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Can Early Weightbearing Be Beneficial In Conservative Care Of Ruptured Achilles Tendons?

A recent study validates the benefits of early weightbearing in the non-surgical treatment of Achilles tendon ruptures.1 The United Kingdom study of tendo Achilles rehabilitation (UKSTAR) caught my attention as several of the authors are among the most prolific researchers in the world studying the effects of surgical and non-surgical treatment of the ruptured Achilles tendon.

The lead author of the UKSTAR study, Matthew L. Costa, PhD, previously published one of the landmark prospective studies comparing surgical versus non-operative treatment for acute Achilles tendon ruptures.2 That study, as well as several others, showed no difference in final outcome when comparing surgical repair of the ruptured tendo Achilles versus non-operative treatment intervention.3-5

Another author of the UKSTAR study, Rebecca Kearney, PhD, conducted several important investigations studying the effects of different types of immobilization in the treatment of Achilles tendon rupture.6-7 Kearney also exposed the lack of agreement and the broad range of non-surgical treatment protocols physicians use in the United Kingdom to treat patients conservatively for an Achilles tendon rupture.8 Indeed, there is a wide range of philosophies and strategies among various specialties in treating patients with an acute rupture of the Achilles tendon. 

While non-surgical treatment of the acute rupture of the Achilles tendon has demonstrated equivalent outcomes to surgical repair, there is no universally accepted protocol for implementing a conservative treatment plan. Twenty years ago, I recall that the standard of care for non-operative treatment of the ruptured Achilles required the use of an above-knee cast with placement of the ankle in full equinus for 12 to 16 weeks. Today, there are encouraging reports of successful outcomes when allowing patients to bear weight immediately in a walking boot or functional brace.9-11

What is still debated is the proper position of the ankle in the immobilizing device and the timeline to implement range of motion and muscle strengthening exercises.8,12 Studies of conservative treatment interventions for treating Achilles tendon ruptures mostly consist of a single center with a patient group of less than 100 patients.9-12

The UKSTAR study is significant in that it involved 540 participants from 39 hospitals around the United Kingdom.1 The mean age of study participants was 48 years and over 70 percent of them ruptured their Achilles tendon during sport activity. Thus, the patient pool was clearly different than the typical patient population in the United States who would be treated non-operatively for an Achilles tendon rupture. According to the American Academy of Orthopedic Surgeons guidelines, patients best treated conservatively for an Achilles tendon rupture are over the age of 50 and are relatively non-athletic.13 In the United Kingdom as well as in Europe, conservative treatment of the ruptured Achilles is preferable regardless of age or activity level of the patient.1,5

The UKSTAR study measured the outcome of treating patients with an acute rupture of the Achilles with a traditional plaster cast in a non-weightbearing condition in comparison to immobilizing the patient in a walking boot with immediate weightbearing after the injury. In both interventions, providers initially positioned the ankle in full equinus with gradual reduction of plantarflexion over a period of eight weeks to reach a neutral or 90-degree position at the ankle joint.

In the UKSTAR study, researchers measured outcomes with the patient-reported Achilles tendon rupture score (ATRS) at nine months post-injury.14  The Achilles tendon rupture score measured 10 items related to symptoms, physical activity and pain. For secondary outcome measures, the authors utilized the EQ-5D-5L health-related quality of life instrument. Also, the study authors documented complications such as re-rupture, deep vein thrombosis, falling while immobilized and skin complications.

When comparing non-weightbearing cast immobilization for eight weeks to immediate weightbearing in a walking boot, the authors of the UKSTAR study found that treatment of the acute rupture of the Achilles tendon had similar outcomes with both interventions.1 Functional scoring was almost identical in both the group receiving a non-weightbearing cast and the group who was weightbearing in a walking boot at three, six and nine months post-injury. The rate of deep vein thrombosis was one percent in both groups. 

The rate of falling while immobilized was about 20 percent for both types of immobilization. This finding is concerning, however, as these same offloading restrictions are necessary for post-surgical rehabilitation. Both groups of patients had a lower incidence of re-rupture (six percent) in comparison to previous studies of non-surgical treatment of Achilles ruptures. Studies of patients treated with surgical repair of the acute rupture of the Achilles tendon show a re-rupture rate of 4.6 percent.5

In summary, the UKSTAR study showed that there is no increased risk of complication with immobilization and immediate weightbearing in non-surgical treatment of the ruptured Achilles tendon. The unanswered question is whether early mobilization with exercise might also be beneficial in the conservative treatment of Achilles tendon ruptures. In the UKSTAR study, range of motion and strengthening did not start until eight weeks post-injury. Other studies have shown benefits of earlier mobilization and strengthening of the affected extremity after rupture of the Achilles tendon.11,12

Dr. Richie is an Adjunct Associate Professor within the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University in Oakland, Calif. He is a Fellow and Past President of the American Academy of Podiatric Sports Medicine. Dr. Richie is a Fellow of the American College of Foot and Ankle Surgeons, and the American Academy of Podiatric Sports Medicine. 

References

1. Costa ML, Achten J, Marian IR, et al. Plaster cast versus functional brace for non-surgical treatment of Achilles tendon rupture (UKSTAR): a multicenter randomised controlled trial and economic evaluation. Lancet. 2020;395(10222):441–448.

2. Costa ML, MacMillan K, Halliday D, et al. Randomised controlled trials of immediate weight-bearing mobilisation for rupture of the tendo Achillis. J Bone Joint Surg Br. 2006;88(1):69–77.

3. Metz R, Kerkhoffs GM, Verleisdonk E-J, van der Heijden GJ. Acute Achilles tendon rupture: minimally invasive surgery versus non-operative treatment, with immediate full weight bearing. Design of a randomized controlled trial. BMC Musculoskelet Disord. 2007;8:108.

4. Willits K, Amendola A, Bryant D, et al. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation. J Bone Joint Surg Am. 2010;92(17):2767–2775.

5. Jiang N, Wang B, Chen A, Yu B. Operative versus nonoperative treatment for acute Achilles tendon rupture: a meta-analysis based on current evidence. Int Orthop. 2012;36(4):765-773.

6. Kearney RS, Lamb SE, Achten J, Parsons NR, Costa ML. In-shoe plantar pressures within ankle-foot orthoses: implications for the management of Achilles tendon ruptures. Am J Sports Med. 2011;39(12):2679–2685.

7. Kearney RS, McGuinness KR, Achten J, Costa ML. A systematic review of early rehabilitation methods following a rupture of the Achilles tendon. Physiotherapy. 2012;98(1):24–32.  

8. Kearney RS, Parsons N, Underwood M, Costa ML. Achilles tendon rupture rehabilitation: a mixed methods investigation of current practice among orthopaedic surgeons in the United Kingdom. Bone Joint Res. 2015;4(4):65–69.

9. Young SW, Patel A, Zhu M, et al. Weight-bearing in the nonoperative treatment of acute Achilles tendon ruptures: a randomized controlled trial. J Bone Joint Surg Am. 2014;96(13):1073–1079.

10. Korkmaz M, Erkoc MF, Yolcu S, Balbaloglu O, Öztemur Z, Karaaslan F. Weight bearing the same day versus non-weight bearing for 4 weeks in Achilles tendon rupture. J Orthop Sci. 2015;20(3):513–516.

11. Barfod KW, Bencke J, Lauridsen HB, Ban I, Ebskov L, Troelsen A. Nonoperative dynamic treatment of acute Achilles tendon rupture: the influence of early weight-bearing on clinical outcome: a blinded, randomized controlled trial. J Bone Joint Surg Am. 2014;96(18):1497–1503.

12. Barfod KW, Hansen MS, HÖlmich P, Kristensen MT, Troelsen A. Efficacy of early controlled motion of the ankle compared with immobilisation in non-operative treatment of patients with an acute Achilles tendon rupture: an assessor-blinded, randomized controlled trial. Br J Sports Med. 2020;54(12):719-724. 

13. Chiodo CP, Glazebrook M, Bluman EM, et al. American Academy of Orthopaedic Surgeons clinical practice guideline on treatment of Achilles tendon rupture. J Bone Joint Surg Am. 2010;92(14):2466–2468. 

14. Nilsson-Helander K, Thomeé R, Silbernagel KG, et al. The Achilles tendon Total Rupture Score (ATRS): development and validation. Am J Sports Med. 2007;35(3):421–426.

15. van Hout B, Janssen MF, Feng Y-S, et al. Interim scoring for the EQ-5D-5L: mapping the EQ-5D-5L to EQ-5D-3L value sets.  Value Health. 2012;15(5):708–715.

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