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Kristoffer W. Barfod, MD, PhD

AAOS Now

Published 10/1/2014
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Jennie McKee

Should Achilles Tendon Rupture Patients Wait to Bear Weight?

JBJS study examines effects of weight-bearing during conservative treatment

Immediate weight bearing following nonsurgical treatment of acute Achilles tendon rupture may offer benefits to patients, according to the results of a Danish study published in the Journal of Bone and Joint Surgery (JBJS) (Sept. 17, 2014).

This study is the first randomized, controlled trial to use validated outcomes measures to investigate the role of immediate weight bearing as part of a nonsurgical, dynamic rehabilitation protocol for treating acute Achilles tendon rupture, according to lead author Kristoffer W. Barfod, MD, PhD. He and his fellow researchers found that immediate weight bearing increases quality of life and does not appear to have detrimental effects on patient outcomes.

AAOS Now spoke with Dr. Barfod to learn more about the study’s design, findings, and future research directions related to treating acute Achilles tendon ruptures.

AAOS Now: Why did you focus on nonsurgical treatment of acute Achilles tendon rupture, rather than surgical intervention?

Dr. Barfod: The role of surgical treatment has been well investigated by researchers such as Kevin R. Willits, MA, MD, FRSCC; Katarina Nilsson Helander, MD; and Bruce C. Twaddle, FRACS. Nonsurgical treatment, however, remains rather uninvestigated, which is why it was our natural focus.

I am convinced the key to improved treatment for acute Achilles tendon rupture lies in individualized treatment. We need to identify predictive measures to more effectively select whom to treat nonsurgically and whom to treat surgically.

AAOS Now: Why did you hypothesize that immediate weight bearing would improve patient outcomes after nonsurgical treatment of Achilles tendon rupture?

Dr. Barfod: We based our assertion on research investigating weight bearing after the Achilles tendon is severed in animal models. Research has shown that early weight bearing makes tendon callus strength two to three times stronger.

AAOS Now: Can you briefly describe your study design?

Dr. Barfod: The study was designed as a randomized clinical trial, with patients allocated to one of two groups: those who began weight bearing from day one (29 patients)—with the possible use of crutches for the first 2 weeks—and those who went 6 weeks without weight bearing (27 patients). The only variation in treatment protocol was whether patients had permission to bear weight.

All patients were treated with a walking boot with three 1.5-cm wedges, fixing the ankle in equinus (20 to 30 degrees of plantar flexion) for 8 weeks. Every 2 weeks, one wedge was removed to gradually bring the ankle into a neutral position. Controlled early motion was begun after 2 weeks, with patients being instructed to remove the walking boot a minimum of five times per day while sitting atop a table with both of their legs hanging down.

After gravity plantar flexed the foot, patients were instructed to dorsiflex the foot to a horizontal position. All patients were told to perform a series of 25 repetitions of this exercise. Patients were not to remove the walking boot during weeks 3–6, except during exercises. Finally, during the last 2 weeks of treatment, patients could remove the walking boot at night.

As treatment progressed to weeks 9–16, a standardized rehabilitation protocol was used. Physiotherapy specialists trained patients three times per week and provided individualized recommendations for return to activity. Cycling was permissible beginning with week 10, while jogging was allowed, in general, starting with week 14. Contact sports were not allowed for the first year after treatment.

The Achilles Tendon Rupture Score (ATRS) was chosen as the primary endpoint because it is the only patient-reported outcome measure validated for use after acute Achilles tendon rupture. At 1 year, we found that the mean ATRS was 73 in the weight-bearing group and 74 in the control group. The weight-bearing group had three re-ruptures, while the non–weight-bearing group had two re-ruptures.

The only significant difference found between patients in the weight-bearing and those in the non–weight-bearing groups was improved quality of life in the weight-bearing group at 1 year.

AAOS Now: What conclusions do you draw from these results?

Dr. Barfod: I believe we found a better quality of life in the weight-bearing group because weight bearing increased the patients’ ability to take care of themselves and maintain normal social relations, compared to non–weight bearing.

AAOS Now: What are the take aways from your study?

Dr. Barfod: We find it reasonable to recommend immediate weight bearing as part of a nonsurgical, dynamic treatment protocol as a safe treatment modality for acute Achilles tendon rupture. According to our results, immediate weight bearing does not seem to have a detrimental effect on outcomes and improves quality of life, which is consistent with previous findings.

AAOS Now: Why is more study needed regarding treatment of this injury?

Dr. Barfod: As previously stated, I believe the best way to improve treatment for acute Achilles tendon rupture is to individualize treatment. To do that correctly, we need to determine whether measures of rupture morphology and tendon length correlate to patient outcomes.

Dr. Barfod’s co-authors of “Nonoperative Dynamic Treatment of Acute Achilles Tendon Rupture: The Influence of Early Weight-Bearing on Clinical Outcome” are Jesper Bencke, MSc, PhD; Hanne Block Lauridsen, MSc; Ilija Ban, MD; Lars Ebskov, MD; and Anders Troelsen, MD, DMSc, PhD. A link to the study can be found in the online version of this article, available at www.aaosnow.org

Disclosure information: Dr. Troelsen—Accumed LLC, Medtronic, Biomet, Danish Orthopaedic Society. No disclosure information available for Ms. Lauridsen or for Drs. Barfod, Bencke, Ban, or Ebskov. Limited grant support for the research was received from DJO Nordic.

Jennie McKee is a senior science writer for AAOS Now. She can be reached at mckee@aaos.org

Bottom Line

  • This Danish study is a randomized, controlled trial using validated outcomes measures to evaluate the effect of immediate weight bearing as part of nonsurgical treatment for acute Achilles tendon rupture.
  • Patients were allocated to one of two groups: those who began weight bearing from day one and those who did not bear weight until 6 weeks into their treatment. Treatment was identical in both groups, with controlled early motion and a standardized rehabilitation protocol being used for both groups.
  • At 1 year, outcomes and re-ruptures were similar in both groups; the only significant difference found was improved quality of life in the weight-bearing group.
  • The researchers believe it is reasonable to begin immediate weight bearing as part of a nonsurgical, dynamic treatment protocol for acute Achilles tendon rupture.