Using An AFO To Treat An Achilles Tendon Rupture

The incidence of Achilles tendon ruptures is on the rise.¹ The largest increase in frequency of this injury has been in patients over the age of 50.² Treatment of the acute Achilles tendon rupture in older individuals has become a focus of controversy as multiple studies have now shown favorable outcomes with non-surgical treatment.^3-5

Recently, a remarkably healthy 92-year-old male patient presented to my office. He was referred by his primary care provider for the treatment of “Achilles tendinitis.” This patient reported significant pain with ambulation, which forced him to curtail his normal walking program. The examination demonstrated diffuse thickening of the proximal zone of the Achilles tendon, but no evidence of rupture.

In a younger patient, I would have initiated treatment with a walking boot but this older patient rightfully declined because of his fear of losing balance while wearing this bulky device. Therefore, I treated this patient with 1 cm heel lifts along with a referral for physical therapy.

Upon the follow-up exam two weeks later, this patient’s condition had worsened. His pain had increased to the point that he walked with a noticeable limp. The examination now revealed a defect or depression in the mid-portion of the Achilles tendon. Magnetic resonance imaging (MRI) revealed extensive intrasubstance tearing of the Achilles with near complete rupture.

Due to the age of this patient, surgical repair of the Achilles was not a viable option yet conservative treatment would require a significant challenge in terms of immobilizing the ankle for a long period of time. Traditional non-operative treatment protocols for the ruptured Achilles tendon usually involve immobilization in an equinus positioned cast with non-weightbearing, crutch-assisted ambulation.^3,4

How do you put an elderly patient on crutches or a walker who does not have the strength to keep the injured extremity non-weightbearing? Even if weightbearing were permitted, how would this be possible while wearing an equinus cast? A walking boot is even bulkier than a cast and imposes a serious risk of traumatic falls in individuals who are already impaired.

It is interesting to note that there are several studies that show positive outcomes treating acute ruptures of the Achilles tendon with ankle-foot orthotic (AFO) bracing and immediate weightbearing.^5-7 Another study has shown that it may not be necessary to protect the Achilles from lengthening during treatment by placing the ankle in equinus and that the goal of bracing should be restricting ankle dorsiflexion.⁸

For my 92-year-old patient with a partial Achilles rupture, a non-operative treatment program, which combined protected weightbearing in a custom solid AFO brace along with supervised physical therapy, was the best option. I chose a custom device because I expected the treatment to last six months or longer. Also, I wanted to achieve tight conformity of the device against the anatomy of the foot and ankle to minimize sagittal plane movement. 

I took the cast for the AFO myself using the full leg “Bermuda” style STS casting sock and sent the cast and prescription to my lab for fabrication of the device. I dispensed the device two weeks later and I was pleased that no adjustments were necessary at the time of fitting. I did all of these steps myself, including the casting, prescription and fitting. Why would I refer or hand off such a critical case to some lesser trained technician? (Remarkably, some leaders of our profession have actually recommended this practice.⁸)

The patient accepted the AFO brace well although he had to purchase new, larger shoes to accommodate the added dimension of the plastic shell. Within several days, the patient had adapted to wearing the brace and his pain symptoms significantly improved.

Previous research has shown that when treating Achilles ruptures with AFO bracing, one should use a 1.5 cm heel raise.⁹ Due to the age and balance compromise this patient demonstrated, I chose not to implement a heel raise and was impressed with how quickly the patient responded favorably without needing this addition to the brace.

My patient has been wearing his AFO brace daily for the past three months with excellent adherence. Since the brace relieved his symptoms quickly, adherence was not an issue. He is ambulating comfortably with good stability although I have required him to use a cane to improve his balance and prevent falling. While my patient eventually wants to move out of his brace, there appears to be no urgency. Clearly, he will have to stay in the device for at least six months before we would consider discontinuing its use.

This case provided one of the most gratifying experiences in my practice over the past few years. An elderly patient for whom maintaining mobility was of critical importance was able to recover from an injury that could have left him bedridden for the remainder of his life. It also underscores the significant advances our profession has made with the expansion of treatment options in the area of ankle-foot orthoses. Finally, the doctor implemented and carried out the treatment instead of a hired technician. In the end, the doctor justifiably received the credit and satisfaction for providing a positive patient outcome.

References

1. Lantto I, Heikkinen J, Flinkkila T, et al. Epidemiology of Achilles tendon ruptures: increasing incidence over a 33-year period. Scand J Med Sci Sports. 2015;25(1):e133-e138.
2. Ganestam A, Kallemose T, Troesen A, Barfod K. Increasing incidence of acute Achilles tendon rupture and a noticeable decline in surgical treatment from 1994 to 2013. The nationwide registry study of 33,160 patients. Knee Surg Sports Traumatol Arthrosc. 2015 Feb 20. [Epub ahead of print]
3. Soroceanu A, Sidhwa F, Arabi S, et al. Surgical vs nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials. J Bone Joint Surg Am. 2012;94(23):2136-2143.
4. Willits K, Amendola A, Bryant D, et al. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multi-center randomized trial using accelerated functional rehabilitation. J Bone Joint Surg Am. 2010;92(17):2767-2775.
5. Metz R, Verleisdonk EJ, van der Heijden GJ, et al. Acute Achilles tendon rupture: minimally invasive surgery versus nonoperative treatment with immediate full weightbearing: a randomized controlled trial. Am J Sports Med. 2008;36(9):1688-1694.
6. Speck M, Klaue K. Early full weightbearing and functional treatment after surgical repair of acute Achilles tendon rupture. Am J Sports Med. 1998;26:789-793
7. Costa ML, Shepstone L, Darrah C, Marshall T, Donell ST. Immediate full-weight-bearing mobilisation for repaired Achilles tendon ruptures: a pilot study. Injury. 2003;34:874-876
8. Richie D. Does the APMA advocate hiring pedorthists? Podiatry Today DPM Blog. Available at https://www.podiatrytoday.com/blogged/does-apma-advocate-dpms-hiring-pedorthists . Published June 25, 2015.
9. Kearney RS, Lamb SE, Achten J, Parsons NR, Costa ML. In-shoe plantar pressures within ankle-foot orthoses: implications for the management of achilles tendon ruptures. Am J Sports Med. 2011;39(12):2679-85.