SLR - July 2021 - Charles B. Penvose

Does the Size of Tendon Gap Affect Patient-reported Outcome Following Achilles Tendon Ruptures Treated with Functional Rehabilitation? 

Reference: Yasin M, Myatt R, Thomas W, Grupta V, Hoque T, Mahadevan D. Does the Size of Tendon Gap Affect Patient-reported Outcome Following Achilles Tendon Ruptures Treated with Functional Rehabilitation? Bone Joint J. 2020 Nov; 102-B(11):1535-1541. 

Level of Evidence: Level III

Scientific Literature Review

Reviewed By: Charles B. Penvose, DPM
Residency Program: Emory University School of Medicine – Decatur, GA

Podiatric Relevance: Achilles tendon ruptures are a sports-related injury that podiatric surgeons commonly treat. There has been a recent paradigm shift in the management of Achilles ruptures due to an increasing amount of literature supporting conservative treatment via functional rehabilitation. Studies show that functional rehabilitation has comparably low re-rupture rates to surgery, while avoiding risks of surgical complications. The aim of the study was to assess gap size between ruptured tendon ends affects patient-reported outcome following ruptures treated with functional rehabilitation. 

Methods: This was a prospective cohort study of 82 patients diagnosed with Achilles tendon rupture at a UK hospital from 2016-2019 managed non-operatively. Diagnosis of ruptures was performed by ultrasound scanning and gap size measured in full plantarflexion of ankle. Achilles tendon rupture scores (ATRS) were completed by patients at a minimum of 12 months following injury. Functional rehabilitation was performed as preferred treatment following an established protocol allowing for early weightbearing and mobilization. Patients with partial tears, open lacerations, who were treated operatively, or those with no outcome scores collected were excluded. 

Results: Eighty-two patients with completed ATRS were included in the analysis. Mean patient age was 51 years. Mean ATRS was 76 at a mean follow up of 20 months (SD 11) following injury. Mean tendon gap with ankle in full plantarflexion was 9 millimeters (SD 10). A lower mean ATRS score was found when tendon gap was >5 millimeters compared to < or = 5 millimeters. No significant correlation between age and ATRS was found. Female sex was associated with a lower mean ATRS. Of the 131 patients treated non-operatively, there were two re-ruptures (1.52%) both occurred one month after boot removal. 

Conclusions: The authors concluded that increasing gap size predicts lower patient-reported outcome, as measured by ATRS. Tendon gaps <5 millimeters may be a useful predictor in physically demanding individuals, and tendon gap > 10 millimeters for those with lower physical demand. While more studies are needed comparing gap size with both non-operative and operative treated ruptures, it’s important for the podiatric surgeon to consider a multitude of factors including gap size in providing the most effective care to patients with Achilles tendon ruptures. 

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