Comparing Non-operative Treatment Pathways for Achilles Tendon Rupture

    Cast immobilization with prolonged non-weight-bearing has traditionally been used to manage patients with a first-time acute Achilles tendon rupture. Could functional rehab and early weight-bearing in a walking boot provide comparable – or even better – outcomes while allowing patients greater mobility?


    Elizabeth Barchi, MD


    Maempel JF, Clement ND, Duckworth AD, Keenan OJF, White TO, Biant LC. A randomized controlled trial comparing traditional plaster cast rehabilitation with functional walking boot rehabilitation for acute achilles tendon ruptures. Am J Sports Med. 2020 Sep;48(11):2755-2764. doi: 10.1177/0363546520944905. Epub 2020 Aug 20.


    In a prospective, randomized, non-blinded controlled trial, Maempel et al compared outcomes of 2 conservative treatment options among patients with an acute Achilles tendon rupture. They included 140 patients ages 16 to 60 who had sustained a first-time rupture within 2 weeks of presentation. Patient with a re-rupture, delayed presentation of more than 2 weeks, or latex allergy were excluded from the study.

    Patients were randomly sorted into 2 groups:

    Standard non-operative pathway: Traditional cast immobilization with prolonged non-weight-bearing (n = 71)

    • Weeks 1-4: Complete below-knee cast with the ankle in full equinus; non-weight-bearing status
    • Weeks 5-8: Conversion of the cast to a complete below-knee cast with the ankle in semi-equinus; non-weight-bearing status
    • Weeks 9-10: Cast with the ankle in plantigrade (neutral) position; full weight-bearing status
    • Week 10: Cast removed; physical therapy begins, including active plantar flexion
    • Weeks 11-12: Use of a 1.5 cm heel raise shoe insert

    Functional non-operative pathway: Functional rehabilitation and early weight-bearing in a walking boot (n = 69)

    • Weeks 1-4: Ossur Rebound walking boot with a 3-cm internal heel raise insert, to be worn continuously; full weight-bearing with the aid of crutches for balance as needed; no range-of-motion exercises while in the boot
    • Weeks 5-6: Internal heel raise reduced to 1.5 cm
    • Weeks 7-8: Internal heel raise removed; walking boot continued in a plantigrade position
    • Week 8: Boot removed; physical therapy begins, including active plantar flexion

    The primary outcome measure was the Short Musculoskeletal Function Assessment (SMFA) score, administered at the initial visit and then at 4, 6, 8, and 10 weeks; 6 months; and 1 year after the date of the injury. At the initial review and at 6 months and 1 years, patients were also asked to complete the validated PROMs: Achilles Tendon Total Rupture Score (ATRS) and the Foot and Ankle Questionnaire (FAQ).

    There was a statistically significant difference in favor of the functional non-operative pathway among all 3 scores at 6 months, but no persistent statistically significant difference between groups at 1 year or at final follow-up.

    A similar pattern emerged with other outcome measures, including calf circumference, active dorsiflexion, and plantarflexion range of motion, with small statistical differences in favor of the functional non-operative pathway that did not persist to 1 year or final follow-up.

    Patients in the functional non-operative pathway returned to driving on average 1 week earlier than patients in the standard non-operative pathway group. Both patient groups returned to work around the same time. Minor skin issues were frequent in the group treated with a walking boot; however, there were no long-term sequelae.

    Clinical Significance

    Achilles tendon rupture is a common injury with a rising incidence. Traditionally, physicians have had to choose between non-operative and operative management for these patients, both involving prolonged periods of immobilization without weight-bearing.

    In recent years however, there has been a growing trend toward early functional rehabilitation programs that allow for early weight-bearing. Weight-bearing status has a significant impact on quality of life and the ability to complete activities of daily living. The improved short-term outcomes and similar long-term outcomes reported in this study by Maempel et al demonstrate that early functional non-operative management is a relatively safe treatment alternative for patients who prefer, or need, to remain weight-bearing.

    Author Information

    Elizabeth Barchi, MD is an Assistant Professor with the Department of Orthopedic Surgery at NYU Langone Health – Orthopedic Hospital, New York, New York.

    Disclosures: Dr. Barchi has no disclosures relevant to this article.