What is the initial management for an Achilles tendon injury, specifically regarding the use of a walking boot?

Initial Management of Achilles Tendon Injury

Both surgical and nonsurgical treatment options are viable for acute Achilles tendon rupture, with initial management typically involving immobilization, though evidence for specific bracing approaches remains inconclusive. 1

Diagnosis and Assessment

• Diagnosis of Achilles tendon rupture typically involves:

  • Physical examination including palpation to establish presence of a gap
  • Thompson/Simonds squeeze test (calf squeeze)
  • Matles test (increased passive ankle dorsiflexion) 1

• While MRI, ultrasonography, and radiography may be used, there is insufficient evidence to recommend their routine use for confirming diagnosis 1

Initial Management Options

Nonsurgical Treatment

• Nonsurgical treatment is a viable option for acute Achilles tendon rupture 1
• Initial immobilization is typically employed, though the specific approach varies:
  • Walking boots that secure the ankle at a specific position aim to reduce tendon loading 2
  • Boot characteristics to consider:
    • Ankle angle constraint (most significant factor affecting tendon loading)
    • Immobilization style
    • Boot construction 3

Surgical Treatment

• Surgical treatment is also a viable option for acute Achilles tendon rupture 1
• Surgical options include:
  • Open repair: extended incision allowing visualization of rupture
  • Limited open repair: small incision allowing direct visualization of ruptured ends
  • Percutaneous repair: procedure without direct exposure of rupture site 1

Immobilization Considerations

• For nonsurgical treatment, the evidence regarding immediate functional bracing is inconclusive 1

• Boot selection factors that affect Achilles tendon loading:

  • Ankle position has the greatest effect on tendon loading
  • More plantarflexed positions generally reduce tendon loading
  • Boot construction is the second most important factor
  • Walking speed has a smaller but still relevant effect 3

• One approach for functional nonsurgical treatment includes:

  • High-shaft boot with 3-cm hindfoot elevation
  • Physical therapy beginning after 3 weeks
  • Total boot wear time of 8 weeks (extended from 6 weeks in earlier protocols)
  • Followed by shoes with 1-cm hindfoot elevation for another 3 months 4

Treatment Selection Considerations

• Surgical treatment may be more appropriate for:

  • Young, physically active patients
  • Patients with delayed diagnosis or treatment 5

• Nonsurgical treatment may be more appropriate for:

  • Older patients with sedentary lifestyles 5
  • Patients whose ultrasound shows ≤10 mm distance between tendon ends with ankle in neutral position and complete apposition in 20° plantarflexion 4

Potential Complications and Monitoring

• Rerupture is a significant concern with nonsurgical treatment

  • Reported rerupture rates vary (6.4% in one study using functional bracing) 4
  • Higher rerupture rates may occur with traditional cast immobilization 4

• Surgical complications may include:

  • Wound breakdown/delayed healing
  • Scar adhesions
  • Superficial infections
  • Sural nerve injuries 1

Key Pitfalls to Avoid

• Failing to properly assess tendon gap distance before deciding on treatment approach
• Using inappropriate ankle positioning in boots (affects tendon loading)
• Starting rehabilitation too early or too aggressively
• Insufficient duration of immobilization
• Not monitoring for signs of rerupture during treatment