Nonsurgical and surgical treatments provide successful outcomes for an Achilles tear

ROSEMONT, Ill. (January 9, 2017) — A new literature review published in the Journal of the American Academy of Orthopaedic Surgeons (JAAOS) reports successful outcomes for an Achilles tendon tear with either minimally invasive surgery or nonsurgical bracing with a removable boot, especially in recreational athletes. The use of platelet rich plasma (PRP), the injection of plasma-enriched platelets at the injury site, was not deemed an effective treatment.
 
A tear (rupture) of the Achilles tendon — the largest tendon in the body that connects the calf muscles to the heel bone — is among the most common injuries, affecting approximately 30,000 Americans^1,2 each year, primarily recreational athletes age 30 to 49.
 
Earlier studies found a higher rate of re-injury, with nonsurgical casting following an Achilles tear.  Today, nonsurgical treatment options include functional rehabilitation—the use of an adjustable, removable boot that allows for movement and exercise after a brief 2 week course of casting—thereby providing a lower re-rupture than immobilization with a hard cast that is similar to that of surgical repair.  Surgical repair of an Achilles tendon tear also has evolved with the use of minimally invasive techniques and specialized instrumentation to minimize the risk of complication and infection, and so may still be optimal for high-performance athletes, or patients in physically-demanding professions.

Among the research findings highlighted in the review:

• Re-injury rates with functional rehabilitation were lower than previously reported; recent research found no difference in re-rupture rates between functional rehabilitation and minimally invasive surgical repair (a small incision with minimal disruption of the surrounding soft tissue).
• There were no significant long-term differences in ankle range of motion, strength, calf circumference, or functional outcome scores between patients undergoing functional rehabilitation and those with surgical treatment.
• Functional rehabilitation resulted in faster return to mobility and work compared with casting for eight weeks.
• Surgical treatment (full, open or minimally invasive) was associated with return to work up to 19 days earlier than nonsurgical treatment; however, specific criteria for returning to work were not defined in the research parameters and likely varied among the studies.
• Patients undergoing surgery had a small yet statistically significant increase in plantar flexion (flexing of the ankle when pointing the foot and toes) strength at one and two years after surgical repair, which may be advantageous for high-performance athletes.

"The treatment of acute Achilles tendon ruptures has evolved over the last decade, demonstrating improved outcomes with functional rehabilitation compared to prolonged cast immobilization,” said Anish Kadakia, MD, associate professor of orthopaedic surgery at Northwestern University-Feinberg School of Medicine, and lead author of the article. “Given the high demands of the athlete, minimally-invasive surgical treatment should be considered over non-operative management as it minimizes the soft tissue complications while maximizing the power and strength of the patient.”
 
Finally, no existing research to support the use of platelet-rich plasma injections for Achilles tendon tears, as studies, to date, have found no improvement in functional outcomes with use. However, the use of bone marrow-derived stem cells has shown promising results in animal studies.

Disclosures
From the Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Ill. (Anish R. Kadakia, MD and Robert G. Dekker II, MD) and Hinsdale Orthopaedics, Hinsdale, Ill. (Bryant S. Ho, MD).
 
Dr. Kadakia or an immediate family member has received royalties from Acumed and Biomedical Enterprises; is a member of a speakers’ bureau or has made paid presentations on behalf of Acumed and DePuy Synthes; serves as a paid consultant to or is an employee of Acumed, BioMedical Enterprises, and Celling Biosciences; has received research or institutional support from Acumed and DePuy Synthes; and serves as a board member, owner, office or committee member of the American Academy of Orthopaedic Surgeons and the American Orthopaedic Foot and Ankle Society. Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Dekker and Dr. Ho.
 
References
¹HCUP National (Nationwide) Emergency Department Sample (NEDS), 2012-13.
Agency for Healthcare Research and Quality (AHRQ). Accessed December 2016.
 
²NCHS National Ambulatory Medical Carey Survey (NAMCS), 2012-2013. Centers for Disease Control and Prevention (CDC). Accessed December 2016.