New York State Medical Treatment Guidelines for
Achilles Tendon Rupture in workers compensation patients
The New York State Workers Compensation Board has formulated guidelines to aid physicians in offering suitable treatment for Achilles Tendon Rupture. These guidelines are designed to support healthcare professionals in determining the optimal level of care for patients with ankle and foot disorders.
It’s important to note that these guidelines do not replace clinical judgment or professional expertise. The final decision regarding care should be a collaborative one, involving the patient and their healthcare provider.
Achilles Tendon Rupture for Ankle and Foot Disorders
A sudden pain at the back of the heel, often accompanied by a distinctive “pop,” is the primary indicator of a ruptured Achilles tendon. Typically, there is no preceding history of symptoms like pain or stiffness before the rupture occurs.
The most common symptom used for diagnosing an Achilles tendon rupture is a loss of plantar flexion. Other signs include the presence of a gap in the middle of the tendon that can be felt (around the calcaneal insertion) and a positive calf muscle squeeze test that doesn’t result in plantar flexion. In most cases of acute ruptures, specialized imaging is not immediately necessary.
There are no specific diagnostic criteria beyond these, and unlike chronic ruptures, which are examined four to six weeks or more after the injury, acute ruptures are evaluated within four weeks of the incident.
Once the diagnosis is confirmed, initial care is focused on managing symptoms until a formal treatment plan is established. This may involve cryotherapy, nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and relative rest.
Diagnostic Studies for Achilles Tendon Rupture
The diagnosis of an Achilles tendon rupture is typically based on clinical history and findings from a physical examination. X-rays are not commonly used for diagnosing acute Achilles ruptures, although they may be useful for identifying tendon calcification.
Routine X-ray for Diagnosis of Acute Achilles Rupture: Not recommended.
Indications: Used in cases of Achilles tendon ruptures caused by direct trauma, suspected involvement of the calcaneal insertion, or when there’s a strong suspicion of tendon calcification.
Rationale for Recommendation: While ruptures at the calcaneal insertion are rare, X-rays may be employed if suspected, as they can reveal avulsion of the bony insertion.
Ultrasound for Diagnosis of Acute Achilles Tendon Rupture: Recommended.
Indications: When the clinical likelihood of a rupture is high but uncertain.
Rationale for Recommendation: Ultrasound is advised as the primary method to confirm the diagnosis of Achilles ruptures, especially when there’s diagnostic uncertainty.
MRI for Diagnosis of Acute Achilles Tendon Rupture: Recommended.
Indications: When the clinical likelihood of a rupture is high but uncertain.
Rationale for Recommendation: MRI is recommended in specific cases where there’s a high level of clinical suspicion of a rupture. While ultrasound is generally preferred, MRI can be used in situations of diagnostic doubt, providing detailed information
Medications of Achilles Tendon Rupture
Ibuprofen, naproxen, or other NSAIDs from an earlier generation are recommended as the first-line treatments for the majority of patients. For those not suitable for NSAIDs, acetaminophen (or the analogue paracetamol) may be a viable alternative, even though research suggests it is slightly less effective than NSAIDs.
There is evidence that NSAIDs are less risky and equally effective in treating pain as opioids, such as tramadol.
NSAIDs for Treatment of Acute, Subacute, Chronic, or Postoperative Achilles Tendon Rupture Pain: Recommended.
Indications: Advised for the treatment of pain associated with acute, subacute, chronic, or postoperative Achilles tendon rupture. Over-the-counter (OTC) medications should be tried first.
Frequency/Duration: Patients may find it reasonable to use NSAIDs as needed.
Indications for Discontinuation: Discontinue when ankle/foot discomfort resolves, if they prove ineffective, or if adverse effects necessitate cessation.
NSAIDs for Patients at High-Risk of Gastrointestinal Bleeding for Achilles Tendon Rupture: Recommended.
Indications: Consider cytoprotective drugs for patients with a high-risk profile who also require NSAIDs, especially for prolonged treatment. Those at risk include individuals with a history of previous gastrointestinal bleeding, the elderly, those with diabetes, and smokers.
Frequency/Dose/Duration: Proton pump inhibitors, misoprostol, sucralfate, and H2 blockers are recommended. Dosage and frequency should follow the manufacturer’s guidelines. There is generally believed to be no substantial difference in efficacy for preventing gastrointestinal bleeding.
Indications for Discontinuation: Discontinue if intolerant, adverse effects emerge, or if NSAIDs are stopped.
NSAIDs for Patients at Risk for Cardiovascular Adverse Effects for Achilles Tendon Rupture: Recommended.
Indications: Intolerance, emergence of negative effects, or discontinuation of NSAIDs. If needed, non-selective NSAIDs are preferred over COX-2-specific medications.
Rationale for Recommendation: To minimize the risk of NSAIDs negating the protective effects of low-dose aspirin in individuals using it for cardiovascular disease prevention, NSAIDs should be taken at least 30 minutes after or eight hours before the daily aspirin.
Acetaminophen for Treatment of Acute, Subacute, or Chronic Achilles Rupture Pain: Recommended.
Indications: Acute, subacute, chronic, and postoperative cases with foot/ankle pain.
Dose/Frequency: As per the manufacturer’s recommendations; can be used as required. Liver toxicity is observed over four gm/day.
Indications for Discontinuation: Resolution of pain, adverse effects, or intolerance.
Opioids for Pain from Acute or Postoperative Achilles Tendon Repair: Recommended in select cases.
Indications: Treatment for postoperative pain in patients with moderate to severe pain or acute rupture.
Frequency/Dose/Duration: Follow the manufacturer’s instructions. Short courses of a few days, followed by a weaning period to nocturnal use if necessary, before withdrawal. Typically used as an additional form of pain management to NSAIDs or acetaminophen.
Indications for Discontinuation: Resolution of pain, adequate pain management with other treatments such as NSAIDs, intolerance, negative side effects, lack of benefits, or failure to make progress after a few weeks.
Rationale for Recommendations: Opioids are advised to be used sparingly and selectively in postoperative patients, primarily at night, to promote adequate postoperative sleep.
Opioids for Pain from Subacute or Chronic Achilles Tendon Repair: Not recommended for the treatment of acute or chronic pain.
Rationale for Recommendation: Opioids should not be used frequently due to associated risks and considerations.
Prophylaxis for Prevention of Deep Venous Thrombosis for Achilles Tendon Rupture: Recommended.
Indications: Patients with predisposing risks for developing venous thrombosis events. High-risk populations are not well defined and require a high degree of physician and patient judgment. A low threshold for prophylaxis may be appropriate for patients with a prior history of thrombotic events, delayed rehabilitation or ambulation, obesity, diabetes, or other coagulation disorders.
Rationale for Recommendation: To avoid deep vein thrombosis, especially in patients with predisposing risks. Prophylaxis is crucial for preventing thrombotic events.
Thrombosis Prophylaxis for Prevention of Deep Venous Thrombosis for Achilles Tendon Rupture: Not recommended.
Rationale for Recommendation: Thrombosis prophylaxis is not advised for preventing deep vein thrombosis in the context of Achilles tendon rupture.
Treatments for Achilles Tendon Rupture
Self-application of Cryotherapy or Heat Therapy for Acute, Subacute, Chronic, or Postoperative Achilles Tendon Rupture: Recommended for the treatment of Achilles tendon rupture that is acute, subacute, chronic, or postoperative.
Indications: Achilles tendon rupture in patients who are acute, subacute, chronic, or postoperative.
Frequency/Duration: As needed, three to five self-applications are made each day.
Indications for Discontinuation: Resolution, negative consequences, and noncompliance.
Rationale for Recommendation: Applying ice to an acute rupture in the near term may help reduce discomfort and swelling. Heat can be beneficial for recovery for a few days following the rupture or surgery. The self-application of cryotherapy or heat therapy provides a flexible and accessible approach to managing Achilles tendon rupture at different stages.
Rehabilitation Therapy for Achilles Tendon Rupture
Rehabilitation (supervised formal therapy) after a work-related injury should focus on restoring the functional ability necessary to meet daily and work obligations, aiming to return the patient to their pre-injury status to the extent practical. The goal is to enable a return to work.
Active therapy requires the patient’s internal effort to complete a specific activity or task, while passive therapy relies on modalities administered by a therapist without the patient exerting effort. Passive therapies are often used to complement an active therapy program and achieve concurrent functional gains. However, active initiatives should be prioritized over passive interventions. Patients are encouraged to continue both active and passive therapies at home to maintain progress.
Therapeutic Exercise – Physical/Occupational Therapy is recommended to improve function, including range of motion and strength.
- Frequency/Dose/Duration: The frequency of visits is determined by the severity of the constraint. Typically, two to three visits per week for the first two weeks are common, with the total number of visits varying based on functional improvement.
- Indications: All postoperative and conservatively managed Achilles rupture patients.
- Indications for Discontinuation: Discontinuation may occur in the presence of pain, intolerance, lack of effectiveness, or noncompliance.
Postoperative TENS for Achilles Tendon Repair is not recommended.
Rationale for Recommendation: There is no defined benefit of Transcutaneous Electrical Nerve Stimulation (TENS) for promoting the healing process postoperatively.
Surgery for Treatment of Achilles Tendon Rupture
Surgery for Treatment of Achilles Tendon Rupture is recommended as a treatment option. When discussing treatment choices with patients, it’s crucial to address the conflicting data results supporting both operative and nonoperative therapy. The discussion should encompass the equivocal superiority of surgery compared to non-operative treatment.
Non-Operative Management of Achilles Tendon Rupture with Functional Splinting and Casting is recommended for cases of a ruptured Achilles tendon. Non-operative treatment may be advised in many situations, especially for patients with low physical demands, where the risks may outweigh the benefits.
Open and Percutaneous Operative Approaches for Achilles Tendon Rupture are recommended for individuals undergoing surgical repair. There is no preference for one approach over another.
Augmented Surgical Repair for Acute Ruptures is not recommended for patients undergoing surgical repair. There is no preferred strategy over another.
Augmented Surgical Repair for Chronic or Neglected Ruptures is not recommended for chronic or neglected ruptures.
Early Weight Bearing for Postoperative Rehabilitation of Achilles Tendon Repair is recommended as the main form of postoperative rehabilitation for functional bracing or rigid immobilization of Achilles tendon ruptures. This is indicated for all postoperative, non-augmented Achilles tendon repairs accompanied by rigid casting or functional bracing. The recommended frequency and duration are to start within the two-week postoperative period. Discontinuation is based on criteria such as rerupture, surgical complications, and physical ability. The rationale for this recommendation is backed by strong data suggesting that early immobilization promotes short-term functional recovery, may increase patient mobility and improve quality of life, and has no discernible increase in complication rates.
Functional Bracing for Postoperative Rehabilitation of Achilles Tendon Repair is recommended as the main form of postoperative treatment for Achilles tendon ruptures. This is indicated for all healing of the Achilles tendon following surgery, particularly between 0 and 2 weeks postoperative. Discontinuation criteria include intolerance for devices, discomfort, and noncompliance.