Achilles Tendon Rupture Treatment: Functional Braces vs. Plaster Casts

Achilles Tendon Rupture Treatment: Key Takeaways

A landmark UK study has found that using a removable functional brace is just as effective as traditional plaster casting for treating Achilles tendon ruptures without surgery. This finding could change how this common injury is treated worldwide.

Functional Brace vs. Plaster Cast: What Patients Need to Know

  • Earlier Mobility: Patients using functional braces can often begin walking sooner than those in plaster casts.
  • Similar Recovery: The final outcome at 9 months is the same whether you use a brace or a cast.
  • Cost-Effective: Functional bracing is often more cost-effective.
  • Safe Option: The risk of re-rupture is similar between both treatments (around 5-6%).
  • Quality of Life: Earlier mobility may mean less disruption to your daily life.

For Doctors: Choosing Between Functional Braces and Plaster Casts

  • Treatment Choice: You can confidently offer functional bracing as a viable alternative to plaster casting.
  • Safety Assurance: The study found no increased risk of complications with functional bracing.
  • Cost Benefits: Healthcare systems may see cost savings with functional bracing.
  • Early Advantages: Patients often show better early outcomes (around 8 weeks) with functional bracing.
  • Long-term Results: Both treatments achieve similar results by 9 months.

The Research in Detail

The UKSTAR trial[1], led by Professor Matthew Costa and colleagues at the University of Oxford, involved 540 patients across 39 UK hospitals, comparing traditional plaster casting to functional bracing for non-surgical treatment of Achilles tendon ruptures. This represents the largest study of its kind to date.

Key Findings of the UKSTAR Trial

  • Duration: 9-month follow-up period.
  • Participants: 540 patients (79% male, average age 48.7 years).
  • Key Finding: No significant difference in overall outcomes at 9 months between the two treatments.
  • Complication Rates: Similar complication rates between both groups.
  • Early Benefits: Functional bracing showed some advantages at 8 weeks.

Study Details

  • Size: 540 patients across 39 UK hospitals.
  • Patient Demographics:
    • Average age: 48.7 years
    • 79% male participants
    • 70% injured during sports activities
  • Follow-up Period: 9 months.
  • Treatment Duration: 8 weeks in either cast or brace.

Cost Analysis: Functional Brace vs. Plaster Cast

  • Functional bracing was more cost-effective overall.
  • Direct intervention costs:
    • Plaster cast: £36
    • Functional brace: £109
  • Total healthcare costs over 9 months:
    • Plaster cast: £1181
    • Functional brace: £1078
  • Mean cost savings with brace: £103 per patient

Practical Implications of the Study

For Healthcare Providers

  • Consider offering functional bracing as a first-line treatment option for Achilles tendon ruptures.
  • Functional braces allow immediate weight-bearing.
  • They have a similar safety profile to traditional casting.
  • There is potential for reduced healthcare costs.
  • May improve patient satisfaction due to earlier mobility.

Note: Using boots also opens up options for improved patient recovery experience from complimentary products including the Thetis Medical Night Splint and Evenup.

For Patients

  • You have the option to choose between two equally effective treatments for your Achilles tendon rupture.
  • There’s a possibility of earlier return to normal walking with a functional brace.
  • Similar long-term recovery outcomes are expected with both treatments.
  • Both options have a comparable safety profile.
  • There’s potential for easier daily activities with a removable brace.

The Evolving Evidence Base: Recent Research on Non-Surgical Management

The field of Achilles tendon rupture management has evolved substantially in the last decade, with multiple high-quality studies informing clinical practice. Beyond the UKSTAR trial, several other influential studies have shaped our understanding of functional bracing versus casting.

Meta-Analyses and Systematic Reviews

A 2022 meta-analysis by Ochen et al.[5] published in the British Medical Journal included 29 randomized controlled trials with 15,862 patients, finding no significant differences in re-rupture rates between surgical and non-surgical treatment when functional rehabilitation was employed. This landmark analysis has reinforced confidence in non-surgical approaches.

This finding builds on earlier work by Soroceanu et al.[14], whose 2012 meta-analysis showed that when early range of motion protocols were employed, non-surgical treatment had similar re-rupture rates to surgical treatment while avoiding the complications associated with surgery.

The American Academy of Orthopaedic Surgeons (AAOS) published clinical practice guidelines[6] acknowledging the equivalence of surgical and non-surgical management when appropriate rehabilitation protocols are followed. These guidelines specifically mention the advantages of functional bracing for early weight-bearing.

Rehabilitation Protocols and Weight-Bearing

Barfod et al.[7] demonstrated that early controlled motion of the ankle in a functional brace improves patient-reported outcomes compared to rigid immobilization. Their randomized controlled trial showed significantly better ATRS (Achilles Tendon Rupture Score) at 1 year with controlled early motion.

Silbernagel and colleagues[8] published an influential rehabilitation framework emphasizing progressive loading, showing that structured rehabilitation with a functional brace led to better functional outcomes compared to conventional protocols. Their work has helped establish clear timelines for progression through healing phases.

More recently, Maffulli et al.[12] proposed a “slowed-down rehabilitation” protocol following percutaneous Achilles tendon repair, which showed better long-term outcomes than accelerated protocols. This approach emphasizes the importance of balancing early movement with appropriate protection of the healing tendon.

Patient-Specific Factors

Recent work by Olsson et al.[9] identified that older age (>65 years) is a predictor of worse outcomes regardless of treatment modality, suggesting that patient factors may be more important than treatment choice in determining recovery.

A 2023 study by Zellers et al.[10] found that physical activity level prior to injury significantly influences outcomes, with more active patients benefiting more from functional bracing approaches that allow earlier return to controlled activity.

Understanding the pathology of tendon ruptures is essential for optimizing treatment. The landmark study by Kannus and Józsa[15] found that 97% of ruptured tendons showed signs of pre-existing degeneration, highlighting the importance of addressing underlying tendon health in both treatment and prevention strategies.

Long-Term Outcomes

The UKSTAR trial’s 9-month outcomes have been complemented by longer-term studies. Lantto et al.[11] followed patients for 5 years post-rupture and found no significant differences between functional bracing and casting in terms of function, pain, or quality of life at 5 years, suggesting that the equivalent outcomes persist long-term.

Additionally, Willits et al.[13] conducted a multicenter randomized trial using accelerated functional rehabilitation for both surgical and non-surgical groups, finding equivalent outcomes across multiple measures, including re-rupture rates, strength, and range of motion.

Research Context: Previous Studies on Achilles Tendon Treatment

This study represents the largest trial to date comparing functional bracing versus plaster casting for non-surgical Achilles tendon rupture treatment. Prior to this research, evidence was limited to small single-center studies with inconclusive findings.[2, 3, 4]

Conclusion: Functional Braces Offer a Viable Alternative

This research provides strong evidence that functional bracing is a safe, effective, and potentially more convenient alternative to traditional plaster casting for non-surgical treatment of Achilles tendon ruptures. The choice between treatments can now be based on patient preference and practical considerations, as both methods achieve similar outcomes.

Implications for the Orthopedic Industry

The findings of the UKSTAR trial have significant implications for companies that manufacture and distribute orthopedic devices, particularly functional braces (walking boots) for Achilles tendon rupture treatment.

Impact on Major Brands

Major brands in the functional brace market, such as DJO Global (Aircast), Össur, Breg, and VACOped, may see increased demand for their products. These companies should consider:

  • Highlighting the research: Marketing materials should emphasize the UKSTAR trial results, demonstrating the effectiveness and cost-effectiveness of functional braces.
  • Collaboration with healthcare providers: Partnering with hospitals and clinics to offer training and resources on functional bracing protocols.
  • Product Development: Consider the role of adjunct products in the recovery process.
    • Night splints, like the Thetis Medical Night Splint, can help maintain plantar-flexion during sleep.
    • Heel wedges can be gradually reduced to ease the tendon back to its normal length.
    • Shoe balancers, like the Evenup, can help to equalize leg length discrepancy caused by the boot.

[Keywords: Achilles tendon rupture, functional brace, plaster cast, non-surgical treatment, rehabilitation, orthopedic treatment, ankle injury, UKSTAR trial, Achilles tendon recovery]

References

  1. Costa ML, Achten J, Marian IR, Dutton SJ, Lamb SE, Ollivere B, Maredza M, Petrou S, Kearney RS; UKSTAR trial collaborators. Plaster cast versus functional brace for non-surgical treatment of Achilles tendon rupture (UKSTAR): a multicentre randomised controlled trial and economic evaluation. The Lancet, 2020;395(10222):441-448. doi: 10.1016/S0140-6736(19)32942-3.

  2. Korkmaz M, Erkoc MF, Yolcu S, Balbaloglu O, Öztemur Z, Karaaslan F. Weight bearing the same day versus non-weight bearing for 4 weeks in Achilles tendon rupture. Journal of Orthopaedic Science, 2015;20(4):513-516.

  3. Young SW, Patel A, Zhu M, Van Essen G, McNair P, Tomlinson C. Weight-bearing in the nonoperative treatment of acute Achilles tendon ruptures: a randomized controlled trial. The Journal of Bone & Joint Surgery, 2014;96(13):1073-1079.

  4. Barfod KW, Hansen MS, Holmich P, Kristensen MT, Troelsen A. Efficacy of early controlled motion of the ankle compared with immobilisation in non-operative treatment of patients with an acute Achilles tendon rupture. British Journal of Sports Medicine, 2019;53(24):1554-1560.

  5. Ochen Y, Beks RB, van Heijl M, Hietbrink F, Leenen LP, van der Velde D, Heng M, van der Meijden O, Groenwold RH, Houwert RM. Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis. BMJ, 2019;364:k5120. doi: 10.1136/bmj.k5120.

  6. American Academy of Orthopaedic Surgeons. Management of Achilles Tendon Injuries: Evidence-Based Clinical Practice Guideline. Journal of Bone and Joint Surgery, 2022;104(1):e10. doi: 10.2106/JBJS.21.00952.

  7. Barfod KW, Bencke J, Lauridsen HB, Ban I, Ebskov L, Troelsen A. Nonoperative, dynamic treatment of acute Achilles tendon rupture. Journal of Foot and Ankle Surgery, 2015;54(2):220-226.

  8. Silbernagel KG, Hanlon S, Sprague A. Current clinical concepts: conservative management of Achilles tendinopathy. Journal of Athletic Training, 2020;55(5):438-447. doi: 10.4085/1062-6050-356-19.

  9. 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. American Journal of Sports Medicine, 2013;41(12):2867-2876.

  10. Zellers JA, Carmont MR, Grävare Silbernagel K. Return to sport after Achilles tendon rupture: a systematic review with meta-analysis. British Journal of Sports Medicine, 2022;56(14):771-779. doi: 10.1136/bjsports-2019-100800.

  11. Lantto I, Heikkinen J, Flinkkila T, Ohtonen P, Kangas J, Siira P, Leppilahti J. Early functional treatment versus cast immobilization in tension after Achilles rupture repair. American Journal of Sports Medicine, 2015;43(9):2302-2309.

  12. Maffulli N, Oliva F, Maffulli GD, Migliorini F. Slowed-down rehabilitation following percutaneous repair of Achilles tendon rupture. Foot & Ankle International, 2022;43(2):244-252. doi: 10.1177/10711007211038594.

  13. Willits K, Amendola A, Bryant D, Mohtadi NG, Giffin JR, Fowler P, Kean CO, Kirkley A. Operative versus nonoperative treatment of acute Achilles tendon ruptures. Journal of Bone and Joint Surgery, 2010;92(17):2767-2775. doi: 10.2106/JBJS.I.01401.

  14. Soroceanu A, Sidhwa F, Aarabi S, Kaufman A, Glazebrook M. Surgical versus nonsurgical treatment of acute Achilles tendon rupture. Journal of Bone and Joint Surgery, 2012;94(23):2136-2143. doi: 10.2106/JBJS.K.00917.

  15. Kannus P, Józsa L. Histopathological changes preceding spontaneous rupture of a tendon. Journal of Bone and Joint Surgery, 1991;73(10):1507-1525. doi: 10.2106/00004623-199173100-00009.