What is the initial disposition for someone with an Achilles tendon rupture?

Initial Management of Achilles Tendon Rupture

For patients with acute Achilles tendon rupture, the initial disposition should include protected weight bearing with a device that limits dorsiflexion, rather than strict non-weight bearing with rest and ice. 1

Diagnosis

Before determining disposition, confirm diagnosis using:

• Clinical Thompson test (squeeze test)
• Decreased ankle plantar flexion strength
• Presence of a palpable gap
• Increased passive ankle dorsiflexion with gentle manipulation 1

Advanced imaging (MRI, ultrasound) is generally not required for diagnosis when clinical examination is conclusive 1.

Treatment Options

Two main treatment pathways exist:

1. Surgical Management

• Surgical repair is an option for acute Achilles tendon rupture 1
• Open, limited open, and percutaneous techniques are all viable options 1
• Surgical approach may be preferred for:
  • Younger, active patients
  • Athletes
  • Patients needing to return to high-level activities

2. Non-Surgical Management

• Nonsurgical treatment is also a viable option 1
• May be preferred for:
  • Older patients
  • Those with comorbidities
  • Patients who accept potentially higher rerupture risk

Initial Disposition Recommendations

Regardless of whether surgical or non-surgical management is chosen:

Weight Bearing Protocol

• Early protected weight bearing is recommended over strict non-weight bearing 1, 2, 3
• Immediate weight bearing has shown better health-related quality of life outcomes 2
• Early weight bearing leads to higher patient satisfaction, earlier ambulation, and faster return to pre-injury activity 3
• Weight bearing can begin as early as day one with proper protection 2, 4

Immobilization

• Use a protective device that limits dorsiflexion to prevent compromise of the repair/healing 1
• For surgical patients: Early (≤2 weeks) postoperative protected weight bearing with dorsiflexion limitation is recommended 1
• For non-surgical patients: A protective device allowing controlled mobilization is preferred over rigid immobilization 1, 3

Rehabilitation Timeline

• Early mobilization (after 2-4 weeks) with a protective device is recommended 1, 3
• Return to sports activities typically occurs within 3-6 months after treatment 1
• Return to daily activities varies by individual and treatment approach 1

Important Considerations and Pitfalls

1. Patient Compliance: Emphasize the importance of adherence to the rehabilitation protocol, as non-compliance increases rerupture risk 1

2. Rerupture Risk: Early weight bearing has not been shown to increase rerupture rates when proper protection is used 2, 4, 5

3. Functional Deficits: Patients should be counseled that substantial functional deficits may persist in the injured limb compared to the uninjured limb, even at 12 months post-injury 2

4. Rehabilitation Components: The key components of rehabilitation include:

   • Degree of maintained plantarflexion
   • Whether daily range of motion exercises are permitted
   • Type of orthotic used
   • Duration of orthotic wear 6

5. Monitoring for Complications: Watch for signs of rerupture, infection (if surgical), and tendon elongation during follow-up 1, 4