From the Guidelines
Treatment for a partial tear of the Achilles tendon should prioritize a non-surgical approach, focusing on rest, immobilization, and gradual rehabilitation to minimize morbidity, mortality, and improve quality of life. The initial management involves the RICE protocol (Rest, Ice, Compression, Elevation) to reduce pain and swelling, as recommended by 1. Immobilization using a walking boot or cast for 4-6 weeks is often necessary, with the foot positioned in slight plantar flexion to reduce tension on the tendon.
Pain management is crucial and can include over-the-counter medications like acetaminophen or NSAIDs such as ibuprofen for the first 1-2 weeks, as mentioned in 1. After the immobilization period, physical therapy becomes essential, focusing on progressive strengthening exercises, stretching, and proprioception training for 8-12 weeks. Eccentric heel drop exercises are particularly effective, as they stimulate collagen production and guide normal alignment of newly formed collagen fibers, as noted in 1.
Key aspects of the treatment include:
- Relative rest to decrease repetitive loading of the damaged tendon, as encouraged by 1
- Use of cryotherapy for short-term pain relief, as discussed in 1
- Avoidance of complete immobilization to prevent muscular atrophy and deconditioning, highlighted in 1
- Gradual return to normal activities over 3-6 months to ensure full recovery and minimize the risk of further injury. Surgery is rarely needed for partial tears unless conservative treatment fails after several months, emphasizing the importance of a well-structured rehabilitation program. This approach is supported by the understanding that the Achilles tendon has a good blood supply in its mid-portion, allowing for effective healing when the tendon ends are kept in proximity through immobilization and controlled rehabilitation, as implied by 1.
From the Research
Treatment Options for Partial Tear of Achilles Tendon
- Conservative management is considered acceptable in partial tendon ruptures affecting less than 50% of the tendon's width, but supporting experimental evidence is currently lacking 2
- Conservative treatment includes orthotic devices to reduce tendon load and physiotherapy to correct training errors and strengthen the muscle-tendon unit 3
- A conservative approach using a 2 cm heel lift for the first 6 weeks and avoiding tendon stretching (for 12 weeks) can be used as first-line therapy 4
- If conservative management has a poor effect, surgical exploration and the excision of the partial rupture and suturing is required 3, 4
- Augmentation procedures or anchor applications might be useful for partial ruptures in the Achilles insertion, but this depends on the size and exact location 4
Rehabilitation Protocols
- Rehabilitation programs can be modified based on ankle angle, boot type, and walking speed to change loading progression during rehabilitation 5
- A 12 to 14-week rehabilitation program can be recommended after surgery, including progressive tendon loading and eccentric exercises 4, 6
- The use of a 1/8th-1/4th inch heel cushions in daily shoes after 8 weeks, the use of an antigravity treadmill for rehabilitation, and the return to sports based on heel raise repetitions is strongly recommended 6
Considerations for Treatment
- Significant partial ruptures seem to respond poorly to conservative measures and do not improve with time 3
- Progression to complete ruptures occurred even with less than a 50% loss of continuity, regardless of subtendon twisting, and material parameters 2
- The current criteria for surgical treatment of partial ruptures should be reconsidered based on new findings 2