Achilles tendon rupture; assessment of nonoperative treatment

Abstract

Background: Acute Achilles tendon rupture is a frequent and potentially disabling injury. Over the past decade a change in treatment of acute Achilles tendon rupture away from operative towards non-operative treatment has taken place. However, the optimal non-operative treatment protocol remains to be clarified, particularly the role of weight-bearing during early rehabilitation. Also, there is a need for a clinically applicable and accurate measurement to detect patients in risk of developing Achilles tendon elongation.

Purpose: The aim of this PhD thesis was to evaluate non-operative treatment of acute Achilles tendon rupture.

Methods: In study I, a cross-sectional survey was performed investigating the chosen treatment protocols across Scandinavia. In study II, the effect of immediate weight-bearing on patient reported and functional outcomes was investigated in a randomized controlled trial (RCT). In study III, the effect of immediate weight-bearing on the biomechanical properties of the plantar flexor muscle-tendon complex was investigated in an RCT. In study IV, validity, reliability and agreement of a novel ultrasound measurement of Achilles tendon length and elongation was tested.

Results: Study I found surgery to be the preferred treatment in 83% of departments in Denmark, 92% in Norway, 65% in Sweden, and 30% in Finland (p < 0.001). Study II and III showed no statistically significant effects of controlled early weight-bearing at one year follow-up except from a better health-related quality of life in the weight-bearing group (p=0.009). Compared to the unaffected limb, the affected limb had decreased stiffness (77%, p < 0.001) and strength (93%, p = 0.009) of the plantar flexor muscle-tendon complex. Study IV showed excellent intra-rater reliability (ICC 0.96, SEM 3.7 mm and MDC 10.3 mm), inter-rater reliability (ICC 0.97, SEM 3.3 mm and MDC 9.3 mm) and validity (measurement error 2%).

Conclusion: Treatment algorithms across Scandinavia showed considerable variation, though operative treatment and controlled early weight-bearing was the preferred treatment in Denmark, Norway and Sweden. Immediate weight-bearing was found to be safe and recommendable in non-operative treatment of acute Achilles tendon rupture. The novel ultrasound measurement showed excellent reliability and acceptable validity and agreement.