An Achilles tendon rupture can be a devastating injury for both the competitive athlete and the ‘weekend warrior.’ When a patient arrives at my clinic with an acute rupture, their first question is always: “Doc, do I need surgery?”
The management of Achilles tendon ruptures has become a contentious topic among sports medicine and foot & ankle specialists over the past few years. For most patients, this is a hypothetical question and the anticipated answer is obvious: ‘Yes - of course you need surgery!’ However, as clinical research has shown us, this is usually not the case; the majority of acute Achilles tendon ruptures can (and should) be managed non-operatively – that’s right, surgery is NOT necessary.
Before I go any further, I should take a step back. I am a surgeon and I love to operate. And yes, there is a time when surgery is necessary to achieve a better functional outcome for this injury (I will elaborate on this point a little later). However, in the majority of cases, a non-operative management approach (with an accelerated functional rehab program) will produce a clinically equivalent result to surgery. In other words, surgery is not always necessary to achieve a good outcome, and, for the most part, shouldn’t be considered the norm in the majority of acute tears. Furthermore, the conservative, non-surgical approach also eliminates the potentially devastating complications associated with surgery (Example 1, Example 2, Example 3).
The Achilles tendon debate and impetus for change was largely prompted by a ground-breaking study by Willits et al. in 2010 (JBJS). Prior to this point, there had been only two small randomized trials comparing the outcomes of surgery with non-operative management (where early weight bearing and mobilization was the focus in both groups). Both of these studies showed no significant difference between groups in re-rupture rate or any of the other outcomes including range of motion, strength, calf circumference, or functional assessment (Study 1, Study 2). The study by Willits was the first large scale, prospective, multicenter, randomized trial to compare surgery with a functional rehab program for similar patients. A total of 144 patients were randomized (72 patients to each group: surgery or no surgery, followed by a functional rehab protocol for both groups). Importantly, patients were NOT randomized according to their tears (in other words, patients with bigger tears were not pushed to surgery, or visa versa – each patient was randomized independent of their tear). The result: there was no clinically significant difference between groups with regard to re-rupture rate, strength, range of motion, calf circumference, or Leppilahti score (an outcome measure/score for Achilles tendon ruptures). The major, most notable difference between the two groups was the complication rate, with surgery producing a far greater risk of developing a complication.
This study conformed that surgery was not necessary for the majority of patients with acute Achilles tendon ruptures. There have been a number of studies since this paper, most showing similar results (I have summarized most of the important Achilles papers here).
Two of the primary concerns of patients and clinicians when comparing surgery with conservative management are (1) re-rupture rate and (2) strength. Some studies do show a decreased risk of re-rupture with surgery (Study 1; Study 2; Study 3). However, many others show no difference in the risk of re-rupture (Study 1; Study 2; Study 3; Study 4; Study 5; Study 6; Study 7; Study 8; Study 9; Study 10).
The results for strength are similar. The majority of studies show no difference between surgery and conservative management with regards to strength, calf circumference, or functional outcome. One important consideration that has been shown to negatively affect post-recovery strength is the gap between tendon ends following the injury (Heikkinen et al JBJS 2017). I will always consider this when deciding on the best management option.
Remember, there is a time when surgery will produce a better result than a conservative, non-operative course of care, I believe. If there is a patient who might benefit from surgery, it is a young, active, healthy person with a large gap between the torn tendon ends (greater than 2-3cm with the ankle in a plantar flexed position, although some studies indicate a gap of greater than 1cm maybe be relevant). I believe that the gap between the torn tendon ends is an important factor to consider when deciding between treatment options. A larger gap may result in a functional lengthening of the tendon (and muscle) upon healing. Studies have shown that the length of the tendon is an important factor in the functional outcome of the patient. Length determines strength, and a weaker calf may produce a functionally inferior outcome for a patient that relies on speed as part of their performance and athletic ability, for example. It’s difficult to give an exact cut-off age, but I think that healthy, active patients younger than 30 should certainly entertain the option of surgery. As with any injury, patient history, physical examination, imaging, and a discussion of the potential risks and benefits of surgery versus conservative care should help delineate the decision on a management plan.
In summary, surgery is typically not necessary for acute Achilles tendon ruptures, and this is widely supported in the literature. An accelerated functional rehab program will usually result in an equivalent result while avoiding the complications (and cost) of surgery. Unfortunately, no matter which treatment option is chosen, this is a devastating injury where mediocre results are common (Example 1; Example 2; Example 3; Example 4).
It is my hope that orthobiologics, including mesenchymal stem cell therapy, will help improve our management of these injuries so that they aren’t so devastating in the near future (Example 1; Example 2)!
Finally, this is a summary of 17 years of experience managing these injuries non-operatively: https://www.ncbi.nlm.nih.gov/pubmed/26818449.
Listen to Dr. Dold discuss the management of Achilles tendon ruptures in the Recover With Purpose Podcast, here: