Non-surgical treatment of Achilles tendon ruptures evidently carries little risk of surgical complications, so why are most ruptures of the Achilles tendon in Norway treated with surgical repair? The reason is partly owing to older publications showing an increased risk of re-rupture following non-surgical treatment 1. However, during the last decade, a novel and exciting approach to Achilles tendon injuries has gradually developed. The observation that mechanical loading of tendons stimulates increased tensile strength over time has been recognized for nearly a century 2, but awareness centered on this biomechanical trait has led to the development of new rehabilitation protocols. Importantly, results following non-surgical treatment have been improved by allowing early mobilization and controlled weight bearing 3, and the latest studies have not been able to detect a significant difference in the risk of re-rupture, comparing surgical and non-surgical treatment 4 , 5 , 6 , 7 , 8. However, surgical techniques have also been modified, notably by introducing less invasive procedures requiring only small incisions thereby reducing the risk of infections and other wound complications. As a result, treatment recommendations are hard to make and there are no clear guidelines. The Achilles study is therefor important since it employs modern treatment principles, and because its size allows firm conclusions to be made.
Scope of the study
The Achilles study is conducted jointly by Ahus University Hospital, Oslo University Hospital, Drammen Hospital and Fredrikstad Hospital. The joint catchment area of these four hospitals is more than one-quarter of the Norwegian population, and the planned inclusions of more than 500 patients will make it the largest prospective randomized trial ever conducted regarding ruptures of the Achilles tendon. The study’s participants are randomly allocated to non-surgical treatment or operative treatment with traditional open or mini-invasive surgical repair. The allocation procedure follows strict guidelines ensuring that groups of patients receiving different treatments are as similar as possible, and preparations and planning of the study lasted for two years prior to inclusion of the first patient in March 2013. The participants are closely followed and they receive the same intensive physical therapy. Functional results are evaluated at six and twelve months at the Norwegian Sport Medicine Clinic (NIMI).
The rehabilitation of a ruptured Achilles tendon following initial treatment is of pivotal importance, and the rehabilitation protocol is standardized and identical to all participants in the study. An international collaboration of physiotherapists and physicians has developed the protocol emphasizing accelerated rehabilitation by allowing early motion and weight bearing. Participants in the study are referred to members of a network of physiotherapists with especial interest for Achilles injuries ensuring adequate follow-up and adherence to the protocol. Patients are immobilized in equinus position for the first two weeks using a below-the-knee cast. Following the first two weeks the cast is replaced with a protective boot (orthosis), and the amount of plantar flexion is successively decreased by removing heel lifts. We have chosen to use standardized heel lifts because it eases weight bearing compared to a hinged brace. The protective boot is retained for a total of six weeks, and patients are allowed full weight bearing as tolerated during the entire time period. The boot is worn day and night for the first four weeks, but can be removed during nighttime for the last four weeks. Regular physiotherapy starts already at two weeks but the program is intensified when the boot is removed after eight weeks (six weeks after adaption). Hence, the ankle is immobilized for eight weeks, two weeks with a cast and then six weeks with a protective boot.
Animation describing the brace used in the study
A rupture of the Achilles tendon represents a serious injury, often resulting in lasting functional deficits 9. This emphasizes the importance of the interplay between patient, physician and physiotherapist ensuring optimal results. For patients taking part in the study, physician follow-up is scheduled at two, four and eight weeks, and regular physical therapy appointments start at two weeks. Functional testing and evaluation of treatment results are conducted at six and twelve months. Thorough follow-up will hopefully clarify uncertainties and provide the means to promptly answer any questions that may arise. Participates will also receive personal contact information to those responsible for the trial. A brief description of the rehabilitation protocol can be found by following the link below, exercises are to be performed under supervision of a physiotherapist.
Kjetil Hvaal, Consultant, Orthopaedic centre, OUS Ullevål
Øyvind Paulsrud, Consultant, Orthopaedic centre, OUS Ullevål
Lars Engebretsen, Consultant, Orthopaedic centre, OUS Ullevål
Astrid Grini Johansen, Supervisor, Oslo emergency ward, OUS Ullevål
Knut Melhus, Consultant, Oslo emergency ward, OUS Ullevål
Lars Fredrik Høifødt, Specialty registrar, Fredrikstad Hospital
Asbjørn Sorteberg, Consultant, Fredrikstad Hospital
Faisal Butt, Consultant, Drammen Hospital
Finnur Snorrasson, Consultant, Drammen Hospital
Karin Rydevik, Physiotherapist, NIMI
Katarina Nilsson Helander, Consultant, Kungsbacka Hospital
Michael Amlang, Consultant, Dresden University Hospital