The aim of non-operative means of treatment is to restore and maintain contact between the two ends of the ruptured Achilles tendon to facilitate healing. Conservative treatment regimens vary greatly but commonly involve immobilisation with rigid casting or functional bracing. The foot is initially placed in full equinus (30° namely full plantarflexion). The foot is then brought into neutral sequentially over a period of 8-12 wk. Once ankle position permits it, weight bearing is allowed. There is currently no clinical consensus on whether the cast should extend above the knee or if a below knee cast is sufficient. The above knee plaster is applied with the knee in slight flexion which serves to defunction gastrocnemius, having an origin over the posterior aspect of the femora condyles. However, one study shows the position of the knee does not influence gap between the torn ends of the Achilles tendon[26].

Little evidence exists to recommend one regimen over another. The current evidence is summarised in Table 1. These studies demonstrate that patients can be allowed to weight-bear early in an off-the-shelf orthosis/CAM walker/Sheffield splint with no detriment in any long term outcomes[27,28]. This has obvious practical advantages compared to the traditional treatment of prolonged non weight-bearing in a below knee equinus cast. This is particularly true for frail or elderly patients where non-operative treatment tends to be preferred. Petersen et al also suggest that this may also actually decrease the risk of re-rupture although this was not found to be significant (P = 0.066). Saleh et al[29] also suggested that their splint allowed patients to regain mobility significantly more quickly and that patients preferred the splint to the cast. These findings are in keeping with the literature on operatively managed acute Achilles tendon ruptures which suggests that early weight bearing and mobilisation improve outcomes.

Newer splints for immobilisation have been developed with encouraging initial results. The Vacoped© is a cast in which the patient’s ankle is supported by an air cushion which is then inflated. The cushion is encased in a robust shell. The design of the cast allows the degree of equinus to be dialled from 30° (full) to 15° (mid) and 0° (neutral). In addition there is latch which allows users the facility to perform a restricted range (-10°-10°) of plantar and dorsiflexion. The Vacoped regimen recommends 2 wk in full equinus followed by a further 2 wk in partial equinus. Then the ankle is held in neutral for 1 wk and then restricted (10°) dorsi- plantar flexion for the final week. The Vacoped allows the patient to touch weight bear for two weeks, and partial weight bear from for one week after that. Full weight-bearing is commenced at 3 wk[30]. In addition the periodic insufflations and deflation of air facilitates venous drainage theoretically reducing the risk of deep vein thrombosis. Furthermore, the support is buoyant and supple avoiding the risk of pressure areas.

There are a variety of approaches to the surgical management of this injury. Contention exists over the surgical approach (open or percutaneous), suture repair method and suture type.

In addition to isolated direct tendon repair, various means of augmentation of the tendon have been described. Gastrocnemius augmentation involves raising a flap 2 cm wide by 8 cm long which is reflected across the repair and sutured. The Plantaris tendon can also be used (Figure 2). It is either weaved around the tendon or may be expanded into a membrane which is sutured around the repair. The evidence supporting augmentation is weak. Pajala et al[31] performed a large prospective study of tendoachilles repair and found no benefits between augmented and simple end-to-end repair.

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Figure 2 Achilles tendon repair with plantaris tendon reinforcement.

Percutaneous repair has been described involving minimally invasive stab incisions on the medial and lateral aspect of Achilles tendon and a suture passer. Reduced infection rates have been shown compared to open repair[32]. Increased rates of Sural nerve injury have been demonstrated with this technique[33].

Patient factors have been demonstrated to influence post-operative wound breakdown and infection rates. These included diabetes mellitus, steroid therapy, smoking and rheumatoid disease[34].

Post-operative regime: Postoperatively the patient can progressively increase the extent of weightbearing. Typically, at 6 wk the patient commences active and assisted movement of the ankle. Isokinetic strengthening is commenced 2 to 4 wk. The patient can usually expect full strength and endurance 4 mo after surgery. Although this represents the standard post-operative regimen, the optimum post-operative rehabilitation remains to be determined. Suchak et al[35] explored the effect of early weight bearing at 2 wk vs weight bearing at 6 wk in their randomised controlled trial. They observed that early weight-bearing had statistically significant improvement in quality of life indices (such as social functioning), vitality scores and physical functioning[35]. However, by 6 mo postoperatively there was no difference in the groups. Other sources of clinical controversy include post-operative early mobilisation versus rigid immobilisation for 6 wk. Kangas et al[36] explored this in a randomised controlled trial. They reported that early mobilisation was associated with improved isokinetic calf strength at 60 wk. The re-rupture rate was higher in the immobilisation cohort. However, the difference did not reach statistical significance[36]. Mortenson’s group observed that patients who were allowed to perform early restricted motion had a shorter rehabilitation time when compared to a below knee cast for 8 wk[37].

No published studies conclusively demonstrate the definitive superiority of one modality over another. Meta-analyses of studies have shown that the re-rupture rates are higher in cases of non-operative management: 13% for conservative management compared with 4% for surgically repaired Achilles tendons[31,38]. Meta-analyses report a re-rupture rate of 2% for percutaneous reparative techniques.

Tendon elongation and weaker plantar flexion are also associated with non-operative management. However, recent studies suggest that these benefits of operative repair over conservative management in plaster are only short-lived. Keating and collaborators in the recent prospective randomised trial found that operative repair was associated initially with increased range of ankle movement and plantarflexion power when compared with cast management[39]. However by 26 wk there was no difference between the two groups.

Plaster or simple immobilisation alone avoids the inherent risks of surgery. These include wound infection (4%), fistula formation, skin necrosis, suture granuloma and damage to the sural nerve[31,37]. The skin necrosis can result in significant morbidity and require extensive plastic soft tissue procedures to ensure coverage of the tendon. Operative repair is associated with more rapid rehabilitation and return to work.

Percutaneous operative techniques have been found to have a complication profile superior to that of both conservative and open operative techniques. Meta-analysis report a re-rupture rate of 2%[31,37]. Studies involving functional bracing suggest that the disparity between surgical and conservative management may not be as marked as originally suspected. More recent studies show that re-rupture rates in patients treated operatively vs functional bracing are comparative[19,40-42]. In a recent study the result of percutaneous operative management were compared with those achieved by functional bracing using the Vacoped. Investigators found that the incidence of re-rupture to be 3.9% for percutaneous repair and 3.4% for functional bracing with the Vacoped[43]. The difference did not reach statistical significance. The Vacoped allows early weight-bearing. The protective effect of early weight-bearing appears to be reproduced when patients are allowed early ankle movements. A recent prospective randomised controlled trial observed no difference in rupture rates between operative and non-operatively managed Achilles tendon rupture when both groups are permitted early movement in a functional brace[29].

Assessment of the gap between the ends of the tendon as determined by magnetic resonance imaging or ultrasound may influence re-rupture rates in patients managed conservatively. Kotnis et al[22] elected to manage conservatively only those patients whose gap in full equinus was less than 5 mm. All others were managed operatively. They observed no statistically significant difference in re-rupture rates between the groups[22]. Wallace et al[44] based in Belfast, Ireland and Sheffield, United Kingdom studied 875 non-operatively treated Achilles tendon ruptures. The decision to manage patients non-operatively was based on the presence of opposition of the tendon ends on dorsiflexion. The observed re-rupture rate was 2.9%. A recent series studied by the Swansea and Maudsley group used a protocol of dynamic ultrasound and a tendon gap of less than 1 cm in full equinus. Furthermore, a dedicated clinic and service was established to treat and rehabilitate the patients. They found only a single case of re-rupture (< 1%) in 151 conservatively treated patients since 2008. This was comparable to the single case in the operative group of 63 patients[45]. In two of these series the re-rupture rate is superior to any anything achieved in a published operative series.

In Wallace’s published series of excellent non-operative results patients were managed in a dedicated “Tendo Achilles” clinic. Patients were placed in an equinus non-weight bearing cast for the first four weeks. For the next four weeks they were place placed in a pneumatic walker with heel-raises, which were sequentially removed over a period of 4 wk. The combined time in the equinus cast and boot walker was 8 wk. After this patients engaged in a specialist physiotherapy programme involving gait training, strength and mobility training. Final assessment and discharge was at 14 wk from injury or 6 wk from the time of removing the walking boot. It is uncertain how much the dedicated Achilles tendon clinic contributed to the favourable outcome. Patients were attended to by a specialist physiotherapist and were only discharged when the latter deemed that ankle strength was satisfactory.

Some authors would argue the merits of operative intervention in high performing athletes. The rationale for this argument is the potential loss of power or push off strength with conservative management which is lessened by operative repair. The most recent studies quoted using specific treatment and rehabilitation regimes do not identify a functional benefit to operative repair. It is possible that the cohort may not reflect the athlete group. Furthermore, the measurement tools and assessments may not be sensitive enough to detect a deficit at the high functioning sporting level. For this reason the authors would exercise caution in treating this cohort as it is difficult to draw definitive conclusions.