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Cast or Walking Boot for Achilles Tendon Rupture?

March 23, 2020

Written by Clay Smith

Spoon Feed
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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