Systematic Review of Nonoperative Functional Protocols for Acute Achilles Ruptures Utilizing a Formal Rehabilitation Protocol Showing Lowest Rerupture Rates

Abstract

Aim. To lay out a comprehensive protocol for practitioners and physical therapists that has the lowest rerupture rates for nonoperative treatment of acute Achilles ruptures. Method. Relevant articles were searched in PubMed, CINAHL Plus, and Cochrane Library using keyword combinations: nonoperative AND/OR Achilles rupture AND functional AND/OR protocol or functional AND/OR rehabilitation. To be included in the full analysis, the studies had to have detailed functional protocols with physical therapy program details and outcome scores of rupture rates and/or Achilles Tendon Rupture Score (ATRS). We ultimately found 7 articles that fit our inclusion criteria for analysis. All of them had rerupture rates, and 4 had ATRS scores and functional protocols with mention of formal physical therapy programs. Results. Lowest rerupture rates were found in strict functional rehabilitation protocols that were full weightbearing in boot immediately at full equinus or 30° plantar flexed. They started active range of motion at 5 to 8 weeks and started formal physical therapy at 10 weeks. Levels of Evidence: Level III: Evidence obtained from well-designed non-experimental descriptive studies

Achilles Tendon Rupture: Mechanisms of Injury, Principles of Rehabilitation and Return to Play

“…The concerns rose in the past referred to the risk of re-rupture following a functional rehabilitation protocol have been overcome due to new data that support it, which showed lower re-rupture rates when compared with non-weightbearing and casting [ 70 , 71 , 75 ]. The lowest re-rupture rates were found in strict functional rehabilitation protocols with full weightbearing in boot immediately at full equinus or at 30° of plantar flexion [ 76 ].…”

Nonoperative Management of Achilles Tendon Ruptures

“…The total duration of orthosis use varies considerably, with most studies recommending a brace for 8 weeks. 27,34,38,39 Aujla et al 39 did not find any significant increase in complications when their protocol was modified to decrease the time in the brace from 11 weeks to 8 weeks. In a recent systematic review, removal of the orthosis before 8 weeks demonstrated significantly higher rerupture rates, higher Achilles tendon rupture scores, and lower rates of return to work, but no effect on rates of Deep vein thrombosis or return to sport.…”

“…A tendon gap of 5 mm and 10 mm has been proposed as the cutoff for higher and lower-demand patients, respectively. [26][27][28][29] Some studies have used a 5 mm gap as an absolute cutoff for nonoperative management. 27,30 Other authors have concluded any gap in full equinus is a contraindication to nonoperative management.…”

“…[26][27][28][29] Some studies have used a 5 mm gap as an absolute cutoff for nonoperative management. 27,30 Other authors have concluded any gap in full equinus is a contraindication to nonoperative management. 13,31 A common protocol put forth by Hufner and colleagues, routinely used ultrasound at the date of diagnosis.…”

“…5), Variostabil (Orthotech/Addidas) boots, and controlled ankle motion boots with removable wedges have all been used and advocated for by different studies. 27,29,31,[33][34][35]38,39 One study comparing ankle position in an adjustable external equinus corrected brace compared with a controlled ankle motion boot with wedges demonstrated that the external equinus boot resulted in greater equinus positioning, In addition, traditional boots with wedges produce equinus not through the ankle, but through the midfoot (Fig. 6).…”