP) injection versus placebo injection for Achilles tendon rupture. BMJ (2017).
- Surgical Treatment Versus Conservative Management for Acute Achilles Tendon Rupture: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Foot Ankle Surg (2017).
- Rehabilitation regimen after surgical treatment of acute Achilles tendon ruptures: a systematic review with meta-analysis. AJSM (2015).
- Is Operative Treatment of Achilles Tendon Ruptures Superior to Nonoperative Treatment?: A Systematic Review of Overlapping Meta-analyses. Orthop J Sports Med (2015).
- Effect of Early Versus Late Weightbearing in Conservatively Treated Acute Achilles TendonRupture: A Meta-Analysis. J Foot Ankle Surg (2018).
- The Effect of Obesity on Surgical Treatment of Achilles Tendon Ruptures. JAAOS (2017).
- Achilles tendon rupture healing is enhanced by intermittent pneumatic compression upregulating collagen type I synthesis. KSSTA (2017).
- Professional Athletes' Return to Play and Performance After Operative Repair of an Achilles Tendon Rupture. AJSM (2017).
- Cost-minimization Analysis of the Management of Acute Achilles Tendon Rupture. JAAOS (2017).
- Soleus Atrophy Is Common After the Nonsurgical Treatment of Acute Achilles Tendon Ruptures: A Randomized Clinical Trial Comparing Surgical and Nonsurgical Functional Treatments. AJSM (2017).
- Severe Functional Debilitations After Complications Associated With Acute Achilles Tendon Rupture With 9 Years of Follow-Up. J Foot Ankle Surg (2017).
- Elevated Knee Joint Kinetics and Reduced Ankle Kinetics Are Present During Jogging and Hopping After Achilles Tendon Ruptures. AJSM (2017).
- A Prospective Study of Platelet-Rich Plasma as Biological Augmentation for Acute Achilles Tendon Rupture Repair. Biomed Res Int (2016).
- Outcome following use of the Achillon jig for the repair of acutely ruptured Achilles tendons. Injury (2017).
- Functional outcomes of conservatively managed acute ruptures of the Achilles tendon. Bone Joint J (2017).
- The epidemiology and trends in management of acute Achilles tendon ruptures in Ontario, Canada: a population-based study of 27,607 patients. Bone Joint J (2017).
- Ageing, deep vein thrombosis and male gender predict poor outcome after acute Achilles tendon rupture. Bone Joint J (2016).
- Is surgical intervention more effective than non-surgical treatment for acute Achilles tendonrupture? A systematic review of overlapping meta-analyses. Int J Surg (2016).
- Surgical Versus Conservative Intervention for Acute Achilles Tendon Rupture: A PRISMA-Compliant Systematic Review of Overlapping Meta-Analyses. Medicine (2016).
- Twelve-month outcomes following surgical repair of the Achilles tendon. Injury (2016).
- Operative and Nonoperative Management of Achilles Tendon Ruptures in Active Duty Military Population. Foot Ankle Int (2016).