Should You Cast Achilles Tendon Ruptures?

By Troy J. Boffeli, DPM

Surgeons routinely make treatment decisions based on their training and experience. For example, we typically employ non-operative treatment of Achilles ruptures for the elderly. Surgical repair, on the other hand, is usually recommended for younger, active patients. The traditional teachings on the long-term outcome after Achilles rupture tend to lump conservative treatment of acute rupture with non-operative treatment of delayed presentation and neglected rupture. Surgeons learn that non-operative treatment results in slow healing, weakness, calf atrophy, re-rupture and loss of function.
The problem with this approach is that we cannot ignore the strong evidence supporting conservative treatment via a brace and early weightbearing. Rather than being limited by our biases, the decision to perform surgery or cast a ruptured Achilles tendon is a clinical problem best answered through critical analysis of the best available evidence.

A Closer Look At The Current Literature
The decision to perform surgery or cast an Achilles rupture is a therapy question. The best evidence for a therapy question is a systematic review or meta-analysis of randomized controlled trials (RCTs) that represent Level 1 evidence.
In a meta-analysis of 14 RCTs, Khan, et al., evaluated treatment options for acute Achilles ruptures. This meta-analysis included four RCTs that compared surgical to conservative treatment in 356 patients. The authors concluded that surgical repair significantly decreased the risk of re-rupture (3.5 percent with surgery vs. 12.6 percent with non-operative treatment). However, the authors also found that surgery significantly increased the risk of other complications related to adhesion, infection and disturbed sensation (34 percent with surgery versus 2.7 percent with non-operative treatment).1
In the meta-analysis, the authors noted no statistically significant difference in the power of plantarflexion or heel raise endurance when comparing surgical to non-operative treatments. In three of four RCTs, patients returned to sports after treatment for Achilles ruptures. One study identified a better return to the original level of sports with surgery versus cast treatment alone while two studies showed no statistically significant difference.
The non-operative control groups in these RCTs (Khan, et al.) wore a plantarflexed cast without weightbearing or early range of motion. On the other hand, researchers described functional bracing as a removable brace that prevented dorsiflexion yet allowed immediate weightbearing, plantarflexion and physical therapy.
Khan, et al., evaluated the results of two RCTs that compared non-operative treatment in a traditional cast versus non-operative treatment in a functional brace. The functional brace group represented a small number of patients but demonstrated a re-rupture rate of 2.4 percent. Pooled data from other studies showed a re-rupture rate of 3.5 percent with operative treatment.1
In two independent RCTs, Costa, et al., studied the effectiveness of the functional brace. The first trial evaluated postoperative care via the traditional non-weightbearing cast versus immediate weightbearing in a functional brace. The second trial compared conservative treatment with a traditional non-weightbearing cast versus immediate walking in a functional brace.
The results showed that immediate walking in a brace improved functional outcome after surgery. Non-operative treatment with immediate weightbearing in a functional brace demonstrated no evidence of functional benefit or harm. Costa, et al., recommended “immediate weightbearing mobilization for rehabilitation of all patients with acute rupture of the tendo Achilles.”2

Translating The Evidence Into Practice

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