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Simplifying Treatment for Acute Achilles Tendon Ruptures in Athletes
After performing over 700 Achilles tendon repairs over a 30-year period, I have learned a lot. The majority of my repairs have been on active-duty soldiers and athletes. I have had my share of failures, complications, and a lot of success getting my patients back to the level they were prior to their rupture. So, I am very confident in my protocols and more confident in the techniques that were passed along to me by my residency director and mentor, George Gumann, DPM.
In the Army, we like to keep it simple. After attending countless conferences and reading almost every article on Achilles tendon repairs over the years, I start to question why so many surgeons want to take such a simple repair and make it complicated. I will go through many of the topics I personally question and hope you will ponder why we do some of the things we do.
Why am I questioning these procedures? Because I’ve redone over 100 Achilles repairs and done hundreds of chronic Achilles, Achilles tendinosis, and at least 50 missed ruptures during my career. It’s these redo cases that have taught me a lot. As we all know, we learn from our failures and our mistakes, not necessarily from our successes. As the saying goes, “It’s better to be lucky than good.” I have certainly been the former since I have the best patients in the world—the military.
What You Should Know About the Conservative Approach
It is hard to believe we even need to discuss nonoperative treatment when dealing with athletes, but in my observation of the literature, it seems surgeons still do so. I understand that there are patient populations where this makes sense, but not soldiers.
Much of it goes back to a series of studies that was done in Canada in the 1990s.1,2 I can remember it like it was yesterday, as I witnessed these studies influence those around me. In my observation, these papers were highly biased did not look specifically at athletes; thus, I did not change my treatment practices. I found much of the focus of many of these studies was simply based on avoiding complications, not on outcomes. Conversely, all the surgical studies that came out afterwards to refute these studies focused on “rerupture rates,” yet I cannot recall encountering a single one in 30 years.
Ironically, there was a study done in 2017 by Sheth and colleagues, which found that this series of studies from Canada actually changed how surgeons were treating patients.3 Conservative therapy became much more prevalent amongst all age groups from 2002–2014, which did not surprise me, as I witnessed these debates persist for years.
Conservative treatment still is an option that we need to consider. Believe it or not, at least once a year I see a soldier who refuses surgery. It’s often because of Dr. Google told him or her the long-term outcomes of conservative vs. operative treatment are equal at 1 year based solely on the series from Canada. Many authors and surgeons have focused solely on the complications as did the study published in 1995 by Krueger-Franke from Germany.4 There conclusions were simple: no surgery = no complications. However, the authors didn’t address the fact that we are dealing with athletes.
The key argument I see for surgery over conservative treatment in any patient is simply functional outcome in regard to strength. Yes, plenty of evidence looks at outcomes at 1 year as stated by Keating and Will in 2011 from England, but the outcomes at 2 years are significant.5 The key differential is strength. Failure to resume normal strength will lead to reduced function; and in some cases, it can make a patient apropulsive. Over the years, the number one complaint in the cases that I have treated 6–12 months post-nonoperative treatment is weakness; an inability to run, jump, or even stand on one foot.
A Guide to the Operative Approach
Once we get past the discussion—argument—against surgery, then we can start all the debate on what approach, what technique, and what suture material you want to utilize.
Regarding approach, I am not going to argue for or against open versus minimal incision/percutaneous methods. Our own Bob Baravarian, DPM, FACFAS, wrote an article in January 2023 Podiatry Today and emphatically states he favors the percutaneous Achilles repair system (PARS) method.6
I will stress is that when dealing with an athlete, one must consider the extent of the injury, specifically looking at what we refer to as the zone of injury. In athletes, I have never seen an isolated zone of injury (2–4 cm wide). Instead, I see not only an isolated rupture site but also find longitudinal splitting and tears that can extend proximally as high as the myotendinous junction and distally all the way to the insertion at the calcaneus, as shown in the magnetic resonance image (MRI) in Figure 1. This is very typical of every Achilles rupture that I have treated.
As a result, I urge surgeons to consider if their chosen approach will adequately address the zone of injury. For percutaneous methods, I would stress either getting an MRI or ultrasound to determine the zone of injury and exactly pinpoint the rupture site. One cannot assume the location of the rupture. I routinely utilize a long incisional approach and still often need to extend proximally or distally as shown in Figure 2.
Suture Material and Technique
Carefully decide what you will utilize for suture material. I find the ideal combination is absorbable and non-absorbable suture. My preference is to utilize a braided-type suture (#5 Ethibond [Johnson and Johnson MedTech]) that will promote scarring. We don’t want suture sliding within the tendon. We are relying on the microscopic development of scar tissue binding within the suture surface. Thus, I avoid small or smooth suture material. Some are so strong and smooth that it simply slices through the tendon like a cheese cutter. Having a polyester braid coating helps, and there are numerous types of this suture from numerous vendors.
As for absorbable suture, I recommend limiting the amount to avoid an inflammatory reaction. One critical step, I find, is preparing the paratenon for repair. Nylon versus an absorbable suture may protect the paratenon from developing adhesions. Reminder: the paratenon repair is critical for restoring the Achilles’ gliding mechanism. A simple baseball stitch using 3-0 or 4-0 nylon suffices for me. As shown in Figure 4, you can hardly see the closure.
Suture techniques also have a bearing on the repair. We all know that the Krackow is the strongest repair, but I find it does have some negatives in athletes.7 It deters the gliding mechanism and promotes adhesions on the tendon, in my experience. I have had to remove a lot of suture material, specifically with the Krackow technique in athletes. So, I do not use the Krackow as my first line repair. If I need strength or I am dealing with a tendon with prior tendinosis, then I will opt for a stronger alternate repair technique, as shown in Figure 3. Compare the Krackow with my preferred buried knot technique (double Bunnell). With one technique you can see the suture; with the other you can’t.
A Note on the Surgical Timing
Why do surgeons want to fix ruptures immediately? In my experience, the ideal time to fix an Achilles is 10–14 days after injury. One only has to look at the intraoperative Figure 5 to understand this. Physiologically, it is much harder to repair mop ends then two well-defined tendon ends. By operating sooner, I find you get a weaker repair and require more suture material and will inhibit early range of motion (ROM) and early weight-bearing because the repair simply isn’t as strong by waiting. A 2017 study by Park and another by Misir and colleagues in 2020 involving rats concluded there was no difference between surgery at 24, 48 or 72 hours compared to a week.8,9 However, I am more comfortable with the reliability of 700 soldiers walking at 2 weeks and running by 6 months in my practice.
A critical mistake I have observed that is unique to rushing into surgery is debriding the mop ends, thus encountering shortening. If I wait, then I find there will be no mop ends to contend with.
Also, in 30 years, I haven’t had one case in which I needed to do a lengthening or a fold-down or some type of defect repair for an acute rupture, I feel in part due to not encountering this shortening. Those are techniques that I reserve for missed ruptures 4–6 months post-injury, not acute ruptures.
What You Should Know About Various Achilles Treatment Options
Chemical supplements. One only has to do a literature search on Achilles tendon repairs to see the variety of chemical supplements/injections studied for their effect on tendon healing: vitamin B12, vitamin C, platelet-rich plasma, stem cells, nonsteroidal anti-inflammatory drugs, antibiotics, gene therapy, amniotic injections, steroids, as well as everyday medications. Ultimately, I did not find any evidence that any accelerate healing in a statistically significant manner? The only thing that we can for sure confirm is that smoking is—and will always be—a major factor in promoting complications and will adversely affect healing.10
Adjunct therapies. What about postoperative therapies to speed up healing? Whether it be hyperbaric oxygen, light therapy, compression therapy, ultrasound, bone stimulators, and even shockwave, I did not find any studies that statistically showed an increase in healing?
Augmentation products. I am perplexed by the use of augmentative products in tendon repair. In my experience, I’ve seen the resultant scarring yield some strength, but I’ve also seen adhesions nullify all the gains in an athlete. And when you have a reaction, it will always be bad. Figure 6 shows significant tissue reaction to the suture material and graft material utilized.
Augmentation with tendon autografts. In my experience, you don’t need plantaris, flexor hallucis longus, flexor digitorum longus, semitendinosis, peroneals or any other tendon autograft for an acute repair. Their role, I see it, is with significant defects in a chronic rupture or post-infection repair with tendon loss. In each acute repair, I test and document the integrity of the repair on the table, and I document if the patient even has a plantaris tendon. This guides me in my decision making, and I feel it strengthens my planning.
Pearls on Early ROM and Early Weight-Bearing
One of the most critical steps of any repair is to test the tendon intraoperatively. If your repair cannot hold up to your forced dorsiflexion, then how can you expect to start early ROM, let alone early weight-bearing? You must test your repair. I can’t tell you the number of times I have allowed my residents to do a repair; and then when they tested the repair, it pulled apart.
There is plenty of research on the benefit of early ROM, whether it be post–Achilles repair, Brostrom, or anything else. I start ROM the day after surgery with a goal of obtaining active dorsiflexion to neutral by 2 weeks and 10 degrees of dorsiflexion by 6 weeks.
I have allowed every acute Achilles repair patient, regardless of age, to start weight-bearing in a cast boot by 2 weeks. I have had many a soldier start walking prior to 2 weeks. I have never wedged the cast boot and start all at neutral knowing that we will obtain some stretch over time.
Willits and colleagues in 2010 stressed in their multi-center study the importance of early ROM and early weight-bearing showing superior long-term results.11 For me, when I have a patient struggling to get their ROM back or struggling to get weight-bearing past 4 weeks, then I know they are likely to have a poor outcome. Every soldier who failed to return to full duty struggled to get their ankle dorsiflexion back and struggled to start walking. My repair has never changed in 30 years, and none of those soldiers had problematic repairs or complications. They simply had more pain and swelling than the average patient. No amount of physical therapy ever helps. Some people simply fail to get better, in my experience. No one ever talks about that. We all have seen the patient that has had a perfect repair, beautiful scar, who simply won’t move their ankle. They won’t try to bear weight early and eventually may develop a permanent limp. I find these patients routinely end up elsewhere, perhaps with a heroic revisional surgery, and potential multiple poor outcomes.
When Can Post-Acute Achilles Repair Athletes Return to Sports?
In my practice, no running until patients can single-leg hop on the surgical side. No sports until 6 months postop regardless of jogging status. The majority of my over 700 patients returned to full duty well before 1 year. As previously stated, of those who struggled early on in my patient population, all failed to return to full duty and sports. I believe you will know long before 6 months if an athlete isn’t going to get back. Although some surgeons have stated at meetings that athletes need 12 months to recover and as long as 18 months to resume sports, my experience is that athletes don’t need that long.
In Conclusion
The literature is quite dizzying and confusing. As we get set for another round of meetings in 2023, I can safely predict that you will hear surgeon after surgeon go on and on how their technique is better if you do it their way. That may be true, but I simply ask that you think about how and what you are doing, especially if your patient is an athlete. Does it make sense from a physiologic standpoint? Is it cost-effective? What are the risks? One immediate thing I feel surgeons can do today to see a visible improvement in outcomes is to schedule acute Achilles repair cases 10–14 days post-injury.
A. Douglas Spitalny, DPM is a Staff Podiatrist at General Leonard Wood Army Hospital in Ft. Leonard Wood, MO.
References
1. Cetti R, Christensen SE, Ejsted R, Jensen NM, Jorgensen U. Operative versus nonoperative treatment of Achilles tendon rupture. A prospective randomized study and review of the literature. Am J Sports Med. 1993 Nov-Dec;21(6):791-9.
2. Lo IK, Kirkley A, Nonweiler B, Kumbhare DA. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a quantitative review. Clin J Sport Med. 1997 Jul;7(3):207-11.
3. Sheth U, Wasserstein D, Jenkinson R, Moineddin R, Kreder H, Jaglal S. Practice patterns in the care of acute Achilles tendon ruptures: is there an association with level I evidence? Bone Joint J. 2017 Dec;99-B(12):1629-1636.
4. Krueger-Franke M, Siebert CH, Scherzer S. Surgical treatment of ruptures of the Achilles tendon: a review of long-term results. Br J Sports Med. 1995 Jun;29(2):121-5.
5. Keating JF, Will EM. Operative versus non-operative treatment of acute rupture of tendo Achillis: a prospective randomised evaluation of functional outcome. J Bone Joint Surg Br. 2011 Aug;93(8):1071-8.
6. Baravarian B. The Achilles tendon—an A to Z review of treatment options. Podiatry Today. 2023; 36(1):14–17.
7. Luthfi KAM, Rasyid HN, Arsa W, Ismiarto YD. Biomechanical analysis of Krackow Suture fixation strength of cadaver Achilles tendon with loop distance variance of 5 mm, 7.5 mm, and 10 mm. Muscle Ligament Tendon J. 2020;10 (3):355-363
8. Park YH, Jeong SM, Choi GW, Kim HJ. How early must an acute Achilles tendon rupture be repaired? Injury. 2017 Mar;48(3):776-780.
9. Abdulhamit M, Kizkapan TB, Arikan Y, et al. Repair within the first 48 h in the treatment of acute Achilles tendon ruptures achieves the best biomechanical and histological outcomes. Knee Surg Sports Traumatol Arthrosc. 2020 Sep;28(9):2788-2797.
10. Shamrock AG, Varacallo M. Achilles tendon rupture. StatPearls. Available at https://www.ncbi.nlm.nih.gov/books/NBK430844/ .
11. Willits K, Amendola A, Bryant D, et al. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation. J Bone Joint Surg Am. 2010 Dec 1;92(17):2767-75.
Additional References
Non-Operative
12. Barfod KW. Achilles tendon rupture; assessment of nonoperative treatment. Dan Med J. 2014 Apr;61(4):B4837.
13. Jonas I, Tagil M, Eneroth M. Nonoperative treatment of Achilles tendon rupture: 196 consecutive patients with a 7% re-rupture rate. Acta Orthop. 2005 Aug;76(4):597-601.
Operative
14. Clanton TO, Haytmanek CT, Williams BT, et al. A biomechanical comparison of an open repair and 3 minimally invasive percutaneous Achilles tendon repair techniques during a simulated, progressive rehabilitation protocol. Am J Sports Med. 2015 Aug;43(8):1957-64.
Percutaneous
15. Mathieu A, Jung M, Stern R, Rippstein P, Delmi M, Hoffmeyer P. Limited open repair of Achilles tendon ruptures: a technique with a new instrument and findings of a prospective multicenter study. J Bone Joint Surg Am. 2002 Feb;84(2):161-70.
16. Calder JDF, Saxby TS. Independent evaluation of a recently described Achilles tendon repair technique. Foot Ankle Int. 2006 Feb;27(2):93-6.
17. Henríquez H, Muñoz R, Carcuro G, Bastías C. Is percutaneous repair better than open repair in acute Achilles tendon rupture? Clin Orthop Relat Res. 2012 Apr;470(4):998-1003.
Athletic Population
18. Chauhan A, Stotts J, Ayeno OR, Khan M. Return to play, performance, and value of National Basketball Association players following Achilles tendon rupture. Phys Sportsmed. 2021 Sep;49(3):271-277.
