Surgery Not Always Needed
for Achilles Tendon Tear

Although Achilles tendon ruptures are often repaired with surgery, UK researchers say a more conservative tactic should be the treatment of choice for at least some patients.

Their study of 140 patients treated with non-surgical means found that the long-term outcome was "excellent" or "good" for 86 percent. All of the patients had completely torn their Achilles tendon, the large band of fibrous tissue at the back of the ankle that connects the calf muscles and heel bone.

Surgery is generally regarded as the best treatment for a complete Achilles tear because it's thought to provide better functional recovery and a lower risk of a repeat rupture compared with conservative treatment -- which traditionally has meant immobilizing the ankle with a cast.

But in the new study, doctors used a newer approach in which patients wear a hard cast for only a short time before switching to a lightweight version, and then -- a month after the injury -- to a removable "functional" brace worn for four weeks.

Study patients removed the brace to perform ankle and foot exercises, and learned to walk using the brace for support.

Three years later, most of the 140 patients were doing well, according to findings published in the June issue of the Journal of Bone and Joint Surgery. In fact, the authors report, their outcomes were better than those for patients in a previous study of surgical treatment that the researchers looked at for comparison.

Dr. Richard G. H. Wallace of Musgrave Park Hospital in Belfast, Northern Ireland, led the study.

According to Wallace and his colleagues, 56 percent of their patients had an "excellent" outcome, while the results were "good" for another 30 percent and "fair" for 12 percent. Only 2 percent had a "poor" report.

Overall, 91 percent of those who had been involved in sports before their Achilles injury were active again, although the majority had not returned to the same level of activity. On average, the patients were off work for a week after the injury, and were out of sports for eight weeks after they stopped using the functional brace.

Three patients (2 percent) suffered a repeat rupture of the Achilles, while 6 percent had what was deemed a minor complication, including five patients who had a partial rupture. These complication rates, Wallace's team notes, were lower than those in the surgical study, where 7 percent of patients had a complete rupture and 20 percent a partial tear or other minor complication.

"It is our strong view," the authors conclude, "that our nonoperative treatment protocol should be the treatment of choice."

However, they stress, this should be the case only when doctors and therapists are experienced in this type of treatment.

SOURCE: Journal of Bone and Joint Surgery, June 2004.

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