Diagnosis and Treatment of Acute Achilles Tendon Rupture

Diagnosis and Treatment of AcuteAchilles Tendon Rupture

Abstract

This clinical practice guideline is based on a series of systematicreviews of published studies in the available literature on thediagnosis and treatment of acute Achilles tendon rupture. None ofthe 16 recommendations made by the work group was graded asstrong; most are graded inconclusive; four are graded weak; twoare graded as moderate strength; and two are consensusstatements. The two moderate-strength recommendations includethe suggestions for early postoperative protective weight bearingand for the use of protective devices that allow for postoperativemobilization.

Overview and Rationale

This clinical practice guideline wasapproved by the American Academyof Orthopaedic Surgeons (AAOS) onDecember 4, 2009. It is based on asystematic review of published stud-ies on the diagnosis and treatment ofAchilles tendon rupture in adults.The guideline provides practice rec-ommendations and highlights gapsin the literature and areas that re-quire future research.

The purpose of this clinical prac-tice guideline is to help improvetreatment based on the current bestevidence. Current evidence-basedpractice standards demand that phy-sicians use the best available evi-dence in their clinical decision-making. To assist in this, this clinicalpractice guideline consists of a seriesof systematic reviews of the availableliterature regarding the diagnosisand treatment of Achilles tendonruptures. These systematic reviewswere conducted between January1966 and June 2009; they showwhere good evidence exists, whereevidence is lacking, and which topics

future research must target to im-prove the treatment of patients withrupture of the Achilles tendon.AAOS staff and the Diagnosis andTreatment of Acute Achilles TendonRupture Guideline and Evidence Re-port Work Group systematically re-viewed the available literature andsubsequently wrote the followingrecommendations based on a rigor-ous, standardized process.

Musculoskeletal care is provided inmany different settings by many dif-ferent providers. We created thisguideline as an educational tool toguide qualified physicians through aseries of treatment decisions in an ef-fort to improve the quality and effi-ciency of care. This guideline shouldnot be construed as including allproper methods of care or excludingmethods of care that are reasonablydirected to obtaining the same re-sults. The ultimate judgment regard-ing any specific procedure or treat-ment must be made in light of allcircumstances presented by the pa-tient and the needs and resourcesparticular to the locality or institu-tion.

Christopher P. Chiodo, MD

Mark Glazebrook, MD

Eric Michael Bluman, MD, PhD

Bruce E. Cohen, MD

John E. Femino, MD

Eric Giza, MD

William C. Watters III, MD

Michael J. Goldberg, MD

Michael Keith, MD

Robert H. Haralson III, MD,MBA

Charles M. Turkelson, PhD

Janet L. Wies, MPH

Laura Raymond, MA

Sara Anderson, MPH

Kevin Boyer

Patrick Sluka, MPH

This clinical practice guideline wasapproved by the American Academyof Orthopaedic Surgeons onDecember 4, 2009.

J Am Acad Orthop Surg 2010;18:503-510

Copyright 2010 by the AmericanAcademy of Orthopaedic Surgeons.

AAOS Clinical Practice Guideline Summary

August 2010, Vol 18, No 8 503

Potential Harms andContraindications

Most treatments are associated withsome known risks, especially inva-sive and surgical treatments. In addi-tion, contraindications vary widelybased on the treatment administered.Therefore, discussion of availabletreatments and procedures applica-ble to the individual patient rely onmutual communication between thepatient and physician.

Methods

The methods used to develop thisclinical practice guideline were de-signed to combat bias, enhancetransparency, and promote reproduc-ibility. Their purpose is to allow in-terested readers the ability to inspect

all of the information the workgroup used to reach all of its deci-sions and to verify that these deci-sions are in accord with the bestavailable evidence. The draft wassubject to peer review and publiccommentary. It was approved bythe AAOS Evidence-Based PracticeCommittee; Guidelines and Technol-ogy Oversight Committee; Councilon Research, Quality Assessment,and Technology; and the Board ofDirectors. The methods used to pre-pare this guideline are detailed in thefull clinical practice guideline, avail-able at http://www.aaos.org/research/guidelines/atrguideline.pdf.

Recommendations

Each guideline recommendation wasconstructed using the following lan-

guage, taking into account the rec-ommendation grade and level of evi-dence:

We recommend: Recommendationgrade, Strong. Level of evidence:Level I evidence from more than onestudy with consistent findings forrecommending for or against the in-tervention or diagnostic.

We suggest: Recommendation grade,Moderate. Level of evidence: Level II orIII evidence from more than one studywith consistent findings, or Level I ev-idence from a single study for recom-mending for or against the interventionor diagnostic.

Option: Recommendation grade,Weak. Level of evidence: Level IV or Vevidence from more than one studywith consistent findings, or Level II orIII evidence from a single study for rec-ommending for or against the interven-tion or diagnostic.

From Brigham Orthopedic Associates, Boston, MA (Dr. Chiodo), Queen Elizabeth Health Sciences Center, Halifax Infirmary, Halifax,Nova Scotia, Canada (Dr. Glazebrook), Madigan Army Medical Center, Tacoma, WA (Dr. Bluman), OrthoCarolina, Charlotte, NC(Dr. Cohen), the Department of Orthopedics, University of Iowa Hospital and Clinics, Iowa City, IA (Dr. Femino), the Department ofOrthopaedics, University of California Davis, Ambulatory Care Services, Sacramento, CA (Dr. Giza), the Bone and Joint Clinic ofHouston, Houston, TX (Dr. Watters), the Department of Orthopaedics, Seattle Children’s Hospital, Seattle, WA (Dr. Goldberg),MetroHealth Medical Center, Cleveland, OH (Dr. Keith), and the Department of Medical Affairs (Dr. Haralson) and the Department ofResearch and Scientific Affairs (Dr. Turkelson, Ms. Wies, Ms. Raymond, Ms. Anderson, Mr. Boyer, and Mr. Sluka), the AmericanAcademy of Orthopaedic Surgeons, Rosemont, IL.

Dr. Chiodo or an immediate family member serves as a board member, owner, officer, or committee member of the AmericanAcademy of Orthopaedic Surgeons (AAOS), American Orthopaedic Foot and Ankle Society (AOFAS), and Mass Ortho Association;has received royalties from Aircast and Arthrex; is a member of a speakers’ bureau or has made paid presentations on behalf ofDePuy; serves as a paid consultant to or is an employee of MMI; has received research or institutional support from DJ Orthopaedicsand EBI; and has stock or stock options held in Johnson & Johnson, Merck, and Zimmer. Dr. Glazebrook or an immediate familymember is a member of a speakers’ bureau or has made paid presentations on behalf of Wright Medical Technology; serves as apaid consultant to or is an employee of Biomimetic, CONMED Linvatec, and Wright Medical Technology; has received research orinstitutional support from DePuy; and has stock or stock options held in Smith & Nephew and Stryker. Dr. Bluman or an immediatefamily member serves as a board member, owner, officer, or committee member of the AAOS and AOFAS; is a member of aspeakers’ bureau or has made paid presentations on behalf of Arthrex and DePuy; serves as a paid consultant to or is an employeeof Arthrex and DePuy; and has received nonincome support (such as equipment or services), commercially derived honoraria, orother non-research–related funding (such as paid travel) from EMS/Swiss Dolorclast. Dr. Cohen or an immediate family member hasreceived royalties from Arthrex, DJ Orthopaedics, and Wright Medical Technology; serves as a paid consultant to or is an employeeof Wright Medical Technology; and has received research or institutional support from Wright Medical Technology. Dr. Giza or animmediate family member serves as a paid consultant to or is an employee of Arthrex and has received research or institutionalsupport from Orthopaedic Scientific Research Foundation. Dr. Watters or an immediate family member serves as a board member,owner, officer, or committee member of American Board of Spine Surgery and North American Spine Society; serves as a paidconsultant to or is an employee of Stryker; and has stock or stock options held in Intrinsic Orthopedics. Dr. Goldberg or an immediatefamily member serves as a board member, owner, officer, or committee member of the AAOS. Dr. Keith or an immediate familymember serves as a board member, owner, officer, or committee member of the AAOS, is a member of a speakers’ bureau or hasmade paid presentations on behalf of Synthes, and serves as an unpaid consultant to Neuros. Dr. Haralson or an immediate familymember serves as a board member, owner, officer, or committee member of Allmeds, serves as a paid consultant to or is anemployee of DeRoyal Industries, and has stock or stock options held in Biomet. Ms. Wies or an immediate family member has stockor stock options held in Merck/Schering-Plough. None of the following authors or any immediate family member has receivedanything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article:Dr. Femino, Dr. Turkelson, Ms. Raymond, Ms. Anderson, Mr. Boyer, and Mr. Sluka.

Diagnosis and Treatment of Acute Achilles Tendon Rupture

504 Journal of the American Academy of Orthopaedic Surgeons

We are unable to recommend for oragainst: Recommendation grade, Incon-clusive. Level of evidence: There is in-sufficient or conflicting evidence not al-lowing a recommendation for oragainst intervention.

In the absence of reliable evidence,it is the opinion of the work group:Recommendation grade, Consensus.Level of evidence: There is no sup-porting evidence. In the absence ofreliable evidence, the work group ismaking a recommendation based ontheir clinical opinion, considering theknown harms and benefits associ-ated with the treatment.

Recommendation 1In the absence of reliable evidence, it isthe opinion of this work group that adetailed history and physical examina-tion be performed. The physical exam-ination should include two or more ofthe following tests to establish the di-agnosis of acute Achilles tendon rup-ture:

• Clinical Thompson test (ie, Sim-monds squeeze test)

• Decreased ankle plantar flexionstrength

• Presence of a palpable gap (de-fect, loss of contour)

• Increased passive ankle dorsiflex-ion with gentle manipulation

This recommendation is gradedConsensus.

It is addressed by one level Vstudy.1 The study authors used visual in-spection at surgery as the benchmarkfor the diagnosis in patients who hadundergone open repair. The study au-thors also used clinical examination, ul-trasonography and MRI as the refer-ence standard for diagnosis whendeciphering whether patients had anAchilles tendon tear and to confirm theextent of the tear in patients treatednonsurgically. Health care providerswere not routinely blinded to the resultsof any given test. All patients receiveda physical examination. Palpation (to

establish the presence of a gap) and thecalf squeeze test (ie, Thompson/Sim-monds squeeze test) were performed bythe authors in all patients. The authorsperformed the Matles test (ie, increasedpassive ankle dorsiflexion) on 107 of174 patients.

The authors reported sensitivitiesand specificities for the tests basedon the 133 patients treated withopen repair and the 28 patientstreated who did not have an Achillestendon rupture. The authors re-ported these test results individually.They did not consider whether incre-mental value exists for any combina-tion of the given physical tests whenthe tests are all performed during thephysical examination.

Recommendation 2We are unable to recommend for oragainst the routine use of MRI, ul-trasonography, and radiography toconfirm the diagnosis of acute Achil-les tendon rupture.

This recommendation is graded In-conclusive.

No studies addressed MRI or radiog-raphy as confirmatory tests, and onlytwo level V prospective studies1,2 ad-dressed ultrasonography. These twostudies contain unreliable data and can-not be combined to provide adequateevidence. The studies enrolled patientswith complete Achilles tendon tear1,2

and used visual inspection at surgeryas the benchmark for the diagnosis.In one study, patients underwent theThompson test, followed by surgery.1

In the second study, patients under-went the Thompson test and ultra-sonography, followed by surgery.2

The authors of the studies reportedsensitivities and specificities or pro-vided enough information for theseparameters to be determined.

Recommendation 3Nonsurgical treatment is an optionfor patients with acute Achilles ten-

don rupture.This recommendation is graded

Weak.It is addressed by four level II studies,

including all surgical techniques.3-6 Toaddress this recommendation, we an-alyzed studies that made two differentcomparisons. Three level II studies com-pared patients treated nonsurgically(with casting) with patients treated withopen repair.3-5 One level II studycompared casting with minimally in-vasive open repair.6

Two studies examined functionaloutcomes, and both found nonsignif-icant results.3,4 Based on AAOS cal-culations, the study by Twaddle andPoon3 did have significant results at2, 3, and 6 months, measured bythe Musculoskeletal Function Assess-ment instrument, in which patientswith surgical treatment had betterfunctional ability than did thosetreated nonsurgically. Our resultsdiffer from those of the authors be-cause a higher powered statisticaltest was used. Two studies reportedno significant difference in the num-ber of patients with pain.5,6

Three studies reported that pa-tients treated nonsurgically did notsignificantly differ in the amount oftime to return to work.4-6 Three stud-ies examined return to sports;4-6 thestudy by Cetti et al4 reported signifi-cant results in favor of patientstreated with surgical repair. Thestudy by Möller et al5 reported sig-nificantly fewer reruptures in pa-tients treated surgically. The occur-rence of extreme residual tendonlengthening, deep vein thrombosis(DVT), and “major” complicationswere not significantly different be-tween patients treated surgically andthose treated nonsurgically. Minorcomplications reported in the in-cluded studies were related to thesurgical intervention and thereforeoccurred less in patients treated non-surgically.

Christopher P. Chiodo, MD, et al

August 2010, Vol 18, No 8 505

Recommendation 4For patients treated nonsurgically,we are unable to recommend for oragainst the use of immediate func-tional bracing for patients with acuteAchilles tendon rupture.


It is addressed by one level II andone level IV study for rerupture ratesand by two level IV studies and onelevel V study for functional outcome.We analyzed one level II and onelevel IV study that compared patientstreated with cast plus a functionalbrace versus patients treated with acast only.7,8 In both comparativestudies, rerupture rates did not sig-nificantly differ between patientstreated with cast plus orthosis versuscast.

In the three studies that reportedresults for patients treated with func-tional bracing, 78% of patientstreated with a functional brace hadno pain, 55% reported no stiffness,56% had no weakness, 98% of pa-tients returned to full level of em-ployment, and 37% returned to thesame level of sports at 2 to 9years.9-11 The average time to returnto work was 7 days (range, 21 to 52days). One study reported that 2%of patients had a pulmonary embo-lism;9 another study reported that1% of patients had DVT and “tem-porary dropfoot.”11

Recommendation 5Surgical treatment is an option inpatients with acute Achilles tendonrupture.

This recommendation is gradedWeak.

It is addressed by a systematic reviewof the literature, including eight stud-ies that addressed the efficacy of openrepair4,5,12-17 and six studies that ad-dressed the efficacy of minimally inva-sive techniques.6,12,14,16,18,19 All arelevel IV studies. The 14 studies dem-

onstrate a wide variety of patient-oriented outcome measures and du-ration to follow-up to evaluatepatients receiving surgical treatmentof Achilles tendon rupture. The in-consistency of these outcome mea-sures makes comparisons betweenstudies difficult. Because the body ofevidence is weak, it does not allowfor additional statistical analysis.

Recommendation 6In the absence of reliable evidence, itis the opinion of the work groupthat, although surgical treatment isan option, it should be approachedmore cautiously in patients with dia-betes or neuropathy, those in immu-nocompromised states or aged >65years, those who use tobacco or havea sedentary lifestyle, those who areobese (body mass index >30), andthose with peripheral vascular dis-ease, or local/systemic dermatologicdisorders.

This recommendation is gradedConsensus.

We were unable to find any publishedstudies that addressed the effects of co-morbid conditions on the success of sur-gical repair. Therefore, this recommen-dation is based on expert opinion andis consistent with current clinical prac-tice. The consensus of the work groupis that consideration of nonsurgicaltreatment should occur before perform-ing surgical repair of Achilles tendonruptures in patients with conditions thatmay impair wound healing. These pa-tients may be at increased risk forwound problems and infection, withsubsequent detrimental effect on out-come.

Recommendation 7

For patients who will be treated sur-gically for an acute Achilles tendonrupture, we are unable to recom-mend for or against presurgical im-mobilization or restricted weightbearing.


We were unable to find any pub-lished studies that addressed the ef-fects of presurgical immobilizationor restricted weight bearing on thesuccess of surgical repair of acuterupture of this tendon.

Recommendation 8Open, limited open, and percutane-ous techniques are options for treat-ing patients with acute Achilles ten-don rupture.


It is addressed by three level II com-parative trials investigating percutane-ous repair14,18,20 and by one level II andtwo level III comparative trials study-ing limited open repairs.12,16,21

We defined the following surgicalrepairs:

• Open: a procedure using an ex-tended incision for exposure, allow-ing visualization of the rupture andtendon to allow direct placement ofsutures for the repair.

• Limited open: a procedure usinga small incision for exposure, allow-ing direct visualization of the rup-tured ends.

• Percutaneous: a procedure with-out direct exposure of the tendonrupture site.

Percutaneous VersusOpen RepairTwo level II studies compared percu-taneous repair to open repair.14,18 Pa-tients treated with percutaneous re-pair scored significantly higher onthe Medical Outcomes Study 12-Item Short Form physical and mentalcomponent scores.20 There was nosignificant difference in the numberof patients who returned to func-tional activities, in activities of dailyliving,14,18 or in patient satisfaction.14

The amount of reruptures did notsignificantly differ between treat-ment groups.14,18



Two studies14,18 reported on compli-cations. There was no significant dif-ference in the number of sural nerveinjuries, superficial infections withstaphylococcus, hypertonic scars, or ke-loid formations. Patients treated withpercutaneous repair had significantlyless wound breakdown/delay of heal-ing as well as fewer scar adhesions. Nosignificant difference in the amount ofdeep infections was reported. Limet al14 reported a statistically signifi-cant difference in superficial infec-tion, whereas Ng et al18 did not re-port a difference. However, Limet al,14 who did report more superfi-cial infections in the open repairgroup, did not administer intrave-nous antibiotics. Wound puckeringoccurred significantly more in pa-tients treated with percutaneous re-pair.14

Limited Open VersusOpen RepairPatients treated with limited open re-pair did not have less pain or scorehigher on the American OrthopaedicFoot and Ankle Society scale thandid patients treated with open re-pair.16 Patients treated with limited openrepair returned to normal walking,12

stair climbing,12 and sports21 in sig-nificantly less time than did patientstreated with standard open repair. Asignificantly larger percentage of pa-tients treated with limited open re-pair had fewer symptoms comparedwith patients treated with open re-pair.21

There was no significant differencein the number of reruptures betweentreatment groups.21 There was nostatistically significant difference inDVT, large hematoma, stiffness ofankle, insertional tendinopathy, ordeep infection between the open andlimited repair groups.16 However, pa-tients treated with limited open re-pair had significantly fewer severewound infections,12 superficial infec-tions,16 and minor surgical site infec-

tions12 than did patients treated withopen repair.

Recommendation 9We cannot recommend for or againstthe use of allograft, autograft, xe-nograft, synthetic tissue, or biologicadjuncts in acute Achilles tendonruptures that are treated surgically.


A systematic review failed to iden-tify adequate evidence to make a rec-ommendation for or against the useof allograft, autograft, xenograft,synthetic tissue, or biologic adjunctsin acute Achilles tendon rupturesthat are treated surgically. No studiesaddressed adjunctive augmentationwith allograft, xenograft, or biologicadjuncts. Three level II studies com-pared open repair alone and au-tograft augmentation.17,22,23 One levelIV study compared patients treatedwith synthetic tissue augmentation toopen repair alone.24 All four of thesestudies failed to demonstrate signifi-cant improvement in outcomes orcomplications.

Recommendation 10We cannot recommend for or againstthe use of antithrombotic treatmentof patients with acute Achilles ten-don ruptures.


A systematic review was conductedto determine whether prophylaxisfor thromboembolic events is war-ranted for patients with acute Achil-les tendon rupture. No studies wereidentified that address this issue.

Recommendation 11We suggest early (≤2 weeks) postop-erative protected weight bearing (in-cluding limiting dorsiflexion) for pa-tients with acute Achilles tendonrupture who have been treated surgi-cally.

This recommendation is gradedModerate.

A systematic review identified fourlevel II studies that compared earlypostoperative weight bearing withnon–weight bearing following surgi-cal repair of the Achilles tendon.25-28

All studies compared patients witheither 6 weeks of non–weight bear-ing in a cast to early weight bearing.Two studies permitted immediateweight bearing starting the day ofsurgery in a cast,25,28 defined as toe-touch weight bearing in one study.25

The third study allowed the weight-bearing group to begin immediate re-habilitation on the first postopera-tive day in a modified splint.26 Thepatients in the fourth study beganweight bearing 2 weeks after sur-gery.27 By 2 weeks, three groups ofinvestigators used a splint device thatlimited dorsiflexion to prevent com-promise of the repair.25-27 After 4weeks, Maffulli and colleagues25,28 al-lowed the non–weight-bearing groupto begin full weight bearing in a cast,whereas the authors of the other twostudies kept the non–weight-bearinggroup on crutches for 6 weeks.26,27

One study found a significantlyhigher rerupture rate in the earlypostoperative weight-bearing group(2 of 23 patients) compared with thenon–weight-bearing group (0 of 25patients).26 Both patients had docu-mented noncompliance with the useof their postoperative splint, andboth fell during the first 4 weeks af-ter surgery.

Three studies found that the weight-bearing group had statistical improve-ment in the time to return to activities,including work, sports, and normalwalking.25,26,28 Suchak et al27 reportedsignificantly better scores in physicalfunctioning and reported fewer limi-tations of daily living 6 weeks afterthe operation. By 12 months, all fourstudies found no significant differ-ence between the two groups in out-comes such as pain and function.


August 2010, Vol 18, No 8 507

Although the ultimate level of func-tion achieved after surgical repair of anAchilles rupture is similar regardless ofthe postoperative weight-bearing pro-tocol, early postoperative weight bear-ing allows a quicker return to activitiesduring the first 6 months comparedwith traditional postoperative casting.Treatment decisions should be made inlight of all circumstances presented bythe patient. Mutual communication be-tween patient and physician should in-clude a discussion of the importance ofpatient compliance when a program isprescribed for the use of early weightbearing. Patient compliance to proto-col is important to prevent rerupture.

Recommendation 12We suggest the use of a protectivedevice that allows mobilization by 2to 4 weeks postoperatively.

This recommendation is gradedModerate.

It is addressed by five level IIstudies.25,26,29-31 All five studies random-ized the patients into two groups, witheither 6 weeks in a cast or early motionwith a modified splint device. In allstudies, patients in the mobilizationgroup had a splint or modified cast de-vice that limited dorsiflexion to protectthe repair.

All five studies found that theweight-bearing group had statisticalimprovement in the mean time to re-turn to activities such as work andnormal walking.25,26,29-31 One of threestudies found a significantly higherrate in return to sport activities at 12months,30 while two found no differ-ence.25,26 One study found a signifi-cantly higher rerupture rate in thepostoperative mobilization group (2of 23 patients) compared with theimmobilization group (0 of 25 pa-tients).26 Both patients had docu-mented noncompliance with the useof their postoperative splint and fellduring the first 4 weeks after surgery.By 12 to 18 months, all five studies

reported no significant difference be-tween the two groups in outcomessuch as pain and function.25,26,29-31

Recommendation 13We are unable to recommend for oragainst postoperative physiotherapyfor patients with acute Achilles ten-don rupture.


A systematic review did not identifyany studies that met the inclusion cri-teria. We searched for any studies thataddressed postoperative physical ther-apy, including supervised and unsuper-vised physical therapy. The studies weidentified did not specifically addresswhether physical therapy was effective.Therefore, it is not possible to drawevidence-based conclusions for this rec-ommendation.

Recommendation 14In patients with acute Achilles ten-don rupture, irrespective of treat-ment type, we are unable to recom-mend a specific time at whichpatients can return to activities ofdaily living.


It is addressed by 18 level IVstudies7,11,12,17-27,32-35 that reported onreturn to low-impact activities. Ourmeta-analysis suggested that the re-sults of these studies were very differ-ent from each other, as demonstratedby the high heterogeneity; thus, it isdifficult to draw any conclusionsabout the time to return to recre-ational or athletic activity. This wasconfirmed by examining the individ-ual results.

Recommendation 15In patients who participate in sportsit is an option to return them tosports within 3 to 6 months aftersurgical treatment of acute Achillestendon rupture.


It is addressed by 23 level IV stud-ies that provided data on returnto sports after surgical treat-ment.2,4,7,9-11,18,21,22,24-37 Two studies re-ported return to jogging at 3months.22,28 One study reported re-turn to sport at 4 months.18 Fivestudies reported that 83% to 100% ofpatient returned to sports at 6months.2,22,27-29 Eleven studies re-ported that 32% to 100% of pa-tients returned to sports at 12months or more.7,11,24-30,32,33

Recommendation 16In patients with acute Achilles ten-don rupture treated nonsurgically,we are unable to recommend a spe-cific time at which patients can re-turn to athletic activity.


A systematic review identified fivelevel IV studies that provided dataon return to sports after nonsurgicaltreatment.11,26,32-34 The lack of stud-ies, variation in treatments, and vari-ation in reported outcomes makes itdifficult to draw any conclusionsabout the time to return to athleticactivity following nonsurgical treat-ment. These studies did not provideadequate evidence to permit a rec-ommendation be made for the spe-cific time patients can return to ath-letic activity following nonsurgicaltreatment of Achilles tendon rupture.

Future Research

Although the current guideline is in-structive in many ways, it also dem-onstrates a substantial need for fu-ture research. Wherever the strengthof a specific Recommendation isweak or inconclusive, a need existsfor well-designed studies and high-level evidence.

As such, the most obvious need is for



further, high-level investigations into thefundamental question whether surgicalmanagement is superior to nonsurgicalmanagement of acute Achilles ruptures.Hundreds of studies are centered on thisquestion, but too few are high-level ran-domized control trials.

Beyond this, several other areas ofneeded research exist. Does the clini-cian routinely need MRI or ultra-sonography for the diagnosis of anAchilles rupture? Probably not.However, no high-level studies existto help answer this question. Fornonsurgical treatment, low-level evi-dence supports the use of immediatefunctional bracing, but again, furtherrandomized trials are necessary.Postoperatively, is DVT prophylaxisnecessary? Does the patient reallyneed physical therapy? These arevery important questions that so farremain unanswered.

References

1. Maffulli N: The clinical diagnosis ofsubcutaneous tear of the Achilles tendon:A prospective study in 174 patients. AmJ Sports Med 1998;26(2):266-270.

2. Margetic P, Miklic D, Rakic-Ersek V,Doko Z, Lubina ZI, Brkljacic B:Comparison of ultrasonographic andintraoperative findings in Achilles tendonrupture. Coll Antropol 2007;31(1):279-284.

3. Twaddle BC, Poon P: Early motion forAchilles tendon ruptures: Is surgeryimportant? A randomized, prospectivestudy. Am J Sports Med 2007;35(12):2033-2038.

4. Cetti R, Christensen SE, Ejsted R, JensenNM, Jorgensen U: Operative versusnonoperative treatment of Achillestendon rupture: A prospectiverandomized study and review of theliterature. Am J Sports Med 1993;21(6):791-799.

5. Möller M, Movin T, Granhed H, LindK, Faxén E, Karlsson J: Acute rupture oftendon Achillis: A prospectiverandomised study of comparisonbetween surgical and non-surgicaltreatment. J Bone Joint Surg Br 2001;83(6):843-848.

6. Metz R, Verleisdonk EJ, van der HeijdenGJ, et al: Acute Achilles tendon rupture:

Minimally invasive surgery versusnonoperative treatment with immediatefull weightbearing. A randomizedcontrolled trial. Am J Sports Med 2008;36(9):1688-1694.

7. Saleh M, Marshall PD, Senior R,MacFarlane A: The Sheffield splint forcontrolled early mobilisation afterrupture of the calcaneal tendon: Aprospective, randomised comparisonwith plaster treatment. J Bone Joint SurgBr 1992;74(2):206-209.

8. Ingvar J, Tägil M, Eneroth M:Nonoperative treatment of Achillestendon rupture: 196 consecutive patientswith a 7% re-rupture rate. Acta Orthop2005;76(4):597-601.

9. Neumayer F, Mouhsine E, Arlettaz Y,Gremion G, Wettstein M, Crevoisier X:A new conservative-dynamic treatmentfor the acute ruptured Achilles tendon.Arch Orthop Trauma Surg 2010;130(3):363-368.

10. McComis GP, Nawoczenski DA,DeHaven KE: Functional bracing forrupture of the Achilles tendon: Clinicalresults and analysis of ground-reactionforces and temporal data. J Bone JointSurg Am 1997;79(12):1799-1808.

11. Wallace RG, Traynor IE, Kernohan WG,Eames MH: Combined conservative andorthotic management of acute rupturesof the Achilles tendon. J Bone Joint SurgAm 2004;86(6):1198-1202.

12. Bhattacharyya M, Gerber B: Mini-invasive surgical repair of the Achillestendon: Does it reduce post-operativemorbidity? Int Orthop 2009;33(1):151-156.

13. Uchiyama E, Nomura A, Takeda Y,Hiranuma K, Iwaso H: A modifiedoperation for Achilles tendon ruptures.Am J Sports Med 2007;35(10):1739-1743.

14. Lim J, Dalal R, Waseem M:Percutaneous vs. open repair of theruptured Achilles tendon: A prospectiverandomized controlled study. Foot AnkleInt 2001;22(7):559-568.

15. Coutts A, MacGregor A, Gibson J,Maffulli N: Clinical and functionalresults of open operative repair forAchilles tendon rupture in a non-specialist surgical unit. J R Coll SurgEdinb 2002;47(6):753-762.

16. Aktas S, Kocaoglu B: Open versusminimal invasive repair with Achillondevice. Foot Ankle Int 2009;30(5):391-397.

17. Aktas S, Kocaoglu B, Nalbantoglu U,Seyhan M, Guven O: End-to-end versusaugmented repair in the treatment ofacute Achilles tendon ruptures. J FootAnkle Surg 2007;46(5):336-340.

18. Ng ES, Ng YO, Gupta R, Lim F, Mah E:

Repair of acute Achilles tendon ruptureusing a double-ended needle. J OrthopSurg (Hong Kong) 2006;14(2):142-146.

19. Chillemi C, Gigante A, Verdenelli A,et al: Percutaneous repair of Achillestendon rupture: Ultrasonographical andisokinetic evaluation. Foot Ankle Surg2002;8(4):267-276.

20. Gigante A, Moschini A, Verdenelli A,Del Torto M, Ulisse S, de Palma L: Openversus percutaneous repair in thetreatment of acute Achilles tendonrupture: A randomized prospective study.Knee Surg Sports Traumatol Arthrosc2008;16(2):204-209.

21. Kakiuchi M: A combined open andpercutaneous technique for repair oftendo Achillis: Comparison with openrepair. J Bone Joint Surg Br 1995;77(1):60-63.

22. Pajala A, Kangas J, Siira P, Ohtonen P,Leppilahti J: Augmented compared withnonaugmented surgical repair of a freshtotal Achilles tendon rupture: Aprospective randomized study. J BoneJoint Surg Am 2009;91(5):1092-1100.

23. Taglialavoro G, Stecco C: Thesubcutaneous Achilles tendon rupture:Comparison of three surgical techniques.Foot Ankle Surg 2004;10(4):187-194.

24. Giannini S, Girolami M, Ceccarelli F,Catani F, Stea S: Surgical repair ofachilles tendon ruptures usingpolypropylene braid augmentation. FootAnkle Int 1994;15(7):372-375.

25. Maffulli N, Tallon C, Wong J, Lim KP,Bleakney R: Early weightbearing andankle mobilization after open repair ofacute midsubstance tears of the achillestendon. Am J Sports Med 2003;31(5):692-700.

26. Costa ML, MacMillan K, Halliday D,et al: Randomised controlled trials ofimmediate weight-bearing mobilisationfor rupture of the tendo Achillis. J BoneJoint Surg Br 2006;88(1):69-77.

27. Suchak AA, Bostick GP, Beaupré LA,Durand DC, Jomha NM: The influenceof early weight-bearing compared withnon-weight-bearing after surgical repairof the Achilles tendon. J Bone Joint SurgAm 2008;90(9):1876-1883.

28. Maffulli N, Tallon C, Wong J, Peng LimK, Bleakney R: No adverse effect of earlyweight bearing following open repair ofacute tears of the Achilles tendon.J Sports Med Phys Fitness 2003;43(3):367-379.

29. Mortensen HM, Skov O, Jensen PE:Early motion of the ankle after operativetreatment of a rupture of the Achillestendon: A prospective, randomizedclinical and radiographic study. J BoneJoint Surg Am 1999;81(7):983-990.

30. Cetti R, Henriksen LO, Jacobsen KS: A


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new treatment of ruptured Achillestendons: A prospective randomizedstudy. Clin Orthop Relat Res 1994;308:155-165.

31. Kangas J, Pajala A, Siira P, HämäläinenM, Leppilahti J: Early functionaltreatment versus early immobilization intension of the musculotendinous unitafter Achilles rupture repair: Aprospective, randomized, clinical study.J Trauma 2003;54(6):1171-1180.

32. Leppilahti J, Puranen J, Orava S:Incidence of Achilles tendon rupture.Acta Orthop Scand 1996;67(3):277-279.

33. Cook DJ, Mulrow CD, Haynes RB:Systematic reviews: Synthesis of bestevidence for clinical decisions. AnnIntern Med 1997;126(5):376-380.

34. Treadwell JR, Tregear SJ, Reston JT,Turkelson CM: A system for rating thestability and strength of medicalevidence. BMC Med Res Methodol2006;6:52.

35. Hozo SP, Djulbegovic B, Hozo I:Estimating the mean and variance fromthe median, range, and the size of asample. BMC Med Res Methodol 2005;5(1):13.

36. Hedges LV, Olkin I: Statistical Methodsfor Meta-Analysis. Orlando, FL,Academic Press, 1985.

37. Hufner TM, Brandes DB, Thermann H,Richter M, Knobloch K, Krettek C:Long-term results after functionalnonoperative treatment of achillestendon rupture. Foot Ankle Int 2006;27(3):167-171.



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Diagnosis and Treatment of Acute Achilles Tendon Rupture