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Study links nonoperative treatment of Achilles tendon ruptures with soleus muscle atrophy
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Greater soleus muscle atrophy was seen among patients with Achilles tendon ruptures treated with nonoperative care and a functional rehabilitation protocol compared with patients who underwent surgical treatment with a similar rehabilitation protocol, according to recently published results.
Researchers performed a randomized trial of 60 patients. Volume of the calf muscles at determined by MRI at 3 months and 18 months was the primary outcome. Investigators also assessed fatty degeneration of the calf muscles, length of the affected Achilles tendon and isokinetic plantarflexion strength in both legs.
Investigators found that at 3 months, patients who received surgical treatment and those who received nonsurgical treatment were not significantly different regarding muscle volume and fatty degeneration. At 18 months, investigators found the mean difference between the affected soleus muscle volume and the healthy soleus muscle volume after surgery was 83.2 cm3. After nonsurgical treatment, it was 115.5 cm3.
From 3 months to 18 months, both groups had compensatory hypertrophy in the flexor halluces longus and the deep flexors. The mean difference between the affected flexor hallucis longus and the healthy flexor hallucis longus in the nonsurgical treatment group was -9.3 cm3 and was -8.4 cm3 in the surgical treatment group. The Achilles tendon, on average, was 19 mm longer in nonsurgically treated patients compared with surgically treated patients after 18 months. Surgically treated patients had 10% to 18% greater strength results at 18 months. There was an association seen between calf muscle isokinetic strength deficits for range of ankle motion and soleus atrophy. – by Monica Jaramillo
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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James T. Vosseller, MD
The optimal treatment of Achilles tendon ruptures has been, and continues to be, a subject of some debate. Traditionally, surgeons favored operative treatment as the risk of re-rupture with nonoperative treatment was thought to generally outweigh the risk of wound issues with operative treatment. In the last 10 years to 20 years, however, with the advent of early functional rehabilitation, surgeons have noted a decreased rate of re-rupture with nonoperatively treated patients. As nonoperative treatment has become more prevalent, multiple studies, even those supporting nonoperative treatment, have shown strength deficits in the nonoperatively treated patients relative to the operative ones.
Heikkinen and colleagues prospectively studied a group of operatively and nonoperatively treated patients to assess calf volume, Achilles tendon length and strength at 3 months and 18 months after treatment. The authors noted significantly greater loss of soleus volume, a mean 19-mm lengthening of the Achilles tendons in the nonoperative group and greater plantarflexion weakness in the nonoperative group. Strength testing after Achilles tendon rupture treatment has been inconsistent in the literature; this study goes some way toward objectifying this subject.
The principle weakness of this study, based on MRI findings, lies in the fact that the contralateral, normal Achilles tendon was not imaged and there was thus, no internal control. However, this data does shed light on a subject that has been noted by many, but not fully understood. It further sets the table for exploration into the genesis of strength deficits and the best means to address them.
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