A Randomized Controlled Trial Comparing Traditional Plaster Cast Rehabilitation With Functional Walking Boot Rehabilitation for Acute Achilles Tendon Ruptures

Abstract

Background: There has been a shift toward functional nonoperative rehabilitation in the treatment of Achilles tendon rupture (ATR) despite a shortage of studies directly comparing nonoperative functional rehabilitation with traditional nonoperative immobilization. Purpose: To compare patient-reported outcome measures and functional outcomes for nonoperatively treated ATR with traditional cast immobilization or functional rehabilitation in a walking boot. Study Design: Randomized controlled clinical trial; Level of evidence, 2. Methods: In a single-center nonblinded study, 140 patients were randomized to compare treatment for acute ATR in (1) an immobilizing cast in reducing degrees of equinus over a 10-week period with 8 weeks of nonweightbearing mobilization or (2) a walking boot for 8 weeks with reducing equinus and immediate full weightbearing. Exclusion criteria were delayed presentation >2 weeks after injury, tendon reruptures, and latex allergy. Analysis was undertaken on an intention-to-treat basis. Results: A total of 69 patients (median age, 41 years [interquartile range, 33-50.5 years]) were randomized to walking boot treatment and 71 patients (41 [32-49]) to cast treatment. At 6 months, patients treated in a walking boot reported better Short Musculoskeletal Function Assessment (SMFA) dysfunction index (6.62 [2.21-12.50] vs 10.66 [4.96-13.42]; P = .050), SMFA bother index (7.29 [2.08-14.58] vs 10.42 [5.73-19.27]; P = .04), Achilles Tendon Total Rupture Score (71.5 [53.50-84.25] vs 54.0 [37-76]; P = .01), and Foot and Ankle Questionnaire core score (91 [81.89-97.55] vs 85 [78.25-92.09]; P = .04). At 1 year, there was no difference in SMFA dysfunction index (2.21 [0.74-5.88] vs 2.94 [1.47-6.62]; P = .25), SMFA bother index (2.08 [0-9.38] vs 5.21 [0.52-11.98]; P = .25), Achilles Tendon Total Rupture Score (92 [72.50-96] vs 87.5 [66.0-94.75]; P = .21), or Foot and Ankle Questionnaire core score (97.75 [89.46-99.00] vs 95.50 [90.88-97.50]; P = .18). Rerupture occurred in 5 and 11 patients ( P = .075) and venous thromboembolism in 2 and 3 patients ( P = .67) in the boot and cast groups, respectively. Fifteen patients in the boot group but none in the cast group had skin problems ( P < .001). Patients treated in a boot returned to driving at a median 12 weeks (vs 13 weeks for cast; P = .045), but there was no difference in time to return to work ( P = .48). Conclusion: Functional rehabilitation with early weightbearing is a safe alternative to traditional immobilizing treatment for ATR, giving better early functional outcomes, albeit with a higher incidence of transient minor skin complications. Registration: NCT02598843 (ClinicalTrials.gov identifier).

Persistent Deficits after an Achilles Tendon Rupture: A Narrative Review

“…e score of uninjured healthy persons approaches 100, which is the maximal score on the ATRS [31]. Patients report mean scores of 31-56 at three months [10,11,13] and 54-87 at six months [11,[32][33][34][35][36][37][38][39][40][41][42][43][44]. One year after the rupture, the mean score has been reported to be 74-91 [11,24,32,33,35,36,[38][39][40][42][43][44][45][46][47][48][49][50][51][52][53][54][55], and it does not appear to appreciably improve further thereafter [14,15,24,39,42,46,47,[56]…”

Age, personal and family history are independently associated with venous thromboembolism following acute Achilles tendon rupture

“…Direct trauma included patients who sustained their ATR in the context of an incised wound (n=1). or early weight-bearing in a walking boot orthosis (n=69) [23]. Walking boot immobilisation comprised four weeks in a full equinus position, two weeks in semi-equinus and two weeks in a plantigrade position (a '4-2-2' regime) with full weight-bearing encouraged throughout.…”

“…Once the preliminary results of this trial were available, functional rehabilitation with early weight-bearing in a walking boot was adopted as the standard treatment protocol. Details of operative and nonoperative management and functional rehabilitation at our institution have previously been described in detail [23,24].…”

Achilles' tendon rupture dancing the ‘Jerusalema’ – A case series

“…Regardless of operative or non-operative treatment the rehabilitative phase of TA rupture has seen a shift towards early weight bearing and graduated physiotherapy. There is extensive research showing it is safe, has a low complication rate and achieves a superior functional outcome to conventional immobilisation [7] , [10] , [11] , [12] , [13] .There is however a lack of consensus on what exactly these functional rehabilitation programmes should consist of given that most trials to are heterogenous in their outcome measurements [14] .…”