The incident
“Not AGAIN!” …among the words that escaped me (forcefully) as I pounded my fist into the volleyball court. A familiar pop sensation and an immediate sharp pain that felt as if my teammate had kicked the back of my calf… but they hadn’t.
“I’ve just ruptured my achilles!,” certainty founded in my professional knowledge as a physiotherapist, but also as a person who experienced the same injury on the other side a decade ago. Despite consistent work with preventative exercise to avoid a repeat event, the injury had come to me all the same.
An emotional injury
As I often tell my patients, there is no physical injury that doesn’t come with an associated emotional injury. This truth hit home for me immediately. In the moment an emotional snap hit me as hard as the physical one. Would I ever move beautifully as I did before? There was (is) a grieving in advance for a potential long term loss of athleticism, loss of quality of life and a perceived loss of youth.
On the flip side though, I also felt resolve to maximise my recovery. And if I can update myself on everything there is to know about cutting edge rehabilitation of this common injury then all the better!
Operate or not to operate
One of my first critical decisions was whether to opt for surgical or conservative management of the tear. Conservative management in our context refers to casting or booting over a 6 week period in an equinus, or foot pointed position. The choice between surgery and conservative treatment is complex and nuanced.
There is plenty of research that suggests that many outcomes are similar between the two interventions. But the word “outcomes” can mean many different things, what exactly are we measuring?
For example, a 2019 review by Ochen et. al. found that patients receiving surgery experienced slightly lower re-rupture rates compared with conservative treatment. That same review found that surgery was also slightly more prone to complications like infection and nerve injury. But the differences between conservative treatment and surgery on these outcomes were so small that that may not be clinically meaningful.
What about athletic performance?
Moreover, outcomes like injury related complications, or rates of re-rupture do not address athletic performance which in truth is really my driving motivation.
Recently, a large 2022 Randomised Controlled Trial by Mhyrvold et al. showed no clinically meaningful difference between surgery and conservative treatment on many performance based and patient reported measures of physical performance. This study examined patients aged 18-60 from the general population and found remarkably similar athletic outcomes 12 months after injury including multiple measures of strength and power regardless of treatment choice.
Other researchers however found different results. A 2022 review by LaPrade reports that calf pushoff strength may be better by 10-18% for general population patients who choose surgery over conservative treatment.
So it’s not entirely clear if and how much surgery may improve calf pushoff strength over conservative treatment. And if there are differences it’s not clear how athletically relevant they may be. In other words does a 10% calf pushoff strength difference provide for meaningful performance improvement when playing basketball, soccer or tennis? Currently we do not have definitive evidence but for context, a mechanical analysis by Vanrenterghem in 2004 found that calf strength/power contributed only a small portion (23%) of maximal jumping effort. Hip and knee musculature (mainly glutes and quadriceps) accounted for the lions share (52% and 25% respectively) of that important athletic activity.
But why do professional athletes choose surgery?
And yet it seems that professional athletes who rupture an achilles tendon get surgical repairs. Why is this? Well one explanation is that their needs are different to most of ours. As emphasised in a 2020 review article by Tarantino et. al., while functional outcomes are comparable for conservative and surgery interventions in the general population, those outcomes might not fully capture the physical demands of elite athletes (this means division 1 collegiate athletes or higher).
If there is any possibility for better peak calf strength after surgery then the choice for surgery may be more appropriate for these individuals. Notably though, there currently is no research that compares the athletic outcomes from surgery versus conservative management in elite athletes, so we don’t actually know if their performance is better with a choice of surgery over conservative treatment.
Considering my personal goals…
I am a highly active person, but certainly not a professional athlete, my delusions for grandeur aside of course…
For recreational athletes like me, the quality of physical training and rehabilitation is likely the limiting factor for my athletic performance – not whether I choose surgery . According to that Tarantino review mentioned above, return to sports is about 90% for recreational athletes like me.
So, while I have not completely yet ruled out surgery for myself, on assessment of the research I am certainly leaning toward conservative management -booting rather than surgery- of my achilles tendon tear.
Next up: the loading dilemma
The next consideration for me is how early and aggressively should I be loading the healing tendon. This choice too is the subject of much discussion in research. Should I load early and promote tendon healing? Or does that risk re-injury?
Let’s dive into that assessment next. Join me in the next post as I explore the controversial realms of early tendon loading.
References (If you really want to impress your friends)
LaPrade, C. M., Chona, D. V., Cinque, M. E., Freehill, M. T., McAdams, T. R., Abrams, G. D., … & Safran, M. R. (2022). Return-to-play and performance after operative treatment of Achilles tendon rupture in elite male athletes: a scoping review. British Journal of Sports Medicine, 56(9), 515-520.
Myhrvold, S. B., Brouwer, E. F., Andresen, T. K., Rydevik, K., Amundsen, M., Grün, W., … & Hoelsbrekken, S. E. (2022). Nonoperative or surgical treatment of acute Achilles’ tendon rupture. New England Journal of Medicine, 386(15), 1409-1420.
Ochen, Y., Beks, R. B., Van Heijl, M., Hietbrink, F., Leenen, L. P., Van Der Velde, D., … & Houwert, R. M. (2019). Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis. bmj, 364.
Tarantino, D., Palermi, S., Sirico, F., & Corrado, B. (2020). Achilles tendon rupture: mechanisms of injury, principles of rehabilitation and return to play. Journal of functional morphology and kinesiology, 5(4), 95.
Vanrenterghem, J., Lees, A., Lenoir, M., Aerts, P., & De Clercq, D. (2004). Performing the vertical jump: movement adaptations for submaximal jumping. Human movement science, 22(6), 713-727.
