Partial achilles injury

[Guest guest]

I have a client with a 3yo F/S New Zealand Heading dog (Like a Border Collie but

less obsessive!) that was flipped by a ewe and came up 3-legged lame in the RHL.

I saw her 2 days later and there was swelling at the hock, heat and what seemed

to be a partial tear. I think I can palpate the end of a tendon deep just

proximal to the calcaneous. The SDF tendon is intact. It is painful to

flex/palpate and I can not say whether there is hyperflexion because she resists

end ROM due to pain. I would love to have an MRI, CT scan or other diagnostic

to be positive of the diagnostics but the owner can not afford that and

treatment. So... assuming my hands are telling me the correct story should the

hock be casted/splinted for a certain period of time before we go to a brace and

rehab?? The owner would like to return to a limited amount of stock work if

possible.

Tracey DVM,CCRT

[Guest guest]

Tracey,

I was reading my recent issue of Clinical Journal of Sport Medicine and read a

review on a previous published study comparing surgical vs. non-surgical therapy

of achilles rupture in people.(1) Authors concluded that there was not a

significant difference in reruputure rates. A larger recent study by Willits et

al with earlier weight bearing and more aggressive functional range of motion

exercise had even lower rates of rerupture.(2)

Based on work with tendon injuries in horses, early use of adult mesenchymal

stem cells maybe of benefit in the dog however costs are involved with this

therapy.

Rick Wall, DVM

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(1)

Clin J Sport Med. 2012 Mar;22(2):169-70.

Surgical versus nonsurgical treatment of acute achilles tendon rupture.

son PR.

Source

Beaumont School of Medicine, Oakland University, Royal Oak, Michigan.

Abstract

OBJECTIVE:

To compare the incidence of reruptures and the functional outcomes of patients

with acute Achilles tendon rupture treated with or without surgery in addition

to identical rehabilitation protocols.

DESIGN:

Randomized controlled unblinded trial, with 1 year of follow-up. Sample size was

calculated with 80% power to show a previously observed difference of 19% in

rerupture rates between treatments at P & #8804;0.05.

SETTING:

The emergency department at the Sahlgrenska University Hospital, Gothenburg,

Sweden, in the period 2004 to 2007.

PARTICIPANTS:

Persons between 16 and 65 years of age with a unilateral Achilles tendon rupture

(based on medical history, tendon palpation, and the test) were

included in the study if they were randomized and treated within 72 hours of the

injury. Exclusion criteria were diabetes mellitus, previous Achilles tendon

rupture, other lower leg injuries, immunosuppressive therapy, and neurovascular

disease. The included patients were 79 men and 18 women, with a mean age of 41

years. The groups did not differ in age, sex, stature, side of injury, and

whether their work was sedentary or heavy.

INTERVENTION:

Surgery was performed on 49 patients by orthopedic surgeons familiar with the

modified Kessler suture technique. A longitudinal medial skin and paratenon

incision was made, and the Achilles tendon was repaired using an end-to-end

suture. The paratenon was repaired, and the skin was closed. After surgery, the

patients were placed in a below-the-knee cast with the foot in 30 degree equinus

position. The nonsurgical group (n = 48) were treated immediately with a similar

cast. All patients kept the cast on for 2 weeks, when it was replaced by a brace

for 6 weeks. The brace was adjusted by a physiotherapist to allow full flexion

and to gradually increase dorsiflexion from -30 to +10 degrees. All patients

followed a supervised standardized progressive exercise program from weeks 11 to

24 (or longer) and then started a group exercise program and a gradual return to

sports.

MAIN OUTCOME MEASURES:

The primary outcome was occurrence of rerupture. Secondary outcomes were

patient-reported Achilles tendon rupture scores and a physical activity scale

and function evaluations using the MuscleLab (Ergotest Technology) measurement

system, which included jump, strength, and muscular endurance tests. Patients

were assessed at 6 and 12 months by 2 independent physiotherapists.

MAIN RESULTS:

There were 6 reruptures in the nonsurgical group compared with 2 in the surgical

group (difference, 8.42%; 95% confidence interval, -2.46% to 19.3%). Achilles

tendon rupture scores improved during rehabilitation for both groups (P <

0.001), but they did not differ between groups. Physical activity scale scores

did not differ between groups but remained lower for both groups than before

injury (P < 0.05). Complications of surgery included 1 Achilles tendon

contracture, 2 infections, and 2 nerve disturbances on the side of the foot. The

rate of deep vein thrombosis was 34% and did not differ between groups. After 6

months, 2 endurance tests, hopping, and a strength test were superior in the

surgical group (P & #8804; 0.05), but at 12 months, only heel-rise work remained

superior (P < 0.012). The function of the injured leg was poorer than that of

the uninjured leg after 6 and 12 months.

CONCLUSIONS:

Rerupture rates and patients' assessment of their function were similar after

surgical or nonsurgical treatment for acute ruptures of the Achilles tendon.

Some strength and endurance tests improved earlier in the surgery group.

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(2)

J Bone Joint Surg Am. 2010 Dec 1;92(17):2767-75. Epub 2010 Oct 29.

Operative versus nonoperative treatment of acute Achilles tendon ruptures: a

multicenter randomized trial using accelerated functional rehabilitation.

Willits K, Amendola A, D, Mohtadi NG, Giffin JR, Fowler P, Kean CO,

Kirkley A.

Source

Fowler Kennedy Sport Medicine Clinic, 3M Centre, The University of Western

Ontario, London, ON N6A 3K7, Canada. kwillit@...

Abstract

BACKGROUND:

To date, studies directly comparing the rerupture rate in patients with an

Achilles tendon rupture who are treated with surgical repair with the rate in

patients treated nonoperatively have been inconclusive but the pooled relative

risk of rerupture favored surgical repair. In all but one study, the limb was

immobilized for six to eight weeks. Published studies of animals and humans have

shown a benefit of early functional stimulus to healing tendons. The purpose of

the present study was to compare the outcomes of patients with an acute Achilles

tendon rupture treated with operative repair and accelerated functional

rehabilitation with the outcomes of similar patients treated with accelerated

functional rehabilitation alone.

METHODS:

Patients were randomized to operative or nonoperative treatment for acute

Achilles tendon rupture. All patients underwent an accelerated rehabilitation

protocol that featured early weight-bearing and early range of motion. The

primary outcome was the rerupture rate as demonstrated by a positive

squeeze test, the presence of a palpable gap, and loss of plantar flexion

strength. Secondary outcomes included isokinetic strength, the Leppilahti score,

range of motion, and calf circumference measured at three, six, twelve, and

twenty-four months after injury.

RESULTS:

A total of 144 patients (seventy-two treated operatively and seventy-two treated

nonoperatively) were randomized. There were 118 males and twenty-six females,

and the mean age (and standard deviation) was 40.4 ± 8.8 years. Rerupture

occurred in two patients in the operative group and in three patients in the

nonoperative group. There was no clinically important difference between groups

with regard to strength, range of motion, calf circumference, or Leppilahti

score. There were thirteen complications in the operative group and six in the

nonoperative group, with the main difference being the greater number of

soft-tissue-related complications in the operative group.

CONCLUSIONS:

This study supports accelerated functional rehabilitation and nonoperative

treatment for acute Achilles tendon ruptures. All measured outcomes of

nonoperative treatment were acceptable and were clinically similar to those for

operative treatment. In addition, this study suggests that the application of an

accelerated-rehabilitation nonoperative protocol avoids serious complications

related to surgical management.

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