Surgery or rehabilitation for ruptured Achilles tendons? Which is best ?

This meta-analysis found non-surgical management of an acute Achilles tendon rupture had the same risk of tendon re-rupture if an early functional range of motion protocol was also followed. The two groups had equivalent proportions of patients returning to the same level of sporting activity, while the surgical group had higher rates of other complications1.

Due to the nature of sudden accelerations and jumping movements in football Achilles tendon rupture is a relatively common injury. It remains controversial whether surgical or non-surgical treatment is best. It is often assumed that young athletes do better with surgery based on data showing a lower rate of re-rupture and a better functional outcome than traditional immobilisation. However, it is also accepted that this may also lead to a higher complication rate. More recent trials have demonstrated that early functional rehabilitation, with early weight-bearing and range of motion exercises, could stimulate tendon repair and reduce re-rupture rates.

This meta-analysis reviewed ten published randomised controlled trials with a total of 934 patients. The aim was to compare the two methods of managing an acute Achilles tendon rupture in terms of re-rupture rate, functional outcomes, other complications and ability to return to sport. It also specifically reviewed the difference in re-rupture rate if established early functional rehabilitation protocols were followed.

It was found that when traditional non-surgical treatment methods were employed there was a higher rate of re-rupture in the non-surgical group. When an early functional rehabilitation protocol was implemented however, re-rupture rates were no different from surgical treatment. There were also no significant differences in the proportions of patients returning to previous levels of sporting activities. The surgical treatment group had better results in two functional jumps tests and a muscular endurance test, however the two groups were equivalent in terms of strength test results. Surgical management had significantly higher rates of other complications including deep infection, adhesions, and sural nerve injury.

The findings of this meta-analysis highlight that there are different options for managing an acute Achilles tendon rupture. If an early functional rehabilitation protocol can be offered then non-surgical management may be preferred given the equivalent re-rupture rate and return to previous playing level, with less risk of other complications. It is however important to acknowledge that there are some limitations with the available data. The applicability of these results to elite players returning to their comparatively higher demand level of sport remains unknown.

To learn more about ankle injuries among football players complete the ‘ankle module’ in the FIFA Diploma in Football Medicine.

1Zhou K, Song L, Zhang P, Wang C, Wang W. Surgical versus non-surgical methods for acute Achilles tendon rupture: A meta-analysis of randomised controlled trials. The Journal of Foot and Ankle Surgery 57 (2018) 1191-1199.