Cast or Walking Boot for Achilles Tendon Rupture?

Written by Clay Smith

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A walking boot vs rigid cast resulted in equal outcomes and adverse events, including tendon re-rupture rate at 9 months for patients with Achilles tendon rupture.

Why does this matter?
Nonoperative treatment of Achilles tendon rupture is a viable option, with equal outcomes. Usually, patients are treated in a cast for 8 weeks. Casts offer maximum protection for the tendon but at the expense of being non-weightbearing, along with muscle atrophy, ankle stiffness, and the potential increased risk of DVT. Would a functional brace work for this?

What are you talking – a boot?
This was an unblinded, multicenter RCT called UKSTAR, with 540 patients who had Achilles tendon rupture and chose a nonoperative approach. They were randomized to a plaster cast with slight plantar flexion (usual care) or functional, weight-bearing brace. The cast was successively altered to allow less and less plantar flexion over 8 weeks; at 6 weeks, weight bearing was allowed. The brace consisted of a removable walking boot with wedges to lift the heel and relax the Achilles tendon. These patients were allowed immediate weight bearing and had wedges removed over 8 weeks until the foot was perpendicular to the floor by 8 weeks. Then the brace was removed. See images. All had usual PT starting at 8 weeks. Most patients were compliant with assigned treatment, with minimal crossover. At 9 months, there was no difference in the primary outcome of Achilles tendon rupture score. Adverse outcomes were statistically equal among groups and included: tendon re-rupture (6% cast/5% brace; p=0.40), DVT/PE, fall with or without injury, heel pain or numbness and pressure sores. Total cost was not statistically different. I know which one I would choose if I opted for non-op treatment. Non-weightbearing is very difficult. And the ability to remove the brace and take a shower is a big deal.

Adapted from cited article

Plaster cast versus functional brace for non-surgical treatment of Achilles tendon rupture (UKSTAR): a multicentre randomised controlled trial and economic evaluation. Lancet. 2020 Feb 8;395(10222):441-448. doi: 10.1016/S0140-6736(19)32942-3.

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3 thoughts on “Cast or Walking Boot for Achilles Tendon Rupture?”

  1. take off the boot to go to bed can you use something else for support while you are sleeping if so what can you use

What are your thoughts?

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