Page 157 - Athletic Health Handbook
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Sagittal MRI of an Acute Achilles to the significantly lower rate significant differences in strength,
Rupture of rerupture. calf circumference, ROM, functional
scores, or rerupture rates.8
remains controversial. With The majority of earlier studies
conflicting evidence, and a lack comparing operative to non-operative Nilsson-Helander et al. performed
of standardization of rehabilitation treatment employed an extended a similar randomized controlled trial
protocols, making a decision on period of immobilization, often utilizing early ROM in an AFO,
treatment based on current data delaying the initiation of rehabilitation with weight-bearing by eight weeks
is now more difficult than ever. for 8 to 12 weeks. The prevailing in 98 patients with an average age
notion was that surgical repairs of 40. They found no significant
Operative Versus Non-Operative needed to be protected, and that differences in rerupture rates, strength,
Treatment non-surgical treatment needed to or functional scores at one year,
include prolonged plantar flexion although the level of function of the
The decision for operative versus to allow tendon edge apposition. injured leg remained less than the
non-operative treatment of acute good leg in most cases.9 Interestingly,
Achilles ruptures is controversial. There is increasing evidence the same group published a similar
Prior to 2005, there was sufficient that early functional rehabilitation RCT in 2001 comparing operative
evidence supporting a lower re-rupture improves tendon healing, similar to non-operative intervention, with
rate and increased complication to the methods employed with hand the non-operative group treated with
rate with operative repair. In a meta- flexor tendon repair. The proponents a cast in plantar flexion for eight
analysis of 12 trials with 800 patients of non-operative management point weeks. Early functional rehabilitation
published in 2005, Khan et al. found to anecdotal evidence of healed was utilized in the operative group.
a rerupture risk of 3.5 percent Achilles tendon ruptures with In that study, there was a significant
in the surgical group compared to neglected treatment. In a sheep model, difference in rerupture rates, with
12.6 percent in the non-operative transected Achilles tendons have been 1.7 percent in the surgical group
group. The complication rate in the shown to heal spontaneously without compared to 20.8 percent in the
operative group was 34.1 percent immobilization.6 In the rat model, non-operative group.10 The fact that
compared to 2.7 percent in the non- early physical activity following the same physicians and techniques
operative group.4 An expected-value Achilles tendon repair has been shown were utilized in both studies, with
decision analysis by Kocher et al. in to accelerate tendon healing through the only difference being the non-
2002 favored surgical repair as the an increase of the diameter of collagen operative group’s immobilization,
optimal treatment strategy based formation and stimulating earlier truly underscores the likely importance
on the available literature evidence.5 neuronal in-growth.7 Based on of early rehabilitation in the success
Based on these earlier studies, most this information, there has been of treatment of Achilles injuries.
surgeons accepted that in the athletic an evolution in both operative and
population surgical repair was the non-operative Achilles rehabilitation, In 2010, Willits et al. published
preferred treatment strategy due with an emphasis on early functional a landmark multi-centered RCT of
range of motion (ROM) and 144 patients with an acute Achilles
progression of weight bearing. rupture with an average age of 40.
They utilized the same early
In 2007, Twaddle et al. performed functional rehabilitation in both
a randomized, controlled prospective groups. The authors found no
trial (RCT) of non-operative versus significant differences in rerupture
operative repair of acute Achilles rates, strength, ROM, calf
ruptures in 42 patients with an circumference, or functional scores.
average age of 40. All surgical and There were more complications in
non-surgical patients were placed the operative group, with the increase
in a removable ankle-foot orthosis related to wound problems.11
(AFO), and began ROM by 10 days.
Dorsiflexion was progressively In a more recent meta-analysis
increased, and assisted weight-bearing of operative versus non-operative
with progression was initiated at six intervention with more than 400
weeks. At one year, there were no patients in both groups, Soroceanu

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