Australian heart break: If you were like most of Australia glued to the Olympics over the recent weeks, you may have seen Australian steeplechase athlete Genevieve Gregson suffer an Achilles tendon rupture during the final water jump in her medal race. 

The scenes were devastating with Genevieve falling face first onto the track and unable to continue. 

We now know that Genevieve will be having a surgical repair on both her achilles (she actually injured her “good” achilles).  But this is not necessarily the path for everyone.  It would be easy to think that since the tendon has been fully torn, it must be repaired surgically to ensure it heals.   

But recent evidence has demonstrated that this is not necessarily the case.  

Let’s have a look. 

What is an Achilles Tendon rupture? 

The Achilles Tendon is a tendon that connects the major calf muscles to the heel. This tendon plays a role in most of our movement, including propulsion while walking and being the driving force in explosive movements including running, jumping and hopping. 

A rupture occurs when there is a complete disconnect of this tendon, usually following a traumatic incident, which is predictably very painful and debilitating. This is a very significant injury, so much so that some studies report only 50% of patients returning to their pre-injury level of sport. Patients can expect at least a year long recovery, with some patients not achieving a complete return of strength and function despite extensive rehabilitation. 

This injury most commonly occurs in middle aged males during a high force mechanism, particularly in situations where the Achilles has to absorb force, such as forcefully stepping back during sport or landing from a jump. 

Surgical and non-surgical management have many similarities in outcomes 

In surgical management, the tendon is pulled together and sutured. After this, the management plan is similar to non-operative management, including a period of wearing a rigid brace for roughly 6-8 weeks with a raised heel, and then gradually progressing mobility and strength of the ankle. 

Recent research has recommended early rehab and weight bearing in both approaches, even as early as day one, which is thought to improve outcomes. This is because early, controlled loading stimulates collagen and the tendon healing process. 

Both management pathways seem to see very comparable results. Both approaches see a similar rate of return to pre-injury activities, and recent evidence also suggests that there are no significant differences in functional outcome or quality of life 6 and 12-months post injury. One study that followed up patients over a 15-year period showed patient satisfaction and reported functional outcomes were no different between groups. 

Differences between the management pathways 

While there has been promising research demonstrating the potential of non-operative management, this does not mean EVERYONE is suitable to attempt conservative care. Below are some of the differences between management pathways and some considerations that are important in the decision process.  

Tendon elongation 

• The position of the tendon after injury is likely to play an important role in the decision regarding the management pathway. 
• If the Achilles can be put in a protected and optimal position sooner, this may mean that the tendon is less retracted and can heal in a stronger position. 

• If left in a suboptimal position, the tendon may heal in a more lengthened position (tendon elongation), which is thought to result in worse functional outcomes. 
• If tendon retraction has occurred, this may be an indication for surgical management.
  Complication 

• Some of the common complaints include deep vein thrombosis, tendon adhesions, nerve injury and infection. 
• Research has suggested that these conditions may occur more often when treated surgically.
  Re-rupture 

• Re-rupture rate has been documented to be higher when management is non-surgical. 
• This has implications particularly for high level athletes who can not afford additional time off the court following a re-injury. 
• Re-rupture appears to be lower in groups that participate in early-accelerated rehab. 
• It is important to note that in some patients who have a re-rupture during a course of non-operative management, undergoing surgery after this does not necessarily result in worse outcomes later. This suggests that for some, the only risk of delaying surgery is additional recovery time meaning a trial of non-operative management initially can be a sensible strategy.
  High level athletes 

• The desired return to very high level and competitive sport will factor into the decision. 
• Some studies have demonstrated better explosive ability during hopping and jumping in the surgical group, which is likely to have an impact on returning to pre-injury function.  

It is important that the management decisions are made in conjunction with your physiotherapist, doctor and surgeon due to the complex nature and severity of this condition. As you have just read, it is not as simple as saying one method is superior to the other. The individual, injury severity, past history, level of activity and personal preference will all factor into the final decision. 

We are all wishing a speedy recovery for Genevieve Gregson to hopefully see her do what she does best in Paris! 

About the author

Hugh Feary is a CSSM physio who has previously worked in GP clinics as well as a variety of local sporting teams including the Fremantle Dockers in the AFLW. Spending a lot of time strength training in the gym, Hugh enjoys helping others who have any niggles or injuries to modify their program to keep them moving. 

Reference 

Olsson N, Silbernagel KG, Eriksson BI, Sansone M, Brorsson A, Nilsson-Helander K, Karlsson J. Stable surgical repair with accelerated rehabilitation versus nonsurgical treatment for acute Achilles tendon ruptures: a randomized controlled study. Am J Sports Med. 2013 Dec;41(12):2867-76. doi: 10.1177/0363546513503282. Epub 2013 Sep 6. PMID: 24013347. 

Maempel JF, Clement ND, Wickramasinghe NR, Duckworth AD, Keating JF. Operative repair of acute Achilles tendon rupture does not give superior patient-reported outcomes to nonoperative management. Bone Joint J. 2020 Jul;102-B(7):933-940. doi: 10.1302/0301-620X.102B7.BJJ-2019-0783.R3. PMID: 32600149. 

She G, Teng Q, Li J, Zheng X, Chen L, Hou H. Comparing Surgical and Conservative Treatment on Achilles Tendon Rupture: A Comprehensive Meta-Analysis of RCTs. Front Surg. 2021 Feb 18;8:607743. doi: 10.3389/fsurg.2021.607743. PMID: 33681281; PMCID: PMC7931800.