Table Of ContentTHE DIAGNOSIS AND TREATMENT OF ACUTE
ACHILLES TENDON RUPTURE
GUIDELINE AND EVIDENCE REPORT
Adopted by the American Academy of Orthopaedic Surgeons
Board of Directors
December 4, 2009
Disclaimer
This Clinical Practice Guideline was developed by an AAOS physician volunteer Work
Group based on a systematic review of the current scientific and clinical information and
accepted approaches to treatment and/or diagnosis. This Clinical Practice Guideline is not
intended to be a fixed protocol, as some patients may require more or less treatment or
different means of diagnosis. Clinical patients may not necessarily be the same as those
found in a clinical trial. Patient care and treatment should always be based on a
clinician’s independent medical judgment, given the individual patient’s clinical
circumstances.
Disclosure Requirement
In accordance with AAOS policy, all individuals whose names appear as authors or
contributors to Clinical Practice Guideline filed a disclosure statement as part of the
submission process. All panel members provided full disclosure of potential conflicts of
interest prior to voting on the recommendations contained within this Clinical Practice
Guidelines.
Funding Source
This Clinical Practice Guideline was funded exclusively by the American Academy of
Orthopaedic Surgeons who received no funding from outside commercial sources to
support the development of this document.
FDA Clearance
Some drugs or medical devices referenced or described in this Clinical Practice Guideline
may not have been cleared by the Food and Drug Administration (FDA) or may have
been cleared for a specific use only. The FDA has stated that it is the responsibility of the
physician to determine the FDA clearance status of each drug or device he or she wishes
to use in clinical practice.
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All rights reserved. No part of this Clinical Practice Guideline may be reproduced, stored
in a retrieval system, or transmitted, in any form, or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without prior written permission
from the AAOS.
Published 2009 by the American Academy of Orthopaedic Surgeons
6300 North River Road
Rosemont, IL 60018
First Edition
Copyright 2007 by the American Academy of Orthopaedic Surgeons
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Summary of Recommendations
The following is a summary of the recommendations in the AAOS’ clinical practice
guideline, The Diagnosis and Treatment of Acute Achilles Tendon Rupture. The scope of
this guideline is specifically limited to acute Achilles tendon rupture. This summary does
not contain rationales that explain how and why these recommendations were developed
nor does it contain the evidence supporting these recommendations. All readers of this
summary are strongly urged to consult the full guideline and evidence report for this
information. We are confident that those who read the full guideline and evidence report
will also see that the recommendations were developed using systematic evidence-based
processes designed to combat bias, enhance transparency, and promote reproducibility.
This summary of recommendations is not intended to stand alone. Treatment decisions
should be made in light of all circumstances presented by the patient. Treatments and
procedures applicable to the individual patient rely on mutual communication between
patient, physician and other healthcare practitioners.
1. In the absence of reliable evidence, it is the opinion of this work group that a
detailed history and physical exam be performed. The physical examination
should include two or more of the following tests to establish the diagnosis of
acute Achilles tendon rupture:
Clinical Thompson test (Simmonds squeeze test)
o
Decreased ankle plantar flexion strength
o
Presence of a palpable gap (defect, loss of contour)
o
Increased passive ankle dorsiflexion with gentle manipulation
o
Strength of Recommendation – Consensus*
Description: The supporting evidence is lacking and requires the work group to make a
recommendation based on expert opinion by considering the known potential harm and
benefits associated with the treatment. A Consensus recommendation means that expert
opinion supports the guideline recommendation even though there is no available
empirical evidence that meets the inclusion criteria of the guideline’s systematic review.
Implications: Practitioners should be flexible in deciding whether to follow a
recommendation classified as Consensus, although they may set boundaries on
alternatives. Patient preference should have a substantial influencing role.
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2. We are unable to recommend for or against the routine use of magnetic resonance
imaging (MRI), ultrasound (ultrasonography), and radiograph (roentgengrams, x-
rays) to confirm the diagnosis of acute Achilles tendon rupture.
Strength of Recommendation – Inconclusive
Description: Evidence from a single low quality study or conflicting findings that do not
allow a recommendation for or against the intervention. An Inconclusive
recommendation means that there is a lack of compelling evidence resulting in an unclear
balance between benefits and potential harm.
Implications: Practitioners should feel little constraint in deciding whether to follow a
recommendation labeled as Inconclusive and should exercise judgment and be alert to
future publications that clarify existing evidence for determining balance of benefits
versus potential harm. Patient preference should have a substantial influencing role.
3. Non-operative treatment is an option for all patients with acute Achilles tendon
rupture.
Strength of Recommendation: Limited
Description: Evidence from two or more “Low” strength studies with consistent findings,
or evidence from a single “Moderate” quality study recommending for or against the
intervention or diagnostic. A Limited recommendation means the quality of the
supporting evidence that exists is unconvincing, or that well-conducted studies show little
clear advantage to one approach versus another.
Implications: Practitioners should be cautious in deciding whether to follow a
recommendation classified as Limited, and should exercise judgment and be alert to
emerging publications that report evidence. Patient preference should have a substantial
influencing role.
4. For patients treated non-operatively, we are unable to recommend for or against
the use of immediate functional bracing for patients with acute Achilles tendon
rupture.
Strength of Recommendation: Inconclusive
Description: Evidence from a single low quality study or conflicting findings that do not
allow a recommendation for or against the intervention. An Inconclusive
recommendation means that there is a lack of compelling evidence resulting in an unclear
balance between benefits and potential harm.
Implications: Practitioners should feel little constraint in deciding whether to follow a
recommendation labeled as Inconclusive and should exercise judgment and be alert to
future publications that clarify existing evidence for determining balance of benefits
versus potential harm. Patient preference should have a substantial influencing role.
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5. Operative treatment is an option in patients with acute Achilles tendon rupture.
Strength of Recommendation: Limited
Description: Evidence from two or more “Low” strength studies with consistent findings,
or evidence from a single “Moderate” quality study recommending for or against the
intervention or diagnostic. A Limited recommendation means the quality of the
supporting evidence that exists is unconvincing, or that well-conducted studies show little
clear advantage to one approach versus another.
Implications: Practitioners should be cautious in deciding whether to follow a
recommendation classified as Limited, and should exercise judgment and be alert to
emerging publications that report evidence. Patient preference should have a substantial
influencing role.
6. In the absence of reliable evidence, it is the opinion of the work group that
although operative treatment is an option, it should be approached more
cautiously in patients with diabetes, neuropathy, immunocompromised states, age
above 65, tobacco use, sedentary lifestyle, obesity (BMI >30), peripheral vascular
disease or local/systemic dermatologic disorders.
Strength of Recommendation: Consensus
Description: The supporting evidence is lacking and requires the work group to make a
recommendation based on expert opinion by considering the known potential harm and
benefits associated with the treatment. A Consensus recommendation means that expert
opinion supports the guideline recommendation even though there is no available
empirical evidence that meets the inclusion criteria of the guideline’s systematic review.
Implications: Practitioners should be flexible in deciding whether to follow a
recommendation classified as Consensus, although they may set boundaries on
alternatives. Patient preference should have a substantial influencing role.
7. For patients who will be treated operatively for an acute Achilles tendon rupture,
we are unable to recommend for or against preoperative immobilization or
restricted weight bearing.
Strength of Recommendation: Inconclusive
Description: Evidence from a single low quality study or conflicting findings that do not
allow a recommendation for or against the intervention. An Inconclusive
recommendation means that there is a lack of compelling evidence resulting in an unclear
balance between benefits and potential harm.
Implications: Practitioners should feel little constraint in deciding whether to follow a
recommendation labeled as Inconclusive and should exercise judgment and be alert to
future publications that clarify existing evidence for determining balance of benefits
versus potential harm. Patient preference should have a substantial influencing role.
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8. Open, limited open and percutaneous techniques are options for treating patients
with acute Achilles tendon rupture.
Strength of Recommendation: Limited
Description: Evidence from two or more “Low” strength studies with consistent findings,
or evidence from a single “Moderate” quality study recommending for or against the
intervention or diagnostic. A Limited recommendation means the quality of the
supporting evidence that exists is unconvincing, or that well-conducted studies show little
clear advantage to one approach versus another.
Implications: Practitioners should be cautious in deciding whether to follow a
recommendation classified as Limited, and should exercise judgment and be alert to
emerging publications that report evidence. Patient preference should have a substantial
influencing role.
9. We cannot recommend for or against the use of allograft, autograft, xenograft,
synthetic tissue, or biologic adjuncts in all acute Achilles tendon ruptures that are
treated operatively.
Strength of Recommendation: Inconclusive
Description: Evidence from a single low quality study or conflicting findings that do not
allow a recommendation for or against the intervention. An Inconclusive
recommendation means that there is a lack of compelling evidence resulting in an unclear
balance between benefits and potential harm.
Implications: Practitioners should feel little constraint in deciding whether to follow a
recommendation labeled as Inconclusive and should exercise judgment and be alert to
future publications that clarify existing evidence for determining balance of benefits
versus potential harm. Patient preference should have a substantial influencing role.
10. We cannot recommend for or against the use of antithrombotic treatment for
patients with acute Achilles tendon ruptures.
Strength of Recommendation: Inconclusive
Description: Evidence from a single low quality study or conflicting findings that do not
allow a recommendation for or against the intervention. An Inconclusive
recommendation means that there is a lack of compelling evidence resulting in an unclear
balance between benefits and potential harm.
Implications: Practitioners should feel little constraint in deciding whether to follow a
recommendation labeled as Inconclusive and should exercise judgment and be alert to
future publications that clarify existing evidence for determining balance of benefits
versus potential harm. Patient preference should have a substantial influencing role.
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11. We suggest early (≤ 2 weeks) post-operative protected weight bearing for patients
with acute Achilles tendon rupture who have been treated operatively
Strength of Recommendation: Moderate
Description: Evidence from two or more “Moderate” strength studies with consistent
findings, or evidence from a single “High” quality study for recommending for or against
the intervention. A Moderate recommendation means that the benefits exceed the
potential harm (or that the potential harm clearly exceeds the benefits in the case of a
negative recommendation), but the strength of the supporting evidence is not as strong.
Implications: Practitioners should generally follow a Moderate recommendation but
remain alert to new information and be sensitive to patient preferences.
12. We suggest the use of a protective device that allows mobilization by 2- 4 weeks
post operatively.
Strength of Recommendation: Moderate
Description: Evidence from two or more “Moderate” strength studies with consistent
findings, or evidence from a single “High” quality study for recommending for or against
the intervention. A Moderate recommendation means that the benefits exceed the
potential harm (or that the potential harm clearly exceeds the benefits in the case of a
negative recommendation), but the strength of the supporting evidence is not as strong.
Implications: Practitioners should generally follow a Moderate recommendation but
remain alert to new information and be sensitive to patient preferences.
13. We are unable to recommend for or against post-operative physiotherapy for
patients with acute Achilles tendon rupture
Strength of Recommendation: Inconclusive
Description: Evidence from a single low quality study or conflicting findings that do not
allow a recommendation for or against the intervention. An Inconclusive
recommendation means that there is a lack of compelling evidence resulting in an unclear
balance between benefits and potential harm.
Implications: Practitioners should feel little constraint in deciding whether to follow a
recommendation labeled as Inconclusive and should exercise judgment and be alert to
future publications that clarify existing evidence for determining balance of benefits
versus potential harm. Patient preference should have a substantial influencing role.
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14. In all patients with acute Achilles tendon rupture, irrespective of treatment type,
we are unable to recommend a specific time at which patients can return to
activities of daily living.
Strength of Recommendation: Inconclusive
Description: Evidence from a single low quality study or conflicting findings that do not
allow a recommendation for or against the intervention. An Inconclusive
recommendation means that there is a lack of compelling evidence resulting in an unclear
balance between benefits and potential harm.
Implications: Practitioners should feel little constraint in deciding whether to follow a
recommendation labeled as Inconclusive and should exercise judgment and be alert to
future publications that clarify existing evidence for determining balance of benefits
versus potential harm. Patient preference should have a substantial influencing role.
15. In patients who participate in sports it is an option to return them to sports within
3-6 months after operative treatment for acute Achilles tendon rupture.
Strength of Recommendation: Limited
Description: Evidence from two or more “Low” strength studies with consistent findings,
or evidence from a single “Moderate” quality study recommending for or against the
intervention or diagnostic. A Limited recommendation means the quality of the
supporting evidence that exists is unconvincing, or that well-conducted studies show little
clear advantage to one approach versus another.
Implications: Practitioners should be cautious in deciding whether to follow a
recommendation classified as Limited, and should exercise judgment and be alert to
emerging publications that report evidence. Patient preference should have a substantial
influencing role.
16. In patients with acute Achilles tendon rupture treated non-operatively, we are
unable to recommend a specific time at which patients can return to athletic
activity.
Strength of Recommendation: Inconclusive
Description: Evidence from a single low quality study or conflicting findings that do not
allow a recommendation for or against the intervention. An Inconclusive
recommendation means that there is a lack of compelling evidence resulting in an unclear
balance between benefits and potential harm.
Implications: Practitioners should feel little constraint in deciding whether to follow
a recommendation labeled as Inconclusive and should exercise judgment and be alert to
future publications that clarify existing evidence for determining balance of benefits
versus potential harm. Patient preference should have a substantial influencing role.
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* While we strongly encourage reviewers to read the full guideline, please refer to the
sections titled “Judging the Quality of Evidence” and “Defining the Strength of the
Recommendations Table 1” for a detailed description of the link between the evidence
supporting the Strength of a Recommendation and the language of the guideline.
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Work Group
Christopher P Chiodo MD, Chair Guidelines and Technology Oversight
Brigham Orthopedic Associates Chair:
75 Francis Street William C. Watters, III, MD
Boston MA 02115 6624 Fannin #2600
Houston, TX 77030
Mark Glazebrook MD, Vice-Chair
Queen Elizabeth Health Sciences Center Guidelines and Technology Oversight Vice-
Halifax Infirmary Suite 4867 Chair:
1796 Summer Street Michael J. Goldberg, MD
Halifax NS B3H 3A7 Canada Department of Orthopaedics
Seattle Children’s Hospital
Eric Michael Bluman MD PhD 4800 Sand Point Way NE
Madigan Army Medical Center Seattle, WA 98105
ATTN: MCHJ-SOP (Ortho Clinic)
9040 A Reid Street Evidence Based Practice Committee Chair:
Tacoma WA 98431-1100 Michael Keith, MD
2500 Metro Health Drive
Bruce E Cohen MD Cleveland, OH 44109-1900
1783 Sterling Road
Charlotte NC 28209 AAOS Staff:
Robert H. Haralson III, MD, MBA
John E Femino MD AAOS Medical Director
Department of Orthopedics 6300 N River Road
University of Iowa Hospital and Clinics Rosemont, IL 60018
JPP 01022
200 Hawkins Drive Charles M. Turkelson, PhD
Iowa City IA 52242 Director of Research and Scientific Affairs
Eric Giza MD Janet L. Wies MPH
UC Davis Dept of Orthopaedics AAOS Clinical Practice Guideline Mgr
Ambulatory Care Services Bldg
4860 Y St #3800 AAOS Research Analysts
Sacramento, CA 95817 Laura Raymond MA - Lead Analyst
Sara Anderson MPH – Lead Analyst
Kevin Boyer BS
Patrick Sluka MPH
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Description:Achilles tendon ruptures identified four level II studies including all operative techniques.18-21 Three studies included standard open treatment and one included a
