1
|
Sukanen M, Khair RM, Reito A, Ponkilainen V, Paloneva J, Cronin N, Hautala AJ, Finni T. Early Predictors of Recovery From Nonoperatively Treated Achilles Tendon Rupture: 1 Year Follow-Up Study. Scand J Med Sci Sports 2024; 34:e14700. [PMID: 39010659 DOI: 10.1111/sms.14700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 06/10/2024] [Accepted: 06/28/2024] [Indexed: 07/17/2024]
Abstract
PURPOSE To investigate early structural and mechanical predictors of plantarflexor muscle strength and the magnitude of Achilles tendon (AT) nonuniform displacement at 6 and 12 months after AT rupture. METHODS Thirty-five participants (28 males and 7 females; mean ± SD age 41.7 ± 11.1 years) were assessed for isometric plantarflexion maximal voluntary contraction (MVC) and AT nonuniformity at 6 and 12 months after rupture. Structural and mechanical AT and plantarflexor muscle properties were measured at 2 months. Limb asymmetry index (LSI) was calculated for all variables. Multiple linear regression was used with the 6 and 12 month MVC LSI and 12 month AT nonuniformity LSI as dependent variables and AT and plantarflexor muscle properties at 2 months as independent variables. The level of pre- and post-injury sports participation was inquired using Tegner score at 2 and 12 months (scale 0-10, 10 = best possible score). Subjective perception of recovery was assessed with Achilles tendon total rupture score (ATRS) at 12 months (scale 0-100, 100=best possible score). RESULTS Achilles tendon resting angle (ATRA) symmetry at 2 months predicted MVC symmetry at 6 and 12 months after rupture (β = 2.530, 95% CI 1.041-4.018, adjusted R2 = 0.416, p = 0.002; β = 1.659, 95% CI 0.330-2.988, adjusted R2 = 0.418, p = 0.016, respectively). At 12 months, participants had recovered their pre-injury level of sports participation (Tegner 6 ± 2 points). The median (IQR) ATRS score was 92 (7) points at 12 months. CONCLUSION Greater asymmetry of ATRA in the early recovery phase may be a predictor of plantarflexor muscle strength deficits up to 1 year after rupture. TRIAL REGISTRATION This research is a part of "nonoperative treatment of Achilles tendon rupture in Central Finland: a prospective cohort study" that has been registered in ClinicalTrials.gov (NCT03704532).
Collapse
Affiliation(s)
- Maria Sukanen
- Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Ra'ad M Khair
- Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Aleksi Reito
- Department of Orthopaedics, Tampere University Hospital, Tampere, Finland
| | - Ville Ponkilainen
- Center for Musculoskeletal Diseases, Tampere University Hospital, Tampere, Finland
| | - Juha Paloneva
- Hospital Nova of Central Finland, Wellbeing Services County of Central Finland, Jyväskylä, Finland
- University of Eastern Finland, Kuopio, Finland
| | - Neil Cronin
- Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
- School of Education and Science, University of Gloucestershire, Cheltenham, UK
| | - Arto J Hautala
- Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Taija Finni
- Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| |
Collapse
|
2
|
Hébert-Losier K, Fernandez MR, Athens J, Kubo M, O'Neill S. A randomised crossover trial on the effects of foot starting position on calf raise test outcomes: Position does matter. Foot (Edinb) 2024; 60:102112. [PMID: 38905944 DOI: 10.1016/j.foot.2024.102112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 06/12/2024] [Accepted: 06/15/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND This randomised crossover study with repeated measures examined the influence of the three most common foot starting positions used in conducting the calf raise test (CRT) on test outcomes. This study also accounted for the potential influence of gender, age, body mass index (BMI), and level of physical activity on test outcomes. METHODS Forty-nine healthy individuals (59 % female, 21 ± 4 years) performed single-leg calf raise repetitions in a human movement laboratory in three randomised foot starting positions: flat, 10° incline, and step. The validated Calf Raise application was used to track the vertical displacement of a marker placed on the foot using computer vision. The application extracted the following CRT outcomes from the vertical displacement curve: number of repetitions, peak vertical height, total vertical displacement, and total positive work. Data were analysed using mixed-effects models and stepwise regression. RESULTS There was a significant main effect (P < 0.001) of foot starting position on all outcomes, with all paired comparisons being statistically significant (P ≤ 0.023). Repetitions, total vertical displacement, and total positive work were greatest in flat and lowest in step, whereas peak vertical height was greatest in incline and lowest in step. Gender (P = 0.021; males>females) and BMI (P = 0.002; lower BMI>higher BMI) significantly influenced the number of repetitions. Gender (P < 0.001; males>females) also influenced total positive work. Age and physical activity levels did not significantly influence CRT outcomes. CONCLUSIONS CRT foot starting position mattered and significantly affected all CRT outcomes. CRT foot starting position needs consideration when contrasting data in research and practice.
Collapse
Affiliation(s)
- Kim Hébert-Losier
- Division of Health, Engineering, Computing and Science, Te Huataki Waiora School of Health, University of Waikato, Tauranga, New Zealand.
| | - Ma Roxanne Fernandez
- Division of Health, Engineering, Computing and Science, Te Huataki Waiora School of Health, University of Waikato, Tauranga, New Zealand; Department of Physical Therapy, College of Rehabilitation Sciences, University of Santo Tomas, Philippines.
| | - Josie Athens
- Systems Biology Enabling Platform, AgResearch Ltd, Invermay Agricultural Centre, 176 Puddle Alley, Mosgiel 9022, New Zealand
| | - Masayoshi Kubo
- Department of Physical Therapy, Niigata University of Health and Welfare, Japan
| | - Seth O'Neill
- School of Healthcare, Life Sciences, University of Leicester, United Kingdom
| |
Collapse
|
3
|
Hoeffner R, Agergaard AS, Svensson RB, Cullum C, Mikkelsen RK, Konradsen L, Krogsgaard M, Boesen M, Kjaer M, Magnusson SP. Tendon Elongation and Function After Delayed or Standard Loading of Surgically Repaired Achilles Tendon Ruptures: A Randomized Controlled Trial. Am J Sports Med 2024; 52:1022-1031. [PMID: 38353060 DOI: 10.1177/03635465241227178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
BACKGROUND Achilles tendon ruptures often result in long-term functional deficits despite accelerated (standard) rehabilitation. PURPOSE/HYPOTHESIS The purpose of this study was to investigate if delayed loading would influence functional, clinical, and structural outcomes of the muscles and tendon 1 year after a surgical repair. It was hypothesized that delaying the loading would reduce the heel-rise height deficit 1 year after Achilles tendon rupture. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS In total, 48 patients with a surgically repaired Achilles tendon rupture were randomized to 2 groups: the standard group received the currently accepted rehabilitation, and the delayed group received the same rehabilitation except that initial loading was delayed by 6 weeks. The primary outcome was the heel-rise height difference between the injured and uninjured sides at 1 year. The secondary outcomes were (1) tendon length measured with magnetic resonance imaging, (2) muscle fascicle length and pennation angle of the gastrocnemius medialis muscle, (3) Doppler activity measured with ultrasonography, (4) Achilles tendon Total Rupture Score (ATRS), and (5) isometric muscle strength. RESULTS The mean heel-rise height deficits for the standard and delayed groups were -2.2 cm and -2.1 cm, respectively (P = .719). The soleus part of the tendon was already elongated 1 week after surgery in both groups without a between-group difference (side-to-side difference: standard, 16.3 mm; delayed, 17.5 mm; P = .997) and did not change over 52 weeks. The gastrocnemius tendon length was unchanged at 1 week but elongated over time without a between-group difference (side-to-side difference at 52 weeks: standard, 10.5 mm; delayed, 13.0 mm; P = .899). The delayed group had less Doppler activity at 12 weeks (P = .006) and a better ATRS (standard, 60 points; delayed, 72 points; P = .032) at 52 weeks. CONCLUSION Delayed loading was not superior to standard loading in reducing the heel-rise height difference at 1 year. The data indirectly suggested reduced inflammation in the initial months and a better patient-reported outcome at 1 year in the delayed group. The soleus part of the tendon was already markedly elongated (35%) 1 week after surgery, while the length of the gastrocnemius tendon was unchanged at 1 week but was 6% elongated at 1 year. Together, these data indirectly suggest that the delayed group fared better, although this finding needs to be confirmed in future investigations. REGISTRATION NCT04263493 (ClinicalTrials.gov identifier).
Collapse
Affiliation(s)
- Rikke Hoeffner
- Institute of Sports Medicine Copenhagen, Department of Orthopaedic Surgery, University Hospital Bispebjerg-Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Physical and Occupational Therapy, University Hospital Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Anne-Sofie Agergaard
- Institute of Sports Medicine Copenhagen, Department of Orthopaedic Surgery, University Hospital Bispebjerg-Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Physical and Occupational Therapy, University Hospital Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Rene B Svensson
- Institute of Sports Medicine Copenhagen, Department of Orthopaedic Surgery, University Hospital Bispebjerg-Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Camilla Cullum
- Department of Physical and Occupational Therapy, University Hospital Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Rasmus Kramer Mikkelsen
- Section for Sports Traumatology, Department of Orthopedic Surgery, University Hospital Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Lars Konradsen
- Section for Sports Traumatology, Department of Orthopedic Surgery, University Hospital Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Michael Krogsgaard
- Section for Sports Traumatology, Department of Orthopedic Surgery, University Hospital Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Mikael Boesen
- Department of Radiology, University Hospital Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Michael Kjaer
- Institute of Sports Medicine Copenhagen, Department of Orthopaedic Surgery, University Hospital Bispebjerg-Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - S Peter Magnusson
- Institute of Sports Medicine Copenhagen, Department of Orthopaedic Surgery, University Hospital Bispebjerg-Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Physical and Occupational Therapy, University Hospital Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| |
Collapse
|
4
|
Barfod KW, Overgård AB, Hansen MS, Haddouchi IE, Toft M, Hölmich P. Effect of the Copenhagen Achilles Rupture Treatment Algorithm (CARTA) on Calf Muscle Volume and Tendon Elongation After Acute Achilles Tendon Rupture: A Predefined Secondary Analysis of the First 60 Patients in a Randomized Controlled Trial. Orthop J Sports Med 2023; 11:23259671231211282. [PMID: 38021304 PMCID: PMC10664448 DOI: 10.1177/23259671231211282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 06/19/2023] [Indexed: 12/01/2023] Open
Abstract
Background Surgical treatment of acute Achilles tendon rupture (ATR) lowers the risk of rerupture and may reduce calf atrophy and elongation of the Achilles tendon. The Copenhagen Achilles Rupture Treatment Algorithm (CARTA) was developed to provide individualized treatment selection based on ultrasonographic evaluation of the rupture. Purpose In a randomized setup, the present study aimed to investigate whether treatment selection using the CARTA could reduce atrophy and tendon elongation compared with (1) patients treated surgically and (2) patients treated nonsurgically. Study Design Randomized controlled trial; Level of evidence, 2. Methods A total of 60 patients with an acute ATR were randomly assigned to receive treatment based on the CARTA (intervention), surgical treatment (control), or nonsurgical treatment (control) in a 1 to 1 to 1 ratio. After 1 year, magnetic resonance imaging of both calves was performed, and muscle volume and Achilles tendon length were measured. Results were presented as the ratio between the affected and the unaffected limbs (ie, limb symmetry index; %). Results A total of 156 patients were assessed for eligibility, 60 patients were randomized, and 54 patients provided data for the study-19 patients received treatment based on the CARTA (intervention group), 17 patients received nonsurgical treatment (control), and 18 patients received surgical treatment (control). No statistically significant differences were found between the intervention group and the 2 control groups regarding muscle volume and tendon length. No statistically significant differences were found between patients treated surgically and patients treated nonsurgically. Comparison between the affected and the unaffected limb showed statistically significant muscle atrophy (24%-30%) and tendon elongation (soleus, 59%-76%; gastrocnemius, 8%-14%) in the affected limb in all 3 groups. Conclusion Individualized treatment of acute ATR using an ultrasonographic selection algorithm did not reduce calf muscle atrophy or tendon elongation when compared with surgical and nonsurgical treatment. Surgical treatment did not reduce calf muscle atrophy or tendon elongation compared with nonsurgical treatment.
Collapse
Affiliation(s)
- Kristoffer Weisskirchner Barfod
- Department of Orthopedic Surgery, Sports Orthopedic Research Center–Copenhagen (SORC-C), Copenhagen University Hospital Amager-Hvidovre, Denmark
| | - Anders Brøgger Overgård
- Department of Orthopedic Surgery, Sports Orthopedic Research Center–Copenhagen (SORC-C), Copenhagen University Hospital Amager-Hvidovre, Denmark
| | - Maria Swennergren Hansen
- Department of Physical and Occupational Therapy, Physical Medicine & Rehabilitation Research–Copenhagen (PMR-C), Copenhagen University Hospital Amager-Hvidovre, Denmark
| | - Ibrahim El Haddouchi
- Department of Orthopedic Surgery, Sports Orthopedic Research Center–Copenhagen (SORC-C), Copenhagen University Hospital Amager-Hvidovre, Denmark
| | - Marianne Toft
- Department of Orthopedic Surgery, Viborg Regional Hospital, Viborg, Denmark
| | - Per Hölmich
- Department of Orthopedic Surgery, Sports Orthopedic Research Center–Copenhagen (SORC-C), Copenhagen University Hospital Amager-Hvidovre, Denmark
| |
Collapse
|
5
|
Fernandez MR, Hébert-Losier K. Devices to measure calf raise test outcomes: A narrative review. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2023; 28:e2039. [PMID: 37440324 DOI: 10.1002/pri.2039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 05/10/2023] [Accepted: 06/29/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND The calf raise test (CRT) is commonly administered without a device in clinics to measure triceps surae muscle function. To standardise and objectively quantify outcomes, researchers use research-grade or customised CRT devices. To incorporate evidence-based practice and apply testing devices effectively in clinics, it is essential to understand their design, applicability, psychometric properties, strengths, and limitations. Therefore, this review identifies, summarises, and critically appraises the CRT devices used in science. METHODS Four electronic databases were searched in April 2022. Studies that used devices to measure unilateral CRT outcomes (i.e., number of repetitions, work, height) were included. RESULTS Thirty-five studies met inclusion, from which seven CRT devices were identified. Linear encoder (n = 18) was the most commonly used device, followed by laboratory equipment (n = 6) (three-dimensional motion capture and force plate). These measured the three CRT outcomes. Other devices used were electrogoniometer, Häggmark and Liedberg light beam device, Ankle Measure for Endurance and Strength (AMES), Haberometer, and custom-made. Devices were mostly used in healthy populations or Achilles tendon pathologies. AMES, Haberometer, and custom-made devices were the most clinician-friendly, but only quantified repetitions were completed. In late 2022, a computer vision mobile application appeared in the literature and offered clinicians a low-cost, research-grade alternative. CONCLUSION This review details seven devices used to measure CRT outcomes. The linear encoder is the most common in research and quantifies all three CRT outcomes. Recent advances in computer-vision provide a low-cost research-grade alternative to clinicians and researchers via a n iOS mobile application.
Collapse
Affiliation(s)
- Ma Roxanne Fernandez
- Division of Health, Engineering, Computing and Science, Te Huataki Waiora School of Health, University of Waikato, Hamilton, New Zealand
- Department of Physical Therapy, College of Rehabilitation Sciences, University of Santo Tomas, Manila, Philippines
| | - Kim Hébert-Losier
- Division of Health, Engineering, Computing and Science, Te Huataki Waiora School of Health, University of Waikato, Hamilton, New Zealand
| |
Collapse
|
6
|
Hoeffner R, Svensson RB, Dietrich-Zagonel F, Schefte D, Kjær M, Eliasson P, Magnusson SP. Muscle fascicle and sarcomere adaptation in response to Achilles tendon elongation in an animal model. J Appl Physiol (1985) 2023; 135:326-333. [PMID: 37348011 DOI: 10.1152/japplphysiol.00040.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 06/16/2023] [Accepted: 06/16/2023] [Indexed: 06/24/2023] Open
Abstract
Permanent loss of muscle function seen after an Achilles tendon rupture may partly be explained by tendon elongation and accompanying shortening of the muscle. Muscle fascicle length shortens, serial sarcomere number is reduced, and the sarcomere length is unchanged after Achilles tendon transection (ATT), and these changes are mitigated with suturing. The method involved in this study was a controlled laboratory study. Two groups of rats underwent ATT on one side with a contralateral control (CTRL): A) ATT with 3 mm removal of the Achilles tendon and no suturing (substantial tendon elongation), and B) ATT with suture repair (minimal tendon elongation). The operated limb was immobilized for 2 wk to reduce load. Four weeks after surgery the rats were euthanized, and hindlimbs were analyzed for tendon length, gastrocnemius medialis (GM) muscle mass, length, fascicle length, sarcomere number and length. No differences were observed between the groups, and in both groups the Achilles tendon length was longer (15.2%, P < 0.001), GM muscle mass was smaller (17.5%, P < 0.001), and muscle length was shorter (8.2%, P < 0.001) on the ATT compared with CTRL side. GM fascicle length was shorter (11.2%, P < 0.001), and sarcomere number was lower (13.8%, P < 0.001) on the ATT side in all regions. Sarcomere length was greater in the proximal (5.8%, P < 0.001) and mid (4.2%, P = 0.003), but not distal region on the ATT side. In this animal model, regardless of suturing, ATT resulted in tendon elongation, loss of muscle mass and length, and reduced serial sarcomere number, which resulted in an "overshoot" lengthening of the sarcomeres.NEW & NOTEWORTHY Following acute Achilles tendon rupture, patients are often left with functional deficits. The specific reason remains largely unknown. The shortened muscle leads to reduced fascicle length, in turn leading to adaptation by reduced serial sarcomere numbers. Surprisingly, this adaptation appears to "overshoot" and lead to increased sarcomere length. The present animal model advances understanding of how muscle sarcomeres, which are difficult to measure in humans, are affected when undue elongation takes place after tendon rupture.
Collapse
Affiliation(s)
- Rikke Hoeffner
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Physical and Occupational Therapy, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Rene B Svensson
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Franciele Dietrich-Zagonel
- Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Science, Linköping University, Linköping, Sweden
| | - Daniel Schefte
- Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Science, Linköping University, Linköping, Sweden
| | - Michael Kjær
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Pernilla Eliasson
- Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Science, Linköping University, Linköping, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - S Peter Magnusson
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Physical and Occupational Therapy, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
| |
Collapse
|
7
|
van Dijk K, Khair RM, Sukanen M, Cronin NJ, Finni T. Medial gastrocnemius muscle fascicle function during heel-rise after non-operative repair of Achilles tendon rupture. Clin Biomech (Bristol, Avon) 2023; 105:105977. [PMID: 37156191 DOI: 10.1016/j.clinbiomech.2023.105977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 03/23/2023] [Accepted: 04/27/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND To better understand muscle remodelling in dynamic conditions after an Achilles tendon rupture, this study examined the length of medial gastrocnemius muscle fascicles during a heel-rise at 6- and 12-months after non-operative ATR treatment. METHODS Participants (15 M, 3F) were diagnosed with acute Achilles tendon rupture. Medial gastrocnemius subtendon length, fascicle length and pennation angle were assessed in resting conditions, and fascicle shortening during bi- and unilateral heel-rises. FINDINGS Fascicle shortening was smaller on the injured side (mean difference [95% CI]: -9.7 mm [-14.7 to -4.7 mm]; -11.1 mm [-16.5 to -5.8 mm]) and increased from 6- to 12 months (4.5 mm [2.8-6.3 mm]; 3.2 mm [1.4-4.9 mm]) in bi- and unilateral heel-rise, respectively. The injured tendon was longer compared to contralateral limb (2.16 cm [0.54-3.79 cm]) and the length decreased over time (-0.78 cm [-1.28 to -0.29 cm]). Tendon length correlated with fascicle shortening in bilateral (r = -0.671, p = 0.002; r = -0.666, p = 0.003) and unilateral (r = -0.773, p ≤ 0.001; r = -0.616, p = 0.006) heel-rise, at 6- and 12-months, respectively. In the injured limb, the change over time in fascicle shortening correlated with change in subtendon length in unilateral heel-rise (r = 0.544, p = 0.02). INTERPRETATION This study showed that the lengths of the injured tendon and associated muscle can adapt throughout the first year after rupture when patients continue physiotherapy and physical exercises. For muscle, measures of resting length may not be very informative about adaptations, which manifest themselves during functional tasks such as unilateral heel-rise.
Collapse
Affiliation(s)
- Koen van Dijk
- Faculty of Sport and Health Sciences, Neuromuscular Research Center, University of Jyväskylä, Rautpohjankatu 8, 40700 Jyväskylä, Jyväskylä, Finland
| | - Raad M Khair
- Faculty of Sport and Health Sciences, Neuromuscular Research Center, University of Jyväskylä, Rautpohjankatu 8, 40700 Jyväskylä, Jyväskylä, Finland
| | - Maria Sukanen
- Faculty of Sport and Health Sciences, Neuromuscular Research Center, University of Jyväskylä, Rautpohjankatu 8, 40700 Jyväskylä, Jyväskylä, Finland
| | - Neil J Cronin
- Faculty of Sport and Health Sciences, Neuromuscular Research Center, University of Jyväskylä, Rautpohjankatu 8, 40700 Jyväskylä, Jyväskylä, Finland; School of Sport & Exercise, University of Gloucestershire, Gloucestershire, UK
| | - Taija Finni
- Faculty of Sport and Health Sciences, Neuromuscular Research Center, University of Jyväskylä, Rautpohjankatu 8, 40700 Jyväskylä, Jyväskylä, Finland.
| |
Collapse
|
8
|
Khair RM, Stenroth L, Cronin NJ, Ponkilainen V, Reito A, Finni T. Exploration of muscle-tendon biomechanics one year after Achilles tendon rupture and the compensatory role of flexor hallucis longus. J Biomech 2023; 152:111586. [PMID: 37080080 DOI: 10.1016/j.jbiomech.2023.111586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/30/2023] [Accepted: 04/10/2023] [Indexed: 04/22/2023]
Abstract
Achilles tendon (AT) rupture leads to long-term structural and functional impairments. Currently, the predictors of good recovery after rupture are poorly known. Thus, we aimed to explore the interconnections between structural, mechanical, and neuromuscular parameters and their associations with factors that could explain good recovery in patients with non-surgically treated AT rupture. A total of 35 patients with unilateral rupture (6 females) participated in this study. Muscle-tendon structural, mechanical, and neuromuscular parameters were measured 1-year after rupture. Interconnections between the inter-limb differences (Δ) were explored using partial correlations, followed by multivariable linear regression to find associations between the measured factors and the following markers that indicate good recovery: 1) tendon length, 2) tendon non-uniform displacement, and 3) flexor hallucis longus (FHL) normalized EMG amplitude difference between limbs. Δmedial gastrocnemius (MG) (β = -0.12, p = 0.007) and Δlateral gastrocnemius (β = -0.086, p = 0.030) subtendon lengths were associated with MG tendon Δstiffness. MG (β = 11.56, p = 0.003) and soleus (β = 2.18, p = 0.040) Δsubtendon lengths explained 48 % of variance in FHL EMG amplitude. Regression models for tendon length and non-uniform displacement were not significant. Smaller inter-limb differences in Achilles subtendon lengths were associated with smaller differences in the AT stiffness between limbs, and a smaller contribution of FHL muscle to the plantarflexion torque. In the injured limb, the increased contribution of FHL appears to partially counteract a smaller contribution from MG due to the elongated tendon, however the role of FHL should not be emphasized during rehabilitation to allow recovery of the TS muscles.
Collapse
Affiliation(s)
- Ra'ad M Khair
- Faculty of Sport and Health Sciences, Neuromuscular Research Center, University of Jyväskylä, Jyväskylä, Finland.
| | - Lauri Stenroth
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland
| | - Neil J Cronin
- Faculty of Sport and Health Sciences, Neuromuscular Research Center, University of Jyväskylä, Jyväskylä, Finland; School of Sport and Exercise, University of Gloucestershire, UK
| | | | - Aleksi Reito
- Central Finland Central Hospital Nova, Jyväskylä, Finland
| | - Taija Finni
- Faculty of Sport and Health Sciences, Neuromuscular Research Center, University of Jyväskylä, Jyväskylä, Finland
| |
Collapse
|
9
|
Fernandez MR, Athens J, Balsalobre-Fernandez C, Kubo M, Hébert-Losier K. Concurrent validity and reliability of a mobile iOS application used to assess calf raise test kinematics. Musculoskelet Sci Pract 2023; 63:102711. [PMID: 36604270 DOI: 10.1016/j.msksp.2022.102711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 11/04/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Calf raise test (CRT) is used in rehabilitation and sports medicine to evaluate calf muscle function. The Calf Raise application (CRapp) uses computer-vision algorithms to objectively measure CRT outcomes and replicate laboratory-based metrics that are difficult to measure clinically. OBJECTIVE To validate the CRapp by examining its concurrent validity and agreement levels against laboratory-based equipment, and its intra- and inter-rater reliability. DESIGN Observational cross-sectional validation study. METHODS CRT outcomes (i.e., repetitions, positive work, total height, peak height, fatigue index, and peak power) were assessed in thirteen individuals (6 males, 7 females) on three occasions on both legs using the CRapp, 3D motion capture, and force plate simultaneously. Data were extracted from two markers: below lateral malleolus (n = 77) and on the heel (n = 77). Concurrent validity and agreement were determined from 154 data files using intraclass correlation coefficients (ICC3,k), typical errors expressed as coefficient of variations (CV), and Bland-Altman plots to assess biases and precision. Reliability was assessed using ICC3,1 and CV values. RESULTS Validity of CRapp outcomes was good to excellent across measures for both markers (mean ICC ≥0.878), precision plots showing good agreement and precision. CV ranged from 0% (repetitions) to 33.3% (fatigue index) and were on average better for the lateral malleolus marker. Inter- and intra-rater reliability were excellent (ICC≥0.949, CV ≤ 5.6%). CONCLUSION CRapp is valid and reliable within and between users for measuring CRT outcomes in healthy adults. CRapp provides a tool to objectivise CRT outcomes in research and practice, aligning with recent advances in mobile technologies and their increased use in healthcare.
Collapse
Affiliation(s)
- Ma Roxanne Fernandez
- Division of Health, Engineering, Computing and Science, Te Huataki Waiora School of Health, University of Waikato, New Zealand; Department of Physical Therapy, College of Rehabilitation Sciences, University of Santo Tomas, Philippines.
| | - Josie Athens
- Department of Preventive and Social Medicine, University of Otago, PO Box 56, Dunedin, 9054, New Zealand.
| | | | - Masayoshi Kubo
- Department of Physical Therapy, Niigata University of Health and Welfare, Japan.
| | - Kim Hébert-Losier
- Division of Health, Engineering, Computing and Science, Te Huataki Waiora School of Health, University of Waikato, New Zealand.
| |
Collapse
|
10
|
Nakamura G, Yasuda T, Shima H, Togei K, Hirai Y, Neo M. Morphology of the asymptomatic Αchilles tendon: Measurement of tendon length and shape using magnetic resonance imaging, and investigation of related factors. J Orthop Sci 2023; 28:204-211. [PMID: 34756633 DOI: 10.1016/j.jos.2021.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 08/27/2021] [Accepted: 09/20/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND One of the severe complications of Achilles tendon (AT) rupture is muscle weakness due to tendon lengthening. It is very important to prevent tendon lengthening during treatment; however, data on the length, thickness, and width of normal ATs are scarce. Furthermore, no studies have investigated the factors related to the AT length and shape. We aimed to determine the normal AT length and shape and to investigate any correlating factors. METHODS We measured the AT length, thickness, and width of 100 asymptomatic patients using magnetic resonance imaging. We also investigated the correlation between the AT length, thickness, and width and factors including age, sex, height, body weight, body mass index, history of sports activities, and the area of Kager's fat pad. RESULTS The mean AT length was 42.1 ± 12.9 mm. The AT length in 73% of the patients was within the range of 30-55 mm. Individual differences in the tendon length were large, but there was no correlation between the tendon length and patient height (P = 0.505). There was a strong correlation between the AT length and area of Kager's fat pad on magnetic resonance imaging (r = 0.734, P < 0.001). Furthermore, the correlation coefficient between the area of Kager's fat pad on magnetic resonance imaging and the area of Kager's triangle on radiography was extremely high (r = 0.851, P < 0.001). CONCLUSIONS The AT length can be predicted based on the area of Kager's triangle of the unaffected ankle on radiography. If the AT length is > 55 mm or longer than the length measured directly or calculated from the estimated area of Kager's triangle, tendon lengthening should be suspected. Our findings could provide an important indicator for the evaluation of AT lengthening not only in daily clinical situations but also in clinical studies.
Collapse
Affiliation(s)
- Gen Nakamura
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, 2-7, Daigaku-machi, Takatsuki City, Osaka 569-8686 Japan
| | - Toshito Yasuda
- Faculty of Nursing, Osaka Medical and Pharmaceutical University, 7-6 Hatchonishi-machi, Takatsuki City, Osaka 569-0095, Japan.
| | - Hiroaki Shima
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, 2-7, Daigaku-machi, Takatsuki City, Osaka 569-8686 Japan
| | - Kosho Togei
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, 2-7, Daigaku-machi, Takatsuki City, Osaka 569-8686 Japan
| | - Yoshihiro Hirai
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, 2-7, Daigaku-machi, Takatsuki City, Osaka 569-8686 Japan
| | - Masashi Neo
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, 2-7, Daigaku-machi, Takatsuki City, Osaka 569-8686 Japan
| |
Collapse
|
11
|
Mikkelsen RK, Somodi S, Hölmich P, Barfod KW. Calcaneal positioning in equinus immobilization of the ankle joint: A comparison of common orthoses used in the treatment of acute Achilles tendon ruptures. Foot Ankle Surg 2022; 28:1314-1320. [PMID: 35798616 DOI: 10.1016/j.fas.2022.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 04/03/2022] [Accepted: 06/16/2022] [Indexed: 02/04/2023]
Abstract
Orthoses are an important part of both conservative and operative treatment of acute Achilles tendon rupture as they can be used to position the foot in equinus and protect the torn tendon from strain in the healing phase. The aim of the study was to test four different orthoses ability to position the foot in equinus. The study was performed as a cross-sectional study. 15 healthy study participants underwent radiographic examination with 11 true lateral radiographs of the right ankle and foot, one with the ankle joint in neutral position; one of a circular equinus cast (CEC); three of an adjustable equinus boot (AEB) with the foot in 30°, 15°, and 0° of plantar flexion, respectively; three of a fixed angle orthosis with 1, 2, and 3 wedges with a plateau (WWP); and three of a fixed angle orthosis with 1, 2, and 3 wedges without plateau (WWOP). The primary outcome was the Achilles Relief Distance (ARD). Secondary outcomes were the tibiocalcaneal angle (TCA), the tibiotalar angle (TTA), and the tibio- 1st metatarsal angle (1MTP). All measurements were performed by a radiologist. The mean (SD) ARD was 11 mm (7) in CEC, 23 mm (6) with 3 WWP, 11 mm (5) with 3 WWOP, and 15 mm (5) using AEB in 30° of plantarflexion. The mean (SD) TCA was 86° (7,8) in CEC, 76° (7,3) with 3 WWP, 90° (6,9) with 3 WWOP, and 84° (6,6) using the AEB in 30° of plantarflexion. CEC, AEB, and WWOP showed statistically significantly larger plantarflexion than WWP. CEC, AEB and WWOP produced significantly greater plantarflexion compared to WWP.
Collapse
Affiliation(s)
- Rasmus Kramer Mikkelsen
- Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre, Kettegård Allé 30, 2650 Hvidovre, Denmark; Sports Orthopedic Research Center - Copenhagen (SORC-C), Denmark.
| | - Sanja Somodi
- Department of Radiology, Copenhagen University Hospital Hvidovre, Kettegård Allé 30, 2650 Hvidovre, Denmark
| | - Per Hölmich
- Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre, Kettegård Allé 30, 2650 Hvidovre, Denmark; Sports Orthopedic Research Center - Copenhagen (SORC-C), Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Kristoffer Weisskirchner Barfod
- Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre, Kettegård Allé 30, 2650 Hvidovre, Denmark; Sports Orthopedic Research Center - Copenhagen (SORC-C), Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
12
|
Aufwerber S, Silbernagel KG, Ackermann PW, Naili JE. Comparable Recovery and Compensatory Strategies in Heel-Rise Performance After a Surgically Repaired Acute Achilles Tendon Rupture: An In Vivo Kinematic Analysis Comparing Early Functional Mobilization and Standard Treatment. Am J Sports Med 2022; 50:3856-3865. [PMID: 36322396 DOI: 10.1177/03635465221129284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Deficits in calf muscle function and heel-rise performance are common after an Achilles tendon rupture (ATR) and are related to tendon elongation and calf muscle atrophy. Whether early functional mobilization (EFM) can improve calf muscle function compared with standard treatment (ST) with 2 weeks of immobilization and unloading in a plaster cast is unknown. HYPOTHESIS EFM would lead to superior recovery of heel-rise performance, as demonstrated by more symmetrical side-to-side ankle and knee joint kinematics, compared with ST. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS In total, 47 patients with an ATR were prospectively included and treated with open surgical repair and randomized 2:1 postoperatively to either EFM or ST. Overall, 29 patients were treated with a dynamic orthosis (EFM), and 18 underwent ST. At 8 weeks and 6 months after ATR repair, 3-dimensional motion analysis of heel-rise performance was conducted. At 6 months, tendon length and muscle volume were assessed with ultrasound imaging, calf muscle function with the heel-rise test, and patient-reported outcomes with the Achilles tendon Total Rupture Score. RESULTS At 8 weeks and 6 months, there were no significant group differences between the EFM and ST groups in heel-rise performance, but significant side-to-side differences in ankle and knee kinematics were detected. At 8 weeks and 6 months, both the EFM and ST groups showed a significantly decreased peak ankle plantarflexion angle and increased knee flexion angle on the injured limb compared with the uninjured limb during bilateral heel raises. Linear regression demonstrated that greater atrophy of the medial gastrocnemius muscle (P = .008) and higher body weight (P < .001) were predictors of a decreased maximum peak ankle plantarflexion angle on the injured limb at 6 months. CONCLUSION EFM after an ATR repair did not lead to superior recovery of calf muscle function, as assessed by heel-rise performance, compared with ST. Increased knee flexion seemed to be a compensatory strategy for decreased ankle plantarflexion. Medial gastrocnemius atrophy and increased body weight were additional factors associated with a decreased ankle plantarflexion angle. REGISTRATION NCT02318472 (ClinicalTrials.gov identifier).
Collapse
Affiliation(s)
- Susanna Aufwerber
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Women's Health and Allied Health Professionals Theme, Medical Unit of Occupational Therapy and Physiotherapy, Karolinska University Hospital, Stockholm, Sweden
| | | | - Paul W Ackermann
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Trauma, Acute Surgery and Orthopaedics, Karolinska University Hospital, Stockholm, Sweden
| | - Josefine E Naili
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
13
|
Kastoft R, Barfod K, Bencke J, Speedtsberg MB, Hansen SB, Penny JØ. 1.7 cm elongated Achilles tendon did not alter walking gait kinematics 4.5 years after non-surgical treatment. Knee Surg Sports Traumatol Arthrosc 2022; 30:3579-3587. [PMID: 35234975 DOI: 10.1007/s00167-022-06874-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 01/12/2022] [Indexed: 12/19/2022]
Abstract
PURPOSE The aim of the present study was to evaluate Achilles tendon length after non-surgical treatment of acute Achilles tendon rupture (aATR), and to evaluate indirect effects of possible persistent elongation on kinematics. METHODS The study was performed as a cross-sectional study based on a population of patients from an RCT regarding non-operative treatment of aATR. Thirty-seven patients out of the 56 in the original RCT participated with at a follow up of 4-5 years after aATR. Primary outcome was Achilles tendon elongation. Additional outcomes were Achilles tendon resting angle (ATRA), calf circumference, passive ankle plantar and dorsiflexion and loading pattern. Foot pressure mapping was performed to measure plantar loading distribution pattern; medial and lateral forefoot peak pressure, heel peak pressure, medial versus lateral loading pattern and timing of heel lift during roll over process. The healthy leg was used as a control. RESULTS The injured Achilles tendon was significantly elongated by 1.7 (SD 1.6) cm compared to the non-injured leg. A slight delay of 2.6% (SD 6.0) was measured in heel lift in the injured side compared to the non-injured leg. We found no significant difference in forefoot peak pressure, medial and lateral peak pressure as well as heel peak pressure, and no correlation was found between Achilles tendon length and pressure measurements. Finally, dorsiflexion was 1.9°(SD1.28) larger, ATRA 8.1°(SD6.7) larger, and calf circumference 1.6 cm (SD1.1) lower on the injured leg. CONCLUSION The Achilles tendon was 1.7 cm elongated 4.5 years after the initial injury and significant changes in ATRA, calf circumference and passive dorsiflexion was present. Except for a slight delay in heel lift-off, kinematics during walking was symmetrical between injured and healthy leg, even with an elongated tendon on the injured leg. The clinical relevance of the Achilles tendon elongation is uncertain. LEVEL OF EVIDENCE II. CLINICAL TRIALS IDENTIFIER NCT02760784.
Collapse
Affiliation(s)
- Rasmus Kastoft
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark.
| | - Kristoffer Barfod
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark
| | - Jesper Bencke
- Laboratory of Human Movement Analysis, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager, Hvidovre, Denmark
| | - Merete B Speedtsberg
- Laboratory of Human Movement Analysis, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager, Hvidovre, Denmark
| | - Sanja Bay Hansen
- Department of Radiology, Center for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital, Hvidovre, Denmark
| | - Jeannette Ø Penny
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark
- Department of Orthopaedic Surgery, Zealand University Hospital, Koege, Denmark
| |
Collapse
|
14
|
Rendek Z, Bon Beckman L, Schepull T, Dånmark I, Aspenberg P, Schilcher J, Eliasson P. Early Tensile Loading in Nonsurgically Treated Achilles Tendon Ruptures Leads to a Larger Tendon Callus and a Lower Elastic Modulus: A Randomized Controlled Trial. Am J Sports Med 2022; 50:3286-3298. [PMID: 36005394 PMCID: PMC9527451 DOI: 10.1177/03635465221117780] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Early tensile loading improves material properties of healing Achilles tendon ruptures in animal models and in surgically treated human ruptures. However, the effect of such rehabilitation in patients who are nonsurgically treated remains unknown. HYPOTHESIS In nonsurgically treated Achilles tendon ruptures, early tensile loading would lead to higher elastic modulus 19 weeks after the injury compared with controls. STUDY DESIGN Randomized controlled trial; Level of evidence, 2. METHODS Between October 2015 and November 2018, a total of 40 nonsurgically treated patients with acute Achilles tendon rupture were randomized to an early tensile loading (loaded group) or control group. Tantalum bead markers were inserted percutaneously into the tendon stumps 2 weeks after the injury to allow high-precision measurements of callus deformation under mechanical testing. The loaded group used a training pedal twice daily to produce a gradual increase in tensile load during the following 5 weeks. Both groups were allowed full weightbearing in an ankle orthosis and unloaded range of motion exercises. Patients were followed clinically and via roentgen stereophotogrammetric analysis and computed tomography at 7, 19, and 52 weeks after the injury. RESULTS The mean ± standard deviation elastic modulus at 19 weeks was 95.6 ± 38.2 MPa in the loaded group and 108 ± 45.2 MPa in controls (P = .37). The elastic modulus increased in both groups, although it was lower in the loaded group at all time points. Tendon cross-sectional area increased from 7 weeks to 19 weeks, from 231 ± 99.5 to 388 ± 142 mm2 in the loaded group and from 188 ± 65.4 to 335 ± 87.2 mm2 in controls (P < .001 for the effect of time). Cross-sectional area for the loaded group versus controls at 52 weeks was 302 ± 62.4 mm2 versus 252 ± 49.2 mm2, respectively (P = .03). Gap elongation was 7.35 ± 13.9 mm in the loaded group versus 2.86 ± 5.52 mm in controls (P = .27). CONCLUSION Early tensile loading in nonsurgically treated Achilles tendon ruptures did not lead to higher elastic modulus in the healing tendon but altered the structural properties of the tendon via an increased tendon thickness. REGISTRATION NCT0280575 (ClinicalTrials.gov identifier).
Collapse
Affiliation(s)
- Zlatica Rendek
- Orthopedic Department, Linköping University Hospital, Linköping, Sweden
| | - Leo Bon Beckman
- Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Science, Linköping University, Linköping, Sweden
| | - Thorsten Schepull
- Orthopedic Department, Linköping University Hospital, Linköping, Sweden
| | - Ida Dånmark
- Orthopedic Department, Linköping University Hospital, Linköping, Sweden
| | - Per Aspenberg
- Author deceased,Orthopedic Department, Linköping University Hospital, Linköping, Sweden,Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Science, Linköping University, Linköping, Sweden
| | - Jörg Schilcher
- Orthopedic Department, Linköping University Hospital, Linköping, Sweden,Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Science, Linköping University, Linköping, Sweden
| | - Pernilla Eliasson
- Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Science, Linköping University, Linköping, Sweden,Pernilla Eliasson, MSc, PhD, Department of Biomedical and Clinical Sciences, Division of Cell Biology, Linköping University, Cell Biology Building Floor 10, Linköping, SE-58183, Sweden ()
| |
Collapse
|
15
|
Hébert-Losier K, Ngawhika TM, Gill N, Balsalobre-Fernandez C. Validity, reliability, and normative data on calf muscle function in rugby union players from the Calf Raise application. Sports Biomech 2022:1-22. [PMID: 36121030 DOI: 10.1080/14763141.2022.2118158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 08/23/2022] [Indexed: 10/14/2022]
Abstract
We examined the validity and reliability of biomechanical outcomes extracted using the Calf Raise application of three calf muscle tests. We then established normative calf muscle function values for male rugby union players accounting for rugby-related factors (position, level) alone and together with clinical factors (age, leg dominance, BMI, previous injury). In total, 120 athletes performed three single-leg calf muscle tests. Twenty athletes participated in application validation; 18 in test-retest reliability; and all in establishing normative equations. Validity of application outcomes against 3D motion and force plate data was good-to-excellent (CV ≤ 6.6%, ICC ≥0.84). Test-retest reliability was good across outcomes following familiarisation (CV < 10%, ICC ≥0.83). Forwards produced superior power than backs during the bodyweight (59 W, p = 0.007) and weighted (73 W, p < 0.001) power tests. Playing level influenced power outcomes (p < 0.009). Super Rugby players were more powerful than Club (both power tests), Provincial (both power tests), and International (bodyweight power). Backs completed more repetitions (3 repetitions, p = 0.001) and positive displacement (30 cm, p = 0.001) than forwards during endurance testing. When accounting for clinical factors; BMI, age, and previous injury explained some of the differences observed between positions and levels. This study provides initial benchmark values of calf muscle function in rugby union.
Collapse
Affiliation(s)
- Kim Hébert-Losier
- Division of Health, Engineering, Computing and Science, Te Huataki Waiora School of Health, University of Waikato, Tauranga, New Zealand
| | - Te Manawa Ngawhika
- Division of Health, Engineering, Computing and Science, Te Huataki Waiora School of Health, University of Waikato, Tauranga, New Zealand
| | - Nicholas Gill
- Division of Health, Engineering, Computing and Science, Te Huataki Waiora School of Health, University of Waikato, Tauranga, New Zealand
- New Zealand Rugby Union, Wellington, New Zealand
| | | |
Collapse
|
16
|
Barfod KW, Hansen MS, Sandholdt H, Boesen A, Hölmich P, Troelsen A, Kristensen MT. The Copenhagen Achilles Length Measurement Performed at Time of Acute Achilles Tendon Rupture is Correlated to Tendon Elongation After 1 Year. J Foot Ankle Surg 2022; 61:1098-1102. [PMID: 35241344 DOI: 10.1053/j.jfas.2022.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 01/25/2022] [Indexed: 02/03/2023]
Abstract
Elongation of the tendon has been proposed as the most important factor leading to poor outcome after acute Achilles tendon rupture (ATR). The aim of this paper was to investigate if Amlang's ultrasound classification (AmC) or the Copenhagen Achilles Length Measurement (CALM) when assessed in the acute phase after ATR could predict elongation 1 y after rupture. 107 males and 27 females, aged 18 to 70 y and treated nonsurgically were included. AmC and CALM were assessed at time of rupture and correlated to elongation measured with CALM and Achilles Tendon Resting Angle (ATRA) at 1 y. Receiver operating characteristic (ROC) analysis was performed to determine a cut off for acceptable elongation at time of rupture given that elongation at 1 y was not to exceed 10%. AmC showed no statistically significant correlation. CALM at baseline correlated to CALM at 1 y r = 0.214 (p = .02) and ATRA at 1 y r = 0.218 (p = .02). The ROC model had AUC = 0.67 for 7% elongation at baseline yielding a sensitivity of 0.77 and specificity of 0.50 for predicting elongation of 10% or more at 1 y. Elongation of the Achilles tendon at baseline measured with CALM was weakly correlated to elongation at 1 y. A cut off of 7% elongation at baseline caught 77% of patients who, when treated nonsurgically, ended up with an elongation above 10% at 1 y. A prospective trial investigating CALM as part of a selection algorithm for deciding between operative and nonoperative treatment is needed.
Collapse
Affiliation(s)
- Kristoffer Weisskirchner Barfod
- Sports Orthopedic Research Center - Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark.
| | - Maria Swennergren Hansen
- Sports Orthopedic Research Center - Copenhagen (SORC-C), Department of Orthopedic Surgery, Physical Medicine and Rehabilitation Research - Copenhagen (PMR-C), Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Håkon Sandholdt
- Clinical Research Center, Copenhagen University Hospital, Amager-Hvidovre, Denmark
| | - Anders Boesen
- Sports Orthopedic Research Center - Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark
| | - Per Hölmich
- Sports Orthopedic Research Center - Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark
| | - Anders Troelsen
- Department of Orthopaedic Surgery, Clinical Orthopaedic Research Hvidovre, Copenhagen University Hospital, Amager-Hvidovre, Denmark
| | - Morten Tange Kristensen
- Physical Medicine and Rehabilitation Research - Copenhagen (PMR-C), Department of Physiotherapy and Occupational Therapy, and Department of Orthopaedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark
| |
Collapse
|
17
|
Hoeffner R, Svensson RB, Bjerregaard N, Kjær M, Magnusson SP. Persistent Deficits after an Achilles Tendon Rupture: A Narrative Review. TRANSLATIONAL SPORTS MEDICINE 2022; 2022:7445398. [PMID: 38655161 PMCID: PMC11022787 DOI: 10.1155/2022/7445398] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/03/2022] [Accepted: 06/15/2022] [Indexed: 04/26/2024]
Abstract
Persistent muscle weakness, tendon elongation, and incomplete return to preinjury level are frequent sequelae after acute Achilles tendon rupture, and evidence-based knowledge of how to best rehabilitate the injury is largely absent in the literature. The objective of this review is to illuminate and discuss to what extent an Achilles tendon rupture affects muscle, tendon, and function when assessed with the Achilles tendon total rupture score (ATRS), muscle strength, muscle cross-sectional area, tendon length, and the heel-rise test. The patient-reported outcome measures (PROM) data in the literature suggest that the recovery takes longer than 6 months (ATRS, 70 out of 100), that one-year postinjury, the ATRS only reaches 82, and that this does not appear to noticeably improve thereafter. Loss of muscle mass, strength, and function can in some cases be permanent. Over the first 6 months postinjury, the tendon undergoes elongation, which appears to be negatively correlated to heel-rise function. More recently, there has been some interest in how muscle length and excursion is related to the reduced function. The available literature indicates that further research is highly warranted and that efforts to restore normal tendon length may improve the likelihood of returning to preinjury level after an Achilles tendon rupture.
Collapse
Affiliation(s)
- Rikke Hoeffner
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Physical and Occupational Therapy, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Rene B. Svensson
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Nicolai Bjerregaard
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Michael Kjær
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Stig Peter Magnusson
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Physical and Occupational Therapy, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
| |
Collapse
|
18
|
Khair RM, Stenroth L, Cronin NJ, Reito A, Paloneva J, Finni T. In vivo localised gastrocnemius subtendon representation within the healthy and ruptured human Achilles tendon. J Appl Physiol (1985) 2022; 133:11-19. [PMID: 35546126 DOI: 10.1152/japplphysiol.00084.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The Achilles tendon (AT) is composed of three distinct in-series elastic subtendons, arising from different muscles in the triceps surae. Independent activation of any of these muscles is thought to induce sliding between the adjacent AT subtendons. We aimed to investigate displacement patterns during voluntary contraction (VOL) and selective transcutaneous stimulation of medial (MGstim) and lateral (LGstim) gastrocnemius between ruptured and healthy tendons, and to examine the representative areas of AT subtendons. Twenty-eight patients with unilateral AT rupture performed bilateral VOL at 30% of the maximal isometric un-injured plantarflexion torque. AT displacement was analysed from sagittal B-mode ultrasonography images during VOL, MGstim and LGstim. Three-way ANOVA revealed a significant two-way interaction of contraction type*location on the tendon displacement (F(10-815)=3.72, p<0.001). The subsequent two-way analysis revealed a significant contraction type*location interaction for tendon displacement (F(10-410)=3.79, p<0.001) in the un-injured limb only, where LGstim displacement pattern was significantly different from MGstim (p=0.008) and VOL (p=0.005). When comparing contraction types between limbs the there were no difference in the displacement patterns, but displacement amplitudes differed. There was no significant difference in the location of maximum or minimum displacement between limbs. The displacement pattern was not different in non-surgically treated compared to un-injured tendons one-year post rupture. Our results suggest that near the calcaneus, LG subtendon is located in the most anterior region adjacent to medial gastrocnemius. However, free tendon stiffness seems to be lower in the injured AT, leading to more displacement during electrically-induced contractions compared to the un-injured.
Collapse
Affiliation(s)
- Raad M Khair
- Faculty of Sport and Health Sciences, Neuromuscular Research Center, University of Jyväskylä, Jyväskylä, Finland
| | - Lauri Stenroth
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland
| | - Neil J Cronin
- Faculty of Sport and Health Sciences, Neuromuscular Research Center, University of Jyväskylä, Jyväskylä, Finland.,School of Sport and Exercise, University of Gloucestershire, United Kingdom
| | - Aleksi Reito
- Central Finland Health Care District, Finland and University of Eastern Finland, Finland
| | - Juha Paloneva
- Central Finland Health Care District, Finland and University of Eastern Finland, Finland
| | - Taija Finni
- Faculty of Sport and Health Sciences, Neuromuscular Research Center, University of Jyväskylä, Jyväskylä, Finland
| |
Collapse
|
19
|
Stäudle B, Seynnes O, Laps G, Brüggemann GP, Albracht K. Altered Gastrocnemius Contractile Behavior in Former Achilles Tendon Rupture Patients During Walking. Front Physiol 2022; 13:792576. [PMID: 35299659 PMCID: PMC8921480 DOI: 10.3389/fphys.2022.792576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 02/01/2022] [Indexed: 11/17/2022] Open
Abstract
Achilles tendon rupture (ATR) remains associated with functional limitations years after injury. Architectural remodeling of the gastrocnemius medialis (GM) muscle is typically observed in the affected leg and may compensate force deficits caused by a longer tendon. Yet patients seem to retain functional limitations during-low-force-walking gait. To explore the potential limits imposed by the remodeled GM muscle-tendon unit (MTU) on walking gait, we examined the contractile behavior of muscle fascicles during the stance phase. In a cross-sectional design, we studied nine former patients (males; age: 45 ± 9 years; height: 180 ± 7 cm; weight: 83 ± 6 kg) with a history of complete unilateral ATR, approximately 4 years post-surgery. Using ultrasonography, GM tendon morphology, muscle architecture at rest, and fascicular behavior were assessed during walking at 1.5 m⋅s-1 on a treadmill. Walking patterns were recorded with a motion capture system. The unaffected leg served as control. Lower limbs kinematics were largely similar between legs during walking. Typical features of ATR-related MTU remodeling were observed during the stance sub-phases corresponding to series elastic element (SEE) lengthening (energy storage) and SEE shortening (energy release), with shorter GM fascicles (36 and 36%, respectively) and greater pennation angles (8° and 12°, respectively). However, relative to the optimal fascicle length for force production, fascicles operated at comparable length in both legs. Similarly, when expressed relative to optimal fascicle length, fascicle contraction velocity was not different between sides, except at the time-point of peak series elastic element (SEE) length, where it was 39 ± 49% lower in the affected leg. Concomitantly, fascicles rotation during contraction was greater in the affected leg during the whole stance-phase, and architectural gear ratios (AGR) was larger during SEE lengthening. Under the present testing conditions, former ATR patients had recovered a relatively symmetrical walking gait pattern. Differences in seen AGR seem to accommodate the profound changes in MTU architecture, limiting the required fascicle shortening velocity. Overall, the contractile behavior of the GM fascicles does not restrict length- or velocity-dependent force potentials during this locomotor task.
Collapse
Affiliation(s)
- Benjamin Stäudle
- Faculty of Medical Engineering and Technomathematics, Aachen University of Applied Sciences, Aachen, Germany
- Institute of Movement and Neurosciences, German Sport University Cologne, Cologne, Germany
| | - Olivier Seynnes
- Department of Physical Performance, Norwegian School of Sport Sciences, Oslo, Norway
| | - Guido Laps
- Orthopädie am Gürzenich, Cologne, Germany
| | - Gert-Peter Brüggemann
- Institute of Biomechanics and Orthopedics, German Sport University Cologne, Cologne, Germany
| | - Kirsten Albracht
- Faculty of Medical Engineering and Technomathematics, Aachen University of Applied Sciences, Aachen, Germany
- Institute of Movement and Neurosciences, German Sport University Cologne, Cologne, Germany
| |
Collapse
|
20
|
Hansen MS, Kristensen MT, Hölmich P, Barfod KW. The Achilles Tendon Length Measure and the Achilles Tendon Resting Angle show acceptable construct validity using the Copenhagen Achilles Length Measure as gold standard. Foot Ankle Surg 2021; 27:655-659. [PMID: 32873503 DOI: 10.1016/j.fas.2020.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/28/2020] [Accepted: 08/19/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Elongation of the Achilles tendon after rupture is a frequent complication. The Achilles Tendon Length Measure (ATLM) and the Achilles Tendon Resting Angle (ATRA) are indirect length measures using the resting angle of the ankle. Copenhagen Achilles Length Measure (CALM) is a direct ultrasound measure. The purpose of this study was to examine the construct validity of ATLM and ATRA using CALM as gold standard. METHODS As the three measurements measure slightly different constructs and have different scales a direct comparison was not possible. Instead a mixed linear regression model was performed investigating the three models: CALM-ATRA, CALMATLM and ATRA-ATLM. RESULTS 130 patients were available for analysis. All three regression models demonstrated a statistically significant (p < 0.01) linear relationship and acceptable certainty of the estimates. CONCLUSION ATRA and ATLM were found to have acceptable construct validity when using CALM as gold standard for assessing tendon elongation after an Achilles tendon rupture.
Collapse
Affiliation(s)
- Maria Swennergren Hansen
- Sports Orthopedic Research Center - Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Denmark; Physical Medicine & Rehabilitation Research-Copenhagen (PMR-C), Department of Physical and Occupational Therapy, Copenhagen University Hospital Amager-Hvidovre, Denmark.
| | - Morten Tange Kristensen
- Physical Medicine & Rehabilitation Research-Copenhagen (PMR-C), Department of Physical and Occupational Therapy, Copenhagen University Hospital Amager-Hvidovre, Denmark; Department of Orthopaedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Denmark.
| | - Per Hölmich
- Sports Orthopedic Research Center - Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Denmark.
| | - Kristoffer Weisskrichner Barfod
- Sports Orthopedic Research Center - Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Denmark.
| |
Collapse
|
21
|
Stäudle B, Seynnes O, Laps G, Göll F, Brüggemann GP, Albracht K. Recovery from Achilles Tendon Repair: A Combination of Postsurgery Outcomes and Insufficient Remodeling of Muscle and Tendon. Med Sci Sports Exerc 2021; 53:1356-1366. [PMID: 33433154 DOI: 10.1249/mss.0000000000002592] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Achilles tendon rupture (ATR) patients have persistent functional deficits in the triceps surae muscle-tendon unit (MTU). The complex remodeling of the MTU accompanying these deficits remains poorly understood. The purpose of the present study was to associate in vivo and in silico data to investigate the relations between changes in MTU properties and strength deficits in ATR patients. METHODS Eleven male subjects who had undergone surgical repair of complete unilateral ATR were examined 4.6 ± 2.0 (mean ± SD) yr after rupture. Gastrocnemius medialis (GM) tendon stiffness, morphology, and muscle architecture were determined using ultrasonography. The force-length relation of the plantar flexor muscles was assessed at five ankle joint angles. In addition, simulations (OpenSim) of the GM MTU force-length properties were performed with various iterations of MTU properties found between the unaffected and the affected side. RESULTS The affected side of the patients displayed a longer, larger, and stiffer GM tendon (13% ± 10%, 105% ± 28%, and 54% ± 24%, respectively) compared with the unaffected side. The GM muscle fascicles of the affected side were shorter (32% ± 12%) and with greater pennation angles (31% ± 26%). A mean deficit in plantarflexion moment of 31% ± 10% was measured. Simulations indicate that pairing an intact muscle with a longer tendon shifts the optimal angular range of peak force outside physiological angular ranges, whereas the shorter muscle fascicles and tendon stiffening seen in the affected side decrease this shift, albeit incompletely. CONCLUSIONS These results suggest that the substantial changes in MTU properties found in ATR patients may partly result from compensatory remodeling, although this process appears insufficient to fully restore muscle function.
Collapse
Affiliation(s)
| | - Olivier Seynnes
- Department of Physical Performance, Norwegian School of Sport Sciences, Oslo, NORWAY
| | - Guido Laps
- Orthopaedie am Guerzenich, Cologne, GERMANY
| | - Fabian Göll
- Institute of Movement and Neurosciences, German Sport University Cologne, Cologne, GERMANY
| | - Gert-Peter Brüggemann
- Institute of Biomechanics and Orthopaedics, German Sport University Cologne, Cologne, GERMANY
| | | |
Collapse
|
22
|
Andreasen KR, Hansen MS, Bencke J, Hölmich P, Barfod KW. The heel-rise work test overestimates the performed work with 21-25% after an Achilles tendon rupture. Knee Surg Sports Traumatol Arthrosc 2021; 29:1604-1611. [PMID: 33236164 DOI: 10.1007/s00167-020-06369-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 11/05/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE The purpose of this study was to evaluate concurrent validity of the heel-rise work test performed with use of the heel as a surrogate for the center of body mass. METHODS The study was a validity study performed on a prospective cohort of consecutive patients. Forty-five patients were included in the study. The heel-rise work test estimates the total work performed by repeated heel-rises until fatigue. In this study, the heel-rise work was assessed by the linear encoder and a motion capture system simultaneously for validation. The linear encoder was attached to the patient's heel and reflective marker was attached to the pelvis and heel. Student's paired t-test, linear regression analysis and Bland Altman plots were used to estimate the measurement error of the linear encoder. RESULTS The heel-rise work test overestimated the total work with 21.0% on the injured leg and 24.7% on the non-injured leg. Student's paired t-test showed no difference in measurement error between the limbs (n.s.). The linear regression analysis showed no difference in limb symmetry index between the two methods of heel-rise work estimation (a (slope) = 1.00, R = 0.94, p < 0.0001). CONCLUSION The heel-rise work test performed using the heel as a surrogate for center of body mass overestimates the total work with 21.0-24.7% compared to a gold standard but was able to precisely detect the relative difference between the limbs. The heel marker can be considered a valid measurement device for assessing relative differences between the limbs. CLINICAL RELEVANCE Clinical testing of injuries to the lower body using the heel-rise work test is valid when using the relative difference between the limbs. LEVEL OF EVIDENCE I.
Collapse
Affiliation(s)
- Kristine Rask Andreasen
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark. .,Department of Orthopaedic Surgery, Sports Orthopaedic Research Center-Copenhagen (SORC-C), Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark.
| | - Maria Swennergren Hansen
- Department of Physical and Occupational Therapy, Physical Medicine and Rehabilitation Research-Copenhagen (PMR-C), Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark.,Department of Orthopaedic Surgery, Sports Orthopaedic Research Center-Copenhagen (SORC-C), Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark
| | - Jesper Bencke
- Department of Orthopaedic Surgery, Laboratory of Human Movement Analysis, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Per Hölmich
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.,Department of Orthopaedic Surgery, Sports Orthopaedic Research Center-Copenhagen (SORC-C), Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark
| | - Kristoffer Weisskirchner Barfod
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.,Department of Orthopaedic Surgery, Sports Orthopaedic Research Center-Copenhagen (SORC-C), Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark
| |
Collapse
|
23
|
Khayyeri H, Hammerman M, Turunen MJ, Blomgran P, Notermans T, Guizar-Sicairos M, Eliasson P, Aspenberg P, Isaksson H. Diminishing effects of mechanical loading over time during rat Achilles tendon healing. PLoS One 2020; 15:e0236681. [PMID: 33315857 PMCID: PMC7735574 DOI: 10.1371/journal.pone.0236681] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 11/23/2020] [Indexed: 01/07/2023] Open
Abstract
Mechanical loading affects tendon healing and recovery. However, our understanding about how physical loading affects recovery of viscoelastic functions, collagen production and tissue organisation is limited. The objective of this study was to investigate how different magnitudes of loading affects biomechanical and collagen properties of healing Achilles tendons over time. Achilles tendon from female Sprague Dawley rats were cut transversely and divided into two groups; normal loading (control) and reduced loading by Botox (unloading). The rats were sacrificed at 1, 2- and 4-weeks post-injury and mechanical testing (creep test and load to failure), small angle x-ray scattering (SAXS) and histological analysis were performed. The effect of unloading was primarily seen at the early time points, with inferior mechanical and collagen properties (SAXS), and reduced histological maturation of the tissue in unloaded compared to loaded tendons. However, by 4 weeks no differences remained. SAXS and histology revealed heterogeneous tissue maturation with more mature tissue at the peripheral region compared to the center of the callus. Thus, mechanical loading advances Achilles tendon biomechanical and collagen properties earlier compared to unloaded tendons, and the spatial variation in tissue maturation and collagen organization across the callus suggests important regional (mechano-) biological activities that require more investigation.
Collapse
Affiliation(s)
- Hanifeh Khayyeri
- Department of Biomedical Engineering, Lund University, Lund, Sweden
| | - Malin Hammerman
- Department of Biomedical Engineering, Lund University, Lund, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Mikael J. Turunen
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland
| | - Parmis Blomgran
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Thomas Notermans
- Department of Biomedical Engineering, Lund University, Lund, Sweden
| | | | - Pernilla Eliasson
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Per Aspenberg
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Hanna Isaksson
- Department of Biomedical Engineering, Lund University, Lund, Sweden
- * E-mail:
| |
Collapse
|
24
|
Aufwerber S, Edman G, Grävare Silbernagel K, Ackermann PW. Changes in Tendon Elongation and Muscle Atrophy Over Time After Achilles Tendon Rupture Repair: A Prospective Cohort Study on the Effects of Early Functional Mobilization. Am J Sports Med 2020; 48:3296-3305. [PMID: 32986466 DOI: 10.1177/0363546520956677] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Early functional mobilization (EFM) may improve patient outcome after Achilles tendon rupture (ATR). However, whether EFM affects patient outcome via changes in tendon elongation, thickening, or calf muscle atrophy is unknown. PURPOSE To analyze differences in tendon and muscle morphology recovery over time between groups treated with EFM or standard treatment after ATR repair. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS This prospective cohort study included 86 patients (20 women) with ATR repair who had a mean (SD) age of 39.3 (8.2) years and were part of a larger prospective randomized controlled trial. Patients were postoperatively randomized to immediate postoperative weightbearing and ankle motion (EFM group) or to immobilization in a below-knee plaster cast for 2 weeks (control group). Patient-reported and functional outcomes were assessed at 6 and 12 months with the Achilles Tendon Total Rupture Score and the heel-rise test for endurance. At 2 and 6 weeks and 6 and 12 months postoperatively, B-mode ultrasound imaging was performed to assess the length and cross-sectional area (CSA) of the Achilles tendon, the gastrocnemius CSA, as well as the thickness of soleus. RESULTS The Achilles Tendon Total Rupture Score for the EFM and control groups were 65.8 (18.7) and 56.8 (20.1; P = .045), respectively, at 6 months and 79.6 (15.8) and 78.9 (17.2; P = .87), respectively, at 12 months. At 2 weeks, tendon elongation was significantly more pronounced in the EFM group as compared with the control group (mean side-to-side difference, 1.88 cm vs 0.71 cm; P = .005). Subsequently, tendon elongation increased in the control group while it decreased in the EFM group so that at 6 and 12 months no significant differences between groups were found. Mean Achilles tendon elongation at 1 year was 1.73 (1.07) cm for the EFM group (n = 55) and 1.67 (0.92) cm for the control group (n = 27), with a mean difference of 0.06 cm (95% CI, 0.54 to -0.42; P = .80). Achilles tendon CSA and calf muscle atrophy displayed no significant differences between the groups; however, significant changes were demonstrated over time (P ≤ .001) in both groups. CONCLUSION EFM results in more Achilles tendon elongation at early healing, but this difference subsides over time. EFM does not seem to affect patient outcome via changes in tendon elongation, thickening, or calf muscle atrophy. REGISTRATION NCT02318472 (ClinicalTrials.gov identifier).
Collapse
Affiliation(s)
- Susanna Aufwerber
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Medical Unit Occupational Therapy and Physiotherapy, Function Allied Health Professionals, Karolinska University Hospital, Stockholm, Sweden
| | - Gunnar Edman
- R&D, Norrtälje Hospital, Tiohundra AB, Norrtälje, Sweden
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden
| | | | - Paul W Ackermann
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Orthopedic Surgery, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
25
|
Zadro JR, Maher CG, Barton CJ. High‐ and low‐value care in sport and exercise medicine: Areas for consideration. TRANSLATIONAL SPORTS MEDICINE 2020. [DOI: 10.1002/tsm2.163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Joshua R. Zadro
- Faculty of Medicine and Health School of Public Health The University of Sydney Sydney NSW Australia
- Institute for Musculoskeletal Health Sydney NSW Australia
| | - Christopher G. Maher
- Faculty of Medicine and Health School of Public Health The University of Sydney Sydney NSW Australia
- Institute for Musculoskeletal Health Sydney NSW Australia
| | - Christian J. Barton
- La Trobe Sport and Exercise Medicine Research Centre School of Allied Health La Trobe University Bundoora Vic Australia
- Department of Surgery St Vincents Hospital University of Melbourne Melbourne Vic Australia
| |
Collapse
|