Torn achilles – conservative management or surgery?

Torn achilles conservative approach or surgery

Multifactorial approach to managing a torn achilles

This blog will review the causes, signs and symptoms, and early management of a torn achilles; and will discuss the risks and rewards of conservative (non-surgical management). A subsequent blog will look at the surgical approach for achilles rupture management. It is important to note that each patient is entirely unique. Our advice will always factor in age, health, the patient’s own opinion, sport, hobbies, work, family, and a whole lot of other information. None of the information detailed here should be used in isolation as health advice. It is intended to help the patient or athlete understand the process involved in injury recovery.

Part 1 – Achilles Rupture

In the post-COVID world, we have seen a slight increase in torn achilles injuries presenting to us at our Randwick clinic. Our early suspicion is that a return to impact and high-intensity sport after a few years of COVID-induced rest is to blame. Lots of us took the COVID years as a chance to jog and walk more. These are brilliant exercises that certainly use our calves and achilles an awful lot. However this exercise falls short of exposing us to the elastic responses and explosive forces that many team sports require. As a result, people are now returning to team sports thinking they have spent 2 years doing perfect pre-hab. Training, and game play uses our calves in a variety of ways. Acceleration off the mark, jogging backwards to then push off the defensive line, and jumping and landing all require very specific strength from our achilles. And importantly, this isn’t necessarily a strength that is forged from 3 x 5km runs a week.

Common achilles injury presentations

The most common presentation for an achilles rupture is a fit and healthy 30-40 year old. Usually the injury occurs in a social team sport. The mechanism of injury is often an athlete who has tried to push off and felt a generally pain-free pop in the base of their calf. Several of our patients report looking to see if a teammate had tripped them as a joke. After this mechanism, the main sign of achilles rupture is near complete loss of power in the ankle, and a palpable deformity in the achilles. There may still be some movement in plantarflexion (pointing the toes), but vastly reduced compared to pre-injury.

Acute management of a torn achilles

In the event of a torn achilles, or suspected rupture, early management is vital. There should be no weight put through the forefoot with walking or standing. Crutches are to be used until the injured person can be seen by a physio or doctor to be fully assessed. This is to ensure any remaining intact tendon material is preserved, and there isn’t any further retraction of the ruptured tendon. Ice and compression can be used to limit swelling in the area, although these injuries often don’t swell like simple ankle sprains, due to the paucity of blood supply in the achilles. Any one suffering from a suspected Achilles rupture – we recommend presenting to a physio as soon as possible. At Movement Centre we always make room to fit in acute injuries of this nature, so you are never left waiting to get appropriate health advice. After presenting to physio, the patient will often be provided with advice for protecting the injured leg – including provision of crutches. Advice for managing the acute pain and swelling is generally also provided. If potential other injuries are present, a scan (ultrasound or MRI) may be indicated. In most cases, the physio will recommend an orthopedic surgeon who specialises in achilles rupture management. At Movement Centre in Randwick we have several local surgeons who we recommend, and we are always happy to discuss other options with our patients.

Conservative achilles repair

Conservative management for an achilles repair refers to the management of the injury without surgical repair. This is an increasingly common approach for achilles ruptures. Non-operative management is generally more suitable to patients over 40, and who have more time for a slower return to sport. Conservative approach is also more suited to an athlete who isn’t returning to high-impact or explosive sports There are many reasons that patients may wish to avoid surgery – too many to list here. What we always stress to our patients is that the process without surgical repair generally requires a lot more management, patience and attention to detail, not less. This isn’t a bad thing. But often we find patients who have undergone surgery have a greater commitment to the rehab process, as they have invested more time, risk and even money into the recovery. We encourage all our non-operative patients to approach their recovery with the same diligence.

Time frames for recovery following a torn achilles

Usually with conservative management, the injured ankle is put in a cast in plantar flexion for 2 weeks non-weight bearing. They usually then progress to a boot with some increases to weightbearing and slight changes to the plantar flexion angle setting every 2 weeks, for another 6-8 weeks. This process means that the non-weight bearing and boot period of recovery is generally slightly longer than with surgical repair. Despite this, delays in getting into surgery can mean that surgical repair can result in a week or two delay. Because of this, we don’t advise using time comparisons as a significant reason in considering which option to choose.

Conservative repair

With all this in mind, there are some real pros and cons to conservative management. We are always happy to chat through all of this with our patients and their surgeon, and help them come to a decision. Both options involve a lengthy rehabilitation process, and significant buy-in from the patient to ensure they are doing all the little things possible to ensure a great outcome. In the next blog we will chat through the process of surgical repair for the achilles and the pros and cons of this management. Please remember these blogs are to be used only as further information, and not to bemused as medical advice. Please do not hesitate to come and see or team if you have an achilles injury that requires physiotherapy management.
Disclaimer: The Movement Centre provides this information as an educational service. The information contained on this website and in this blog is not intended to serve as or replace actual medical advice. Anyone seeking specific advice or assistance should consult their local Randwick Physio, general practitioner, medical specialist, or otherwise appropriately skilled practitioner.