What is the treatment for a partial Achilles tendon (AT) midsubstance tear?

Treatment for Partial Achilles Tendon Midsubstance Tear

The initial treatment for a partial Achilles tendon midsubstance tear should begin with conservative management including activity modification, regular stretching exercises, NSAIDs for pain relief, and appropriate footwear modifications, with progression to protected weight bearing and mobilization by 2-4 weeks if symptoms persist. 1

Initial Conservative Management

• Activity limitation that avoids movements aggravating the pain is recommended, but complete immobilization should be avoided to prevent muscular atrophy and deconditioning 1
• Apply ice through a wet towel for 10-minute periods to reduce inflammation and provide short-term pain relief 1
• Implement daily calf muscle and Achilles tendon stretching exercises to improve flexibility and reduce pain 1
• Use nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief, with topical NSAIDs being an option to avoid gastrointestinal side effects 1
• Wear open-backed shoes to reduce pressure on the inflamed area 1, 2
• Use heel lifts or orthotic devices to reduce tension on the Achilles tendon 1, 2
• Encourage weight loss if indicated to reduce stress on the tendon 1, 2

Progressive Treatment (if no improvement after 6 weeks)

• Transition to a protective device that allows mobilization by 2-4 weeks, with a splint or modified cast device that limits dorsiflexion to protect the healing tendon 3, 1
• Implement early (≤2 weeks) protected weight bearing with limitation of dorsiflexion 3, 1
• Begin eccentric exercise protocols which have proven beneficial in Achilles tendinopathy 1, 4
• Consider tendon loading exercises as the primary focus of rehabilitation 4
• Refer to a podiatric foot and ankle surgeon if no improvement occurs after 6 weeks of initial treatment 1

Advanced Treatment Options (if conservative treatment fails)

• Consider immobilization with a walking boot or cast for more stubborn cases 1
• Obtain advanced imaging such as MRI to assess the condition more thoroughly 1
• For cases unresponsive to initial management, consider shockwave therapy or sclerosing treatment before considering surgical options 4
• If surgical intervention becomes necessary, minimally invasive techniques show good outcomes with lower complication rates compared to open procedures 5

Important Considerations and Pitfalls

• Patient compliance with treatment protocols is crucial to prevent complications and ensure optimal healing 3
• Avoid local corticosteroid injections directly into the tendon substance as they may inhibit healing and reduce tensile strength, potentially predisposing to spontaneous rupture 1
• Early mobilization allows quicker return to activities during the first 6 months compared to traditional immobilization 3, 6
• Monitor for signs of infection which, though rare, can be a devastating complication requiring extensive debridement and antibiotic therapy 7
• The ultimate level of function achieved is similar regardless of the postoperative weight-bearing protocol, but early weight bearing accelerates return to activities 3
• For patients who participate in sports, return to athletic activities typically occurs within 3-6 months after treatment 3

Treatment Algorithm

1. First 6 weeks: Conservative management with activity modification, ice, NSAIDs, stretching, and appropriate footwear 1
2. Weeks 2-4: Transition to protected weight bearing with a device that limits dorsiflexion 3, 1
3. Weeks 4-12: Progressive rehabilitation with eccentric exercises and gradual increase in activity 1, 4
4. After 12 weeks: Gradual return to sports and high-impact activities if healing is adequate 3
5. If no improvement after 6 weeks: Consider specialist referral and advanced imaging 1
6. For persistent cases: Consider advanced interventions or surgical options 4, 5