What is the initial treatment for an Achilles tendon rupture in the emergency room (ER)?

Initial Treatment of Achilles Tendon Rupture in the Emergency Room

The initial treatment for an Achilles tendon rupture in the emergency room should include diagnostic confirmation, pain management, immobilization, and early referral for definitive management, with both surgical and nonsurgical options being viable depending on patient factors. 1

Diagnosis Confirmation

Before initiating treatment, proper diagnosis is essential:

• Perform at least two of the following tests 1:

  • Thompson/Simonds squeeze test (squeezing the calf muscle should cause plantar flexion if tendon is intact)
  • Assessment of ankle plantar flexion strength
  • Palpation for gap or defect in tendon
  • Evaluation of passive ankle dorsiflexion

• Initial imaging in the ER:

  • Plain radiographs to rule out bony avulsion fractures or other osseous abnormalities 1
  • Ultrasound can be used as a point-of-care diagnostic tool with good specificity (94%) 1
  • MRI is preferred for definitive diagnosis but typically not performed in the ER setting 1

Immediate ER Management

1. Pain Control:

   • NSAIDs for pain management 1
   • Ice therapy with 10-minute applications through a wet towel 1
   • Elevation of the affected limb

2. Immobilization:

   • Apply a posterior splint or walking boot with the ankle in slight plantar flexion (10-20°) to reduce tension on the tendon 2, 1
   • Avoid complete immobilization in neutral position as this may increase gap formation 1

3. Weight-bearing Status:

   • Initially non-weight bearing with crutches 2
   • Early protected weight-bearing may be considered depending on the treatment plan 2

4. Patient Education:

   • Explain injury mechanism and treatment options
   • Discuss the pros and cons of surgical versus nonsurgical management
   • Set realistic expectations for recovery timeline

Treatment Decision-Making

The American Academy of Orthopaedic Surgeons guidelines indicate that both surgical and nonsurgical treatments are viable options 2, 1:

Surgical Treatment Considerations:

• Recommended for young, active patients and athletes 1
• Lower rerupture rates compared to nonsurgical treatment 3
• Options include open repair, limited open repair, and percutaneous techniques 2, 4
• Limited open and percutaneous techniques reduce wound complications compared to open repair 2

Nonsurgical Treatment Considerations:

• Appropriate for older, less active patients or those with significant comorbidities 1
• Higher rerupture rates but fewer complications related to surgery 3
• Involves immobilization and progressive rehabilitation 1

Referral Guidelines

• All patients with confirmed Achilles tendon ruptures should be referred to an orthopedic surgeon or podiatric foot and ankle surgeon within 1-2 weeks 2, 1
• If no improvement occurs after initial treatment, referral to a specialist is appropriate 2

Rehabilitation Considerations

While not part of immediate ER management, patients should be informed that:

• Early functional rehabilitation with controlled ankle mobilization shows better outcomes than prolonged immobilization 5, 6
• Early protected weight-bearing (within 2 weeks) is recommended after surgical repair 2
• Rehabilitation protocols typically include progressive tensile loading exercises, eccentric strengthening, and stretching 1

Common Pitfalls to Avoid

• Misdiagnosis - ensure proper clinical testing is performed 1
• Injecting corticosteroids directly into the tendon substance 2, 1
• Prolonged immobilization leading to muscle atrophy 1, 5
• Overly aggressive early rehabilitation 1
• Failure to recognize associated injuries or comorbidities that may affect treatment decisions

By following this approach, emergency physicians can provide appropriate initial management for patients with Achilles tendon ruptures while facilitating timely referral for definitive care.