Comparison of Patient-Reported Outcomes for Molded Ankle-Foot Orthosis vs Traditional Walking Boot for Achilles Tendinopathy: A Retrospective Study

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose: Treatment of Achilles tendinopathy remains a therapeutic challenge for orthopaedic surgeons due to lack of consensus regarding optimal patient-centered treatment protocol. Available treatment options include physical therapy, analgesics, immobilization, and surgery. However, not every patient is an optimal candidate for surgery, thus making the need for a sustainable and effective alternative necessary. Common non-operative management includes immobilization via tall CAM walker boot (walking boot) and less commonly, use of custom molded ankle-foot orthoses (mAFO). However, little objective evidence exists to evaluate the efficacy of the mAFO compared to the walking boot. This study aims to identify the level of patient satisfaction and treatment efficacy in using the mAFO and the walking boot for Achilles tendinopathy. Methods: Patients with Achilles tendinopathy were identified in this retrospective study by ICD-10 codes and prescription for a mAFO or walking boot by an Orthopaedic foot and ankle provider between 2016 and 2024. Patients were excluded if they had prior Achilles rupture or subsequent surgery, neurological foot/ankle disorders, and ankle injury or corticosteroid injection within 3 months of enrollment. After collection of patient contact information, surveys regarding satisfaction, functionality, and treatment course were sent to patients prescribed a mAFO or a walking boot for Achilles tendinopathy. The initial round of surveys was sent as a link to patients via email and text message. Non-responders were sent a reminder text each day for the following three days, which was then repeated two weeks later if no response was received. Patients were declared official non-respondents after receiving and not responding to a phone call from team members after the first two attempts. Results: Seventy-nine of 305 mAFO patients (26%) and 27 of 78 walking boot patients (35%) completed the survey. Fifty (63%) mAFO and 16 (59%) walking boot patients reported treatment interventions prior to immobilization. Fifty-three (67%) mAFO and 24 (89%) walking boot patients were “satisfied” with their treatment. Twenty-five (32%) mAFO and 13 (48%) walking boot patients underwent additional treatment after completion of the immobilization course. The mean Achilles tendon function rating score was 72 in the mAFO group and 75 in the walking boot group on a scale of 1 (nonfunctional) to 100 (completely functional), with the TOST procedure confirming equivalence within an equivalence margin of 1 (lower t = 0.2944, upper t = 0.6395, t-critical = 1.660, df = 101, α = 0.05). Conclusion: Both the mAFO and the walking boot are acceptable non-operative treatment options for Achilles tendinopathy as both demonstrate a high level of patient satisfaction, restoration of acceptable functional status, and reduction in the need of additional treatment after completing their prescribed immobilization course. The TOST procedure demonstrated that Achilles function scores in both the mAFO and walking boot groups are equivalent, indicating that both treatment options are viable non-operative alternatives to surgical intervention. These non-surgical options can be valuable for patients with Achilles tendinopathy who either prefer to defer surgery or are not suitable surgical candidates.