Aims

The aims of this study were to establish the incidence of acute Achilles tendon rupture (AATR) in a North American population, to select demographic subgroups and to examine trends in the management of this injury in the province of Ontario, Canada.

Introduction. Achilles Tendon Rupture (ATR) is a prevalent injury in Western society. Much of the recent research has focused on measuring surgical methods and strength regained, rather than practical measures such as Return to Sport (RTS). A large systematic review was published in 2016 setting a benchmark RTS as 80%. The aim of this systematic review was to provide an up-to-date RTS following ATR. Methods. PubMed and SPORTdiscuss databases were used to search for eligible studies published since 2017 that focused on closed Achilles tendon ruptures with clear definitions of return to sport and a minimum length of follow-up. The Newcastle-Ottawa grading tool was used to assess risk of bias in all included studies. Results. Of 15 articles identified, 9 were ‘good’ and 6 were ‘fair’ after bias assessment, with none excluded for being poor. Return-to-sport (RTS) rate following Achilles tendon rupture was 76.76% (95% CI 74.19, 79.34 P= <0.001). Non-professional athletes had a higher RTS rate (78.29%; 95% CI 74.89, 81.68 P= <0.001) than professional athletes (74.91%; 95% CI 70.98, 78.85 P= <0.001). Surgical intervention resulted in a lower RTS rate (74.17%; 95% CI 70.74, 77.60 P= <0.001) than conservative management (70.00%; 95% CI 60.48, 79.52 P= <0.001). Conclusion. These findings highlight the need to identify factors affecting RTS rates, including the type of management, level of sport, and patient-specific factors. Clinicians can use these findings to guide informed shared decision-making with patients regarding the long-term implications of ATR and to develop more targeted rehabilitation strategies for this injury

One of the factors that influence the outcome after Achilles tendon rupture is gait abnormality. We prospectively assessed 14 patients with Achilles tendon rupture and 15 normal control subjects using an in-shoe plantar pressure measurement system. There was a significant reduction in peak mean forefoot pressure in the early period of rehabilitation (p < 0.001). There was a concomitant rise in heel pressure on the injured side (p=0.05). However, there was no difference in cadence, as determined by the duration of the terminal stance and pre-swing phases as a proportion of the total stance component of the gait cycle. The forefoot pressure deficit in the Achilles tendon rupture group was smaller when assessed six months after the injury but was still significant (p=0.029). Pedobarographic assessment of patients after Achilles tendon rupture confirms that there are marked abnormalities within the gait cycle. Rehabilitation programmes which address these abnormalities may improve outcome

Aims. Functional rehabilitation has become an increasingly popular treatment for Achilles tendon rupture (ATR), providing comparably low re-rupture rates to surgery, while avoiding risks of surgical complications. Limited evidence exists on whether gap size should affect patient selection for this treatment option. The aim of this study was to assess if size of gap between ruptured tendon ends affects patient-reported outcome following ATR treated with functional rehabilitation. Methods. Analysis of prospectively collected data on all 131 patients diagnosed with ATR at Royal Berkshire Hospital, UK, from August 2016 to January 2019 and managed non-operatively was performed. Diagnosis was confirmed on all patients by dynamic ultrasound scanning and gap size measured with ankle in full plantarflexion. Functional rehabilitation using an established protocol was the preferred treatment. All non-operatively treated patients with completed Achilles Tendon Rupture Scores (ATRS) at a minimum of 12 months following injury were included. Results. In all, 82 patients with completed ATRS were included in the analysis. Their mean age was 51 years (standard deviation (SD) 14). The mean ATRS was 76 (SD 19) at a mean follow-up of 20 months (SD 11) following injury. Gap inversely affected ATRS with a Pearson’s correlation of -0.30 (p = 0.008). Mean ATRS was lower with gaps > 5 mm compared with ≤ 5 mm (73 (SD 21) vs 82 (SD 16); p = 0.031). Mean ATRS was lowest (70 (SD 23)) with gaps > 10 mm, with significant differences in perceived strength and pain. The overall re-rupture rate was two out of 131 (1.5%). Conclusion. Increasing gap size predicts lower patient-reported outcome, as measured by ATRS. Tendon gap > 5 mm may be a useful predictor in physically demanding individuals, and tendon gap > 10 mm for those with low physical demand. Further studies that control for gap size when comparing non-operative and operative treatment are required to assess if these patients may benefit from surgery, particularly when balanced against the surgical risks. Cite this article: Bone Joint J 2020;102-B(11):1535–1541

Abstract. Introduction. FHL transfer for management of chronic Achilles' tendon ruptures is done both open and endoscopically. But there are no published studies comparing open and endoscopic results. Our study aims to compare them and determine the suitability of these methods. Materials and methods. Fourteen patients were treated endoscopically while 26 with an open technique. Of the 26, fourteen had an open Achilles tendon repair and FHL transfer while 12 has only open FHL transfer. All the endoscopic patients had only an FHL transfer. We compared demographics, complications of the procedure, recovery times, return to work and strength after 1 year. We noted ATRS at 6 months and 1 year for all three groups. We also conducted an MRI scan of three patients each of the three groups to determine the state of Achilles tendon and FHL tendon after 1 year of surgery. Results. There were similar complication rates for both the only FHL groups but the open FHL + Achilles' repair had more complications both for wound complications and saphenous neuropraxia. The recovery time, return to work and ATRS at 6 months was better for the endoscopic group as compared to both open groups. The strength and ATRS at 1 year were similar for all three groups. Conclusion. Endoscopic FHL transfer is safe and provides earlier return to work and better 6 months patient satisfaction then the open method. It also has less post op complications than open FHL + Achilles tendon repair, while maintains the same strength after 1 year

Introduction. Patients with neglected rupture of the Achilles tendon typically present with weakness and reduced function rather than pain. Shortening of the musculotendinous unit and atrophy of the muscle belly in chronic rupture potentially leads to poorer recovery following tendon transfer. Few papers have looked at the outcomes of FHL reconstruction specifically in neglected TA rupture. Of those that have none report functional outcomes following a transtendinous repair. Methods. Twenty patients with irreparable unilateral tendoachilles ruptures treated with transtendinous FHL reconstruction between 2003 and 2011 were reviewed. Achilles Tendon Rupture Score (ATRS), AOFAS hindfoot score, Tegner score and SF12 were recorded. Standard isokinetic assessment of ankle plantarflexion was performed with a Cybex dynamometer. Great toe flexion strength was tested clinically. Results. The mean age at surgery was 53 years (22–83 years). Mean time from rupture to surgery was 7 months (1–36 months). Follow up ranged from 29–120 months (mean 73 months). Sixteen patients were completely satisfied and four moderately satisfied. The mean ATRS was 80 (range 25–100) and AOFAS 94 (range 82–100). Postoperative Tegner score showed a reduction by one level from pre-injury (mean 5.1 pre injury to 4.3 post surgery). No cases of re-rupture were encountered. Six patients had wound issues. The mean maximal strength of ankle plantar flexion on the operated leg 95Nm (41–163) was less than the non-operated leg 123 Nm (50–190Nm). The average difference in strength was 24%. The operated hallux had only 40% of strength in flexion of the contralateral toe. There were no floating toes. Conclusion. Transtendinous FHL transfer for late presenting Achilles tendon ruptures provides reliable long term function and reasonable ankle plantar flexion strength. Long FHL harvest has little morbidity and lack of a distal tenodesis did not result in any notable functional loss or alignment issues to the great toe

Introduction. The delayed presentation of Achilles tendon rupture is common, and is a difficult problem to manage. A number of surgical techniques have been described to treat this problem. We describe the use of Flexor Hallucis Longus (FHL) transfer to augment the surgical reconstruction of the delayed presentation of achilles tendon rupture. Materials and Methods. Fourteen patients with chronic tendo-Achilles rupture, presenting between April 2008 and December 2010, underwent surgical reconstruction and FHL transfer. Surgery was performed employing standard operative techniques, with shortening of the Achilles tendon and FHL transfer into the calcaneum with a Biotenodesis screw (Arthrex). VISA-A scores were performed preoperatively and six months postoperatively. Complication data was collected by review of the electronic patient record and direct patient questioning. Results. One patient died of an unrelated cause shortly before outcome scoring, and another patient was excluded because casting in the preoperative period prevented accurate scoring, although he achieved a good post-treatment score. Analysis was therefore carried out on twelve patients. Eleven of the twelve patients had significant improvement in their VISA-A score, with a mean improvement in score of 30 (p < 0.05). There were no significant complications in any of the patients. Conclusion. Our results show that FHL transfer in the management of chronic Achilles tendon rupture is a good, safe and reliable technique. There is excellent improvement in the mean VISA-A score, with no significant complications. Our results support the use of FHL tendon transfer for patients with chronic tendo-Achilles rupture

The August 2023 Foot & Ankle Roundup. 360. looks at: Achilles tendon rupture: surgery or conservative treatment for the high-demand patient?; First ray amputation in diabetic patients; Survival of ankle arthroplasty in the UK; First metatarsophalangeal joint fusion and flat foot correction; Intra-articular corticosteroid injections with or without hyaluronic acid in the management of subtalar osteoarthritis; Factors associated with nonunion of post-traumatic subtalar arthrodesis; The Mayo Prosthetic Joint Infection Risk Score for total ankle arthroplasty

Muscle and tendon have an adaptive, symbiotic biomechanical relationship that is drastically altered following acute tendon injury. Such injuries, like Achilles tendon rupture (ATR), do not only lead to impairments in the resultant tendinous tissue, but also to irrecoverable atrophy in the connected muscle in series. As a result, a new relationship between muscle and tendon is established after ATR, leading to lasting functional deficits in the lower limb. It remains unclear how these develop, particularly since this imbalance may be influenced by the dependent relationship of the two tissues to each other. A further confounding factor is that tendon and muscle tissues adapt on different time scales in response to mechanical loading, such as those introduced during rehabilitation. Thus, it is warranted to perform assessments not only of the overall muscle-tendon unit, but also its constituent tissues. This presentation will discuss findings from both short-term and long-term follow-ups of ATR patients, with a focus on the recovery of gait and changes in the muscle-tendon unit tissues following ATR repair. Both the influence of the rehabilitation process and suggestions for future research directions will be additionally presented

Local dysregulation of the proteolytic matrix metalloproteinases (MMPs) and their tissue inhibitors of metalloproteinases (TIMPs) is a feature of tendon degeneration and rupture. 1. ,. 2. To assess the role of systemic MMPs and TIMPs in tendon rupture we compared serum MMPs and TIMPs between patients who have previously suffered Achilles tendon rupture and healthy controls. We also followed serum MMPs and TIMPs prospectively in patients with acute tendon rupture. At three years after injury, we measured serum MMP-1, -2, -3, -7, -8, -9 and -13 and TIMP-1 and -2 in eight patients who had suffered Achilles tendon rupture. Serum was also obtained from 12 blood donors with similar age and sex distribution. In another eight patients, MMPs and TIMPs were followed over time, with samples taken at the time of Achilles tendon injury, and after 4, 8 and 24 weeks. MMPs were determined using Fluorokine Multi Analyte Profiling kits while TIMPs were analysed using ELISA (R& D systems). The study was approved by the ethics committee and written informed consent was obtained from all patients. Patients who had previously suffered tendon rupture had increased levels of MMP-2 (median difference (m.d.) 10 %; p = 0.01), MMP-7 (m.d. 15 %; p = 0.02) and TIMP-2 (m.d. 36%; p = 0.02), as compared to controls. In patients with acute tendon rupture, MMP-2 was the only MMP or TIMP to change significantly over time (p = 0.009). MMP-7 appeared to be higher than control values already at the time of rupture. MMP-13 could not be detected in any sample. In conclusion, patients with a history of tendon rupture had elevated serum levels of MMP-2, MMP-7 and TIMP-2. Changes in MMP-7 might be present already at the time of rupture. This suggests that disturbances in proteolytic control might render tendons prone to rupture

Background: Prophylaxis against thromboembolic complications has become routine after major trauma and major orthopaedic surgery. In contrast, it remains an issue for debate whether prophylaxis after minor surgery and immobilization is necessary, even though these treatments are well-known risk factors for deep vein thrombosis (DVT). Objectives: The objective of this study was to evaluate the efficacy of Dalteparin (5,000 U given subcutaneously once daily for six weeks) during lower limb immobilization after surgical treatment of Achilles tendon rupture. Methods: After surgery, 105 consecutive patients were randomized to a placebo-controlled double-blind study to evaluate the efficacy of given thromboprophylaxis. DVT screening using validated color duplex sonography was performed three weeks and six weeks after surgery, and all DVTs were confirmed with phlebography. Results: Primary endpoint analysis was available for 91 patients. DVT was diagnosed in 16/47 patients (34%) in the Dalteparin group and in 16/44 patients (36%) in the placebo group. These figures are not significantly different (p=0.8). Proximal DVT was diagnosed in one patient (2%) in the Dalteparin group and in three patients (6%) in the placebo group (p=0.6). No pulmonary emboli or major bleeding occurred in either of the groups. Conclusions: DVT is common after surgical treatment of Achilles tendon rupture and therefore effective thromboprophylaxis is desirable. Thromboprophylaxis with Dalteparin however, does not affect the incidence of DVT during the immobilization after Achilles tendon rupture surgery. Long-term effects of immobilization, such as the risk for post-thrombotic syndrome, need to be investigated further

Introduction: The diagnosis of Achilles tendon rupture must be made promptly and reliably to prevent avoidable morbidity. The calf squeeze test (CST) offers a simple clinical test with high sensitivity. However, in our clinical practice we have noticed a lack of clarity in the medical notes. We believe there is confusion regarding what constitutes a positive CST. Movement of the foot being positive or lack of movement of the foot indicating the test is positive. The purpose of this study was to assess the degree of error and to determine whether this is due to lack of knowledge, an inability to perform or correctly interpret and record the result of the CST. We assessed SHO’s , Registrars and Consultants in the Accident & Emergency and Orthopaedic Departments. Method: Ninety one doctors completed a supervised questionaire. They were asked four questions 1) What tests they chose to diagnose Achilles tendon rupture. 2) How they would perform a CST. 3) What they considered a positive CST to mean . 4) How they would record the diagnosis of a ruptured Achilles tendon. Results: 92%(84/91) of doctors overall chose to use a CST. 88%(80/91) performed the CST correctly. The CST was interpreted incorrectly by 41%(15/37) and 26%(14/54) of A + E and Orthopaedic doctors respectively. Also 32%(12/37) of A + E and 19%(10/54) of Orthopaedic department doctors mistakenly thought that the diagnosis of an Achilles tendon rupture was consistent with a negative test. Conclusion: The results suggest that the recording of AT rupture may be inaccurate in as many as 32%(12/37) when patients present to the A + E department. This error is not a result of lack of knowledge or performance of the CST but of interpretation and recording. We would strongly discourage the recording of the CST in terms of a positive or negative result. The result should be described in words, for example ‘No movement of the foot on squeezing the calf muscle.’ We suggest that all SHOs and Registrars who may be called upon to assess patients with suspected Achilles tendon rupture are informed of this source of error

The aim of this study was to determine the outcome of patients treated with Achilles tendon rupture randomized to surgical or non-surgical treatment where both groups received the same early motion and weight bearing rehabilitation protocol. Fifty patients between the ages of 18 and 50 years with a clinical diagnosis of Achilles tendon rupture were randomized to surgical or conservative treatment. All injuries had occurred within ten days. Both groups received the same rehabilitation program with initial cast immobilization then splintage in a removable orthosis with ankle motion commencing at two weeks. Patients completed the MFAI, a validated outcome questionnaire and clinical assessment including range of motion and calf squeeze response at 2, 6 and 12 weeks, 6 months and one year. There was no difference between the surgical and non-surgical groups for difference in dorsiflexion and plantar flexion between the injured and non-injured sides. There was no difference in the MFAI quality of life scores for either treatment group. There was the same number of re-ruptures in both groups. There were no infections in the operated patients. Early motion rehabilitation after Achilles tendon rupture results in similar functional results and patient satisfaction in both surgically and non-surgically treated patients

Introduction. Active patients may benefit from surgical repair of the achilles tendon with the aim of preserving functional length and optimising push-off power. A mini-open device assisted technique has the potential to reduce wound complications, but risks nerve injury. We present the largest published series of midsubstance achilles tendon repairs using the Achillon® device. Methods. A prospective cohort study was run at the Princess Royal Devon & Exeter Hospital between 2008 and 2015. We included all patients who presented with a midsubstance Achilles tendon rupture within 2 weeks of injury, and device assisted mini-open repair was offered to a young active adult population. All patients in the conservative and surgical treatment pathway had the same functional rehabilitation protocol with a plaster for 2 weeks, and a VACOped boot in reducing equinus for a further 8 weeks. Results. 354 patients presented with a midsubstance achilles tendon rupture over a 7-year period, of which 204 had conservative treatment and 150 patients had surgical repair with the Achillon device. Patients were assessed clinically for a minimum of 10 weeks, with long-term notes surveillance for late complications. The rerupture rate for conservative treatment was 1.5%, with no reruptures in the Achillon group. Infections in the surgical group were superficial in 2 cases (1.3%) and deep in 3 cases (2%). Pulmonary embolus occurred in 2 Achillon cases (1.3%), and 1 conservatively managed case (0.5%). There was 1 case of temporary sural nerve irritation in each group. Discussion. Our series show encouraging results for the Achillon® repair with no reruptures and a low complication profile. Functional rehabilitation is likely to have contributed to the low rerupture rate. Studies are emerging that show earlier and improved calf muscle strength in those having surgical repair, suggesting a role for device assisted mini open repair in a selected population

Significant variation exists amongst surgeons regarding the post operative rehabilitation protocol after surgical repair of Achilles tendon ruptures. The objective of this study was to determine the effect of early weight bearing on the postoperative recovery after surgical repair of ruptured Achilles tendons. The hypothesis was that an early weight bearing routine does not increase the rate of re-rupture or other complications, and improves the quality of life by reducing discomfort of the rehabilitation phase and allowing an earlier return to work and sport. A prospective, randomised controlled trial of patients with Achilles tendon ruptures undergoing surgical repair was performed over a three year period concluding in April 2006. Specific inclusion and exclusion criteria were used to include one hundred and ten patients in the study at two centers involving twelve surgeons. Patients were randomised to either weight bearing or non weight bearing at the initial postoperative visit and compliance was monitored with a pressure sensor in the fixed-hinged ankle foot orthosis. Patients were assessed at six, twelve and twenty-six weeks postoperatively for 1) re-rupture rate, 2) strength of calf musculature 3) ankle range of motion, 4) complications, 5) return to sporting activities, and 6) return to work. In addition, health–related quality of life was measured using the SF-36 and AOFAS Ankle-Hindfoot Scale. Enrollment was completed as of May 2006 and six month data is over 90% completed. We are on course for < 10% loss to follow-up. Thus far, there have been no re-ruptures in either group. Definitive data analysis can only be performed once all one hundred and ten patients have completed their six month follow up. Once data analysis is completed, comparisons of patient satisfaction, strength, range of motion, complications, return to sport and return to work will be discussed. Early weight bearing after Achilles tendon repair did not increase the rate of re-rupture. Final data analysis will document any significant differences in the parameters measured. We believe this study will provide a definitive answer on the safety of early weight bearing after surgical repair of Achilles tendon ruptures

Introduction. Chronic ruptures of the Achilles tendon pose a significant management challenge to the clinician. Numerous methods of surgical reconstruction have been described and are generally associated with a higher complication rate than with immediate repair. We report our results with a single 5cm incision technique to reconstruct chronic Achilles tendon ruptures with transfer of FHL. This simple technique also enables easy tensioning of the graft/reconstruction to match the uninjured leg and early mobilisation. Materials & Methods. All patients undergoing late Achilles tendon reconstruction (over 4 months from rupture) during the period September 2006 to January 2010 were included in the study. All patients were treated using a single incision technique and posterior ankle FHL harvest with bio absorbable interference screw fixation in the calcaneum. Weight bearing was allowed from 2 weeks post operatively with a dynamic rehabilitation regime identical to that which we use following repair of acute ruptures. A retrospective review of the records was performed and a further telephone review undertaken. Results. 15 ‘late’ Achilles tendon reconstructions were undertaken in the study period. Their mean age was 55 years (38-80). Mean time from rupture was 16 months (5-96). Significant co-morbities included diabetes, chronic renal failure, multiple schlerosis and Parkinson's disease. The mean duration of follow-up was 20 months (7–38). There were no post-operative complications. AOFAS score improved significantly in all patients and all reported good or excellent improvement in strength and return to pre-injury function (including sport in 2 cases). Conclusion. This less invasive single incision technique of FHL transfer reconstruction of chronic Achilles tendon ruptures as previously published from our unit seems to be a safe and reliable undertaking in patients with symptomatic chronic Achilles ruptures and is our preferred technique for all chronic ruptures especially in the presence of significant co-morbities

Operative and non-operative treatment regimens for Achilles tendon ruptures vary greatly but commonly involve rigid casting or functional bracing. The aim of our study was to investigate the extent of tendon apposition following such treatments. Twelve fresh-frozen, adult below knee lower-extremity cadaveric specimens with intact proximal tibiofibular joints were used. Each was prepared by excising a 10cm × 5cm skin and soft tissue window exposing the Achilles tendon. With the ankle in neutral position, the tendon was transfixed with a 2mm k-wire into the tibia, 8cm from its calcaneal insertion. A typical post-rupture gap was created by excising a 2.5cm portion of tendon between 3.5cm and 6cm from its calcaneal insertion. The specimens were then placed into a low profile walker boot (SideKICK. TM. , Procare) without wedges and a window cut into the back. The distance between the proximal and distal Achilles tendon cut edges was measured and repeated with 1, 2 and 3 (10mm) wedges. Subsequently the specimens were placed into a complete below knee cast in full equinus which was also windowed. The Achilles tendon gap (mean +/− SD) measured: 2.7cm (0.5) with no wedge, 2.3cm (0.4) with 1, 2.0cm (0.4) with 2, 1.5cm (0.4) with 3 wedges and 0.4cm (0.3) in full equinus cast. The choice of treatment had a significant effect on tendon gap (p< 0.0001 – repeated measures ANOVA), and all pairwise comparisons were significantly different (Bonferroni), with all p< 0.001, apart from 0 wedge vs. 1 wedge (p< 0.01) and 1 wedge vs. 2 wedges (p< 0.05). Our results showed that each wedge apposed the tendon edges by approximately 0.5cm with the equinus cast achieving the best apposition. Surgeons should consider this when planning appropriate immobilisation regimes for Achilles tendon ruptures

Limited long term data exists comparing operatively and non-operatively treated Achilles tendon ruptures. A previous randomised controlled trial comparing early outcomes showed a short term advantage for surgery, but there are no long term prospective randomised comparisons. Our aim was to determine whether surgery conferred long term benefits in terms of patient reported outcomes or re-rupture. 64 patients (80%) were followed up with postal questionnaires. Patients were asked to complete the Short Musculoskeletal Function Assessment (SMFA), Achilles Tendon Total Rupture Score (ATRS) and EQ-5D questionnaires, and to report re-ruptures. 32 patients were treated non-operatively and 32 operatively; 59 completed the SMFA and 64 the ATRS and EQ-5D assessments. There was no significant difference in SMFA score (median 1.09, IQR 4.89 in the cast group versus 2.17 and 7.07 in the operative group; p=0.347), ATRS (median 96, IQR 18 versus 93 and 15; p=0.509), EQ-5D Index (median 1.0, IQR 0.163 versus 1.0 and 0.257; p=0.327) and EQ-5D Visual Analogue Score (median score 85, IQR 15 versus 85 and 24; p=0.650). There were 2 re-ruptures in the operative group and 4 in the non-operative group (p=0.067). This is the first prospective, randomised, long term report comparing operative and non-operative management. At follow up between 13–17 years after injury, patients reported good function and health related quality of life. There was no significant difference in re-rupture rate between the treatment groups

Background. A large number of Tendo-Achilles (TA) injuries occur during sporting activity. Typically occurring in males aged 30–50, whom occasionally undertake sporting activities, the so called ‘weekend warriors’. Aims. To assess the impact of TA rupture on return to sporting activity in the non-elite athlete. Methods. Single unit 5 year retrospective analysis of TA rupture patients. Clinical notes were reviewed and a telephone interview was conducted using a designed questionnaire. Results. 68 patients were identified, 39 responded of which 25 were male and 14 were female. The mean age was 46 years with an age range of 17–77 years. Sporting activity was the major cause of rupture, causative in 27/39 patients, 84% of males and 43% of females. A third of patients had only just returned to the causative sport. In males, football contributed the most injuries, 48%, however for females, badminton contributed the highest number, 67%. 23 patients did not return to their pre-injury sporting activity level. Of these patients, 87% stopped the causative sport completely, 22% stopped sporting activity altogether with 78% returning to sport at a lower level, reducing both the intensity and variety. 20/23 of these patients were treated operatively. Reasons given for a reduction in sporting activity were a “real worry” of re-rupture, 83%, and a “loss of confidence” caused by the injury, 74%. Other reasons were related to pain in the Achilles, 65%, and “previous plans” to reduce level of activity anyway, 35%. Conclusion. Many patients cite the ability to return to sport as a reason for operative intervention. Our study highlights that many patients do not return to sports at all, with those that do, a significant number return at a lower level of intensity, irrespective of treatment. This information could be useful when assessing treatment options in the non-elite athlete

Introduction: Current evidence for treatment of Achilles tendon rupture suggests that open surgical repair reduces the re-rupture rate compared to conservative treatment, but with a higher risk of infection. Modern non-surgical treatment and surgical aftercare involves early weight-bearing in functional orthoses. It is therefore appropriate to measure the re-rupture rates and outcomes in patients treated in this manner. Materials and methods: Between 2002 and 2008 our unit prospectively collected data on 80 patients treated with a below-knee functional orthoses for complete Achilles tendon rupture. Patients made their own choice of treatment following evidence-based counselling. The patients were treated either surgically or conservatively and entered the appropriate arm of the standard orthotic and early weight-bearing treatment protocol. Patients were contacted by telephone or post for follow-up and completed a VISA-A and Achilles Total Rupture Score (ATRS) questionnaire. Results: There were 61 Males, 19 Females with an age range of 24–80 (median 42). The median time in the functional brace was eight weeks. 51 patients were treated conservatively and 29 patients surgically. The conservative group were a decade older (median age 47y, range 27–80) than the surgical group (median age 37y, range 24–55y). In the non-operative treatment group the re-rupture rate was 3.9% (2/51, 95% confidence interval 0.5–13.5%). In the surgical group it was 3.4% (1/29, 95% confidence interval 0–17.8%), in this group the wound infection rate was 6.8% (2/29, 95% confidence interval 0.9–22.8%) with no nerve injuries reported. The median ATRS was 82 in the conservative group and 95 in the surgical group. The median VISA-A scores were 57 and 92 respectively. Discussion: Our case series shows comparable low re-rupture rates in both groups. Functional scores, using the newly validated ATRS score, were lower in the non-surgical, older group. Conclusion: Functional care after surgical and non-surgical treatment of Achilles rupture produces similar re-rupture rates