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Achilles Tendon

NIHR Signal Functional braces are effective alternatives to plaster casts for ruptured Achilles tendons

Published on 25 March 2020

doi: 10.3310/signal-000894

Early weight-bearing in a below-knee rigid boot, a functional brace, following ruptured Achilles tendon can achieve similar results to traditional plaster casting. This NIHR-funded trial included 540 people, and after nine months there appeared to be no difference between the two treatments in terms of how well patients recovered from their injury. The functional brace was preferred by patients.

Functional bracing is an alternative to traditional plaster casting that allows earlier weight-bearing and mobilisation.

The researchers in this trial found that the rate of re-rupture was 5% to 6% and this was lower than that reported in the previous literature.

Clinicians treating Achilles tendon rupture may consider the use of early weight-bearing in a functional brace as a safe and effective alternative to plaster casting.

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Why was this study needed?

A new rupture of the Achilles tendon occurs in about 5–10 people per 100,000 each year. Rates depend on age and are increasing. Injures in men are more common than in women. Rupture results from a sporting injury in 80% of cases and affects people in their 40s and 50s, while non-sports related injuries typically peak in the 50s and 60s; however, all adults can be affected. This can result in time away from work and normal activities.

Non-surgical treatment is increasingly preferred for treatment but surgical repair is an alternative.

Traditional non-surgical treatment is by plaster cast. The cast protects the healing tendon, but is heavy and may lead to muscle wasting and increase the risk of blood clots. Functional bracing, where a patient’s calf is placed in a rigid walking boot containing wedges to lift the heel, allows earlier weight-bearing.

To date most trials have been small, single-centre studies, leading to inconclusive results. In the face of the lack of strong evidence, these researchers undertook a larger multicentre trial, with enough participants to find a difference between options if one existed.

What did this study do?

The UKSTAR trial was a randomised controlled superiority trial conducted in 39 UK hospitals between 2016 and 2018. Participants (average age 49 years) all had a primary Achilles tendon rupture.

Those randomised to plaster cast (266 people) had a below-knee cast fitted, with the toes pointing downwards. The cast position was gradually changed, with weight-bearing usually possible at six weeks. The cast was removed at eight weeks.

Those randomised to functional brace (274 people) had a removable, rigid walking boot. Full weight-bearing was possible immediately after fitting. The brace was removed at eight weeks.

All participants received standard physiotherapy advice, although additional rehabilitation support varied. Patients were assessed at eight weeks, and at nine months 93 per cent completed a questionnaire — the Achilles Tendon Total Rupture Score (ATRS). This questionnaire asks about symptoms, physical activity, and pain related to the Achilles tendon and results in a score between 0 and 100 across 10 items, with 100 as the best possible score. The researchers pre-specified the lowest important clinical difference as 8 points.

What did it find?

  • There was no difference in ATRS between the groups at nine months post-injury. Mean score in the cast group was 74.4 and in the functional brace group was 72.8. The adjusted mean difference of -1.38 (95% confidence interval [CI] -4.9 to 2.1) was not clinically important or statistically significant.
  • The rate of re-rupture of the tendon was about 5–6% in the plaster cast group and the functional brace group. None of the re-ruptures occurred more than six months after the injury.
  • Health-related quality of life, measured by EQ-5D-5L, showed a statistically significant benefit for functional brace at eight weeks, but not at later time points.
  • The mean total health and personal social care cost was £1,181 for the plaster cast group and £1,078 for the functional brace group, suggesting there is little difference in these average costs between treatments.

What does current guidance say on this issue?

There are no specific national guidelines on treatments for Achilles tendon rupture in the UK. The American Academy of Orthopaedic Surgeons published a guideline in 2009 which was unable to recommend for or against the use of immediate functional bracing for patients with acute Achilles tendon rupture.

Many UK hospitals offer both plaster and functional brace options for those being treated non-operatively, with the choice being made between the treating clinician and the patient.

What are the implications?

This large, well-conducted trial provides no evidence that traditional plaster casting is superior to early weight-bearing in a functional brace. The use of functional bracing was preferred by patients.

The results can give confidence to treating clinicians and patients that functional bracing is a good option for many patients.

Citation and Funding

Costa ML, Achten J, Marian IR et al. Plaster cast versus functional brace for non-surgical treatment of Achilles tendon rupture (UKSTAR): a multicentre randomised controlled trial and economic evaluation.  Lancet. 2020;395:441–8.

This project was funded by the NIHR Health Technology Assessment Programme (project number 13/115/62).

Bibliography

American Academy of Orthopaedic Surgeons. The diagnosis and treatment of acute Achilles tendon rupture: guideline and evidence report. Rosemont [IL]: American Academy of Orthopaedic Surgeons; 2009; (reviewed 2014).

NICE. Achilles tendinopathy: when should I suspect Achilles tendon rupture? Clinical Knowledge Summary. London: National Institute for Health and Care Excellence; (reviewed 2016).

Why was this study needed?

A new rupture of the Achilles tendon occurs in about 5–10 people per 100,000 each year. Rates depend on age and are increasing. Injures in men are more common than in women. Rupture results from a sporting injury in 80% of cases and affects people in their 40s and 50s, while non-sports related injuries typically peak in the 50s and 60s; however, all adults can be affected. This can result in time away from work and normal activities.

Non-surgical treatment is increasingly preferred for treatment but surgical repair is an alternative.

Traditional non-surgical treatment is by plaster cast. The cast protects the healing tendon, but is heavy and may lead to muscle wasting and increase the risk of blood clots. Functional bracing, where a patient’s calf is placed in a rigid walking boot containing wedges to lift the heel, allows earlier weight-bearing.

To date most trials have been small, single-centre studies, leading to inconclusive results. In the face of the lack of strong evidence, these researchers undertook a larger multicentre trial, with enough participants to find a difference between options if one existed.

What did this study do?

The UKSTAR trial was a randomised controlled superiority trial conducted in 39 UK hospitals between 2016 and 2018. Participants (average age 49 years) all had a primary Achilles tendon rupture.

Those randomised to plaster cast (266 people) had a below-knee cast fitted, with the toes pointing downwards. The cast position was gradually changed, with weight-bearing usually possible at six weeks. The cast was removed at eight weeks.

Those randomised to functional brace (274 people) had a removable, rigid walking boot. Full weight-bearing was possible immediately after fitting. The brace was removed at eight weeks.

All participants received standard physiotherapy advice, although additional rehabilitation support varied. Patients were assessed at eight weeks, and at nine months 93 per cent completed a questionnaire — the Achilles Tendon Total Rupture Score (ATRS). This questionnaire asks about symptoms, physical activity, and pain related to the Achilles tendon and results in a score between 0 and 100 across 10 items, with 100 as the best possible score. The researchers pre-specified the lowest important clinical difference as 8 points.

What did it find?

  • There was no difference in ATRS between the groups at nine months post-injury. Mean score in the cast group was 74.4 and in the functional brace group was 72.8. The adjusted mean difference of -1.38 (95% confidence interval [CI] -4.9 to 2.1) was not clinically important or statistically significant.
  • The rate of re-rupture of the tendon was about 5–6% in the plaster cast group and the functional brace group. None of the re-ruptures occurred more than six months after the injury.
  • Health-related quality of life, measured by EQ-5D-5L, showed a statistically significant benefit for functional brace at eight weeks, but not at later time points.
  • The mean total health and personal social care cost was £1,181 for the plaster cast group and £1,078 for the functional brace group, suggesting there is little difference in these average costs between treatments.

What does current guidance say on this issue?

There are no specific national guidelines on treatments for Achilles tendon rupture in the UK. The American Academy of Orthopaedic Surgeons published a guideline in 2009 which was unable to recommend for or against the use of immediate functional bracing for patients with acute Achilles tendon rupture.

Many UK hospitals offer both plaster and functional brace options for those being treated non-operatively, with the choice being made between the treating clinician and the patient.

What are the implications?

This large, well-conducted trial provides no evidence that traditional plaster casting is superior to early weight-bearing in a functional brace. The use of functional bracing was preferred by patients.

The results can give confidence to treating clinicians and patients that functional bracing is a good option for many patients.

Citation and Funding

Costa ML, Achten J, Marian IR et al. Plaster cast versus functional brace for non-surgical treatment of Achilles tendon rupture (UKSTAR): a multicentre randomised controlled trial and economic evaluation.  Lancet. 2020;395:441–8.

This project was funded by the NIHR Health Technology Assessment Programme (project number 13/115/62).

Bibliography

American Academy of Orthopaedic Surgeons. The diagnosis and treatment of acute Achilles tendon rupture: guideline and evidence report. Rosemont [IL]: American Academy of Orthopaedic Surgeons; 2009; (reviewed 2014).

NICE. Achilles tendinopathy: when should I suspect Achilles tendon rupture? Clinical Knowledge Summary. London: National Institute for Health and Care Excellence; (reviewed 2016).

Plaster cast versus functional brace for non-surgical treatment of Achilles tendon rupture (UKSTAR): a multicentre randomised controlled trial and economic evaluation

Published on 8 February 2020

Prof Matthew L Costa, PhD Juul Achten, PhDIoana R Marian, MScSusan J Dutton, MScProf Sarah E Lamb, PhDBenjamin Ollivere, MDMandy Maredza, PhDProf Stavros Petrou, PhDRebecca S Kearney, PhD

The Lancet , 2020

Background Patients with Achilles tendon rupture who have non-operative treatment have traditionally been treated with immobilisation of the tendon in plaster casts for several weeks. Functional bracing is an alternative non-operative treatment that allows earlier mobilisation, but evidence on its effectiveness and safety is scarce. The aim of the UKSTAR trial was to compare functional and quality-of-life outcomes and resource use in patients treated non-operatively with plaster cast versus functional brace. Methods UKSTAR was a pragmatic, superiority, multicentre, randomised controlled trial done at 39 hospitals in the UK. Patients (aged ≥16 years) who were being treated non-operatively for a primary Achilles tendon rupture at the participating centres were potentially eligible. The exclusion criteria were presenting more than 14 days after injury, previous rupture of the same Achilles tendon, or being unable to complete the questionnaires. Eligible participants were randomly assigned (1:1) to receive a plaster cast or functional brace using a centralised web-based system. Because the interventions were clearly visible, neither patients nor clinicians could be masked. Participants wore the intervention for 8 weeks. The primary outcome was patient-reported Achilles tendon rupture score (ATRS) at 9 months, analysed in the modified intention-to-treat population (all patients in the groups to which they were allocated, excluding participants who withdrew or died before providing any outcome data). The main safety outcome was the incidence of tendon re-rupture. Resource use was recorded from a health and personal social care perspective. The trial is registered with ISRCTN, ISRCTN62639639. Findings Between Aug 15, 2016, and May 31, 2018, 1451 patients were screened, of whom 540 participants (mean age 48·7 years, 79% male) were randomly allocated to receive plaster cast (n=266) or functional brace (n=274). 527 (98%) of 540 were included in the modified intention-to-treat population, and 13 (2%) were excluded because they withdrew or died before providing any outcome data. There was no difference in ATRS at 9 months post injury (cast group n=244, mean ATRS 74∙4 [SD 19∙8]; functional brace group n=259, ATRS 72∙8 [20∙4]; adjusted mean difference –1∙38 [95% CI –4∙9 to 2∙1], p=0·44). There was no difference in the rate of re-rupture of the tendon (17 [6%] of 266 in the plaster cast group vs 13 [5%] of 274 in the functional brace group, p=0·40). The mean total health and personal social care cost was £1181 for the plaster cast group and £1078 for the functional bract group (mean between-group difference –£103 [95% CI –289 to 84]). Interpretation Traditional plaster casting was not found to be superior to early weight-bearing in a functional brace, as measured by ATRS, in the management of patients treated non-surgically for Achilles tendon rupture. Clinicians may consider the use of early weight-bearing in a functional brace as a safe and cost-effective alternative to plaster casting.

Expert commentary

Rupture of the Achilles tendon is an increasingly common injury but the best method of treatment remains unclear.

This multicentre, randomised controlled trial done in the UK is especially relevant for the rehabilitation of older patients. The findings of this study showed no difference in ATRS at nine months between plaster cast and functional bracing. The safety profile of the functional brace was another important consideration of this trial. It was found that the risk of re-rupture was generally lower than that reported in the literature.

As this trial provides no evidence that traditional plaster casting is superior to early weight-bearing in a functional brace, many surgeons may select this latter method to allow early weight-bearing in the management of patients treated non-operatively for Achilles tendon rupture.

Behrooz Mostofi, Professor in Orthopaedics, Consultant Orthopaedic Surgeon, East Kent Hospital University NHS Foundation Trust

The commentator declares no conflicting interests