Surgery or Functional Rehab for Achilles Rupture
An Achilles rupture can take away push-off for walking, stairs and running, and the choice between surgery and a brace trades a rerupture against a wound infection or nerve injury.
Key terminology
- Achilles tendon
- This cord joins the gastrocnemius and soleus to the back of the calcaneus. Its midportion has the poorest blood supply and tears most often.
- Thompson test
- This exam squeezes the calf with the patient prone and the feet off the table. No passive plantarflexion of the foot means the tendon is torn.
- Matles test
- This exam watches the resting feet with the patient prone and both knees bent to 90°. A foot that hangs in neutral or dorsiflexion suggests a rupture.
- Functional rehabilitation
- This plan starts protected weight bearing and ankle motion early in a boot or brace. It replaces 6 to 8 weeks of cast immobilization.
- Minimally invasive repair
- This repair passes sutures through small incisions instead of opening the full tendon sheath. It spares the wound and puts the nearby nerve at more risk.
- Achilles tendon Total Rupture Score
- This patient questionnaire scores symptoms and function after an Achilles rupture from 0 to 100. Higher scores mean better function.
- Sural nerve
- This sensory nerve runs down the back of the calf and crosses the lateral edge of the Achilles tendon. It supplies the lateral border of the foot.
Takeaways
- Acute Achilles rupture is a clinical diagnosis made at the bedside. In 174 ruptures, the calf squeeze (Thompson) test had a sensitivity of 0.96 and a specificity of 0.93, and the Matles test 0.88 and 0.85. Palpating the gap was the least sensitive test at 0.73. At least 2 tests were positive in every rupture, so a clear exam does not need an MRI to confirm it (Maffulli, Am J Sports Med 1998;26:266-270, PMID 9548122).
- The Achilles tendon tears in its poorly perfused midportion. It is the conjoint tendon of the gastrocnemius and soleus and the strongest tendon in the body. The peroneal artery supplies the midsection and the posterior tibial artery supplies both ends, which leaves a relatively hypovascular midportion where most problems occur. Running loads it to as much as 12.5 times body weight (Doral et al, Knee Surg Sports Traumatol Arthrosc 2010;18:638-643, PMID 20182867).
- Surgery and nonoperative care are both acceptable, so patient factors decide. The AAOS guideline lists each as an option, and none of its 16 recommendations was graded strong. It advises caution with surgery in diabetes, neuropathy, immunocompromise, age >65, smoking, a sedentary lifestyle, BMI >30 and peripheral vascular disease. A large meta-analysis also left the choice to shared decision making (Chiodo et al, J Am Acad Orthop Surg 2010;18:503-510, PMID 20675643; Ochen et al, BMJ 2019;364:k5120, PMID 30617123).
- Early motion and weight bearing decide whether surgery lowers rerupture. In a meta-analysis of 10 RCTs, rerupture was equal with functional rehabilitation (risk difference 1.7%, p = 0.45). Without early motion, surgery cut rerupture by an absolute 8.8%. Surgery added an absolute 15.8% risk of other complications and returned patients to work about 19 days sooner (Soroceanu et al, J Bone Joint Surg Am 2012;94:2136-2143, PMID 23224384).
- With the same accelerated rehab in both arms, surgery and a brace gave similar function. Willits randomized 144 patients (mean age 40, 118 men). Rerupture occurred in 2 operative vs 3 nonoperative patients, with 13 vs 6 complications. A Swedish RCT of 97 patients had 12% vs 4% rerupture (p = 0.377), a gap some may call clinically important (Willits et al, J Bone Joint Surg Am 2010;92:2767-2775, PMID 21037028; Nilsson-Helander et al, Am J Sports Med 2010;38:2186-2193, PMID 20802094).
- The largest trial found equal function and fewer reruptures with surgery. ACHILLES randomized 554 patients to nonoperative care, open repair or minimally invasive repair. The change in Achilles tendon Total Rupture Score at 12 months did not differ (p = 0.57). Rerupture was 6.2% without surgery vs 0.6% in each surgical arm, so the rerupture question is still open (Myhrvold et al, N Engl J Med 2022;386:1409-1420, PMID 35417636).
- Surgery trades a small drop in rerupture for a larger rise in other complications. Across 29 studies (15,862 patients), rerupture was 2.3% with surgery vs 3.9% without (risk difference 1.6%). Complications were 4.9% vs 1.6%, mostly a 2.8% infection rate with surgery. In studies using accelerated functional rehab, rerupture did not differ (risk ratio 0.60, p = 0.23) (Ochen et al, BMJ 2019;364:k5120, PMID 30617123).
- The sural nerve is the structure at risk during Achilles repair. In 30 cadaver legs it crossed the lateral border of the tendon a mean 9.8 cm above the calcaneus. In ACHILLES, nerve injuries occurred in 5.2% after minimally invasive repair, 2.8% after open repair and 0.6% without surgery. (Webb et al, Foot Ankle Int 2000;21:475-477, PMID 10884105; Myhrvold et al, N Engl J Med 2022;386:1409-1420, PMID 35417636).