Achilles Tendon Rupture

Author: Mark Karadsheh

Topic updated on 06/01/13 8:49pm

Introduction

Acute rupture of the achilles tendon
- often misdiagnosed as an ankle sprain
- may be missed in up to 25%
Epidemiology
- incidence
  - 18:100,000 per year
- demographics
  - more common in men
  - most common in ages 30-40
- risk factors
  - episodic athletes, "weekend warrior"
  - flouroquinolone antibiotics
  - steroid injections
Mechanism
- usually traumatic injury during a sporting event
- may occur with
  - sudden forced plantar flexion
  - violent dorsiflexion in a plantar flexed foot
Pathoanatomy
- rupture usually occurs 4-6 cm above the calcaneal insertion in hypovascular region

Anatomy

Achilles tendon
- largest tendon in body
- formed by the confluence of
  - soleus muscle tendon
  - medial and lateral gastrocnemius tendons
- blood supply from posterior tibial artery

Presentation

History
- patients usually reports a "pop"
Symptoms
- weakness and difficulty walking
- pain in heel
Physical exam
- inspection
  - increased resting ankle dorsiflexion in prone position with knees bent
  - calf atrophy may be apparent in chronic cases
- palpation
  - palpable gap
- motion
  - weakness to ankle plantar flexion
- provocative test
  - Thompson test
    - lack of plantar flexion when calf is squeezed

Imaging

Radiographs
- indications
  - used to rule-out other pathology
Ultrasound
- indications
  - may be useful to determine complete vs. partial ruptures
MRI
- indications
  - equivocal physical exam findings
  - chronic ruptures
- findings
  - will show acute rupture with retracted tendon edges

Treatment

Nonoperative
- functional bracing/casting in resting equinus
  - indications
    - sedentary patient
    - elderly patients
    - medically frail patients
  - outcomes
    - no significant difference between early weight-bearing with protected range of motion compared to non-weight bearing with cast immobilization
    - decreased plantar flexion strength compared to operative management
    - increased risk of re-rupture compared to operative management
    - fewer wound complications compared to operative treatment
Operative
- end-to-end achilles tendon repair
  - indications
    - acute ruptures (<3 months)
  - outcomes
    - decreased rate of rerupture compared to non-operative management
    - increased plantar flexion strength compared to non-operative management
- percutaneous achilles tendon repair
  - indications
    - concerns over cosmesis of traditional scar
  - outcomes
    - higher risk of sural nerve damage
- reconstruction with VY advancement
  - indications
    - chronic ruptures with defect < 4cm
- flexor hallucis longus transfer +/- VY advancement of gastrocnemius
  - indications
    - chronic ruptures with defect > 4cm

Surgical Techniques

Functional bracing/casting in resting equinus
- technique
  - cast/brace in 20 degrees of plantar flexion
  - early functional rehab for those treated without a cast
End-to-end achilles tendon repair
- approach
  - make incision just medial to achilles tendon to avoid sural nerve
- technique
  - incise paratenon
  - expose tendon edges
  - repair with heavy non-absorbable suture
- postoperative care
  - immobilize in 20° of plantar flexion to decrease tension on skin and protect tendon repair for 4-6 weeks
Percutaneous achilles tendon repair
- technique
Reconstruction with VY advancement
- technique
  - make V cut with apex at musculotendinous junction with limbs divergent to exit the tendon
  - V is incised through only the superficial tendinous portion leaving the muscle fibers intact
Flexor hallucis longus transfer +/- VY advancement of gastrocnemius
- technique
  - excise degenerative tendon edges
  - release FHL tendon at the Knot of Henry and transfer through the calcaneus

Complications

Re-rupture
- incidence
  - generally considered to be higher with non-operative management (~10-40% vs 2%)
- treatment
  - surgical repair
Wound healing complications
- incidence
  - 5-10%
- risk factors
  - smoking (most common)
  - female gender
  - steroid use
- treatment
  - deep infection
    - debridement of necrotic/infected achilles tendon
    - culture-spcific antibiotics for 6 weeks
Sural nerve injury
- incidence
  - higher when percutaneous approach is used

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Qbank (6 Questions)

TAG

(OBQ12.36) A 36-year-old man presents with fever, pain, and wound drainage 4 months after repair of an acute achilles tendon rupture. A clinical image is shown in Figure A. Laboratory studies show an ESR of 29 (reference range 0-22 mm/hr). It is decided that he will undergo debridement and irrigation followed by culture specific antibiotic therapy. In the operating room, the achilles tendon is found to have re-ruptured with a 5cm defect. What is the most appropriate surgical treatment at this time? Topic

Review Topic

FIGURES: A

1. Primary repair of the re-ruptured achilles tendon
2. Debridement of necrotic and infected tendon tissue, with no attempt at reconstruction
3. V-Y plasty of the re-ruptured achilles tendon
4. Repair of the re-ruptured achilles tendon with a turndown procedure
5. Repair of defect with flexor hallucis longus tendon transfer

PREFERRED RESPONSE ▶

DISCUSSION: In the setting of a deep infection and a re-ruptured achilles tendon, initial management consists of extensive debridement and irrigation with no attempt at reconstruction followed by culture-specific IV antibiotics for 6 weeks.

Deep infection following achilles tendon repair is a rare but devastating complication. In the setting of a deep infection, the first step should be a thorough irrigation and debridement with excision of any necrotic or infected tendon. Culture-specific antibiotics are administered for a duration of 6 weeks. Once this has been completed, issues such as soft tissue coverage and reconstruction of the re-reptured achilles tendon may be entertained.

Pajala et al. review 409 patients that were treated surgically for an acute achilles tendon rupture. 23 cases of re-rupture and 9 cases of deep infection were noted. Deep infections were treated with debridement and antibiotics, followed by soft tissue coverage at a later date.

Bruggeman et al retrospectively reviewed 167 operative open achilles tendon repairs and determined that risk factors for wound problems included tobacco use, diabetes, and steroid use.

Figure A shows a clinical image of a deep infection following achilles tendon repair. Illustration V shows the ultrasonic appearance of a ruptured Achilles tendon.

Incorrect Answers:
Answers 1, 3, 4, 5: Repair of a re-ruptured achilles tendon is not advised in the setting of an active infection.

Illustrations: V

REFERENCES:

1. Coughlin MJ, Schon LC. Disorders of tendons. In: Coughlin MJ, Mann RA, Saltzman CL,eds. Surgery of the Foot and Ankle. 8th ed. St Louis, MO: Mosby Elsevier; 2007:1149-1275.

2. Pajala A, Kangas J, Ohtonen P, Leppilahti J. Rerupture and deep infection following treatment of total Achilles tendon rupture. J Bone Joint Surg Am. 2002 Nov;84-A(11):2016-21. PMID:12429764 (Link to Abstract)

3. Bruggeman NB, Turner NS, Dahm DL, Voll AE, Hoskin TL, Jacofsky DJ, Haidukewych GJ. Wound complications after open Achilles tendon repair: an analysis of risk factors. Clin Orthop Relat Res. 2004 Oct;(427):63-6. PMID:15552138 (Link to Abstract)

Question Authors:

Mark Karadsheh MD, Dave Marcu MD, Derek Moore, Daniel Farber MD,

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TAG

(OBQ10.36) A 58-year-old golfer fell stepping into a sand trap and ruptured his achilles tendon one year ago. He initially chose non-operative treatment, but became unsatisfied with a tender fullness behind his ankle and ankle weakness noticeable during his tee shots. At the time of surgery, a large disorganized fibrous mass is found at the site of rupture. Following extensive debridement there is a 5 cm gap between viable tissue ends. Which of the following surgical techniques provides the greatest likelihood of a successful clinical outcome? Topic

Review Topic

1. Gastocnemius turndown repair augmented with transfer of the posterior tibial tendon
2. Gastocnemius turndown repair augmented with transfer of the extensor digitorum longus
3. Gastocnemius turndown repair augmented with transfer of the flexor hallucis longus
4. Reconstruction with hamstring autograft
5. Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program

PREFERRED RESPONSE ▶

DISCUSSION: Tendon loss is a complication associated with secondary ruptures of a repaired achilles tendon and chronic achilles tendon ruptures. Gastrocnemius turndown utilizes a slip of the central third of the gastrocnemius tendon to bridge the gap. Flexor hallicus longus (FHL) is the preferred tendon transfer to augment tissue loss due to its proximity and vascularity. Answer choice 5 is not a prudent option given the risk of equinus contracture and recurrent rupture.

Wapner et al conducted a case review of 7 patients who underwent FHL augmentation for chronic achilles tendon rupture. Results included no surgical complications, a small but functionally insignificant decrease in ankle and great toe range of motion, and clinical satisfaction of all 7 patients.

Chiodo et al summarize the AAOS clinical guidelines for evaluation and treatment of acute achilles tendon ruptures predicated upon an extensive review of the literature.

Illustrations A-C depict the steps for a gastrocnemius turn-down flap consisting of a V-Y incision with the arms of the "V" measuring 6cm.

Illustrations: A

REFERENCES:

1. Praszek AJ. Talus fractures and reconstruction: an overview. In: Pinzur MS, Orthopaedic Knowledge Update: Foot and Ankle 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:91-102.

2. Wapner KL, Pavlock GS, Hecht PJ, Naselli F, Walther R. Repair of chronic Achilles tendon rupture with flexor hallucis longus tendon transfer. Foot Ankle. 1993 Oct;14(8):443-9. PMID:8253436 (Link to Abstract)

3. Chiodo CP, Glazebrook M, Bluman EM, et al: The Diagnosis and Treatment of Acute Achilles Tendon Rupture: Guideline and Evidence Report. Rosemont, IL, American Academy of Orthopaedic Surgeons, December 4, 2009. PMID:20675643 (Link to Abstract)

Question Authors:

John Badylak MD, Ben Taylor MD, Michael Hughes MD,

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TAG

(OBQ08.269) What is the greatest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks? Topic

Review Topic

1. Lower rate of infection
2. Higher rate of normal skin sensation
3. Better skin cosmesis
4. Lower rate of dehiscence
5. Lower rate of re-rupture

PREFERRED RESPONSE ▶

DISCUSSION: Operative treatment with early range of motion has a lower rate of rerupture compared to immobilization in a short leg cast for 6 weeks. However, there is recent evidence that an aggressive nonoperative rehabilitation protocol can have equivalent rates of rerupture compared to operative treatment.

Wilits et al performed a Level 1 study with an aggressive rehabilitation protocol with weightbearing and range of motion starting at the 2 week interval(shown in Illustration A) for achilles tendon ruptures. They found that there was no clinically important difference between groups with regard to strength, range of motion, calf circumference, or Leppilahti score. There were twice as many complications in the operative group than the nonoperative group with the main difference being the greater number of soft-tissue-related complications.

Bhandari et al, in a pooled statistical analysis of 6 randomized studies, found surgical repair significantly reduced the risk of rerupture when compared with nonsurgical treatment. However, it increases the risk of infection and skin complications.

Khan et al found that for postoperative immobilization, functional bracing has been shown to have a significantly lower rate of complications compared with casting, particularly with regard to adhesion formation. Other complications with casting post-operatively include disturbed sensibility, keloid hypertrophic scarring, and infection.

Illustrations: A

REFERENCES:

1. Bhandari M, Guyatt GH, Siddiqui F, et al: Treatment of acute Achilles tendon ruptures: A systematic overview and metaanalysis. Clin Orthop Relat Res 2002;400:190-200 PMID:12072762 (Link to Abstract)

2. Khan RJ, Fick D, Keogh A, et al. Treatment of acute Achilles tendon ruptures: A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am 2005;87:2202-2210 PMID:16203884 (Link to Abstract)

3. Willits K, Amendola A, Bryant D, Mohtadi NG, Giffin JR, Fowler P, Kean CO, Kirkley A. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation. J Bone Joint Surg Am. 2010 Dec 1;92(17):2767-75. Epub 2010 Oct 29. PMID:21037028 (Link to Abstract)

Question Authors:

Ben Taylor MD, Derek Moore, Ben Taylor MD,

Please Rate Educational Value!

3.0

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TAG

(OBQ07.54) A 38-year-old patient has an acute Achilles tendon rupture. He is active in sports and is deciding between operative and nonoperative treatments. Which of the following statements applies to patients undergoing nonoperative treatment? Topic

Review Topic

1. They have lower patient satisfaction scores
2. They are less likely to return to sport
3. Their ultimate strength is decreased
4. They have a higher risk for rerupture
5. They have a higher risk of skin problems

PREFERRED RESPONSE ▶

DISCUSSION: This is a classic tested topic for which the answer has been a higher risk of rerupture in the nonoperative group. This may no longer be true. Weber et al retrospectively compared the results of nonoperative and operative management of Achilles tendon ruptures. They found that patient satisfaction, return to sports, and ultimate strength was the same for both groups. The complication rate was similar except for reruptures, with more occurring in the nonoperative treated group versus the operatively treated group. Khan et al conducted a meta-analysis of randomized controlled trials and they found that open operative treatment of acute Achilles tendon ruptures significantly reduces the risk of rerupture compared with nonoperative treatment, but operative treatment is associated with a significantly higher risk of other complications. A more recent randomized study by Willits et al showed no statistical difference in rerupture rates, which has created new controversy on this subject.

REFERENCES:

1. Weber M, Niemann M, Lanz R, Müller T. Nonoperative treatment of acute rupture of the achilles tendon: results of a new protocol and comparison with operative treatment. Am J Sports Med. 2003 Sep-Oct;31(5):685-91. PMID:12975187 (Link to Abstract)

2. Khan RJ, Fick D, Keogh A, Crawford J, Brammar T, Parker M. Treatment of acute achilles tendon ruptures. A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am. 2005 Oct;87(10):2202-10. PMID:16203884 (Link to Abstract)

3. Willits K, Amendola A, Bryant D, Mohtadi NG, Giffin JR, Fowler P, Kean CO, Kirkley A. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation.J Bone Joint Surg Am. 2010 Dec 1;92(17):2767-75. PMID:21037028 (Link to Abstract)

Question Authors:

Patrick McCulloch MD,

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TAG

(OBQ06.270) Which factor increases the chance of wound complications after Achilles tendon repair? Topic

Review Topic

1. increased body mass index
2. immediate surgery
3. male gender
4. age over 40 years old
5. tobacco use

PREFERRED RESPONSE ▶

DISCUSSION: Bruggeman et al anlayzed risk factors for wound complications after Achilles tendon repair. They found that tobacco use, steroid use, and female sex were significant risk factors for development of wound complications. Over 40% of those patients who had one or more of the following risk factors: diabetes, tobacco use, or steroid use had a complication, compared with 6% for those without risk factors present. Timing of surgery was not examined.

REFERENCES:

1. Bruggeman NB, Turner NS, Dahm DL, Voll AE, Hoskin TL, Jacofsky DJ, Haidukewych GJ. Wound complications after open Achilles tendon repair: an analysis of risk factors. Clin Orthop Relat Res. 2004 Oct;(427):63-6. PMID:15552138 (Link to Abstract)

Question Authors:

Greg Galano MD, Derek Moore,

Please Rate Educational Value!

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Average 3.0 of 6 Ratings

TAG

(OBQ04.136) A 41-year-old female feels a pop in her ankle while playing tennis. She is diagnosed with an acute Achilles tendon rupture and elects to undergo nonoperative management. Which of the following is an advantage of nonoperative management with early weight bearing and protected range of motion compared with non-weight bearing cast immobilization? Topic

Review Topic

1. decreased incidence of DVT
2. decreased re-rupture rates
3. increased strength
4. earlier return to sport
5. no significant difference

PREFERRED RESPONSE ▶

DISCUSSION: Historically, nonoperative management of Achilles tendon ruptures consisted of non-weight bearing and cast immobilization. Recent studies have demonstrated that re-rupture rates are diminished with early protected range of motion when compared with non-weight bearing cast immobilization.

Chiodo et al conducted a systematic review of the available evidence for treatment of acute Achilles tendon ruptures. The authors state that they cannot recommend for or against functional bracing as a form of non-operative management based on the available evidence however this was published to two recent randomized controlled trials demonstrating decreased re-rupture rates with functional rehabilitation.

Soroceanu et al conducted a meta-analysis of randomized control trials comparing surgical versus non-surgical management of patients with acute Achilles tendon ruptures. In those studies utilizing functional rehabilitation, there was no significant difference in rates of re-rupture, as compared to operative treatment.

Incorrect Answers:
Answer 1: No literature exists to demonstrate a difference in DVT rates between cast immobilization and functional rehabilitation
Answer 3: No difference in strength has been demonstrated between these two methods of non-operative management
Answer 4: Earlier return to sport has not been shown when comparing the two techniques
Answer 5: Historically no difference was seen with cast immobilization versus functional rehabilitation, however two recent randomized control trials have indicated that patients with functional rehabilitation have re-rupture rates that are equivalent with surgical management and decreased compared with cast immobilization

REFERENCES:

1. Chiodo CP, Glazebrook M, Bluman EM, Cohen BE, Femino JE, Giza E, Watters WC 3rd, Goldberg MJ, Keith M, Haralson RH 3rd, Turkelson CM, Wies JL, Raymond L, Anderson S, Boyer K, Sluka P; American Academy of Orthopaedic Surgeons. Diagnosis and treatment of acute Achilles tendon rupture. J Am Acad Orthop Surg. 2010 Aug;18(8):503-10. PMID:20675643 (Link to Abstract)

2. Soroceanu A, Sidhwa F, Aarabi S, Kaufman A, Glazebrook M. Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials. J Bone Joint Surg Am. 2012 Dec 5;94(23) PMID:23224384 (Link to Abstract)

Question Authors:

Brian Weatherford MD, Derek Moore, Ben Taylor MD, Daniel Farber MD,

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Cases

http://upload.orthobullets.com/cases/1261/img_1591.jpg

Multiple leg tendon lacerations (C1261)

Trauma - Treatment Consult - Achilles Tendon Rupture

HPI - s/p glass vs. leg, with multiple tendon lacerations and 15cm laceration

How would you rehab this?

9/1/2012

41 responses

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Videos

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	End-to-end Repair of Acute Achilles Tendon Rupture - Dr. Parekh Foot & Ankle - Surgical Techniques - Achilles Tendon Rupture This video shows an end-to-end repair of an acute Achilles tendon rupture by Dr....	6/24/2012 637 views 1
	Chronic Achilles Tendon Rupture Reconstruction with FHL Transfer- Part 2 Foot & Ankle - Surgical Techniques - Achilles Tendon Rupture This video is part two demonstrating the surgical treatment of Chronic Insertion...	6/24/2012 99 views 3
	Percutaneous Achilles Tendon Surgical Repair - Dr. Kevin Stone Foot & Ankle - Surgical Techniques - Achilles Tendon Rupture Rupture of Achilles Tendon repaired using minimally-invasive percutaneous achill...	6/24/2012 394 views 2

See More Videos

Posts

	Treatment of acute achilles tendon ruptures. A meta-analysis of randomized, controlled trials. Khan RJ, Fick D, Keogh A, Crawford J, Brammar T, Parker M J Bone Joint Surg Am. 2005 Oct;87(10):2202-10. PMID: 16203884 (Link to Pubmed) Foot & Ankle - Journal Club - Achilles Tendon Rupture	3/19/2013 16 responses 5
	New Article: Surgical Versus Nonsurgical Treatment of Acute Achilles Tendon Rupture: A Meta-Analysis of Randomized Trials Alexandra Soroceanu, MD, CM, MPH; Feroze Sidhwa, MD, MPH; Shahram Aarabi, M... Foot & Ankle - Journal Club - Achilles Tendon Rupture	1/11/2013 62 responses 2

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Groups

ABOS II: Achilles Tendon Rupture

General - Oral Boards Review

7/29/2011

0 responses

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Evidence & References Show References

Level of Evidence 1 (Randomized Control Trial)

Chiodo CP, Glazebrook M, Bluman EM, Cohen BE, Femino JE, Giza E, Watters WC 3rd, Goldberg MJ, Keith M, Haralson RH 3rd, Turkelson CM, Wies JL, Raymond L, Anderson S, Boyer K, Sluka P; American Academy of Orthopaedic Surgeons. Diagnosis and treatment of acute Achilles tendon rupture. J Am Acad Orthop Surg. 2010 Aug;18(8):503-10. PMID:20675643 (Link to Abstract)
Soroceanu A, Sidhwa F, Aarabi S, Kaufman A, Glazebrook M. Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials. J Bone Joint Surg Am. 2012 Dec 5;94(23) PMID:23224384 (Link to Abstract)
Willits K, Amendola A, Bryant D, Mohtadi NG, Giffin JR, Fowler P, Kean CO, Kirkley A. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation. J Bone Joint Surg Am. 2010 Dec 1;92(17):2767-75. Epub 2010 Oct 29. PMID:21037028 (Link to Abstract)

Level of Evidence 3 (Retrospective Cohort Study or Case-Control Study)

Pajala A, Kangas J, Ohtonen P, Leppilahti J. Rerupture and deep infection following treatment of total Achilles tendon rupture. J Bone Joint Surg Am. 2002 Nov;84-A(11):2016-21. PMID:12429764 (Link to Abstract)

Level of Evidence 4 (Case Series)

Bhandari M, Guyatt GH, Siddiqui F, et al: Treatment of acute Achilles tendon ruptures: A systematic overview and metaanalysis. Clin Orthop Relat Res 2002;400:190-200 PMID:12072762 (Link to Abstract)
Bruggeman NB, Turner NS, Dahm DL, Voll AE, Hoskin TL, Jacofsky DJ, Haidukewych GJ. Wound complications after open Achilles tendon repair: an analysis of risk factors. Clin Orthop Relat Res. 2004 Oct;(427):63-6. PMID:15552138 (Link to Abstract)
Khan RJ, Fick D, Keogh A, et al. Treatment of acute Achilles tendon ruptures: A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am 2005;87:2202-2210 PMID:16203884 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Chiodo CP, Glazebrook M, Bluman EM, et al: The Diagnosis and Treatment of Acute Achilles Tendon Rupture: Guideline and Evidence Report. Rosemont, IL, American Academy of Orthopaedic Surgeons, December 4, 2009. PMID:20675643 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Praszek AJ. Talus fractures and reconstruction: an overview. In: Pinzur MS, Orthopaedic Knowledge Update: Foot and Ankle 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:91-102.

Undefined

Coughlin MJ, Schon LC. Disorders of tendons. In: Coughlin MJ, Mann RA, Saltzman CL,eds. Surgery of the Foot and Ankle. 8th ed. St Louis, MO: Mosby Elsevier; 2007:1149-1275.
Khan RJ, Fick D, Keogh A, Crawford J, Brammar T, Parker M. Treatment of acute achilles tendon ruptures. A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am. 2005 Oct;87(10):2202-10. PMID:16203884 (Link to Abstract)
Wapner KL, Pavlock GS, Hecht PJ, Naselli F, Walther R. Repair of chronic Achilles tendon rupture with flexor hallucis longus tendon transfer. Foot Ankle. 1993 Oct;14(8):443-9. PMID:8253436 (Link to Abstract)
Weber M, Niemann M, Lanz R, Müller T. Nonoperative treatment of acute rupture of the achilles tendon: results of a new protocol and comparison with operative treatment. Am J Sports Med. 2003 Sep-Oct;31(5):685-91. PMID:12975187 (Link to Abstract)
Willits K, Amendola A, Bryant D, Mohtadi NG, Giffin JR, Fowler P, Kean CO, Kirkley A. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation.J Bone Joint Surg Am. 2010 Dec 1;92(17):2767-75. PMID:21037028 (Link to Abstract)

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Achilles Tendon Rupture

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