What is the treatment for Achilles tendon injuries?

Treatment for Achilles Tendon Injuries

For Achilles tendon injuries, treatment should be based on injury type, with conservative management as first-line for tendinopathy (including relative rest, eccentric strengthening exercises, and NSAIDs) and surgical repair typically recommended for complete ruptures in young, active patients, while non-surgical management may be appropriate for older, less active individuals with ruptures. 1

Diagnosis

Before determining treatment, proper diagnosis is essential:

• Physical examination:

  • Thompson/Simonds squeeze test (sensitivity 73-84%, specificity 77-78%)
  • Assessment of decreased ankle plantar flexion strength
  • Palpation for gap in the tendon
  • Evaluation of passive ankle dorsiflexion 1

• Imaging:

  • Plain radiographs (3 views) - initial imaging to detect associated fractures
  • Ultrasound - 92% sensitivity for differentiating full vs. partial tears
  • MRI - 95% sensitivity and 95% specificity when diagnosis remains unclear 1

Treatment Algorithm

1. Achilles Tendinopathy

First-line (Conservative) Treatment (6-8 weeks):

• Relative rest and activity modification
• Ice therapy
• NSAIDs for acute pain relief (not recommended for long-term use)
• Heel lifts or orthoses
• Open-backed shoes
• Eccentric strengthening exercises (most effective conservative treatment)
• Weight loss if indicated 1

Second-line Options:

• Low-level laser therapy
• Ultrasound therapy
• Technique modification
• Address biomechanical factors (foot pronation, pes planus, heel varus) 1

Surgical Treatment Indications:

• Chronic tendinopathy unresponsive to 2-3 months of conservative care
• Persistent partial ruptures not responding to conservative treatment 1

2. Complete Achilles Tendon Rupture

Surgical Management:

• Recommended for:
  • Young, active patients and athletes
  • Patients with delayed diagnosis or treatment 1, 2

Surgical Options:

• Open repair
• Limited open repair
• Percutaneous repair (shows higher quality of life scores)
• Minimally invasive approaches (best balance between preventing rerupture and avoiding complications) 1, 2

Non-surgical Management:

• Appropriate for:
  • Older, less active patients
  • Patients with significant comorbidities 1
• Higher risk of rerupture compared to surgical treatment (relative risk 0.27 for surgery vs. non-operative) 3

Rehabilitation Protocol

For both surgical and non-surgical treatments:

• Early protected weight-bearing and mobilization to prevent muscle atrophy
• Tensile loading exercises to stimulate collagen production
• Eccentric strengthening exercises
• Stretching exercises for posterior thigh muscles 1

Functional Bracing:

• Preferred over rigid casting
• Allows early mobilization
• Associated with lower complication rates (relative risk 1.88 for casting vs. functional bracing) 1, 3

Important Considerations and Pitfalls

• Avoid corticosteroid injections directly into the tendon - increases rupture risk 1
• Avoid prolonged immobilization - leads to muscle atrophy and deconditioning 1
• Consider bilateral assessment - tendon damage is often bilateral even when symptoms appear unilateral 1
• Surgical complications include wound infections, nerve injury, rerupture, and scar adhesions 1
• Non-surgical complications primarily include higher rerupture rates 3

Expected Outcomes

• Most patients (80%) fully recover within 3-6 months with proper conservative care 1
• Regular clinical assessment of pain and function is crucial for optimal recovery 1
• Progressive return to activities should be based on functional improvement 1

The combination of minimally invasive surgical repair (when indicated) and accelerated functional rehabilitation appears to offer the best results in the treatment of Achilles tendon ruptures 2.