G Model

FAS 1028 No. of Pages 6

Foot and Ankle Surgery xxx (2017) xxxxxx

Contents lists available at ScienceDirect

Foot and Ankle Surgery

journal homepage: www.elsevier.com/locate/fas

Predictors of functional outcome in non-operatively managed Achilles

tendon ruptures
Randeep Aujla* , Shakil Patel, Annette Jones, Maneesh Bhatia
Trauma & Orthopaedic Surgery, University Hospitals of Leicester, Leicester, United Kingdom

A R T I C L E I N F O A B S T R A C T

Article history: Background: Acute Achilles tendon (AT) rupture management remains debatable but non-operative
Received 31 October 2016 functional regimes are beginning to gain popularity. The aim of this study was to identify predictors of
Received in revised form 11 March 2017 functional outcome in patients with AT ruptures treated non-operatively with an immediate weight
Accepted 21 March 2017
bearing functional regime in an orthosis.
Available online xxx
Methods: Analysis of prospectively gathered data from a local database of all patients treated non-
operatively at our institution with an AT rupture was performed. For inclusion in the study patients
Keywords:
required a completed Achilles Tendon Rupture Score (ATRS) at a minimum of 6 months post injury. The
Achilles tendon
Rehabilitation
ATRS score was correlated against age, gender, time following rupture, duration (8 or 11 weeks) of
Non-surgical treatment in a functional orthoses and complications were recorded.
Results: 236 patients of average age 49.5 years were included. The mean ATRS on completion of
rehabilitation was 74 points. The mean ATRS was signicantly lower in the 37 females (65.8) as compared
to the 199 males (75.6) (p = 0.013). Age inversely affected ATRS with a Pearsons correlation of 0.2. There
was no signicant difference in the ATRS score when comparing the two different treatment regime
durations. There were 12 episodes of VTE and 4 episodes of re-rupture. The ATRS does not change
signicantly after 6 months following rupture treatment completion.
Conclusion: Patients with AT ruptures treated non-operatively with a functional rehabilitation regime
demonstrate comparable function to other non-surgical regimes with low re-rupture rates. Increasing
age and female gender demonstrate inferior functional outcomes.
Clinical relevance: Females and increasing age predict poorer functional outcome in acute Achilles tendon
ruptures managed in a dynamic full-weight bearing treatment regime.
2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

1. Introduction
The Achilles tendon (AT) remains the most common tendon
ruptured and the incidence of acute ruptures is increasing [13].
The management of these injuries continues to create debate with
the treatment algorithm beginning with deciding between
operative or non-operative treatment methods, albeit with recent
trends going away from operative repair for acute primary ruptures
[46].
There are numerous treatment protocols for the non-opera-
tively managed AT ruptures, each being individualised to surgeon,
department or hospital. Studies have previously looked at
operative versus non-operative regimes, use of cast immobilisa-
tion versus functional orthosis and whether to allow early weight
* Corresponding author at: Specialty Registrar Trauma & Orthopaedics, East
Midlands (South) Rotation, United Kingdom.
E-mail address: Randeep.aujla@hotmail.co.uk (R. Aujla).
bearing or not [711]. Overall no consensus has been reached upon
an ideal treatment protocol but recent studies have shown
promising results from non-operatively treated AT ruptures with
immediate weight bearing with functional rehabilitation regimes
[12,13]. Despite this, operative repair still seems to be the
treatment of choice in the United States of America and
Scandinavia [14].
Multiple studies have shown that non-operative treatment has
the benet of a reduced complication rate due to avoiding
operative risks such as skin breakdown, infection and nerve
damage [9]. This benet was offset by earlier documented higher
re-rupture rates [9]. However, a recent meta-analysis showed no
difference in re-rupture rate between surgery with postoperative
functional bracing (5%) and the sub-group of patients treated in
non-operative accelerated rehabilitation regimes (8%) [15]. A
Cochrane review demonstrated that patients treated with
functional bracing fared better with regards to less time off
work and quicker return to sporting activities when compared
with plaster cast treatment [16]. In addition to this, functional

http://dx.doi.org/10.1016/j.fas.2017.03.007
1268-7731/ 2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: R. Aujla, et al., Predictors of functional outcome in non-operatively managed Achilles tendon ruptures, Foot
Ankle Surg (2017), http://dx.doi.org/10.1016/j.fas.2017.03.007
G Model
FAS 1028 No. of Pages 6

2 R. Aujla et al. / Foot and Ankle Surgery xxx (2017) xxxxxx

treatment with an orthosis is more work and lifestyle compatible

[17,18]. Despite the attention upon functional outcomes following
most orthopaedic injuries, recent meta-analyses have focused on
re-rupture rates and overall complications as primary outcomes
rather than the functional results following AT rupture.
The purpose of this study was to identify predictors of
functional outcome in AT rupture patients treated non-operatively
with an immediate weight bearing functional regime.

2. Methods

A departmental policy was implemented in January 2010 to

standardise the treatment of acute AT ruptures at the University
Hospitals of Leicester. The VACOped1 walking boot orthosis with
immediate full weight bearing mobilisation was used. Initially
there was caution about immediate weight bearing in an orthosis
so a period of 11-weeks of functional mobilisation was used. A
prospective database was created and complications were
recorded as an audit tool by clinic staff. In February 2011 the
Fig. 1. Picture of the VACOped1 boot (Oped Ag Ltd, Germany).
departmental policy changed and the period of functional
mobilisation was reduced to 8-weeks in line with literature at
that time [11,19]. The treatment protocol has remained the same
open injury, patient choice or a high performing athlete these were
since. Both regimes are described in detail in Table 1. Since January
also excluded from functional analysis.
2010, more than 90% of acute AT ruptures have been treated this
The VACOpedJ boot (Oped Ag Ltd, Germany) was used as the
way. The remaining 10% of patients were treated operatively as a
functional orthosis in all cases (Fig. 1). At each time point on return
result of delayed presentation, open injury, patient choice or high
to the clinic, the boot was removed, skin checks were performed
performing athletes. An Achilles Tendon Rupture clinic, led by a
and the liner changed. Boot adjustments were made according to
clinical specialist physiotherapist, has been established in our
the protocol in place by trained staff. All patients were allowed to
department since January 2014. This clinic has aimed to collect
fully weight-bear immediately once their orthosis was applied. The
functional data prospectively to closely monitor progress since
VACOpedJ achieves stability via an inner vacuum cushion that
January 2014January 2015.
conforms to the shape of the leg by evacuating air, while the
All patients with a suspected AT rupture were assessed
external shell provides rigidity. The boot can be locked at a xed
clinically by the Emergency Department or primary care, placed
angle (ranging from 0 to 30 ) or movements can be permitted
into a dorsal plaster slab with the ankle in equinus and referred to
within this range.
the trauma & orthopaedic fracture clinic. The majority of patients
Following completion of the regime, patients returned for a
attended for assessment in the fracture clinic within 3 days, with
clinical review and their boot was removed. Clinical assessment
all attending within one week. Clinical assessment was performed
of the AT was performed, and if felt clinically intact, the
in all patients. This included the calf squeeze test, palpation for
VACOpedJ was discontinued and patients referred to physio-
rupture gap and ability to single leg heel raise. If on clinical
therapy for strengthening exercises. This was the case for all
assessment, the diagnosis was in doubt, then imaging studies
patients involved.
consisting of either a MRI or ultrasound were conducted. Once the
diagnosis was conrmed by a member of the orthopaedic team,
2.1. Outcome measures
patients were placed in the functional VACOpedJ orthosis (Fig. 1)
and the treatment regime initiated (Table 1).
The primary outcome measure was the Achilles Tendon
Inclusion criteria for the study were primary acute AT ruptures
Rupture Score (ATRS). The ATRS is a patient-reported outcome
(as dened by the clinical features above), age >18, presentation
measure developed by Nilsson-Helander et al. in 2007 [20]. It
within 2 weeks of injury, a minimum follow-up of six months, non-
consists of 10 questions based on an 11 point Likert scale, where a
operative treatment, completed functional mobilisation in either
total score of 0 is worst, and 100 is best. This questionnaire is
VACOpedJ regime and completed ATRS questionnaire. Patients
perceived to be the only relevant, validated patient reported
were excluded if they were less than 18 years of age, had a delayed
outcome score for AT ruptures [21]. The ATRS questionnaire was
presentation (>2 weeks) prior to initiation of treatment, other
administered by post a minimum of 6 months after injury. ATRS
injuries in the same limb, poly-trauma, open injury or if they
questionnaire was sent via post for patients treated between
underwent operative repair. The incidence of re-rupture is
January 2010 and January 2014. Following this the outcomes were
presented. However, this group of patients was excluded from
assessed in the dedicated ATR clinic by a research physiotherapist.
the functional analysis of the results. Operative repair was
Secondary outcomes including re-ruptures, venous-thromboem-
performed in patients with a delayed presentation (>2 weeks),
bolic (VTE) events and any other complications were collected

Table 1
A table to show the duration in weeks spent in each position in the VACOPed1 boot for both 11-week and 8-week regimes.

Regime 30 Plantarexion (static) 15 Plantarexion (static) 1530 (dynamic) 030 (dynamic)
11 weeks (January 2010January 2011) 5 3 2 1
8 weeks (February 2011January 2015) 4 0 2 2

Please cite this article in press as: R. Aujla, et al., Predictors of functional outcome in non-operatively managed Achilles tendon ruptures, Foot
Ankle Surg (2017), http://dx.doi.org/10.1016/j.fas.2017.03.007
G Model
FAS 1028 No. of Pages 6
R. Aujla et al. / Foot and Ankle Surgery xxx (2017) xxxxxx
Fig. 2. A owchart to demonstrate the passage of patients through the inclusion/
exclusion criteria.
prospectively. The ATRS was assessed against age, gender,
complications, time following rupture, and duration of functional
rehabilitation regime.
Local ethics approval was obtained via our hospital research
and audit department.
2.2. Statistical methods
The Fishers exact test was used to compare complications
between groups. Correlations were calculated using Pearson
correlation. Parametric data is presented as mean and the
independent Student t-test was used for analysis. A one-way
ANOVA with a Bonferroni correction was used to assess ATRS
outcomes and duration of follow up. Statistical signicance was
dened as p < 0.05. The sample size was calculated using 10-points
on the Achilles Tendon Rupture Score as being signicantly
different. Standard deviation from the original study involving
82 patients was 21.4 [20]. With an alpha error of 0.05, a power of
80% the sample size was calculated to be 38 per group.
3. Results
345 AT ruptures were treated at our hospital, after exclusion
criteria, between January 2010 and January 2015. Complete data
was available in 70% (n = 240) of patients. 4 patients had re-
ruptures whose ATRS scores were post completion of re-rupture
treatment and were therefore excluded from the analysis of ATRS
outcomes. This left 236 patients for the nal analysis (Fig. 2).
There were 199 (84%) male patients with a mean age 49.0 years
(SD 13.7) and 37 (16%) females of average age 52.7 years (SD 16.8).
Patients were followed up for a mean of 24 months (range 658)
following completion of the regime. Results are summarised in
Table 2.
Table 2
A table to show the affect of variable of nal Achilles Tendon Rupture Score in non-surgically managed Achilles tendon ruptures.
Variable Sub-category
Gender Male
Female
Age Continuous variable
Length of treatment 8-week regime
11-week regime
Length of follow-up Contnuous variable
Please cite this article in press as: R. Aujla, et al., Predictors of functional outcome in non-operatively managed Achilles tendon ruptures, Foot
Ankle Surg (2017), http://dx.doi.org/10.1016/j.fas.2017.03.007
3
3.1. Gender
The mean ATRS score for all patients was 74.0 (SD 22.0, range 8
100, 95% CI 71.276.8). The mean ATRS score was signicantly
better (p = 0.013) in male patients (75.6, range 8100, SD 21.5, 95%
CI 72.678.6) as compared to female patients (65.8, range 21100,
SD 22.7, 95% CI 58.273.4).
3.2. Age
Functional outcomes were inversely related to age, Pearsons
correlation of 0.2 (p = 0.002). The negative correlation remained
for both male (Pearson correlation 0.175, p = 0.014) and female
patients ( 0.245, p = 0.143), although did not reach statistical
signicance in females.
3.3. Length of functional rehabilitation
There was no signicant difference (p = 0.546) in the mean ATRS
scores between the 194 patients treated in the 8-week regime
(mean 73.6, range 18100, SD 21.9) as compared to the 42 patients
treated in the 11-week regime (mean 75.9, range 8100, SD 22.5).
3.4. Length of follow-up
Length of follow-up did not signicantly affect ATRS with a
Pearson correlation of 0.076 (p = 0.247). There was no signicant
difference in the ATRS scores when comparing those patients
assessed at 6 months post rupture as compared to those who were
followed up for longer (Fig. 3) (One-Way Anova Post Hoc test p = 1).
3.5. Complications
The overall incidence of venous thromboembolic events was 5%
(n = 12). 2.7% of such cases occurred in females (n = 1) and 5.5% in
males (n = 11) with no statistically signicant difference between
the two (Fishers Exact test p = 0.697). The length of functional
rehabilitation was also not related to the incidence of VTE episodes
(p = 0.549).
The incidence of re-rupture was 2.6% in females (n = 1) as
compared to 1.5% in males (n = 3), without any signicant
differences between the two (p = 0.501). Length of functional
rehabilitation also failed to show any signicant difference in the
re-rupture rate (p = 0.549). Patients with re-rupture were excluded
from all of the analysis above. Three of these patients were treated
successfully with a further functional rehabilitation regime and
one underwent surgical repair. The ATRS score in these 4 patients
following successful treatment for re-rupture was 54.5 as com-
pared to the 74 in the 236 patients who did not. Due to the small
number statistical analysis was not performed.
4. Discussion
Debate remains as to the optimal treatment for acute AT
ruptures. More evidence is available supporting non-operative
ATRS Statistical result
75.6 (SD 21.5) p = 0.013
65.8 (SD 22.7)
Pearsons 0.2 (p = 0.002)
73.6 (SD 21.9) p = 0.546
75.9 (SD 22.5)
Pearsons 0.076 (p = 0.247)
G Model
FAS 1028 No. of Pages 6
4 R. Aujla et al. / Foot and Ankle Surgery xxx (2017) xxxxxx
Fig. 3. A gure to show how duration of follow-up affected functional outcome results in acute Achilles tendon ruptures.
treatment with immediate full weight bearing in a functional
rehabilitation regime over operative repair. However, variables
that may affect outcomes through this method of treatment are not
yet known. This cohort study of acute AT ruptures treated in a
dynamic immediate full-weight bearing regime has attempted to
identify factors that may affect functional outcome.
This is currently the largest cohort of functional results for non-
operatively treated AT ruptures using the ATRS outcome score.
Bergkvist et al. showed a mean ATRS of 79 (SD  20.8) in 189 non-
operatively managed AT ruptures, at a mean follow-up of 3.3 years,
who were managed in functional bracing [13]. Kearney et al.
demonstrated a mean ATRS of 78 (SD  20) at 9 months following
eight weeks of functional non-operative rehabilitation following
AT rupture in 38 patients [22]. These published scores are slightly
better than those demonstrated in this study (ATRS 74). Similar to
other studies, a high standard deviation was also demonstrated
(22). The difference is likely to be due to natural geographical
variation between the groups. However, all patients including
those who had complications, such at VTE, were included in the
nal results. In operatively managed AT ruptures ATRS scores tend
to be higher and range from 82 to 89 [13,2324]. Percutaneous
minimally invasive repair methods have demonstrated an ATRS of
89 at 12-month follow-up [23]. Percutaneous repair with
functional rehabilitation may provide the best functional outcome
but there are few studies to conrm this theory. The minimally
clinically important difference for ATRS has yet to be established
and this may facilitate future study comparisons.
Inferior results in females compared to males were identied
with a 9.7 point difference (p = 0.013). A similar nding has also
been shown by Olsson et al. who demonstrated a 12 point
difference favouring males [25]. Sibernagel et al. focussed on
gender differences for 94 operatively and 88 non-operatively
Please cite this article in press as: R. Aujla, et al., Predictors of functional outcome in non-operatively managed Achilles tendon ruptures, Foot
Ankle Surg (2017), http://dx.doi.org/10.1016/j.fas.2017.03.007
treated AT ruptures. They showed males had a 13 point superiority
over females when operatively managed. However, there was no
difference shown for non-operatively treated AT ruptures [26].
Bostick et al. evaluated predictors of calf muscle endurance at one
year following AT rupture repair. They showed better calf
endurance in females at 3 months in a 73 patient cohort [27].
There has been no gender difference noted in Achilles tendinop-
athy or capillary blood ow but there is clearly a higher proportion
of rupture in males in studies [28]. This study currently represents
the largest series in a functional weight bearing orthoses of
conservatively managed AT ruptures. These results would there-
fore be most accurate in establishing the inuence of gender on
outcomes following AT rupture.
The second strong inuence on functional outcome identied
was age. Increasing age negatively affected functional outcomes in
non-operatively managed AT rupture. Olsson et al. also demon-
strated that an increasing age strongly correlated with a reduced
heel-rise height. They also showed that increasing BMI by 5 points
lead to a reduction in ATRS by 10 points [24].
Bergkvist et a. concluded that older female patients may benet
from surgical intervention and the ndings of this study do show a
similar trend, although failed to reach statistical signicance [13].
This may be due to the smaller number of female patients as
compared to males in this study. Older females do have the poorer
functional results following non-operative treatment. However, it
may be worth considering the functional demands of this cohort
before subjecting them to surgery.
Complications were too infrequent to allow accurate analysis
into the impact upon function. Barfod et al. showed in a
randomised controlled trial that immediate weight bearing has
no detrimental effect on ATRS, re-rupture rates or health related
quality of life [12]. The overall rate of a VTE following
G Model
FAS 1028 No. of Pages 6
R. Aujla et al. / Foot and Ankle Surgery xxx (2017) xxxxxx
conservatively managed AT ruptures in this study is 5%. This is
comparable to recent literature having VTE rates of 1.411% for
similar non-operative regimes [11,2932].
Soroceanu et al. showed that if functional rehabilitation were
employed then the re-rupture rate was equal in operative and non-
operative AT ruptures (risk difference 1.7%; p = 0.45) [33]. The
overall re-rupture rate in this study was 1.7% for a non-operative
functional regime. There was no difference in re-rupture rates
between genders or regimes. This demonstrates how successful
non-operative regimes can be at preventing re-rupture. It can
therefore be concluded that the re-rupture rate is equal to
operative treatment but with fewer complications and associated
risks. The functional outcomes of patients treated following re-
rupture appear to be much lower. However, due to the small
number of patients no conclusions can be drawn.
Duration of functional rehabilitation and length of follow-up
did not affect the ATRS within this cohort who had a minimum
follow-up of 6 months post rupture. It has previously been shown
that the ATRS does not change signicantly beyond one years
follow-up [34]. The ndings of this study show that even this may
be an over-estimate and that an adequate functional outcome can
be established at 6 months post rupture.
Our recommendation would be that all patients be treated in a
dynamic functional non-surgical regime. This has been demon-
strated to lead to good functional results with low re-rupture and
complication rates. However, there is doubt whether absolutely
everyone can be treated this way. Age and gender have been shown
to play key roles in functional outcomes but an individual patients
demands must be considered prior to offering alternatives. We
believe this study can help counsel patients when considering non-
operative regimes, particularly younger males who performed well
with the non-operative treatment regime.
The limitations of this study are acknowledged. Patient
inclusion was dependent upon a completed ATRS being available.
Recent studies assessing ATRS have shown similar response rates
[13,27]. We feel a complete dataset of 70% from a cohort of 345 is
adequate to draw clinical conclusions from. However, a lack of 30%
of responses will add a bias to the results that must be taken into
accounts. The demographics of the non-responders were similar to
the responders. Another limitation was the methodology as this
was not a truly prospective data collection as the ATRS was
obtained via postal questionnaire at unspecied time points in the
patients rehabilitation. Retrospective identication of complica-
tions can cause some cases to be missed and reduce accuracy.
Patient numbers within the female group as well as those treated
in the 11 week regime were small. This may be responsible for the
failure to achieve a statistically signicant result. However,
duration of functional rehabilitation of 8 weeks is now the
recommended norm and the results of this study do show that
there is no need for longer functional rehabilitation regimes.
Our case series of 236 non-operatively managed Achilles
tendon ruptures show good function following a dynamic
immediate weight-bearing regime in an orthosis. Increasing age
and female gender lead to poorer functional outcomes. This
knowledge may aid in clinical decision making and counselling of
patients when treating acute Achilles tendon ruptures.
Conict of interest
No benets in any form have been received or will be received
from a commercial party related directly or indirectly to the
subject of this article.
Funding
None.
Please cite this article in press as: R. Aujla, et al., Predictors of functional outcome in non-operatively managed Achilles tendon ruptures, Foot
Ankle Surg (2017), http://dx.doi.org/10.1016/j.fas.2017.03.007
5
Ethical approval
Ethical approval was conrmed by local committee.
References
[1] Hess GW. Achilles tendon rupture: a review of etiology, population, anatomy,
risk factors, and injury prevention. Foot Ankle Spec 2010;3(1):2932.
[2] Lantto I, Heikkinen J, Flinkkila T, Ohtonen P, Leppilahti J. Epidemiology of
Achilles tendon ruptures: increasing incidence over a 33-year period. Scand J
Med Sci Sports 2014;25(1):e1338.
[3] Mller A, strm M, Westlin NE. Increasing incidence of Achilles tendon
rupture. Acta Orthop 1996;67(5):47981.
[4] Wong J, Barrass V, Maffulli N. Quantitative review of operative and
nonoperative management of Achilles tendon ruptures. Am J Sports Med
2002;30(4):56575.
[5] Mattila VM, Huttunen TT, Haapasalo H, Sillanpaa P, Malmivaara A, Pihlajamaki
H. Declining incidence of surgery for Achilles tendon rupture follows
publication of major RCTs: evidence-inuenced change evident using the
Finish registry study. Br J Sports Med 2013, doi:http://dx.doi.org/10.1136/
bjsports-2013-092756 PMID: 24128757.
[6] Huttunen TT, Kannus P, Rolf C, Fellander-Tsai L, Mattila VM. Acute Achilles
tendon ruptures incidence of injury and surgery in Sweden between 2001 and
2012. Am J Sports Med 2014;42(10):241923.
[7] Bhandari M, Guyatt GH, Siddiqui F, Morrow F, Busse J, Leighton RK, et al.
Treatment of acute Achilles tendon ruptures: a systemic overview and meta-
analysis. Clin Orthop Relat Res 2002;400:190200.
[8] Kearney RS, Costa ML. Current concepts in the rehabilitation of an acute
rupture of the tendoAchillis. J Bone Joint Surg Br 2012;94(1):2831.
[9] Khan RJ, Fick D, Keogh A, Crawford J, Brammar T, Parker M. Treatment of acute
Achilles tendon ruptures. A meta-analysis of randomized, controlled trials. J
Bone Joint Surg Am 2005;87(10):220210.
[10] Twaddle BC, Poon P. Early motion for Achilles tendon ruptures: is surgery
important? A randomized, prospective study. Am J Sports Med 2007;35:2033
8.
[11] Willits K, Amendola A, Bryant D, Mohtadi NG, Grifn JR, Fowler P, et al.
Operative versus nonoperative treatment of acute Achilles tendon ruptures a
multicenter randomized trial using accelerated functional rehabilitation. J
Bone Joint Surg Am 2010;92(17):276775.
[12] Barfod KW, Bencke J, Lauridsen HB, Ban I, Ebskov L, Troelsen A. Nonoperative
dynamic treatment of acute Achilles tendon rupture: the inuence of early
weight-bearing on clinical outcome: a blinded, randomized controlled trial. J
Bone Joint Surg Am 2014;96(19):1497503.
[13] Bergkvist D, strm I, Josefsson PO, Dahlberg LE. Acute Achilles tendon
rupture: a questionnaire follow-up of 487 patients. J Bone Joint Surg Am
2012;94(13):122933.
[14] Barfod KW, Nielsen F, Helander KN, Mattila VM, Tingby O, Boesen A, et al.
Treatment of acute Achilles tendon rupture in Scandinavia does not adhere to
evidence-based guidelines: a cross-sectional questionnaire-based study of
138 departments. J Foot Ankle Surg 2013;52(5):62933.
[15] Jones MP, Khan RJ, Carey Smith RL. Surgical interventions for treating Achilles
tendon rupture. Key ndings from a recent cochrane review. J Bone Joint Surg
Am 2012;94(12):e88.
[16] Khan RJ, Carey Smith RL. Surgical interventions for treating acute Achilles
tendon ruptures. Cochrane Database Syst Rev 2010;8(September (9)):
CD003674, doi:http://dx.doi.org/10.1002/14651858.cd003674.pub4.
[17] Costa ML, MacMillan K, Halliday D, Chester R, Shepstone L, Robinson AH, et al.
Randomised controlled trials of immediate weight-bearing mobilization for
rupture of the tendoAchillis. J Bone Joint Surg Br 2006;88(1):6977.
[18] Suchak AA, Bostick GP, Beaupre LA, Durnad DC, Jomha NM. The inuence of
early weight-bearing compared with non-weight-bearing after surgical repair
of the Achilles tendon. J Bone Joint Surg Am 2008;90(9):187683.
[19] Nilsson-Helander K, Silbernagel KG, Thomee R, Faxen E, Olsson N, Eriksson BI,
et al. Acute Achilles tendon rupture: a randomized, controlled study
comparing surgical and nonsurgical treatments using validated outcome
measure. Am J Sports Med 2010;38(11):218693.
[20] Nilsson-Helander K, Thome R, Grvare-Silbernagel K, Thome P, Faxn E,
Eriksson BI, et al. The Achilles tendon total rupture score (ATRS) development
and validation. Am J Sports Med 2007;35(3):4216.
[21] Kearney RS, Achten J, Lamb SE, Plant C, Costa ML. A systematic review of
patient-reported outcome measures used to assess Achilles tendon rupture
management: Whats being used and should we be using it? Br J Sports Med
2012;46(16):11029.
[22] Kearney RS, Achten J, Lamb SE, Parsons N, Costa ML. The Achilles tendon total
rupture score: a study of responsiveness, internal consistency and convergent
validity on patients with acute Achilles tendon ruptures. Health Qual Life
Outcomes 2012;10(1):24.
[23] Carmont MR, Heaver C, Pradhan A, Mei-Dan O, Gravare Silbernagel K. Surgical
repair of the ruptured Achilles tendon: the cost-effectiveness of open versus
percutaneous repair. Knee Surg Sports Traumatol Arthrosc 2013;21(6):13618.
[24] Olsson N, Silbernagel KG, Eriksson BI, Sansone M, Brorsson A, Nilsson-
Helander K, et al. Stable surgical repair with accelerated rehabilitation versus
nonsurgical treatment for acute Achilles tendon ruptures: a randomized
controlled study. Am J Sports Med 2013;41(12):286776.
G Model
FAS 1028 No. of Pages 6
6 R. Aujla et al. / Foot and Ankle Surgery xxx (2017) xxxxxx
[25] Olsson N, Petzold M, Brorsson A, Karlsson J, Eriksson BI, Silbernagel KG.
Predictors of clinical outcome after acute Achilles tendon ruptures. Am J Sports
Med 2014;42(6):144855.
[26] Sibernagel KG, Brorsson A, Olsson N, Eriksson BI, Karlsson J, Nilsson-Helander
K. Sex differences in outcome after an acute Achilles tendon rupture. Orthop J
Sports Med 2014;3(6):16.
[27] Bostick GP, Jomha NM, Suchak AA, Beaupr LA. Factors associated with calf
muscle endurance recovery 1 year after Achilles tendon rupture repair. J
Orthop Sports Phys Ther 2010;40(6):34551.
[28] Longo UG, Rittweger J, Garau G, Radonic B, Gutwasser C, Gilliver SF, et al. No
inuence of age, gender, weight, height, and impact prole in achilles
tendinopathy in masters track and eld athletes. Am J Sports Med 2009;37
(7):14005.
[29] Healy B, Beasley R, Weatherall M. Venous thromboembolism following
prolonged cast immobilisation for injury to the tendo-Achillis. J Bone Joint
Surg Br 2010;92(5):64650.
Please cite this article in press as: R. Aujla, et al., Predictors of functional outcome in non-operatively managed Achilles tendon ruptures, Foot
Ankle Surg (2017), http://dx.doi.org/10.1016/j.fas.2017.03.007
[30] Metz R, Verleisdonk EJM, Geert JMG, Clevers GJ, Hammacher ER, Verhofstad
MH, et al. Acute Achilles tendon rupture minimally invasive surgery versus
nonoperative treatment with immediate full weight bearinga randomized
controlled trial. Am J Sports Med 2008;36(9):168894.
[31] Keating JF, Will EM. Operative versus non-operative treatment of acute rupture
of tendo Achillis: a prospective randomised evaluation of functional outcome. J
Bone Joint Surg Br 2011;93(8):10718.
[32] Nilsson-Helander K, Thurin A, Karlsson J, Eriksson BI. High incidence of deep
venous thrombosis after Achilles tendon rupture: a prospective study. Knee
Surg Sports Traumatol Arthrosc 2009;17:12348.
[33] Soroceanu A, Sidhwa F, Aarabi S, Kaufman A, Glazebrook M. Surgical versus
nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of
randomized trials. J Bone Joint Surg Am 2012;94(23):213643.
[34] Olsson N, Nilsson-Helander K, Karlsson J, Eriksson BI, Thomee R, Faxen E, et al.
Major functional decits persist 2 years after acute Achilles tendon rupture.
Knee Surg Sports Traumatol Arthrosc 2011;19:138593.