Even though a complete tear of the Achilles Tendon is typically managed by surgical repair, it can be managed well with below knee casting and physical therapy. The literature and my experience point to equal successes and failures with both techniques. Re- rupture rates are slightly higher with conservative treatment, but do exist with surgery. The other complications of serious note all involve surgical problems--excessive scarring, post op infections, and wound healing issues. We always give my patients both options, and the majority go for surgery. Given a good rehabilitation with physical therapy, both types of patients are at the same point one year after injury. All of my patients who have conservative care are at risk for re-rupture in the 45 days following cast removal. If re- rupture occurs, surgery is normally chosen to fix it. With modern day physical therapy, my patients get to 110% strength of their good side. The fastest patient to begin running post rupture with conservative treatment was at 6 and 1/2 months post injury. Since this technique needs the full teamwork between physician, patient, and therapist, there are only certain situations that this perfect storm will gel.
Email Received by Dr Blake
Dear Dr. Blake,
I am a 38 year old adjunct professor of occupational therapy/integrative health at and I recently sustained a right Achilles Tendon Rupture on the evening of August 13th. I went to the ER where my right foot was placed in a posterior cast and was told to see a doctor. I was able to see the doctor on August 15th where I was told that he recommends surgery for all of his Achilles Tendon rupture patients. He was not interested in supporting me through a nonoperative treatment approach. No ultrasound or MRI imaging was ordered.
After having done an extensive literature search on the topic so far and the fact that I have worked in physical rehabilitation for over 20 years I feel comfortable with choosing the nonoperative approach to my Achilles rupture treatment.
I came across an abstract of your article titled Achilles tendon rupture. A protocol for conservative management and I was hoping you might share the protocol with me.
I currently do not have a doctor following me and am willing to to pay out of pocket for a physical therapist that would be interested and open to supporting me through an Accelerated Functional Rehabilitation and/or the protocol you recommend. Do you feel this is an appropriate path to take?
Thank you for your time and consideration. I look forward to hearing from you.
Sarah (name changed)
Dr Blake's Response:
Sarah, thanks for the email. My approach has worked well, but requires 3 months of cast immobilization, normally done by a doctor. The first 6 weeks are crucial to be non weight bearing with your foot maximally planantarflexed at the ankle. I actually change the cast every 2 weeks to gain more plantarflexion with each cast. Due to various reasons, I have started the process up to 5 weeks post tear with no noticeable change in outcome. At 6 weeks, I begin to change the direction towards a more and more dorsiflexed position. These next 6 weeks are weight bearing, although initially not much due to the size of the cast. I carefully measure the amount of ankle joint dorsiflexion with each cast change. The last two weeks of weight bearing casting must be at 0 degrees of dorsiflexion to be on schedule to remove the cast at 12 weeks. I love to use a muscle stimulator under the cast from 6 to 12 weeks. From 12 to 18 weeks, you are still being protected in a removable cast as you begin the re-strengthening process. Here is where the physical therapist becomes the most important part of the team. Keeping the activity below the fatigue/re-rupture level of strength, and keeping the strength/flexibility ratio perfect, and gradually increasing power/endurance/ cardio takes a skilled PT. With the uniqueness/unfamiliarity of this conservative approach, I find that most patients and therapists go naturally slower than need be, but there is no rush. Let me know if you want more info, and good luck! Rich
Dear Dr. Blake,
Thank you so much for your prompt and thorough reply!
I have a particularly unstable lower back and I have found the cast to be quite cumbersome. I ruptured a disc when I had an ACL reconstruction in 2000 and I have trepidations about potentially doing the same thing in this situation.
Would a cast boot system such as the VacoCast (http://www.vacocast.com/pro/) set at maximum degrees of plantar flexion be appropriate for me to use now with the continued non-weight bearing status for 6 weeks as you mention? It seems the VacoCast would put a much less load on my spine over these next several weeks.
Thank you for sharing your wisdom!
Dr Blake's response:
Sarah, Could not get a stong feel from their website pro or con removable vs permanent cast. Normally, patients must be at 15 to 25 degrees of ankle plantarflexion in the first 2 to 4 weeks. This says it only goes to -10. Could you check with them on Monday if it can be adjusted but to -20 at least. Thanks. Rich This is important to bring the ends of the tear into as close proximity as possible!!!
Hi Dr. Blake,
Great recommendation Dr. Blake. I will rent a Roll A Bout! :)