Management of achilles tendon injury: A current concepts systematic review

Table 1 Summary of evidence for non-operative management of acute tendo-achilles rupture

Ref.	Patient group	Study type (level of evidence)	Outcomes	Key results	Study weaknesses
Costa et al[27]	48 adult patients with acute achilles tendon rupture who chose to have non-operative treatment. Randomised to either six weeks in an off-the-shelf, carbon-fibre orthosis with three 1.5 cm heel raises that were encouraged to mobilise fully weight-bearing and move the ankle within the orthosis (trial group) or to six weeks in a below knee gravity equinus cast that were non weight-bearing (control group). This was followed by serial removal of heel raises or casting in increasing dorsiflexion over 6 further weeks. Immobilisation was discontinued at 12 wk. Reviews at 3, 6 and 12 mo	PRCT	Numbers returning to sport	No significant difference found (P = 1.0); 56% trial group vs 52% control group	Of the original 48 patients only 40 were available for review at one year. All patients who presented out of hours were initially placed in below-knee equinus plaster backslab
			Time to return to normal activities	No significant differences found. Sport- (P = 0.631) 18 wk trial group vs 21 wk control group. Walking- (P = 0.765) 16 wk trial group vs 22 wk control group. Stair climbing- (P = 0.484) 16 wk trial group vs 22 wk control group. Work- (P = 0.370) 13 wk trial group vs 17 wk control group
			EuroQol health status questionnaire- EQoL Domain	No significant differences found. 3 mo- (P = 0.372) 80 trial group vs 85 control group. 6 mo (P = 0.598) 89 trial group vs 88 control group. 12 mo- (P = 0.122) 85 trial group vs 91 control group
			EuroQol health status questionnaire- E5D Domain	No significant differences found. 3 mo- (P = 0.450) 0.73 trial group vs 0.69 control group. 6 mo- (P = 0.810) 0.80 trial group vs 0.80 control group. 12 mo- (P = 0.888) 0.85 trial group vs 0.85 control group
			Deficit in calf diameter in mm	No significant difference found (P = 0.634). 1.37 trial group vs 1.11 control group
			Loss of movement in degrees	No significant differences found. Dorsiflexion (P = 0.879) -0.7 trial group vs 0.27 control group. Plantarflexion (P = 0.248) 4.13 trial group vs 7.27 control group
			Deficit in total concentric and eccentric work	No significant differences found
			Complications	1 re-rupture in trial group vs 1 re-rupture, 1 failure of tendon healing and 1 PE in control group
Petersen et al[28]	50 adult patients with acute achilles tendon ruptures. Randomised to either a CAM walker and were encouraged to weight bear (trial group) or to a below knee full equinus cast and were non-weight bearing (control group). Both groups were immobilised for 8 wk. Reviews at 4 and 12 mo	PRCT	Re-rupture rate	No significant difference found (P = 0.066) but suggestive of a trend towards increased re-rupture in the control group. The risk of a type II error was 44% and it was thought likely that should the numbers of patients recruited have been larger this may have become a significant difference. 0% trial group, vs 17% control group	Number lost to follow-up: 8. Length of time between injury and treatment not stated although delayed presentations were excluded
			Patient satisfaction	No significant difference
Saleh et al[29]	40 adult patients with acute achilles tendon ruptures. Randomised to either a below knee full equinus cast for 2 wk followed by, a mid equinus cast for 1 wk and then controlled early mobilisation in a Sheffield splint with full weight-bearing (trial group) or to a full-leg cast, with the ankle in full equinus, for four weeks, followed by two weeks in a below-knee cast with the ankle in mid-equinus, and then two more weeks with the ankle in the neutral position with weight-bearing allowed during the final two weeks only (control group). Review at 3, 6 and 12 mo. The Sheffield splint is an ankle-foot orthosis which holds the ankle at 15 degrees of plantar flexion, but allows some movement at the metatarsophalangeal joints. The orthosis is used in conjunction with an insole within an extra-depth shoe. It is removed to allow controlled movement during physiotherapy	PRCT	Strength of plantar flexion	No significant difference found at 3, 6 or 12 mo	Randomisation method not stated
			Range of plantar flexion (degrees)	No significant difference found at 3, 6 or 12 mo
			Range of dorsiflexion (degrees)	Significantly more in trial group at 3, 6 and 12 mo (P < 0.001)
			Time to walking indoors	Significantly quicker in trial group (P < 0.001). 6 wk trial group vs 11 wk control group
			Time to walking outdoors	Significantly quicker in trial group (P < 0.001). 9 wk trial group vs 15 wk control group
			Complications	1 re-rupture in each group
			Patient preference	All patients in the trial group preferred the time spent in the Sheffield splint to the time spent in the cast