Immediate Weight-bearing in Achilles Rupture Treatment Does Not Harm Clinical Outcomes
In addition, patients who were allowed immediate weight-bearing in the first 8 weeks reported a significant health-related quality of life versus those who were on the delayed weight-bearing protocol.
Kenneth J. Mroczek, MD
Barford KW, Bencke J, Lauridsen HB, Ban I, Ebskov L, Troelsen A: Nonoperative dynamic treatment of acute Achilles tendon rupture: the influence of early weight-bearing on clinical outcome. a blinded, randomized controlled trial. JBJS 96-A 1497-1503 2014.
A blinded, randomized controlled trial between immediate and delayed weight-bearing for non-operative dynamic treatment for acute Achilles tendon ruptures showed no difference in heel-rise work, health quality of life, and re-rupture rates.
All patients were treated with the same protocol, except that one group began with immediate weight-bearing and the other group delayed weight-bearing until 2 weeks after surgery. All patients began their treatment by 4 days after the rupture. The diagnosis was based on clinical history and physical exam showing a palpable defect and a positive calf squeeze test. The age for inclusion was from 18 to 60 years, and there were a total of 60 patients.
The protocol consisted of a fixed ankle orthosis boot with 3 wedges (1.5 cm each) for the first 2 weeks. The boot could not be removed during this period.
Starting at week 3, 1 wedge was removed and the boot was removed 5 times a day for early motion. The patient sat on a table with their knees bent. The foot was allowed to drop to gravity plantar flexion and then active dorsiflexion to the neutral horizontal position. Twenty-five repetitions were performed.
Another wedge was removed at week 5, and the last wedge was removed at week 7. At week 9, a standardized rehabilitation program was begun 3 times a week.
The functional assessment for height and work on the heel-rise test at 6 and 12 months did not differ significantly. The re-rupture rate, sick leave, time to resumption of sport and return to the same level of sport also did not differ significantly.
The patient-reported outcome was measured by the Achilles tendon Total Rupture Score (ATRS) and a health-related quality-of-life questionnaire created by the researchers. While the ATRS did not differ between the groups at 6 and 12 months, the questionnaire created by the researchers was significantly better for the immediate weight-bearing group for the first 8 weeks. The researchers correctly commented that their questionnaire has not been validated.
The discussion also mentions that the overall treatment results leave room for improvement with regard to re-rupture rate (9%), strength deficits of 40% to 50% of the uninjured leg, and only a 16% return to same level of sporting activity at 1 year follow-up.
Pendulums tend to swing in medicine, particularly in orthopaedics. Whereas non-operative treatment for acute Achilles rupture was uncommon years ago, recent data have supported such treatment. While this study does not attempt to solve the debate between operative and non-operative treatment, it does help describe the weight-bearing in those patients who will be treated non-operatively.
It is clear that non-operative treatment does not mean benign neglect or no treatment. A quick diagnosis and plantar flexion immobilization in an ankle orthosis boot is paramount. The question of weight-bearing status is important to our patients. It is obviously easier for patients to bear weight than to be non-weight-bearing on the injured leg.
This study showed no significant differences between those who began immediate weight-bearing and those who delayed weight-bearing by 2 weeks. While there was no difference in the ATRS, a non-validated questionnaire showed a significant health-related quality of life for those with immediate weight-bearing in the first 8 weeks. I think most people who have used crutches in the past would agree.
Kenneth J. Mroczek, MD, is an Assistant Professor of Orthopaedic Surgery and Chief of the Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, NYU Langone Medical Center – Hospital for Joint Diseases, New York, New York.