1. Effectiveness of Surgical Treatment on Achilles Tendon
Rupture
Allyson Hayward
Clinical Scenario
Achilles tendon ruptures are pretty
common and seem to be occurring more
frequently and therefore there is need for
proper treatment, but is surgery or not
the proper treatment? Non-surgical
treatment includes immobilization
and/or casting and rehabilitation.
Surgical treatment will also include
immobilization and rehabilitation just
post surgery. However, there is less of a
recurrence of rerupture with surgery than
without surgery. But that doesn’t mean
that surgery isn’t risky as well, there is
risk of infection and other possible
complications when choosing surgery
for treatment.
Focus Clinical Question
Which type of treatment has a better
non-rerupture rate in patients who
sustained an acute Achilles tendon
rupture, surgical or non-surgical?
Summary of Search
 The literature was searched for
studies that compared the
difference between surgical and
non-surgical treatment for acute
Achilles tendon rupture.
 A randomized control trial, meta-
analysis, and multicenter
randomized trial were included.
 For the most part, patients with
acute Achilles tendon ruptures
that were treated surgically had
less rerupture rates than those
treated non-surgically.
Clinical Bottom Line
There is significant evidence (Level 1)
that surgical treatment with Achilles
tendon ruptures is better than non-
surgical treatment when avoiding the
recurrence of rerupture. It has been
shown that surgical treatment will
decrease the risk of rerupture and in
studies done on patients with later
reports, there was less report of rerupture
than those with non-surgical treatment.
This was noted in all of the articles
reported in Table 1. However, in three of
the four articles reported there was
mention that the surgically treated
patients had a higher risk of infection or
complications from surgery.
Also mentioned in one of the articles
was that there was no significant
difference between symptoms, physical
activity level, or quality of life in both
the surgically treated and non-surgically
treated. The only difference was that the
surgically treated had improved
function.
Search Strategy
Terms Used to Guide Search Strategy
 Patient/client group: acute or first
time Achilles tendon rupture or
injury
Critically Appraised Topic

2.  Intervention/Assessment: non-
surgical or surgical treatment or
surgery
 Comparison: non-surgical or
surgical treatment or surgery
 Outcome: rerupture or
recurrence
Sources of Evidence Searched
 EBSCOHost (MEDLINE,
Academic Search Premier)
 Cochrane
 PubMed
 Google Scholar
Inclusion and Exclusion Criteria
Inclusion Criteria:
 Subjects with acute Achilles
tendon ruptures
 Studies performed on humans
only
 Studies within the past 10 years
(2005-2015)
 Studies that included both
surgical and non-surgical
treatment.
Exclusion Criteria:
 Subjects with chronic Achilles
tendon injuries
 Articles that were not a level 1
level of evidence
Results of Search & Best
Evidence
Four relevant articles were found, as
shown in Table 1 (next page). These
were considered the best evidence for
inclusion the CAT. Reasons for selecting
these studies were that they were graded
as a 1 for level of evidence, and the main
outcomes were that surgical treatment
was favored.
Implications for Practice
Overall, surgical treatment is better for
acute Achilles tendon ruptures when
wanting to reduce the risk of rerupture.
There is a chance of infection or other
complications that can result from
surgery when undergoing this type of
treatment. This would help determine
what type of treatment a clinician should
give to a patient who has obtained such a
rupture: if the patient is a younger
athlete then surgical treatment could be
the better option so that they have a
lesser chance of rerupture, but if the
patient is older and not as active then
non-surgical treatment could be the
better option because they will still
recover and not have to worry about the
risks that can come from the surgical
treatment.
It would be ideal to see more studies
done, especially with surgical treatment
that is done percutaneously to see if that
would aid in avoiding the risks of
surgery, such as infection or other
complications. More studies done on the
rehabilitation of Achilles tendon ruptures
would also be beneficial to see if there is
a correlation between affect of rerupture
rates, or if there is no correlation
whatsoever.

3. TABLE 1
Article Stable Surgical
Repair with
Accelerated
Rehabilitation vs.
Non-surgical
Treatment for
Acute Achilles
Tendon Ruptures
Surgical and Non-
surgical Treatment
of Achilles Tendon
Rupture: The
Favorable Effect of
Early Functional
Rehabilitation
Operative vs. Non-
operative Treatment
of Acute Achilles
Tendon Ruptures
Surgical
Interventions for
Treating Acute
Achilles Tendon
Ruptures
Study
Design
Randomized
controlled trial
Meta-analysis Multicenter
Randomized Trial
Randomized
controlled trial
Participants
100 patients (86
men, 14 women with
average age of 40)
with an acute
Achilles tendon
rupture.
Patients with a first
acute Achilles
tendon rupture with
treatment initiated
within 3 weeks of
the injury.
418 patients treated
surgically and 408
treated non-
surgically (average
age of 40), most
were men.
144 patients (72 treated
operatively and 72
treated non-
operatively). 118 males
and 26 females, with an
average age of 40.4 ±
8.8.
12 trials involving
844 patients. One
trial tested two
comparisons.
Intervention
Investigated
Surgical treatment,
including an
accelerated rehab
protocol, or non-
surgical treatment.
Surgical treatment
and non-surgical
treatment.
Operative and non-
operative treatment.
Open surgical
versus non-surgical
treatment, or
different surgical
interventions.
Outcome
Measure(s)
Achilles tendon
Total Rupture Score
(ATRS)
Patients evaluated at
3, 6, and 12 moths
for symptoms,
physical activity
level, and function.
Standard forms used
to extract data; main
outcome of interest
was rate of
rerupture.
Rerupture rates as
demonstrated by a
positive Thompson
squeeze test, the
presence of a palpable
gap, and loss of plantar
flexion strength.
Secondary outcomes:
isokinetic strength, the
Leppilahti score, range
of motion, and calf
circumference
measured at 3, 6, 12,
and 24 months after
injury.
Rate of rerupture, using
a risk ratio.
Main
Findings
No significant
difference in terms
Trials that used
prolonged
Rerupture occurred in 2
patients in the operative
Open surgical
treatment had

4. of symptoms,
physical activity
level, or quality of
life. But improved
function in
surgically treated
patients.
Symptoms, reduced
quality of life, and
functional deficits
still existed 12
months after the
injury in both
groups.
immobilization
found a difference in
favor of surgery, and
the trials that used
early functional
rehab found no
difference in
reruptures between
surgical and
nonsurgical
treatments.
Nonsurgical
treatment was
associated with
fewer complications
than surgery. Calf
circumference,
strength, and
functional outcomes
did not differ
between
interventions.
group and 3 patients in
the non-operative
group. No clinically
important difference in
groups with regard to
strength, range of
motion, calf
circumference, or
Leppilahti score. 13
complications in
operative group and 6
in non-operative group,
main difference being
the greater number of
soft-tissue related
complications in the
operative group.
significantly lower
risk of rerupture,
but surgical
treatment had risk
of other
complications such
as infection,
adhesions, and
disturbed skin
sensibility or
numbness.
Level of
Evidence
Level 1 Level 1 Level 1 Level 1
Conclusion
Stable surgical
repair with
accelerated tendon
loading could be
performed in all
patients without
reruptures and major
complications, but it
was not significantly
superior to
nonsurgical
treatment in terms of
function, physical
activity, or quality of
life.
Rates of rerupture
were similar among
patients who were
treated surgically or
non-surgically when
early range of
motion was used as
a cointervention.
Rates of other
complications were
fewer after
nonsurgical
treatment.
Support of accelerated
functional rehab and
non-operative
treatment. All
measured outcomes of
non-operative treatment
were acceptable and
were clinically similar
to those for operative
treatment. The
application of an
accelerated-
rehabilitation non-
operative protocol
avoids serious
complications related
to surgical
management.
Open surgical
treatment reduces
the risk of
rerupture but
produces risk of
infection. To lower
the risk of
infection it is
suggested to do the
surgery with a
needle puncture
instead of open-
where the tissue is
exposed.

5. References
Olsson, N., Silbernagel, K., Eriksson, B., Sansone, M., Brorsson, A., Nilsson-Helander,
K., & Karlsson, J. (n.d.). Stable Surgical Repair With Accelerated Rehabilitation Versus
Nonsurgical Treatment for Acute Achilles Tendon Ruptures: A Randomized Controlled
Study. American Journal of Physical Medicine, 41(12), 2867-2867. Retrieved from
http://web.ebscohost.com/ehost/detail/detail?sid=f74db4eb-851c-4adc-bcc2-
6d5eb8628c10@sessionmgr112&vid=0&hid=105&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ
==#db=s3h&AN=92663220
Soroceanu, A., Sidhwa, F., Aarabi, S., Kaufman, A., & Glazebrook, M. (2012). Surgical
Versus Nonsurgical Treatment of Acute Achilles Tendon Rupture A Meta-Analysis of
Randomized Trials. Journal of Bone & Joint Surgery, 94-A(2136). Retrieved from
http://web.ebscohost.com/ehost/detail/detail?sid=9fe7338a-e9f7-44e5-8415-
d26d30fa7d42@sessionmgr114&vid=0&hid=105&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ
==#db=s3h&AN=84097366
Willits, K., Amendola, A., Bryant, D., Mohtadi, N., Griffin, J., Fowler, P., . . . Kirkley, A.
(2010). Operative versus Nonoperative Treatment of Acute Achilles Tendon
Ruptures. The Journal of Bone & Joint Surgery, 92(17), 2767-2775. Retrieved from
http://jbjs.org/content/92/17/2767.abstract
Khan, R., & Smith, R. (2010). Surgical interventions for treating acute Achilles tendon
ruptures. Retrieved from
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003674.pub4/abstract