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Wei S, Li Q, Wu H, Kong C, Xu F, Cai X. All-inside endoscopic semiautomatic running locked stitch technique shows favourable outcomes for acute Achilles tendon ruptures. Knee Surg Sports Traumatol Arthrosc 2024; 32:1615-1621. [PMID: 38578228 DOI: 10.1002/ksa.12177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 03/12/2024] [Accepted: 03/17/2024] [Indexed: 04/06/2024]
Abstract
PURPOSE The safety and reliability of endoscopic Achilles tendon rupture repair are still concerning aspects. This study's aim is to evaluate an all-inside endoscopic semiautomatic running locked stitch (Endo-SARLS) technique. METHODS Forty cases with acute Achilles tendon rupture were treated with the all-inside Endo-SARLS technique between 2020 and 2021. Under endoscopic control, the proximal tendon stumps were stitched with the running locked method using a semiautomatic flexible suture passer. The threads of the high-strength suture were grasped through the paratenon subspace and then fixed into calcaneal insertion with a knotless anchor. Magnetic resonance imaging (MRI), surgical time and complications were assessed. Achilles Tendon Total Rupture Score (ATRS), Achilles Tendon Resting Angle (ATRA) and Heel Rise Height Scale (HRHS) were utilised to evaluate final outcomes. RESULTS The average follow-up time was 25.4 ± 0.4 (range: 24-32) months. Appropriate tendon regeneration was observed on MRI after 12 months. At the final follow-up, the median value of ATRS score was 95 (interquartile range: 94, 98). Furthermore, there is no significant difference between the injured and contralateral side in the average ATRA (18.2 ± 1.8 vs. 18.3 ± 1.9°, ns) and median value of HRHS [14.5 (13.3, 15.5) vs. 14.8 (13.5, 15.6) cm, ns]. No infection and nerve injuries were encountered. Thirty-nine patients reported that they resumed casual sports activity after 6 months. One patient had a slight anchor cut-out, due to an addition injury, which was removed after 5 months. CONCLUSIONS An all-inside Endo-SARLS technique showed promising clinical results for acute Achilles tendon ruptures. This procedure reduces the risk of sural nerve injuries while establishing a reliable connection between the tendon stumps. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Shijun Wei
- Department of Orthopaedics, General Hospital of Central Theater Command, Wuhan, China
- The First Clinical Medical School, Southern Medical University, Guangzhou, China
| | - Qing Li
- Department of Orthopaedics, General Hospital of Central Theater Command, Wuhan, China
| | - Helin Wu
- Department of Orthopaedics, General Hospital of Central Theater Command, Wuhan, China
- The First Clinical Medical School, Southern Medical University, Guangzhou, China
| | - Changwang Kong
- Department of Orthopaedics, General Hospital of Central Theater Command, Wuhan, China
| | - Feng Xu
- Department of Orthopaedics, General Hospital of Central Theater Command, Wuhan, China
- The First Clinical Medical School, Southern Medical University, Guangzhou, China
| | - Xianhua Cai
- Department of Orthopaedics, South China Hospital of Shenzhen University, Shenzhen, China
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Keklicek H, Selcuk H, Yilmaz A. Fatigue of the intrinsic foot core muscles had a greater effect on gait than extrinsic foot core muscles: A time-series based analyze. Foot (Edinb) 2024; 59:102088. [PMID: 38522258 DOI: 10.1016/j.foot.2024.102088] [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: 10/03/2022] [Accepted: 03/10/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND The Heel Rise endurance (HRE) which indicates the extrinsic foot core (ECO) muscle's performance and the paper grip endurance (PGE) which indicates the intrinsic foot core (ICO) muscle's performance are essential components of a healthy foot function. However, the foot core muscles' fatigue response on spatial and temporal gait parameters after the HRE and the PGE tests were not adequately investigated. The purpose of this study was to determine whether the fatigue of the ICO and the ECO muscles affect gait parameters. MATERIAL AND METHODS A prospective, cross-sectional study was conducted on 22 sedentary individuals (44 feet). Gait was investigated pre and after the Heel Rise (HR) endurance test and the paper grip (PG) endurance test by inertial sensors. At least 500 consecutive steps were collected for each individual. Spatial-temporal gait parameters were used as outcome measures. RESULTS ECO fatigue and ICO fatigue led to increases in the step length (p < 0.05) and the stride lengths (p < 0.05), the single support (p < 0.05), and the terminal stance durations (p < 0.05). It was also seen that ICO fatigue had a greater effect on gait than ECO fatigue. The ECO fatigue had a medium to large effect on the gait parameters (d=0.313-0.646). The ICO fatigue affected gait with a large effect (d=0.524-2.048). CONCLUSION The ECO fatigue and the ICO fatigue led to clinically important changes in long-range gait parameters and the ICO fatigue had a greater effect on gait than ECO fatigue. It was suggested that clinicians add ICO muscle endurance training to improve the physical performance of individuals.
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Affiliation(s)
- Hilal Keklicek
- Trakya Unversity, Faculty of Health Sciences Department of Physiotherapy and Rehabilitation, Edirne, Turkey.
| | - Halit Selcuk
- Trakya Unversity, Faculty of Health Sciences Department of Physiotherapy and Rehabilitation, Edirne, Turkey
| | - Ali Yilmaz
- Trakya Unversity, Faculty of Medicine Department of Anatomy, Edirne, Turkey
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Aufwerber S, Svedman S, Silbernagel KG, Ackermann PW. Long-term patient outcome is affected by deep venous thrombosis after Achilles tendon rupture repair. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 38796725 DOI: 10.1002/ksa.12240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 04/05/2024] [Accepted: 04/24/2024] [Indexed: 05/28/2024]
Abstract
PURPOSE The aim of the study was to examine the impact of a deep venous thrombosis (DVT) on patient outcomes 3 years after Achilles tendon rupture (ATR) repair and if there were continued improvements between 1 and 3 years after surgery. A secondary aim was to determine risk factors associated with impaired patient outcomes in the long term. METHODS This cohort study consisted of 181 ATR-repaired patients, from two large randomized clinical trials, who attended a 3-year follow-up evaluation. Patients were postoperatively randomized to two different weight-bearing interventions compared with immobilization in a below-knee plaster cast for 2 weeks. During immobilization, screening for DVT was performed with Doppler ultrasound. At 1 and 3 years postoperatively, functional- and patient-reported outcomes were evaluated by the validated heel-rise test and self-reported questionnaire, Achilles tendon Total Rupture Score (ATRS). RESULTS In total, 76 out of 181 (42%) patients exhibited a DVT at the 2- or 6-week screening after ATR surgery. Suffering from a DVT during immobilization resulted at 3 years in a worse limb symmetry index (LSI) of heel-rise total work compared to patients without DVT, adjusted for age (DVT mean LSI 68% vs. no DVT 78%, p = 0.027). At 3 years, patients with a DVT during immobilization displayed lower ATRS (DVT median 88 vs. no DVT 93, p = 0.046), which was not significant after adjustment for age. However, patients with DVT exhibited an improvement in ATRS, LSI total work, and LSI maximum height between 1 and 3 years, which was not seen among patients without DVT. Independent risk factors for reduced patient functional outcomes at 3 years were older age, greater calf muscle hypotrophy, and suffering a DVT. CONCLUSIONS DVT during immobilization affects patients' long-term functional outcomes 3 years after ATR repair. Clinicians should adequately address risk factors contributing to impaired patient outcomes in the long term, including calf muscle hypotrophy, DVT, and older age. LEVEL OF EVIDENCE Level Ⅲ.
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Affiliation(s)
- Susanna Aufwerber
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Women's Health and Allied Health Professionals Theme, Medical Unit Occupational Therapy and Physiotherapy, Karolinska University Hospital, Stockholm, Sweden
| | - Simon Svedman
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Trauma, Acute Surgery and Orthopaedics, 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
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Larsson E, Nilsson N, Walstern J, Brorsson A, Helander KN. Females present larger deficit in heel-rise height at 3 months following an Achilles tendon rupture compared with males. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 38651585 DOI: 10.1002/ksa.12208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 03/28/2024] [Accepted: 04/09/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE There is a lack of knowledge concerning differences between females and males in the early stages after an acute Achilles tendon rupture. This article aims to explore the different factors affecting early function after an Achilles tendon rupture with a validated test battery that includes functional tests, clinical measurements and patient-reported outcome at a 3-month follow-up analysis of a larger prospective study. METHODS This study was part of the DUSTAR-study (Diagnostic UltraSonography for the choice of Treatment of acute Achilles tendon Rupture) where the main aim was to evaluate if an acute ultrasonography could determine which patients, with an Achilles tendon rupture, should be treated surgically or nonsurgically. At the 3-month follow-up, the results between males and females were compared. RESULTS One hundred and twenty-seven patients were included at the 3-month follow-up; of these, 102 (80%) were males and 25 (20%) were females. Amongst the females, 11 (44%) were able to perform a single leg heel-rise compared to 48 (47%) of the males; however, the difference was not statistically significant. There was no difference between the sexes in the frequency of completing a single-leg heel-rise at 3 months after injury; however, there were statistically significant differences between the groups when comparing Limb Symmetry Index (LSI) of heel-rise height and heel-rise work. The females had a median heel-rise height LSI/median heel-rise work LSI of 45%/14% compared to males who reached a level of 57%/23% (p = 0.006/p = 0.010). At the 3-month follow-up, the median (range) Achilles tendon Total Rupture Score (ATRS) reported by females was 28.5 (8-51), which had a nonsignificant difference compared to males who reported a median (range) ATRS of 30 (1-86). CONCLUSION The risk of reduced heel-rise height and worse heel-rise work 3 months after an acute Achilles tendon rupture increases by being a female. Through this knowledge, we highlighted the importance of an individualised treatment for acute Achilles tendon ruptures with better outcome for both males and females. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Elin Larsson
- Department of Orthopaedics, Institute of Clinical Science at Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital/Mölndal, Gothenburg, Sweden
| | - Niklas Nilsson
- Department of Orthopaedics, Institute of Clinical Science at Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Julia Walstern
- Department of Orthopaedics, Institute of Clinical Science at Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Annelie Brorsson
- Department of Orthopaedics, Institute of Clinical Science at Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- IFK Kliniken Rehab, Gothenburg, Sweden
| | - Katarina Nilsson Helander
- Department of Orthopaedics, Institute of Clinical Science at Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital/Mölndal, Gothenburg, Sweden
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Ashnai F, Lindskog J, Brorsson A, Nilsson-Helander K, Beischer S. The Calf Raise App shows good concurrent validity compared with a linear encoder in measuring total concentric work. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 38643393 DOI: 10.1002/ksa.12190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 03/22/2024] [Accepted: 04/02/2024] [Indexed: 04/22/2024]
Abstract
PURPOSE The linear encoder and the Calf Raise App have been shown to be valid for measurements of plantar flexor muscular endurance in the heel raise test when compared with gold standard equipment. However, the validity of the Calf Raise App has not yet been compared with a linear encoder, an instrument commonly used in clinical and research settings. The purpose of this study was to determine the concurrent validity of the Calf Raise App compared with a linear encoder for the measurement of average heel raise height and total concentric work in the heel raise test. METHODS Fifty TeamGym athletes (82% females) from an on-going prospective study were included (mean [SD] age: 20 [7] years; body mass index (BMI) = 21.3 [2.5]). Concurrent validity was analysed with single measures intraclass correlation coefficient (ICC) using a two-way mixed effects, consistency model. RESULTS Ninety-eight samples were included in the analysis. The mean (SD) average heel raise height and total concentric work measured by the linear encoder and Calf Raise App were 9.9 (1.4) and 7.5 (1.2) cm, and 1728 (584) and 1291 (450) J, respectively. The mean (SD) number of unilateral heel raises was 30 (7.5). The results showed poor to moderate concurrent validity for the measurement of average heel raise height (ICC: 0.62; 95% confidence interval [CI]: 0.48-0.73). Good to excellent concurrent validity was shown for the measurement of total concentric work (ICC: 0.89; 95% CI: 0.84-0.93). CONCLUSION The Calf Raise App shows good concurrent validity in the heel raise test compared with a linear encoder in measuring total concentric work but not average height. While caution is recommended when comparing results from the different instruments, each instrument can be used separately to compare between-limb differences or changes over time in plantar flexor muscular endurance in clinical and research settings. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Farshad Ashnai
- Department of Orthopaedics, The Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sportrehab Sports Medicine Clinic, Gothenburg, Sweden
| | | | - Annelie Brorsson
- Department of Orthopaedics, The Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- IFK Kliniken Rehab, Gothenburg, Sweden
| | - Katarina Nilsson-Helander
- Department of Orthopaedics, The Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Susanne Beischer
- Sportrehab Sports Medicine Clinic, Gothenburg, Sweden
- Unit of Physiotherapy, Department of Health and Rehabilitation, The Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Carmont MR, Gunnarsson B, Brorsson A, Nilsson-Helander K. Musculotendinous ruptures of the achilles tendon had greater heel-rise height index compared with mid-substance rupture with non-operative management: A retrospective cohort study. J ISAKOS 2024; 9:148-152. [PMID: 38154754 DOI: 10.1016/j.jisako.2023.12.006] [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: 09/04/2023] [Revised: 12/19/2023] [Accepted: 12/22/2023] [Indexed: 12/30/2023]
Abstract
INTRODUCTION Achilles tendon ruptures (ATRs) may occur at varying locations with ruptures at the mid-substance (MS) of the tendon most common, followed tears at the musculotendinous (MT) junction. There is scant literature about the outcome of MT ATR. This study compared the outcome of patients with a MT ATR with patients following a MS ATR. METHODS The diagnostic features and clinical outcome of 37 patients with a MT ATR were compared with a cohort of 19 patients with a MS ATR. Patients in both groups were managed non-operatively and received the same rehabilitation protocol with weight-bearing rehabilitation in protective functional brace. RESULTS From February 2009 to August 2023, 556 patients presented with an ATR. Of these, 37 (6.7 %) patients were diagnosed with a MT tear. At final follow-up, at 12 months following injury, the MT group reported an Achilles tendon total rupture score (ATRS) of mean (standard deviation (SD)) of 83.6 (3.5) (95 % confidence interval (CI) 81.8, 85.4) and median (inter-quartile range (IQR)) ATRS of 86 points (78-95.5) and the MS group mean (SD) of 80.3 (8.5) (95%CI) 76.1, 80.5) and median (IQR) of 87 points (59-95) (p = 0.673). Functional evaluation, however, revealed statistically significant differences in mean (SD) heel-rise height index MT group 79 % (25) (95%CI 65.9, 92.1) and MS group 59 % (13) (95%CI 51.9, 67.1) (p = 0.019). In the MT rupture group, there were considerably less complications than the MS rupture group. CONCLUSIONS When managed non-operatively, with only a 6 weeks period of brace protection, patients have little limitation although have some residual reduction of single heel-rise at the one-year following MT ATR. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Michael R Carmont
- Department of Trauma & Orthopaedic Surgery, Shrewsbury & Telford Hospital NHS Trust, Shropshire, TF1 6TF, United Kingdom; University of Keele, Staffordshire, ST5 5BG, United Kingdom; The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, Gothenburg University, 413 90, Sweden.
| | - Baldvin Gunnarsson
- Department of Orthopaedic Surgery, Mölndal Hospital, University of Gothenburg, 431 60, Sweden; The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, Gothenburg University, 413 90, Sweden
| | - Annelie Brorsson
- Department of Orthopaedic Surgery, Mölndal Hospital, University of Gothenburg, 431 60, Sweden; The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, Gothenburg University, 413 90, Sweden
| | - Katarina Nilsson-Helander
- Department of Orthopaedic Surgery, Mölndal Hospital, University of Gothenburg, 431 60, Sweden; The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, Gothenburg University, 413 90, Sweden
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Coombes BK, Hanna M, Thompson KA, Coppieters MW, Dick TJM, Andrade RJ, Barber L. Mild untreated hypercholesterolaemia affects mechanical properties of the Achilles tendon but not gastrocnemius muscle. J Biomech 2024; 166:112048. [PMID: 38493577 DOI: 10.1016/j.jbiomech.2024.112048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/27/2024] [Accepted: 03/11/2024] [Indexed: 03/19/2024]
Abstract
Tendon xanthoma and altered mechanical properties have been demonstrated in people with familial hypercholesterolaemia. However, it is unclear whether mild, untreated hypercholesterolaemia alters musculotendinous mechanical properties and muscle architecture. We conducted a case-control study of adults aged 50 years and over, without lower limb injury or history of statin medication. Based on fasting low-density lipoprotein (LDL) cholesterol levels, 6 participants had borderline high LDL (>3.33 mmol/L) and 6 had optimal LDL cholesterol (<2.56 mmol/L). Using shear wave elastography, shear wave velocity (SWV) of the Achilles tendon and gastrocnemius medialis muscle (a proxy for stiffness), along with muscle fascicle length and pennation angle were measured under four passive tensile loads (0, 0.5, 1.0, 1.5 kg) applied via a pulley system. Differences between groups were found for tendon SWV but not muscle SWV, fascicle length or pennation angle. Participants with hypercholesterolaemia showed greater SWV (mean difference, 95 % CI: 2.4 m/s, 0.9 to 4.0, P = 0.024) compared to the control group across all loads. These findings suggest that adults with mild hypercholesterolaemia have increased tendon stiffness under low passive loads, while muscle was not affected. Future research is needed to confirm findings in a larger cohort and explore the impact of hypercholesterolaemia on tendon fatigue injury and tendinopathy.
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Affiliation(s)
- Brooke K Coombes
- School of Health Sciences and Social Work, Griffith University, 170 Kessels Road, Brisbane, Australia 4111; Menzies Health Institute Queensland, 170 Kessels Road, Brisbane, Australia 4111.
| | - Monica Hanna
- School of Health Sciences and Social Work, Griffith University, 170 Kessels Road, Brisbane, Australia 4111
| | - Kaelah A Thompson
- School of Health Sciences and Social Work, Griffith University, 170 Kessels Road, Brisbane, Australia 4111.
| | - Michel W Coppieters
- School of Health Sciences and Social Work, Griffith University, 170 Kessels Road, Brisbane, Australia 4111; Menzies Health Institute Queensland, 170 Kessels Road, Brisbane, Australia 4111; Adjunct, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands.
| | - Taylor J M Dick
- School of Biomedical Sciences, Faculty of Medicine, University of Queensland, Chancellors Place, St Lucia, Brisbane 4067, Australia.
| | - Ricardo J Andrade
- School of Health Sciences and Social Work, Griffith University, 170 Kessels Road, Brisbane, Australia 4111; Menzies Health Institute Queensland, 170 Kessels Road, Brisbane, Australia 4111; Nantes Université, Movement - Interactions - Performance, MIP, UR 4334, Nantes F 44000, France.
| | - Lee Barber
- School of Health Sciences and Social Work, Griffith University, 170 Kessels Road, Brisbane, Australia 4111; Menzies Health Institute Queensland, 170 Kessels Road, Brisbane, Australia 4111.
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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).
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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
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Hwang UJ, Kwon OY, Kim JH, Gwak GT. Classification of chronic ankle instability using machine learning technique based on ankle kinematics during heel rise in delivery workers. Digit Health 2024; 10:20552076241235116. [PMID: 38419804 PMCID: PMC10901058 DOI: 10.1177/20552076241235116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 02/07/2024] [Indexed: 03/02/2024] Open
Abstract
Objective Ankle injuries in delivery workers (DWs) are often caused by trips, and high recurrence rates of ankle sprains are related to chronic ankle instability (CAI). Heel rise requires joint angles and moments similar to those of the terminal stance phase of walking that the foot supinates. Thus, our study aimed to develop, determine, and compare the predictive performance of statistical machine learning models to classify DWs with and without CAI using ankle kinematics during heel rise. Methods In total, 203 DWs were screened for eligibility. Seven predictors were included in our study (age, work duration, body mass index, calcaneal stance position angle [CSPA] in the initial and terminal positions during heel rise, calcaneal movement during heel rise [CMHR], and plantar flexion angle during heel rise). Six machine learning algorithms, including logistic regression, decision tree, AdaBoost, Extreme Gradient boosting machines, random forest, and support vector machine, were trained. Results The random forest model (area under the curve [AUC], 0.967 [excellent]; F1, 0.889; accuracy, 0.925) confirmed the best predictive performance in the test datasets among the six machine learning models. For Shapley Additive Explanations, old age, low CMHR, high CSPA in the initial position, high PFA, long work duration, low CSPA in the terminal position, and high body mass index were the most important predictors of CAI in the random forest model. Conclusion Ankle kinematics during heel rise can be considered in the classification of DWs with and without CAI.
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Affiliation(s)
- Ui-jae Hwang
- Department of Physical Therapy, College of Health Science, Laboratory of KEMA AI Research (KAIR), Yonsei University, Wonju, South Korea
| | - Oh-yun Kwon
- Department of Physical Therapy, College of Health Science, Laboratory of Kinetic Ergocise Based on Movement Analysis, Yonsei University, Wonju, South Korea
| | - Jun-hee Kim
- Department of Physical Therapy, College of Health Science, Laboratory of KEMA AI Research (KAIR), Yonsei University, Wonju, South Korea
| | - Gyeong-tae Gwak
- Department of Physical Therapy, College of Health Science, Laboratory of KEMA AI Research (KAIR), Yonsei University, Wonju, South Korea
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Nilsson N, Alim MDA, Dietrich-Zagonel F, Concaro S, Brorsson A, Nilsson Helander K, Eliasson P. The Delayed Presentation of Achilles Tendon Ruptures Is Associated With Marked Alterations in the Gene Expression of COL1A1, MMPs, TIMPs, and IL-6. Am J Sports Med 2024; 52:164-173. [PMID: 38164679 DOI: 10.1177/03635465231212669] [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: 01/03/2024]
Abstract
BACKGROUND Both acute and chronic Achilles tendon ruptures are affected by alterations in the extracellular matrix during the healing process of the tendon. Yet, these alterations in gene expression patterns are not well characterized. PURPOSE To characterize temporal and spatial differences in gene expression patterns after an Achilles tendon rupture and to evaluate if cells from chronic Achilles tendon ruptures have the same ability to form new tendon tissue (tendon constructs) as healthy tendon cells. STUDY DESIGN Controlled laboratory study. METHODS A total of 35 patients with surgically treated Achilles tendon ruptures were included in the study and divided into 3 groups: acute (<4 weeks), short-term chronic (1-6 months), and long-term chronic (>6 months). Biopsy specimens were collected during surgical repair and were used to analyze the gene expression within the different groups and to compare mRNA levels in the proximal and distal tendon ends. A complementary in vitro experiment was performed to evaluate if cells from chronic Achilles tendon ruptures can form tendon constructs. RESULTS The mRNA levels for COL1A1 and COL3A1 were significantly higher in the short-term chronic group compared with the acute group (P < .05). Both MMP-1 and MMP-13 had the highest mRNA levels in the acute group (P < .01) compared with the long-term chronic group, while MMP-2 had the highest mRNA level in the short-term chronic group. Significant differences between the proximal and distal tendon ends were only detected for the monocyte and macrophage marker CD163 (P < .05), which was more expressed proximally. Cells extracted from chronic Achilles tendon ruptures displayed a similar ability and effectiveness to form tendon constructs as healthy tendon cells. CONCLUSION A high collagenase gene activity after an Achilles tendon rupture indicated possible rapid matrix degradation in the acute phase. Chronic ruptures appeared to initiate the healing process even before treatment, indicated by the higher expression of collagen in the short-term chronic group. Cells from chronic Achilles tendon ruptures also displayed an ability to form new tendon tissue in vitro. CLINICAL RELEVANCE The study shows a rapid increase in collagenase gene expression, which could lead to matrix degradation that continues for months after an Achilles tendon rupture.
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Affiliation(s)
- Niklas Nilsson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - M D Abdul Alim
- Division of Orthopaedics, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Franciele Dietrich-Zagonel
- Division of Orthopaedics, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Sebastian Concaro
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Annelie Brorsson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- IFK Kliniken Rehab, Gothenburg, Sweden
| | - Katarina Nilsson Helander
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Pernilla Eliasson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Division of Orthopaedics, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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11
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B Nielsen L, B Svensson R, U Fredskild N, H Mertz K, Magnusson SP, Kjaer M, Bayer ML. Chronic changes in muscle architecture and aponeurosis structure following calf muscle strain injuries. Scand J Med Sci Sports 2023; 33:2585-2597. [PMID: 37621063 DOI: 10.1111/sms.14472] [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: 03/02/2023] [Revised: 06/02/2023] [Accepted: 08/09/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Muscle strain injuries in the human calf muscles are frequent sports injuries with high recurrence. Potential structural and functional changes in the medial head of the musculus gastrocnemius (GM) and the associated aponeurosis are not well documented. PURPOSE To test whether a GM muscle strain injury affects muscle fascicle length, pennation angle, and the morphology of the deep aponeurosis at rest and during muscle contraction long time after the injury. Additionally, electromyography (EMG) of the GM and the soleus muscle during a unilateral heel rise was measured in the injured and uninjured calf. METHODS GM fascicle length, pennation angle, and aponeurosis thickness was analyzed on dynamic ultrasonography (US) recordings in 10 participants with a chronic calf strain. In addition, US images taken across the distal portion and mid-belly of the GM were analyzed at three different ankle positions. EMG recordings were obtained during a unilateral heel rise. RESULTS The pennation angle of the injured distal GM was significantly larger compared to the uninjured GM in the contracted, but not the relaxed state. Pennation angle increased more in the injured compared to the uninjured GM during contraction. Fascicle length was shorter in the most distal portion of the injured GM. Fascicles at the distal portion of the injured GM showed a pronounced curvilinear shape as the muscle contracted and the aponeurosis was enlarged in the injured compared to the uninjured GM. The ratio between GM and soleus EMG activity showed a significantly higher relative soleus activity in the injured compared to the healthy calf. CONCLUSION The greater change in pennation angle and curvilinear fascicle shape during contraction suggest that a long-term consequence after a muscle strain injury is that some muscle fibers at the distal GM are not actively engaged. The significantly enlarged aponeurosis indicates a substantial and long-lasting connective tissue involvement following strain injuries.
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Affiliation(s)
- Louise B Nielsen
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery M, Copenhagen University Hospital - Bispebjerg Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Rene B Svensson
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery M, Copenhagen University Hospital - Bispebjerg Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Niels U Fredskild
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery M, Copenhagen University Hospital - Bispebjerg Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kenneth H Mertz
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery M, Copenhagen University Hospital - Bispebjerg Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - S Peter Magnusson
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery M, Copenhagen University Hospital - Bispebjerg Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Physical Therapy, Copenhagen University Hospital - Bispebjerg Frederiksberg, Copenhagen, Denmark
| | - Michael Kjaer
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery M, Copenhagen University Hospital - Bispebjerg Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Monika L Bayer
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery M, Copenhagen University Hospital - Bispebjerg Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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12
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Saarensilta A, Aufwerber S, Grävare Silbernagel K, Ackermann P. Early Tendon Morphology as a Biomarker of Long-term Patient Outcomes After Surgical Repair of Achilles Tendon Rupture: A Prospective Cohort Study. Orthop J Sports Med 2023; 11:23259671231205326. [PMID: 37941888 PMCID: PMC10629330 DOI: 10.1177/23259671231205326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/22/2023] [Indexed: 11/10/2023] Open
Abstract
Background Patient outcome after acute Achilles tendon rupture (ATR) varies and is difficult to predict. Whether early variations in healing, visualized with ultrasonography, can predict long-term patient outcome is unclear. Purpose To (1) examine the associations of Achilles tendon cross-sectional area (CSA) and elongation (TE) during healing of ATR repair with patient outcomes at 12 months postoperatively and (2) investigate the predictive or diagnostic capacity of the morphological biomarkers. Study Design Cohort study; Level of evidence, 2. Methods This study was based on previously collected data from 86 patients who underwent acute standardized ATR repair between 2013 and 2018 and who were included in a prior randomized trial investigating early functional mobilization (EFM). In the EFM group, loading was allowed immediately after surgery, while in the comparison group, loading was allowed first at 2 weeks postoperatively. Achilles tendon CSA and length were measured with ultrasound at 6 weeks, 6 months, and 12 months postoperatively. CSA ratio and absolute difference in the length of the healthy and injured tendons were calculated. Patient-reported outcome was registered with the validated Achilles tendon Total Rupture Score and functional outcome with the heel-rise endurance test at 12 months postoperatively. The limb symmetry index (LSI) was calculated for maximum heel-rise height (HRHmax) and total concentric work. Multiple linear regression adjusted for age was used, and the area under the receiver operating characteristic curve (AUC) was calculated to evaluate predictive capacity. Results A larger CSA ratio at 6 weeks was associated with higher LSI HRHmax at 12 months (R2, 0.35; P < .001) and exhibited good predictive capacity (AUC, 0.82). More TE at 12 months was associated with lower LSI total concentric work at 12 months (R2, 0.21; P = .001) and exhibited acceptable predictive capacity (AUC, 0.71). Conclusion Greater Achilles tendon CSA seen on ultrasound 6 weeks after surgical repair had good clinical prediction for long-term functional outcome. TE at 12 months was predictive of inferior functional outcome. Registration NCT02318472 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Annukka Saarensilta
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Susanna Aufwerber
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Women’s Health and Allied Health Professionals Theme, Medical Unit Occupational Therapy and Physiotherapy, Karolinska University Hospital, Stockholm, Sweden
| | | | - Paul Ackermann
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Trauma, Acute Surgery and Orthopaedics, Karolinska University Hospital, Stockholm, Sweden
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13
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Hébert-Losier K, Ngawhika TM, Balsalobre-Fernandez C, O'Neill S. Calf muscle abilities are related to sprint performance in male Rugby Union players. Phys Ther Sport 2023; 64:117-122. [PMID: 37837863 DOI: 10.1016/j.ptsp.2023.09.001] [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: 06/14/2023] [Revised: 09/08/2023] [Accepted: 09/10/2023] [Indexed: 10/16/2023]
Abstract
OBJECTIVES To examine the strength of the relationship between plantarflexor power and strength-endurance metrics and 10-m sprint times in male Rugby Union players. A secondary aim was to examine the strength of the relationship within calf muscle metrics. DESIGN Observational cross-sectional correlational. SETTING Field-based. PARTICIPANTS Sixteen male Rugby Union players in the National Provincial Championship. MAIN OUTCOME MEASURES Participants completed three single-leg calf muscle tests: bodyweight power, weighted power, and strength-endurance. Data were recorded using the Calf Raise application. Three-to-four days later, average and best 10-m sprint performances were collected using timing lights. RESULTS There were large significant correlations between 10-m sprint performances (average and best times) and calf muscle power (weighted) and strength-endurance (total displacement and work) metrics (r = -0.503 to -0.628). There were large significant correlations between bodyweight and weighted power, weighted power and strength-endurance (total displacement and work), and most strength-endurance metrics (r = 0.520 to 0.943). CONCLUSIONS Our findings emphasise the importance of triceps surae muscle power and strength-endurance for maximal-effort accelerations and sprint performances in Rugby Union. Our data indicate that weighted power and total work from strength-endurance tests are the most useful metrics for further investigation in the context of short sprints and acceleration.
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Affiliation(s)
- Kim Hébert-Losier
- Division of Health, Engineering, Computing and Science, Te Huataki Waiora School of Health, University of Waikato, New Zealand. https://twitter.com/KimHebertLosier
| | - Te Manawa Ngawhika
- Division of Health, Engineering, Computing and Science, Te Huataki Waiora School of Health, University of Waikato, New Zealand; Bay of Plenty Rugby, New Zealand.
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Mitchell A, Waite O, Holding C, Greig M. The Development of a Return to Performance Pathway Involving A Professional Soccer Player Returning From A Multi-Structural Knee Injury: A Case Report. Int J Sports Phys Ther 2023; 18:450-466. [PMID: 37020432 PMCID: PMC10069403 DOI: 10.26603/001c.73317] [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: 09/11/2022] [Accepted: 02/14/2023] [Indexed: 04/04/2023] Open
Abstract
This case report describes a male professional soccer player returning to match play (English Championship League) following a medial meniscectomy that occurred during the course of rehabilitation after Anterior Cruciate Ligament (ACL) reconstruction. The player underwent a medial meniscectomy eight months into an ACL rehabilitation program and following 10 weeks of rehabilitation successfully returned to competitive first team match play. This report outlines description of the pathology, the rehabilitation progressions, and the sports specific performance requirements of the player as they progressed through the return to performance pathway (RTP). The RTP pathway included nine distinct phases with evidenced based criteria required to exit each phase. The first five phases were indoor as the player progressed from the medial meniscectomy, through the rehabilitation pathways to the "gym exit Phase". The gym exit Phase was assessed with multiple criteria: a) capacity; b) strength; c) isokinetic dynamometry (IKD); d) hop test battery; e) force plate jumps; and f) supine isometric hamstring rate of force (RFD) development qualities to evaluate the players readiness to start sport specific rehabilitation. The last four phases of the RTP pathway are designed to regain the maximal physical capabilities (plyometric and explosive qualities) in the gym and included the retraining of on-field sport specific qualities utilizing the 'control-chaos continuum.' The player successfully returned to team play in the ninth and final phase of the RTP pathway. The purpose of this case report was to outline a RTP for a professional soccer player who successfully restored specific injury criteria (strength, capacity and movement quality), physical capabilities (plyometric and explosive qualities). and on-field sport specific criteria utilizing the 'control-chaos continuum.' Level of Evidence Level 4.
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Affiliation(s)
| | - Ollie Waite
- Medical Department Crystal Palace Football Club
| | | | - Matt Greig
- Sports Injuries Research Group Edge Hill University
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15
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Altered Ankle Muscle Activation at 2-Year Post Achilles Tendon Repair: An Age, Gender, and Activity Level-Matched Comparison With Healthy Subjects. J Sport Rehabil 2023; 32:305-314. [PMID: 36623511 DOI: 10.1123/jsr.2022-0064] [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: 02/12/2022] [Revised: 10/31/2022] [Accepted: 11/07/2022] [Indexed: 01/11/2023]
Abstract
CONTEXT The study purpose was to compare the ankle muscle activation and dynamic ankle joint stability of subjects who underwent endoscopy-assisted Achilles tendon repair (ATR; at ≥ 2 y postsurgery) with age, gender, and activity level-matched healthy control group subjects. DESIGN Prospective, cross-sectional study. All functional tests were performed on the involved ankle of the ATR group, and at the matched side of healthy age, gender, and activity-level control group subjects. METHODS Fifteen men in each group were evaluated for medial and lateral gastrocnemius, soleus, tibialis anterior, and peroneus longus muscle activation during modified star excursion balance test and heel-rise test performance. The weight-bearing lunge test (ankle dorsiflexion) and heel-rise test distance (ankle plantar flexion) also determined weight-bearing, active ankle mobility magnitudes. The Achilles Tendon Total Rupture Score and Foot and Ankle Outcome Score provided patient-reported outcome perceptions specific to Achilles tendon rupture and comprehensive foot and ankle symptoms and function, respectively. RESULTS Medial (P = .005) and lateral (P = .012) gastrocnemius displayed greater activation amplitudes in the ATR group during the star excursion balance test, and peroneus longus displayed greater activation amplitudes during the heel-rise test (P = .006). The star excursion balance test reach distance was comparable between groups. Active weight-bearing ankle plantar flexion (heel-rise test) and dorsiflexion (weight-bearing lunge test) mobility magnitudes were lower in the ATR group. CONCLUSIONS Subjects who underwent endoscopy-assisted percutaneous ATR had reduced active weight-bearing ankle dorsiflexion and plantar flexion mobility magnitudes and greater gastrocnemius and peroneus longus neuromuscular activation when performing the same tasks as healthy control group subjects. As surgical approaches evolve to less invasive, soft tissue preserving methods with less tissue morbidity and faster healing, rehabilitation approaches may likewise need to evolve. LEVEL OF EVIDENCE Level III.
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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.
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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.
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Henriksen GJ, Cramer A, Hölmich P, Hansen MS, Hansen JK, Christensen M, Barfod KW. Treatment outcome at 1 year did not differ between use of cast or walker in the first 3 weeks after an acute Achilles tendon rupture. A registry study of 1304 patients from the Danish Achilles tendon database. Foot Ankle Surg 2023; 29:56-62. [PMID: 36163152 DOI: 10.1016/j.fas.2022.09.004] [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: 05/18/2022] [Revised: 09/08/2022] [Accepted: 09/14/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The best choice of orthosis in the treatment of acute Achilles tendon rupture is still under debate. OBJECTIVE To investigate if choice of orthosis in the first 3 weeks of treatment affected patient reported outcome (Achilles tendon Total Rupture Score (ATRS)), tendon elongation (Achilles Tendon Resting Angle (ATRA) and Heel Rise Height (HRH)) and re-rupture. METHODS Registry study in the Danish Achilles tendon Database. Patients treated with cast and patients treated with walker in the first 3 weeks of treatment were compared using a linear mixed-effects model adjusted for potential confounders. RESULTS 1304 patients were included in the study. No clinically relevant difference was found: Adjusted mean difference (using walker the whole period as reference)(95% CI) ATRS after 1 year = 0.1(-3.0; 4.1), ATRS after 6 months = 2.0(-4.5; 5.8), ATRS after 2 years = 3.0(-0.7; 7.0), HRH difference = 0.6(-6.6; 8.2), ATRA difference = 0.03°(-1.5; 1.6), re-rupture(odds ratio) = 0.812(0.4; 1.61). CONCLUSION Patients treated with cast the first 3 weeks after acute Achilles tendon rupture did not have better treatment outcome than patients treated with walker.
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Affiliation(s)
- Guðrun Jóannesardóttir Henriksen
- Sports Orthopedic Research Center - Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark.
| | - Allan Cramer
- 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
| | - Maria Swennergren Hansen
- Sports Orthopedic Research Center - Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark; Physical Medicine & Rehabilitation Research-Copenhagen (PMR-C), Department of Physical and Occupational Therapy, and Clinical Research Centre, Copenhagen University Hospital, Amager-Hvidovre, Denmark
| | - Jeanette Kaae Hansen
- Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospital, Denmark
| | - Marianne Christensen
- Department of Physiotherapy and Occupational Therapy; Interdiciplinary Orthopaedics, Aalborg University Hospital, Denmark
| | - Kristoffer Weisskirchner Barfod
- Sports Orthopedic Research Center - Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark
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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).
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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
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19
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Does Mobility of the Ankle Joint Depends on Length of the Free Part of the Achilles Tendon? Symmetry (Basel) 2022. [DOI: 10.3390/sym14112313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The aim of our study was to evaluate whether the length of the free part of the Achilles tendon affects the mobility of the ankle joint in active motion without a load, as well as in functional motion with a body-weight load. We examined 36 healthy people, aged 21 to 30 years, and divided them into two groups: 1 (n = 15)—participants with a normal range of dorsiflexion in the ankle joint (20° or more), and 2 (n = 21)—participants with a reduced range of dorsiflexion in the ankle joint (below 20°). The length of the free part of the Achilles tendon was measured using ultrasonography. Ankle joint range of dorsiflexion was assessed, and a weight-bearing lunge test (WBLT) was conducted. Group 1 performed the WBLT better and demonstrated significantly greater Achilles tendon length compared to Group 2. A moderate, significant correlation was observed between ankle joint range of dorsiflexion and Achilles tendon length (r = 0.53, p < 0.05); between WBLT and Achilles tendon length (r = 0.61, p < 0.05); as well as between ankle joint range of dorsiflexion and WBLT (r = 0.63, p < 0.05). Thus, we can suggest that both the length of the tendon (measured by USG) and the ankle range of motion under a body-weight load (measured by WBLT) are good indicators regarding the range of foot dorsiflexion, but only up to specific values (6 cm of tendon length and 11 cm of WBLT reach). Therefore, Achilles tendon length, e.g., after injury and during tendon healing, may be monitored using the method of ultrasound imaging presented in this study.
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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).
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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 ()
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21
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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.
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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
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22
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Data driven model of midportion achilles tendinopathy health created with factor analysis. BMC Musculoskelet Disord 2022; 23:744. [PMID: 35922770 PMCID: PMC9347128 DOI: 10.1186/s12891-022-05702-1] [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: 06/07/2021] [Accepted: 07/19/2022] [Indexed: 11/10/2022] Open
Abstract
Background Achilles tendinopathy is a complex injury and the clinical presentation spans multiple different domains: physical and psychological symptoms, lower extremity function and tendon structure. A conceptual model of Achilles tendon health comprising these domains has been proposed in the literature. The aim of the study was to fit a model of Achilles tendinopathy using factor analysis and compare that to the conceptual model. An inclusive approach using a wide range of variables spanning multiple potential domains were included. Methods Participants (N = 99) with midportion Achilles tendinopathy were assessed with variables representing symptoms, physical function, tendon structure, metabolic syndrome, and psychologic symptoms. A Kaiser-Mayer-Olkin index was used to determine suitable variables for a subsequent exploratory factor analysis. Results A model emerged with an acceptable fit to the data (standardized root mean square of residuals = 0.078). Five uncorrelated factors emerged from the model and were labelled as biopsychosocial, lower extremity function, body size, load tolerance, and tendon structure. The total explained variance was 0.51 with the five factors explaining 0.14, 0.12, 0.10, 0.08, and 0.07 respectively. The results differed from the conceptual model as the factors of psychological variables and metabolic variables did not emerge from the analysis. Conclusion A data driven model of Achilles tendon health supports assessment of the clinical presentation over multiple domains. As the factors are uncorrelated, the results of assessment of, for example, tendon structure should not be expected to be associated with lower extremity function or biopsychosocial limitations. The results suggest that the Patient Reported Outcomes Measurement Information System, counter-movement jump height, body mass index, pain with hopping, and the tendon cross-sectional area can evaluate the five factors, respectively. Trial registration Registered on clinicaltrials.gov (Medicine NL of. ClinicalTrials.gov [Internet], 2018), ID number NCT03523325. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05702-1.
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23
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Cramer A, Hansen MS, Hölmich P, Barfod KW. Neither heel-rise Height (HRH) nor Achilles tendon resting angle (ATRA) show strong correlations to patient limitations and return to previous activities one year after acute Achilles tendon rupture. Foot Ankle Surg 2022; 28:795-799. [PMID: 34836720 DOI: 10.1016/j.fas.2021.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 10/20/2021] [Accepted: 11/08/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Knowledge is limited about how Achilles tendon elongation following acute Achilles tendon rupture (ATR) affects the ability to return to work and return to sport. This study aimed to examine if the indirect length measures, the heel-rise height (HRH) and the Achilles tendon resting angle (ATRA), correlated with patient limitations and return to previous activities one year after ATR. METHODS The study was performed as a registry study in the Danish Achilles tendon Database (DADB). The analyses investigated if HRH (limb symmetry index (LSI)) and relative ATRA one year after rupture, correlated with return to the same type of work, return to the same type of sport and the Achilles tendon total rupture score (ATRS) at the same time point. RESULTS 477 patients were included in the study. HRH (LSI) showed fair correlation to ATRS (r = 0.35, p < 0.001), poor correlation to same type of work (r = 0.29, p < 0.001) and did not statistically significantly correlate with return to the same type of sport. Relative ATRA showed poor correlation to ATRS (r = 0.09, p = 0.04) and did not correlate statistically significantly with return to same type of work or sport. CONCLUSIONS Neither relative ATRA nor HRH (LSI) showed strong correlations to return to work, return sport or ATRS. When comparing the relative ATRA and HRH (LSI), HRH (LSI) seems to be a better outcome in reflecting patient limitations and return to previous activities one year after ATR.
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Affiliation(s)
- Allan Cramer
- 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), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark; Department of Physical and Occupational Therapy, Copenhagen University Hospital, Amager-Hvidovre, Denmark; Physical Medicine & Rehabilitation Research - Copenhagen (PMR-C), 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
| | - Kristoffer Weisskirchner Barfod
- Sports Orthopedic Research Center - Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark
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24
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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: 3] [Impact Index Per Article: 1.5] [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.
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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
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25
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Carmont MR. [Not Available]. Foot Ankle Surg 2022; 28:411. [PMID: 34393060 DOI: 10.1016/j.fas.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 08/04/2021] [Indexed: 02/04/2023]
Affiliation(s)
- Michael R Carmont
- The Department of Trauma & Orthopaedic Surgery, Princess Royal Hospital, Shrewsbury & Telford Hospital NHS Trust, Shropshire, United Kingdom.
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26
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Saarensilta A, Juthberg R, Edman G, Ackermann PW. Effect of Surgeon Experience on Long-Term Patient Outcomes in Surgical Repair of Acute Achilles Tendon Rupture. Orthop J Sports Med 2022; 10:23259671221077679. [PMID: 35252464 PMCID: PMC8894962 DOI: 10.1177/23259671221077679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 11/19/2021] [Indexed: 11/23/2022] Open
Abstract
Background: The effect of surgeon experience on patient outcomes after surgical Achilles tendon rupture (ATR) repair has so far been unknown. Purpose: To examine whether patient-reported and functional outcomes as well as adverse events after surgical ATR repair differ between orthopaedic specialist surgeons and resident surgeons. Study Design: Cohort study; Level of evidence, 3. Methods: We retrospectively analyzed data from 295 patients treated with surgical ATR repair with standardized techniques. The level of surgeon experience (specialist vs resident) and number of adverse events (rerupture, infection, and deep venous thrombosis) were recorded. Patient-reported and functional outcomes were assessed 12 months postoperatively using the validated Achilles tendon total rupture score (ATRS) and the heel-rise test, respectively. Analysis of covariance was used to compare differences in outcomes between specialist surgeons and resident surgeons. Pearson chi-square or Fisher exact test was used for analysis of adverse events. Results: The mean ATRS at 12 months for patients operated on by resident surgeons was significantly higher compared with specialist surgeons (85.9 [95% CI, 80.3-91.5] vs 77.8 [95% CI, 73.8-81.9]; P = .028). In addition, the lateral difference (operated vs unoperated side) in mean total concentric work and number of heel-rise repetitions at 12 months was smaller in patients operated on by resident surgeons (P = .011 and 0.015, respectively). The number of adverse events did not differ significantly between the 2 groups. Conclusion: Resident surgeons achieved patient-reported and functional outcomes at least as good as those of specialist surgeons in surgical ATR repair, with a similar risk of adverse events.
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Affiliation(s)
- Annukka Saarensilta
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Robin Juthberg
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Gunnar Edman
- Research and Development, Norrtälje Hospital, Tiohundra AB, Norrtälje, Sweden
- Department of Clinical Sciences, Danderyd 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
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Patients with chronic Achilles tendon rupture have persistent limitations in patient-reported function and calf muscle function one year after surgical treatment - a case series. J Exp Orthop 2022; 9:15. [PMID: 35141849 PMCID: PMC8828811 DOI: 10.1186/s40634-022-00451-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 01/27/2022] [Indexed: 11/21/2022] Open
Abstract
Purpose Evaluate the one-year postoperative outcomes in patients with Chronic Achilles tendon rupture. Methods Patients surgically treated for Chronic Achilles tendon rupture (n = 22, 14 males and 8 females, mean age 61 ± 15) were evaluated by Achilles tendon Total Rupture Score, The Physical Activity Scale, The Foot and Ankle Outcome Score, Calf muscle endurance test, counter movement jump, Hopping, ultrasound measurement of tendon length, Achilles Tendon Resting Angle, dorsi flexion range of motion and calf muscle circumference. Muscle function and tendon length outcomes on the injured side were compared with the healthy side. Results The patients scored a mean of 62 ± 26 on the Achilles tendon Total Rupture Score. Median scores on the injured compared with the healthy side were lower in heel-rise repetitions (20 vs 24 cm, p = 0.004), hel-rise height (8 vs 10 cm, p < 0.001), heel-rise total work (872 vs 1590 joule, p < 0.001) and hopping ratio (0.37 vs 0.48, p = 0.005). Median calf circumference was smaller (37 vs 38 cm, p = 0.001) and the mean tendon elongation greater on the injured side; Achilles tendon resting angle (55 vs 50°, p < 0.001) and ultrasound (22.4 vs 20.5 cm, p = 0.006). Conclusions At one year postoperatively, patients with chronic Achilles tendon rupture reported persistent limitations in subjective foot and ankle function. Heel-rise height and total work as well as hopping ratio were not recovered, and there was an elongation of the injured Achilles tendon compared with the healthy tendon. Level of evidence IV
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Nordenholm A, Hamrin Senorski E, Nilsson Helander K, Möller M, Zügner R. Greater heel-rise endurance is related to better gait biomechanics in patients surgically treated for chronic Achilles tendon rupture. Knee Surg Sports Traumatol Arthrosc 2022; 30:3898-3906. [PMID: 35596012 PMCID: PMC9568482 DOI: 10.1007/s00167-022-06987-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 04/11/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE To determine the relationships among calf muscle function, tendon length and gait biomechanics in patients surgically treated for chronic Achilles tendon rupture. METHODS Twenty-one patients with chronic Achilles tendon rupture (mean age 62 ± 13 years) were evaluated by heel-rise endurance test, Achilles Tendon Resting Angle (ATRA), ultrasound measurement of tendon length and three-dimensional gait analysis. A bivariate two-sided correlation test was performed on all variables in all patients. RESULTS Better performance across all parameters of the heel-rise endurance test correlated with faster walking speed (r = 0.52-0.55), greater peak ankle power (r = 0.56-0.64), shorter stance phase (r = -0.52 to -0.76) and less peak ankle dorsiflexion angle (r = -0.49 to -0.64) during gait. Greater ATRA correlated with longer stance time (r = 0.47), greater peak ankle dorsiflexion angle (r = 0.48), less heel-rise repetitions (r = -0.52) and less heel-rise total work LSI (r = -0.44 to -0.59). CONCLUSION Greater calf muscle endurance, especially heel-rise total work, is moderately correlated (r = 0.49-0.76) to better ankle biomechanics during gait in patients surgically treated for CATR. The heel-rise endurance test may be a clinical proxy for power development in the ankle joint during gait. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Anna Nordenholm
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Medicinaregatan 11-13, 41390, Gothenburg, Sweden.
| | - Eric Hamrin Senorski
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Medicinaregatan 11-13, 41390 Gothenburg, Sweden
| | - Katarina Nilsson Helander
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Michael Möller
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Roland Zügner
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Nilsson N, Gunnarsson B, Carmont MR, Brorsson A, Karlsson J, Nilsson Helander K. Endoscopically assisted reconstruction of chronic Achilles tendon ruptures and re-ruptures using a semitendinosus autograft is a viable alternative to pre-existing techniques. Knee Surg Sports Traumatol Arthrosc 2022; 30:2477-2484. [PMID: 35396938 PMCID: PMC9206609 DOI: 10.1007/s00167-022-06943-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 03/08/2022] [Indexed: 10/29/2022]
Abstract
PURPOSE Achilles tendon ruptures are termed chronic after a delay in treatment for more than 4 weeks. The literature advocates surgical treatment with reconstruction to regain ankle push-off strength. The preferred technique is, however, still unknown and is often individualized. This study aims to present the technique and clinical outcome of an endoscopically assisted free semitendinosus reconstruction of chronic Achilles tendon rupture and Achilles tendon re-ruptures with delayed representation. It is hypothesized that the presented technique is a viable and safe alternative for distal Achilles tendon ruptures and ruptures with large tendon gaps. METHOD Twenty-two patients (13 males and 9 females) with a median (range) age of 64 (34-73) treated surgically with endoscopically assisted Achilles tendon reconstruction using a semitendinosus autograft were included. The patients were evaluated at 12 months post-operatively for Achilles tendon Total Rupture Score (ATRS), calf circumference, Achilles Tendon Resting Angle (ATRA), heel-rise height and repetitions together with tendon length determined by ultrasonography, concentric heel-rise power and heel-rise work. RESULTS The patients reported a median (range) ATRS of 76 (45-99) out of 100. The median (range) ATRA on the injured side was 60° (49°-75°) compared with 49.5° (40-61°), p < 0.001, on the non-injured side. Eighteen out of 22 patients were able to perform a single-leg heel-rise on the non-injured side. Sixteen patients out of those 18 (89%) were also able to perform a single heel-rise on the injured side. They did, however, perform significantly lower number of repetitions compared with the non-injured side with a median (range) heel-rise repetitions of 11 (2-22) compared with 26 (2-27), (p < 0.001), and a median (range) heel-rise height of 5.5 cm (1.0-11.0 cm) compared with 9.0 cm (5.0-11.5 cm), (p < 0.001). The median calf circumference was 1.5 cm smaller on the injured side, 37.5 cm compared with 39 cm, when medians were compared. The median (range) tendon length of the injured side was 24.8 cm (20-28.2 cm) compared with 22 cm (18.4-24.2 cm), (p < 0.001), on the non-injured side. CONCLUSION The study shows that endoscopically assisted reconstruction using a semitendinosus graft to treat chronic Achilles tendon ruptures and re-ruptures with delayed representation produces a satisfactory outcome. The technique can restore heel-rise height in patients with more distal ruptures or large tendon defects and is therefore a viable technique for Achilles tendon reconstruction. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Niklas Nilsson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborgsvägen 31, Mölndal, 431 80, Gothenburg, Sweden. .,Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden.
| | - Baldvin Gunnarsson
- grid.8761.80000 0000 9919 9582Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborgsvägen 31, Mölndal, 431 80 Gothenburg, Sweden ,grid.1649.a000000009445082XDepartment of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Michael R. Carmont
- grid.8761.80000 0000 9919 9582Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborgsvägen 31, Mölndal, 431 80 Gothenburg, Sweden ,grid.415251.60000 0004 0400 9694Department of Orthopaedic Surgery, Princess Royal Hospital, Shrewsbury and Telford Hospital NHS Trust, Shropshire, UK
| | - Annelie Brorsson
- grid.8761.80000 0000 9919 9582Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborgsvägen 31, Mölndal, 431 80 Gothenburg, Sweden ,IFK Kliniken Rehab, Gothenburg, Sweden
| | - Jón Karlsson
- grid.8761.80000 0000 9919 9582Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborgsvägen 31, Mölndal, 431 80 Gothenburg, Sweden ,grid.1649.a000000009445082XDepartment of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Katarina Nilsson Helander
- grid.8761.80000 0000 9919 9582Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborgsvägen 31, Mölndal, 431 80 Gothenburg, Sweden ,grid.1649.a000000009445082XDepartment of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
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Wenning M, Mauch M, Heitner A, Streicher P, Ritzmann R, Paul J. Midterm functional performance following open surgical repair of acute Achilles tendon rupture. Arch Orthop Trauma Surg 2022; 142:1337-1349. [PMID: 33484315 PMCID: PMC9217896 DOI: 10.1007/s00402-020-03746-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 12/19/2020] [Indexed: 12/02/2022]
Abstract
INTRODUCTION Various impairments such as soleus atrophy and consecutive functional deficits in end-range plantarflexion have been described in surgical repair of acute Achilles tendon rupture. The aim of this study was to assess the functional performance at midterm following open surgical repair. MATERIALS AND METHODS This cross-sectional study includes n = 52 patients which were tested on average 3.5 ± 1.4 years postoperatively using three different functional performance tests and patient-reported outcome measures. Two different surgical techniques (anatomical repair = AR vs. conventional repair = CR) were compared in a subanalysis. The testing included isokinetic strength testing, a novel setup of heel-rise testing using a marker-based 3D motion analysis system and a gait analysis. RESULTS At an average 3.5 years post-surgery, there is a persisting deficit in plantarflexion strength of 10.2%. Moreover, analysis of maximum peak torque angle and strength deficits according to the plantarflexion angle revealed that these deficits are not equally distributed across the range of motion. AR results in a significantly smaller deficit at 10° of plantarflexion compared to CR (13.9 vs. 29.9%, p < 0.05). This reflects into the functional performance during different modalities (static vs. dynamic) in this novel method of heel-rise testing. CONCLUSION In summary, there are persisting functional deficits at > 3 years following Achilles tendon repair which range from strength deficits to specific impairments of functional performance e.g. during heel rise. Anatomical reconstruction is associated with an improved functional performance potentially due to a more symmetric strength during end-range plantarflexion which transfers into a higher satisfaction during athletic activities. LEVEL OF EVIDENCE III, retrospective cohort study.
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Affiliation(s)
- Markus Wenning
- Rennbahnklinik, Kriegackerstr. 100, CH-4132, Muttenz, Baselland, Switzerland
- Department of Orthopedic and Trauma Surgery, University Medical Center Freiburg, Faculty of Medicine, Albert-Ludwigs University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Marlene Mauch
- Rennbahnklinik, Kriegackerstr. 100, CH-4132, Muttenz, Baselland, Switzerland
| | - Albrecht Heitner
- Rennbahnklinik, Kriegackerstr. 100, CH-4132, Muttenz, Baselland, Switzerland
| | - Paul Streicher
- Department of Sport and Sport Science, University of Freiburg, Freiburg, Germany
| | - Ramona Ritzmann
- Rennbahnklinik, Kriegackerstr. 100, CH-4132, Muttenz, Baselland, Switzerland
| | - Jochen Paul
- Rennbahnklinik, Kriegackerstr. 100, CH-4132, Muttenz, Baselland, Switzerland.
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The release of adhesions improves outcome following minimally invasive repair of Achilles tendon rupture. Knee Surg Sports Traumatol Arthrosc 2022; 30:1109-1117. [PMID: 34657973 PMCID: PMC8901518 DOI: 10.1007/s00167-021-06767-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 10/04/2021] [Indexed: 12/02/2022]
Abstract
PURPOSE Operative repair of Achilles tendon rupture may lead to complications, which influence outcome adversely. The aim of this study was to determine the incidence, impact and response to treatment of post-operative adhesions. METHODS From February 2009 to 2021, 248 patients operated on with percutaneous or minimally invasive surgical repair have been prospectively evaluated using the Achilles tendon Total Rupture Score (ATRS) and Heel-Rise Height Index (HRHI), following acute Achilles tendon rupture. RESULTS Fourteen (5.6%) patients were identified as having adhesions. Four patients reported superficial adhesions and ten patients reported a deeper tightness of the tendon. At a mean (SD) of 10.5 (2.3) months following repair, the overall ATRS was at a median (IQR) 65 (44.5-78) points and (HRHI) was mean (SD) 81.5 (13.5)%. Of those deemed to have deep adhesions the antero-posterior diameter of the tendon was at mean (SD) 15.6 (4.6) mm. Open release of superficial adhesions resulted in improved ATRS in all patients. Endoscopic debridement anterior to the Achilles tendon led to alleviation of symptoms of tightness and discomfort from deep adhesions and improved outcome in terms of the ATRS score. At a mean (SD) of 15.9 (3.3)-month follow-up from initial rupture and repair, the patients reported at median (IQR) ATRS scores of 85 (64.8-92.8) points, Tegner level 5 (3-9) and mean (SD) HRHI 86.2 (9.5)%. Patients significantly improved both ATRS and HRHI following release at median (IQR) of 16.5 (- 1.8-29.3) points (p = 0.041) and mean (SD) 5.6 (8.3)% (p = 0.043). CONCLUSIONS The incidence of patient-reported adhesions following minimally invasive repair of Achilles tendon rupture was estimated to be 5.6%. The occurrence of superficial adhesions was associated with a lower outcome scores as well as symptoms of anterior tendon tightness and stiffness were associated with a lower score in most patients. Surgical release of adhesions led to a significant improvement in outcome.
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Achilles tendon resting angle is able to detect deficits after an Achilles tendon rupture, but it is not a surrogate for direct measurements of tendon elongation, function or symptoms. Knee Surg Sports Traumatol Arthrosc 2022; 30:4250-4257. [PMID: 36087127 PMCID: PMC9463053 DOI: 10.1007/s00167-022-07142-9] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 08/23/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE The aim of this study was to investigate how the Achilles tendon resting angle (ATRA), an indirect measurement of tendon elongation, correlates with ultrasonography (US) measurements of the Achilles tendon length 6 and 12 months after an acute ATR and relates to other clinical outcome measurements such as heel-rise height, jumping ability and patient-reported outcome measurements (PROMs). METHODS Patients were included following acute Achilles tendon rupture (ATR). Achilles tendon length, ATRA, heel-rise height (HRH), drop countermovement jump (Drop CMJ) and PROMs (Achilles tendon total rupture score (ATRS) and physical activity scale (PAS)) were evaluated 6 and 12 months after injury. Achilles tendon length was evaluated using US, while the ATRA was measured with a goniometer. RESULTS Sixty patients (13 women, 47 men), mean (SD) age 43 (9) years, with an acute ATR undergoing either surgical (35%) or non-surgical (65%) treatment were evaluated. A negative correlation (r = - 0.356, p = 0.010) between relative ATRA and tendon elongation was seen at 12 months after ATR. There were also significant positive correlations at 6 and 12 months between relative ATRA and HRH (r = 0.330, p = 0.011 and r = 0.379, p = 0.004). There were no correlations between ATRA and ATRS or ATRA and Drop CMJ, at either 6 or 12 months after the injury. CONCLUSION In combination with other clinical evaluations such as HRH and US, ATRA could be a clinical tool for indirect measurements of tendon elongation. However, ATRA cannot be recommended as a direct surrogate for US for determining Achilles tendon length. LEVEL OF EVIDENCE III.
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Lee JH, Jung HW, Jung TS, Jang WY. Reliability and usefulness of the single leg heel raise balance test in patients with chronic ankle instability. Sci Rep 2021; 11:20369. [PMID: 34645864 PMCID: PMC8514424 DOI: 10.1038/s41598-021-99466-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 09/17/2021] [Indexed: 12/26/2022] Open
Abstract
We aimed to analyze the differences in static (including conventional and modified [single-leg heel-raise balance]) and dynamic postural stability and muscle endurance between patients with chronic ankle instability (CAI) and healthy controls, and to determine the reliability and usefulness of the single-leg heel-raise balance test in patients with CAI. In total, 26 patients with CAI and 26 healthy controls were enrolled. Postural stability was assessed using a postural stabilometry system. Muscle endurance was measured in dorsiflexion and plantarflexion using an isokinetic device. Modified static postural stability (P < 0.001) and dynamic postural stability (P < 0.001) were significantly poorer in the affected ankles of patients with CAI than in the controls. Plantarflexion endurance was significantly lower in the affected ankles of the patients with CAI than in the controls (P = 0.023). Modified static postural stability significantly correlated with plantarflexion endurance in both groups (CAI group: r = - 0.470, P = 0.015; healthy controls group: r = - 0.413, P = 0.036). Plantarflexion endurance was a significant risk factor for modified static postural stability in both the CAI group (R2 = 0.221, P = 0.015) and healthy controls (R2 = 0.170, P = 0.036). Given the reliability of the modified static postural stability test, clinicians and therapists should consider using it to assess improvements in postural stability and muscle endurance in patients with CAI before and after rehabilitation.
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Affiliation(s)
- Jin Hyuck Lee
- Department of Sports Medical Center, Korea University College of Medicine Anam Hospital, Seoul, Korea
| | - Hae Woon Jung
- Department of Pediatrics, Kyung Hee University Medical Center, Seoul, South Korea
| | | | - Woo Young Jang
- Department of Sports Medical Center, Korea University College of Medicine Anam Hospital, Seoul, Korea. .,Department of Orthopedic Surgery, College of Medicine, Korea University, 73, Inchon‑ro, Seongbuk‑gu, Seoul, 02841, Republic of Korea.
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Slagers AJ, Dams OC, van Zalinge SD, Geertzen JHB, Zwerver J, Reininga IHF, van den Akker-Scheek I. Psychological Factors Change During the Rehabilitation of an Achilles Tendon Rupture: A Multicenter Prospective Cohort Study. Phys Ther 2021; 101:6380795. [PMID: 34636920 PMCID: PMC8697845 DOI: 10.1093/ptj/pzab226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 05/24/2021] [Accepted: 07/23/2021] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The authors sought to gain insight into the changes in psychological factors during rehabilitation after Achilles tendon rupture (ATR) and to explore the association between psychological factors during rehabilitation and functional outcome 12 months after ATR. METHODS Fifty patients clinically diagnosed with ATR were invited to visit the hospital 3, 6, and 12 months after injury for data collection. They completed questionnaires assessing psychological factors: psychological readiness to return to sport (Injury Psychological Readiness to Return to Sport Questionnaire); kinesiophobia (Tampa Scale for Kinesiophobia); expectations, motivation, and outcome measures related to symptoms and physical activity (Achilles Tendon Total Rupture Score); and sports participation and performance (Oslo Sports Trauma Research Centre Overuse Injury Questionnaire). To determine whether psychological factors changed over time, generalized estimating equation analyses were performed. Multivariate regression analyses were used to study the association between psychological factors at 3, 6, and 12 months and outcome measures at 12 months after ATR. RESULTS Psychological readiness to return to sport improved, and kinesiophobia decreased significantly during rehabilitation. Psychological readiness at 6 and 12 months showed significant associations with sports participation and performance. Kinesiophobia at 6 months was significantly associated with symptoms and physical activity. Motivation remained high during rehabilitation and was highly associated with symptoms and physical activity, sports participation, and performance. CONCLUSION Psychological factors change during rehabilitation after ATR. Patients with lower motivation levels during rehabilitation, low psychological readiness to return to sports, and/or high levels of kinesiophobia at 6 months after ATR need to be identified. IMPACT According to these results, psychological factors can affect the rehabilitation of patients with ATR. Physical therapists can play an important role in recognizing patients with low motivation levels and low psychological readiness for return to sport and patients with high levels of kinesiophobia at 6 months post-ATR. Physical therapist interventions to enhance motivation and psychological readiness to return to sport and to reduce kinesiophobia need to be developed and studied in the post-ATR population. LAY SUMMARY With Achilles tendon rupture, level of motivation, psychological readiness for return to sport, and fear of movement can affect rehabilitation outcome. A physical therapist can help recognize these factors.
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Affiliation(s)
- Anton J Slagers
- University of Groningen, University Medical Center Groningen, Center for Rehabilitation, Department of Rehabilitation Medicine, Groningen, the Netherlands,Address all correspondence to Mr Slagers at:
| | - Olivier C Dams
- University of Groningen, University Medical Center Groningen, Department of Orthopaedics, Groningen, The Netherlands
| | - Sara D van Zalinge
- University of Groningen, University Medical Center Groningen, Department of Orthopaedics, Groningen, The Netherlands
| | - Jan HB Geertzen
- University of Groningen, University Medical Center Groningen, Center for Rehabilitation, Department of Rehabilitation Medicine, Groningen, the Netherlands
| | - Johannes Zwerver
- University of Groningen, University Medical Center Groningen, Center for Rehabilitation, Department of Rehabilitation Medicine, Groningen, the Netherlands,University of Groningen, University Medical Center Groningen, Center for Human Movement Sciences, Groningen, The Netherlands,Gelderse Vallei Hospital, Sports Valley, Department of Sports Medicine, Ede, The Netherlands
| | - Inge HF Reininga
- University of Groningen, University Medical Center Groningen, Department of Trauma Surgery, Groningen, The Netherlands
| | - Inge van den Akker-Scheek
- University of Groningen, University Medical Center Groningen, Department of Orthopaedics, Groningen, The Netherlands
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Zhang YJ, Long X, Du JY, Wang Q, Lin XJ. Is Early Controlled Motion and Weightbearing Recommended for Nonoperatively Treated Acute Achilles Tendon Rupture? A Systematic Review and Meta-analysis. Orthop J Sports Med 2021; 9:23259671211024605. [PMID: 34568502 PMCID: PMC8461133 DOI: 10.1177/23259671211024605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 02/28/2021] [Indexed: 12/28/2022] Open
Abstract
Background There is disagreement as to whether early controlled motion and weightbearing confer a beneficial effect for nonoperatively treated acute Achilles tendon rupture (ATR) compared with immobilization and late weightbearing. Purpose To conduct a meta-analysis of randomized controlled trials (RCTs) to determine whether early controlled motion and weightbearing results in different outcomes compared with immobilization and late weightbearing for nonoperatively treated patients with acute ATR. Study Design Systematic review; Level of evidence, 1. Methods We conducted a search in the PubMed, Web of Science, and EMBASE databases for relevant RCTs in humans from January 1981 to August 2020. The primary outcome was the Achilles Tendon Total Rupture Score (ATRS) at 1-year follow-up. The secondary outcomes were the rerupture rate, return to sports activity and work, and the heel-rise work (limb symmetry index [LSI]). Study quality was assessed using the Cochrane Collaboration risk of bias tool. Results Included were 7 RCTs involving 424 participants (n = 215 treated with early controlled motion and weightbearing [early group], n = 209 treated with immobilization and late weightbearing [late group]). The quality assessment indicated a low risk of bias in all included RCTs. There was no difference between the early and late groups regarding the ATRS (mean difference [MD], -0.220; 95% CI, -4.489 to 4.049; P = .920). Likewise, we found no difference between the 2 groups in terms of the rerupture rate (odds ratio [OR], 1.107; 95% CI, 0.552 to 2.219; P = .775), the number of patients who returned to sports (OR, 0.766; 95% CI, 0.438 to 1.341; P = .351) and returned to work (OR, 0.706; 95% CI, 0.397 to 1.253; P = .234), the time to return to work (MD, -2.802 days; 95% CI, -6.525 to 0.921 days; P = .140), or the heel-rise work LSI (MD, -0.135; 95% CI, -6.243 to 5.973; P = .965). Conclusion No significant differences were found between early controlled motion and weightbearing compared with immobilization and late weightbearing regarding the ATRS, the rerupture rate, return to sports activity and work, and the heel-rise work in nonoperatively treated patients with acute ATR.
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Affiliation(s)
- Yi-Jun Zhang
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, PR China
| | - Xiao Long
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, PR China
| | - Jing-Yu Du
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, PR China
| | - Quan Wang
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, PR China
| | - Xiang-Jin Lin
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, PR China
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Sara LK, Gutsch SB, Hunter SK. The single-leg heel raise does not predict maximal plantar flexion strength in healthy males and females. PLoS One 2021; 16:e0253276. [PMID: 34415915 PMCID: PMC8378718 DOI: 10.1371/journal.pone.0253276] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 06/01/2021] [Indexed: 12/04/2022] Open
Abstract
Introduction The single-leg heel raise test (SLHR) is commonly used in clinical settings to approximate plantar flexor strength, yet this is neither validated nor supported physiologically. The purposes of this study were to: determine (1) associations between SLHR repetitions, maximal plantar flexor strength, and reductions in strength; and (2) whether sex differences exist in performance of the SLHR. Methods Twenty-eight young, healthy participants (14 males,14 females, 19–30 years) performed repeated single-leg heel raises to task failure. Pre- and post-task measures included maximal voluntary isometric contractions (MVIC), and voluntary activation and contractile properties of the plantar flexor muscles, assessed using peripheral electrical stimulation of the tibial nerve. Surface electromyography was recorded for the medial and lateral gastrocnemius, soleus, and anterior tibialis muscles. Results The SLHR resulted in 20.5% reductions in MVIC torque (p<0.001). However, the number of SLHR repetitions was not correlated with either the baseline MVIC (maximal strength; p = 0.979) or the reduction in MVIC following the SLHR (p = 0.23). There were no sex differences in either the number of SLHR repetitions (p = 0.14), baseline MVIC torque (p = 0.198), or the reduction of MVIC (p = 0.14). MVIC decline was positively associated with the reduction in voluntary activation (r = 0.841, p<0.001), but was not associated with the change in twitch amplitude (p = 0.597). Conclusions The SLHR was similar in young males and females yet was a poor predictor of maximal plantar flexor strength but evaluates performance fatigability of the lower extremity specific to dynamic contractions. The reduction in maximal strength at task failure was explained by reduced neural drive to the plantar flexor muscles in both males and females. Impact statement SLHR performance is not a clinical assessment of plantar flexor strength but assesses dynamic lower extremity fatigability that is similar in males and females. Alternate clinical measures for maximal plantar flexion strength need to be developed.
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Affiliation(s)
- Lauren K. Sara
- Department of Physical Therapy, Marquette University, Milwaukee, Wisconsin, United States of America
- * E-mail:
| | - Savannah B. Gutsch
- Department of Physical Therapy, Marquette University, Milwaukee, Wisconsin, United States of America
| | - Sandra K. Hunter
- Department of Physical Therapy, Marquette University, Milwaukee, Wisconsin, United States of America
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Zellers JA, Baxter JR, Silbernagel KG. Functional Ankle Range of Motion but Not Peak Achilles Tendon Force Diminished With Heel-Rise and Jumping Tasks After Achilles Tendon Repair. Am J Sports Med 2021; 49:2439-2446. [PMID: 34115525 PMCID: PMC8282709 DOI: 10.1177/03635465211019436] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Deficits in sporting performance after Achilles tendon repair may be due to changes in musculotendinous unit structure, including tendon elongation and muscle fascicle shortening. PURPOSE/HYPOTHESIS The purpose was to discern whether Achilles tendon rupture reduces triceps surae muscle force generation, alters functional ankle range of motion, or both during sports-related tasks. We hypothesized that individuals who have undergone Achilles tendon repair lack the functional ankle range of motion needed to complete sports-related tasks. STUDY DESIGN Descriptive laboratory study. METHODS The study included individuals 1 to 3 years after treatment of Achilles tendon rupture with open repair. Participants (n = 11) completed a heel-rise task and 3 jumping tasks. Lower extremity biomechanics were analyzed using motion capture. Between-limb differences were tested using paired t test. RESULTS Pelvic vertical displacement was reduced during the heel-rise (mean difference, -12.8%; P = .026) but not during the jumping task (P > .1). In the concentric phase of all tasks, peak ankle plantarflexion angle (range of mean difference, -19.2% to -48.8%; P < .05) and total plantar flexor work (defined as the area under the plantar flexor torque - ankle angle curve) (range of mean difference, -9.5% to -25.7%; P < .05) were lower on the repaired side relative to the uninjured side. No significant differences were seen in peak Achilles tendon load or impulse with any of the tasks. There were no differences in plantar flexor work or Achilles tendon load parameters during eccentric phases. CONCLUSION Impaired task performance or increased demands on proximal joints were observed on the repaired side in tasks isolating ankle function. Tasks that did not isolate ankle function appeared to be well recovered, although functional ankle range of motion was reduced with rupture. Reduced plantar flexor muscle-tendon unit work supports previous reports that an elongated tendon and shorter muscle fascicles caused by Achilles tendon rupture constrain functional capacity. Achilles tendon peak load and impulse were not decreased, suggesting that reduced and shifted functional ankle range of motion (favoring dorsiflexion) underlies performance deficits. CLINICAL RELEVANCE These findings point to the need to reduce tendon elongation and restore muscle length of the triceps surae after Achilles tendon rupture in order to address musculature that is short but not necessarily weak for improved performance with sports-related activities.
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Affiliation(s)
- Jennifer A. Zellers
- Program in Physical Therapy, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Josh R. Baxter
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA
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Skovgaard D, Siersma VD, Klausen SB, Visnes H, Haukenes I, Bang CW, Bager P, Grävare Silbernagel K, Gaida J, Magnusson SP, Kjaer M, Couppé C. Chronic hyperglycemia, hypercholesterolemia, and metabolic syndrome are associated with risk of tendon injury. Scand J Med Sci Sports 2021; 31:1822-1831. [PMID: 33963621 DOI: 10.1111/sms.13984] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 04/13/2021] [Accepted: 04/26/2021] [Indexed: 12/19/2022]
Abstract
Tendon injury is a considerable problem affecting both physically active and sedentary people. The aim of this study was to examine the relationship between markers for metabolic disorders (hyperglycemia, hypercholesterolemia, and metabolic syndrome) and the risk of developing tendon injuries requiring referral to a hospital. The Copenhagen City Heart Study is a prospective study of diabetic and non-diabetic individuals from the Danish general population with different physical activity levels. The cohort was followed for 3 years via national registers with respect to tendon injuries. Data from 5856 individuals (median age 62 years) were included. The overall incidence of tendon injury in both upper and lower extremities that required an out-patient or in-house visit to a hospital was ~5.7/1000 person years. Individuals with elevated HbA1c (glycated hemoglobin) even in the prediabetic range (HbA1c>5.7%) had a ~3 times higher risk of tendon injury in the lower extremities only, as compared to individuals with normal HbA1C levels. Hypercholesterolemia (total cholesterol>5 mmol/L) increased risk of tendon injury in the upper extremities by ~1.5 times, and individuals with metabolic syndrome had ~2.5 times higher risk of tendon injury in both upper and lower extremities. In conclusion, these data demonstrate for the first time in a large cohort with different physical activity levels that the indicators for metabolic syndrome are a powerful systemic determinant of tendon injury, and two of its components, hyperglycemia and hypercholesterolemia, each independently make tendons susceptible for damage and injury.
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Affiliation(s)
- Dorthe Skovgaard
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery M, Copenhagen University Hospital - Bispebjerg and Frederiksberg and Center for Healthy Aging, Institute of Sports Medicine Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - Volkert D Siersma
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Soren Bering Klausen
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Musculoskeletal Rehabilitation Research Unit, Department of Physical Therapy, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Håvard Visnes
- Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Orthopedics, Sorlandet Hospital Kristiansand, Oslo, Norway.,Oslo Sports trauma Research Centre, Norwegian School of Sports Sciences, Oslo, Norway
| | - Inger Haukenes
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Christine W Bang
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Peter Bager
- Department of Epidemiology Research, Statens Serum Institute, Copenhagen, Denmark
| | | | - Jamie Gaida
- Institute for Research Institute for Sport and Exercise (UCRISE), University of Canberra, Canberra, ACT, Australia
| | - Stig Peter Magnusson
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery M, Copenhagen University Hospital - Bispebjerg and Frederiksberg and Center for Healthy Aging, Institute of Sports Medicine Copenhagen, University of Copenhagen, Copenhagen, Denmark.,Musculoskeletal Rehabilitation Research Unit, Department of Physical Therapy, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Michael Kjaer
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery M, Copenhagen University Hospital - Bispebjerg and Frederiksberg and Center for Healthy Aging, Institute of Sports Medicine Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - Christian Couppé
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery M, Copenhagen University Hospital - Bispebjerg and Frederiksberg and Center for Healthy Aging, Institute of Sports Medicine Copenhagen, University of Copenhagen, Copenhagen, Denmark.,Musculoskeletal Rehabilitation Research Unit, Department of Physical Therapy, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
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Liu X, Dai TJ, Li BL, Li C, Zheng ZY, Liu Y. Early functional rehabilitation compared with traditional immobilization for acute Achilles tendon ruptures : a meta-analysis. Bone Joint J 2021; 103-B:1021-1030. [PMID: 34058871 DOI: 10.1302/0301-620x.103b6.bjj-2020-1890.r1] [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] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this meta-analysis was to assess the prognosis after early functional rehabilitation or traditional immobilization in patients who underwent operative or nonoperative treatment for rupture of the Achilles tendon. METHODS PubMed, Embase, Web of Science, and Cochrane Library were searched for randomized controlled trials (RCTs) from their inception to 3 June 2020, using keywords related to rupture of the Achilles tendon and rehabilitation. Data extraction was undertaken by independent reviewers and subgroup analyses were performed based on the form of treatment. Risk ratios (RRs) and weighted mean differences (WMDs) (with 95% confidence intervals (CIs)) were used as summary association measures. RESULTS We included 19 trials with a total of 1,758 patients. There was no difference between the re-rupture rate (RR 0.84 (95% CI 0.56 to 1.28); p = 0.423), time to return to work (WMD -1.29 (95% CI -2.63 to 0.05); p = 0.060), and sporting activity (WMD -1.50 (95% CI -4.36 to 1.37); p = 0.306) between the early functional rehabilitation and the traditional immobilization treatment strategies. Early rehabilitation up to 12 weeks yielded significantly better Achilles tendon Total Rupture Scores ((ATRS) WMD 5.11 (95% CI 2.10 to 8.12); p < 0.001). Patients who underwent functional rehabilitation had significantly lower limb symmetry index of heel-rise work ((HRW) WMD -4.19 (95% CI -8.20 to 0.17); p = 0.041) at one year. CONCLUSION Early functional rehabilitation is safe and provides better early function and the same functional outcome in the longer term. Cite this article: Bone Joint J 2021;103-B(6):1021-1030.
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Affiliation(s)
- Xuan Liu
- Beijing Sport University, Beijing, China
| | - Tian-Jiao Dai
- Beijing Sport University, Beijing, China.,Jiangsu College of Nursing, Jiangsu, China
| | - Bao-Lin Li
- Beijing Sport University, Beijing, China
| | - Chen Li
- Beijing Sport University, Beijing, China
| | | | - Ye Liu
- Beijing Sport University, Beijing, China
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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.
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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
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41
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No clinically relevant difference between operative and non-operative treatment in tendon elongation measured with the Achilles tendon resting angle (ATRA) 1 year after acute Achilles tendon rupture. Knee Surg Sports Traumatol Arthrosc 2021; 29:1617-1626. [PMID: 33386883 DOI: 10.1007/s00167-020-06391-w] [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: 08/28/2020] [Accepted: 11/24/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE Studies have shown that elongation of the injured Achilles tendon after acute Achilles tendon rupture (ATR) is negatively associated with clinical outcomes. The difference between operative and non-operative treatment on the length of the Achilles tendon is only sparsely investigated. The aim of the study was to investigate if the operative and non-operative treatment of ATR had different effects on tendon elongation. METHODS The study was performed as a registry study in the Danish Achilles tendon database (DADB). The primary outcome of the study was an indirect measure of Achilles tendon length: the Achilles tendon resting angle (ATRA) at 1-year follow-up. The variable of interest was treatment (operative or non-operative). RESULTS From August 2015 to January 2019, 438 patients (154 operatively treated and 284 non-operatively treated) were registered with full baseline data and had their ATRA correctly registered at 1-year follow-up in DADB. The analysis did not show a clinically relevant nor statistically significant difference in ATRA between operative and non-operatively treated patients at 1-year follow-up (mean difference - 1.2°; 95% CI - 2.5; 0.1; n.s) after adjustment for potential confounders. CONCLUSION There were neither clinically relevant nor statistically significant differences in terms of the ATRA at 1-year follow-up between the operative and non-operatively treated patients. This finding suggests that operative treatment does not lead to a clinically relevant reduction in tendon elongation compared to non-operative treatment and it should therefore not be used as an argument in the choice of treatment. LEVEL OF EVIDENCE Level III.
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Jeong HJ, Mueller MJ, Zellers JA, Yan Y, Hastings MK. Heel Rise and Non-Weight-Bearing Ankle Plantar Flexion Tasks to Assess Foot and Ankle Function in People With Diabetes Mellitus and Peripheral Neuropathy. Phys Ther 2021; 101:6177703. [PMID: 33735386 PMCID: PMC8280925 DOI: 10.1093/ptj/pzab096] [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: 04/14/2020] [Revised: 01/04/2021] [Accepted: 03/16/2021] [Indexed: 01/25/2023]
Abstract
OBJECTIVE The objective of this study was to examine the effects of diabetes mellitus and peripheral neuropathy (DMPN), limited joint mobility, and weight-bearing on foot and ankle sagittal movements and characterize the foot and ankle position during heel rise. METHODS Sixty people with DMPN and 22 controls participated. Primary outcomes were foot (forefoot on hindfoot) and ankle (hindfoot on shank) plantar-flexion/dorsiflexion angle during 3 tasks: unilateral heel rise, bilateral heel rise, and non-weight-bearing ankle plantar flexion. A repeated-measures analysis of variance and Fisher exact test were used. RESULTS Main effects of task and group were significant, but not the interaction in both foot and ankle plantar flexion. Foot and ankle plantar flexion were less in people with DMPN compared with controls in all tasks. Both DMPN and control groups had significantly less foot and ankle plantar flexion with greater weight-bearing; however, the linear trend across tasks was similar between groups. The DMPN group had a greater percentage of individuals in foot and/or ankle dorsiflexion at peak unilateral heel rise compared with controls, but the foot and ankle position was similar at peak bilateral heel rise between DMPN and control groups. CONCLUSION Foot and ankle plantar flexion is less in people with DMPN. Less plantar flexion in non-weight-bearing suggests that people with DMPN have limited joint mobility. However, peak unilateral and bilateral heel rise is less than the available plantar flexion range of motion measured in non-weight-bearing, indicating that limited joint mobility does not limit heel rise performance. A higher frequency of people with DMPN are in foot and ankle dorsiflexion at peak unilateral heel rise compared with controls, but the position improved with lower weight-bearing. IMPACT Proper resistance should be considered with physical therapist interventions utilizing heel rise because foot and ankle plantar flexion position could be improved by reducing the amount of weight-bearing.
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Affiliation(s)
- Hyo-Jung Jeong
- Program in Physical Therapy, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Michael J Mueller
- Program in Physical Therapy, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jennifer A Zellers
- Program in Physical Therapy, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Yan Yan
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Mary K Hastings
- Program in Physical Therapy, Washington University School of Medicine, St. Louis, Missouri, USA,Address all correspondence to Dr Hastings at:
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Cramer A, Jacobsen NC, Hansen MS, Sandholdt H, Hölmich P, Barfod KW. Outcome after acute Achilles tendon rupture is not negatively affected by female sex and age over 65 years. Knee Surg Sports Traumatol Arthrosc 2020; 28:3994-4002. [PMID: 32350575 DOI: 10.1007/s00167-020-06003-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 04/16/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Studies suggest that women have worse treatment outcome than men after acute Achilles tendon rupture (ATR). The aim of this study was to investigate if sex and age affect treatment outcome after ATR. METHODS The study was performed as a registry study in the Danish Achilles tendon Database. The primary outcome was change in the Achilles tendon Total Rupture Score (ATRS) from baseline to 4 months, 1 year and 2 years follow-up. Variables of interest were sex and age group (< 40 years, 40-65 years and > 65 years). RESULTS Data were collected from April 2012 to March 2018. Five-hundred and sixteen patients (416 men, 100 women) were included in the study population. At baseline, women scored 4.3 points lower in ATRS compared to men. No statistically significant difference between the sexes regarding change in ATRS were found. Women scored statistically significantly less in absolute ATRS at 1 year follow-up (mean difference 9.4; 95% CI 3.8, 14.9; P = 0.03). Patients older than 65 years scored statistically significantly more in ATRS change compared to patients between 40-65 years (mean difference 12.8; 95% CI 6.1-19.5; P < 0.001). CONCLUSION This study did not show a statistically significant or clinically relevant difference between the sexes in ATRS change from baseline to follow-up. The mean difference in ATRS change between patients older than 65 years and patients between 40-65 years was clinically relevant with better outcome for patients older than 65 years. When comparing ATRS between groups with an unequal sex distribution, the findings of a baseline difference and a difference in absolute ATRS at 1 year follow-up between the sexes, advocate for reporting of sex-specific data or for use of change in ATRS from baseline to follow-up instead of absolute ATRS. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Allan Cramer
- Sports Orthopedic Research Center-Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Kettegård Allé 30, 2650, Hvidovre, Denmark.
| | - Nanna Cecilie Jacobsen
- Sports Orthopedic Research Center-Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Kettegård Allé 30, 2650, Hvidovre, Denmark
| | - Maria Swennergren Hansen
- Sports Orthopedic Research Center-Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Kettegård Allé 30, 2650, Hvidovre, Denmark.,Physical Medicine and Rehabilitation Research-Copenhagen (PMR-C), Copenhagen, Denmark
| | - Håkon Sandholdt
- Clinical Research Centre, 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, Kettegård Allé 30, 2650, Hvidovre, Denmark
| | - Kristoffer Weisskirchner Barfod
- Sports Orthopedic Research Center-Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Kettegård Allé 30, 2650, Hvidovre, Denmark
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Achilles tendon elongation after acute rupture: is it a problem? A systematic review. Knee Surg Sports Traumatol Arthrosc 2020; 28:4011-4030. [PMID: 32363475 DOI: 10.1007/s00167-020-06010-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 04/16/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE Rupture of the Achilles tendon (AT) is a common injury. Strength deficits may persist over the long term, possibly owing to elongation of the tendon or inferior mechanical properties. This study aimed to provide a systematic review of the literature on the prevalence and consequences of tendon elongation in patients after acute AT rupture treatment. It was hypothesized that an elongated tendon would be associated with a worse clinical outcome. METHODS The databases for MEDLINE, CENTRAL and Web of Science were searched. Clinical studies related to AT rupture reporting tendon elongation and clinical or functional outcomes, with a minimum follow-up of 6 months, were eligible for inclusion. Only studies testing for statistical correlations (SCs) between AT elongation and other outcomes were eligible, with the exception of biomechanical studies in which statistically significant AT elongation was found to be a generalized finding in the study group. For these studies to be eligible, the study group had to be compared with a healthy control group, or the injured limb compared with the uninjured limb, regarding biomechanical parameters. RESULTS Twenty-eight papers were selected for inclusion. Mean AT elongation measured with imaging techniques ranged from 0.15 to 3.1 cm (n = 17). Ten studies investigated SCs with Patient Reported Outcome Measures (PROMs), in which two found SCs with tendon elongation. Five studies reported strength and power evaluations and their correlation with AT elongation, with two having found SCs between decreased strength and tendon elongation. In ten studies reporting data on biomechanical tests, nine found influence of tendon elongation. In this group, four out of five studies found SCs with biomechanical parameters. CONCLUSION Fair evidence of the influence of tendon elongation in biomechanical parameters was found. In a general population, evidence of a detrimental effect of tendon elongation on PROMs or functional strength at follow-up was not found in this review. LEVEL OF EVIDENCE Level IV.
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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: 10] [Impact Index Per Article: 2.5] [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).
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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
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Patient reported outcomes and ankle plantarflexor muscle performance following gastrocnemius recession for Achilles tendinopathy: A prospective case-control study. Foot Ankle Surg 2020; 26:771-776. [PMID: 31727534 DOI: 10.1016/j.fas.2019.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/04/2019] [Accepted: 10/05/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Prospective studies to guide the application of a gastrocnemius recession for Achilles tendinopathy are limited. Our aim was to prospectively evaluate patient reported outcomes and muscle performance. METHODS Patients with unilateral recalcitrant Achilles tendinopathy who received an isolated gastrocnemius recession (n=8) and a healthy control group (n=8) were included. Patient reported outcomes, ankle power during walking and stair ascent, and the heel rise limb symmetry index (total work) were collected. RESULTS Improvements in pain and self-reported function were observed (six months and two years). Sport participation scores reached 92% by two years. Patients demonstrated lower ankle power during stair ascent and decreased limb symmetry during heel rise six months following treatment (p≤.02). CONCLUSIONS Study findings regarding long-term improvements in patient pain, self-reported function and sport participation, and early preservation of ankle function during walking, can help refine patient selection, anticipated outcomes, and rehabilitation strategies.
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Abstract
Strokes are a constant concern for people and pose a major health concern. Tests that allow detection and the rehabilitation of patients have started to become more important and essential. There are several tests used by physiotherapists to speed up the recovery process of patients. This article presents a systematic review of existing studies using the Heel-Rise Test and sensors (i.e., accelerometers, gyroscopes, pressure and tilt sensors) to estimate the different levels and health statuses of individuals. It was found that the most measured parameter was related to the number of repetitions, and the maximum number of repetitions for a healthy adult is 25 repetitions. As for future work, the implementation of these methods with a simple mobile device will facilitate the different measurements on this subject.
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Boesen AP, Boesen MI, Hansen R, Barfod KW, Lenskjold A, Malliaras P, Langberg H. Effect of Platelet-Rich Plasma on Nonsurgically Treated Acute Achilles Tendon Ruptures: A Randomized, Double-Blinded Prospective Study. Am J Sports Med 2020; 48:2268-2276. [PMID: 32485112 DOI: 10.1177/0363546520922541] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND An acute Achilles tendon rupture (ATR) is a long-lasting and devastating injury. Possible biological augmentation to promote and strengthen tendon healing after an ATR would be desirable. PURPOSE To determine whether the application of a platelet-rich plasma (PRP) injection in nonsurgically treated ATRs may promote healing and thereby improve functional outcomes. STUDY DESIGN Randomized controlled trial; Level of evidence, 2. METHODS A total of 40 men (aged 18-60 years) with an ATR incurred within 72 hours were included, and 38 were followed for 12 months. All patients were treated with an orthosis with 3 wedges for 8 weeks; full weightbearing from day 1 was allowed, combined with either 4 PRP or 4 placebo injections (a few drops of saline, <0.5 mL, under the skin) 14 days apart. All patients received the same instructions on an exercise program starting from week 9. Outcomes included the self-reported Achilles tendon Total Rupture Score (ATRS) as well as heel-rise work, heel-rise height, tendon elongation, calf circumference, and ankle dorsiflexion range of motion. RESULTS The mean ATRS score improved in both groups at all time points (P < .001), but there was no difference between the groups at any time points (12 months: 90.1 points in PRP group and 88.8 points in placebo group). No differences in all functional outcomes at any time points were seen between the groups. At 12 months, the injured leg did not reach normal functional values compared with the uninjured leg. CONCLUSION The application of PRP in nonsurgically treated ATRs did not appear to show any superior clinical and functional improvement. REGISTRATION NCT02417922 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Anders Ploug Boesen
- Institute of Sports Medicine, Department of Orthopaedic Surgery M, Bispebjerg Hospital, Copenhagen, Denmark.,Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Orthopaedic Surgery, Hvidovre Hospital, Hvidovre, Denmark
| | | | - Rudi Hansen
- Institute of Sports Medicine, Department of Orthopaedic Surgery M, Bispebjerg Hospital, Copenhagen, Denmark.,Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Anders Lenskjold
- Institute of Sports Medicine, Department of Orthopaedic Surgery M, Bispebjerg Hospital, Copenhagen, Denmark.,Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Peter Malliaras
- Department of Physiotherapy, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Henning Langberg
- CopenRehab, Section of Social Medicine, Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Westin O, Sjögren T, Svedman S, Horvath A, Hamrin Senorski E, Samuelsson K, Ackermann P. Treatment of acute Achilles tendon rupture - a multicentre, non-inferiority analysis. BMC Musculoskelet Disord 2020; 21:358. [PMID: 32513228 PMCID: PMC7282056 DOI: 10.1186/s12891-020-03320-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 04/28/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND While numerous clinical studies have compared the surgical and non-surgical treatment of acute Achilles tendon rupture (ATR), there are no studies that have performed a non-inferiority analysis between treatments. METHODS Data from patients who were included in five randomised controlled trials from two different centres in Sweden were used. Outcomes at 1 year after ATR consisted of the patient-reported Achilles tendon Total Rupture Score (ATRS) and the functional heel-rise tests reported as the limb symmetry index (LSI). The non-inferiority statistical 10% margin was calculated as a reflection of a clinically acceptable disadvantage in ATRS and heel-rise outcome when comparing treatments. RESULTS A total of 422 patients (350 males and 72 females) aged between 18 and 71 years, with a mean age of 40.6 (standard deviation 8.6), were included. A total of 363 (86%) patients were treated surgically. The ATRS (difference (Δ) = - 0.253 [95% confidence interval (CI); - 5.673;5.785] p = 0.36) and LSI of heel-rise height (difference = 1.43 [95% CI; - 2.43;5.59] p = 0.81), total work (difference = 0.686 [95% CI; - 4.520;6.253] p = 0.67), concentric power (difference = 2.93 [95% CI; - 6.38;11.90] p = 0.063) and repetitions (difference = - 1.30 [95% CI; - 6.32;4.13] p = 0.24) resulted in non-inferiority within a Δ - 10% margin for patients treated non-surgically. CONCLUSION The non-surgical treatment of Achilles tendon ruptures is not inferior compared with that of surgery in terms of 1-year patient-reported and functional outcomes.
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Affiliation(s)
- Olof Westin
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden.
| | - Tony Sjögren
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Simon Svedman
- Integrative Orthopedic Laboratory, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Alexandra Horvath
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eric Hamrin Senorski
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kristian Samuelsson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Paul Ackermann
- Department of Orthopedic Surgery, Karolinska University Hospital, Stockholm, Sweden
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Local Anesthetic Injection Resolves Movement Pain, Motor Dysfunction, and Pain Catastrophizing in Individuals With Chronic Achilles Tendinopathy: A Nonrandomized Clinical Trial. J Orthop Sports Phys Ther 2020; 50:334-343. [PMID: 32349638 PMCID: PMC10016231 DOI: 10.2519/jospt.2020.9242] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Peripherally directed treatments (targeted exercise, surgery) can reduce, but not fully eliminate, pain for up to 40% of patients with Achilles tendinopathy. The objectives of the present study were (1) to identify indicators of altered central processing in participants with Achilles tendinopathy compared to controls, and (2) to determine which indicators of altered central processing would persist after a local anesthetic injection in patients with Achilles tendinopathy. DESIGN Mechanistic clinical trial. METHODS Forty-six adults (23 with chronic Achilles tendinopathy, 23 matched controls) repeated (1) a movement-evoked pain rating, (2) motor performance assessment, (3) pain psychology questionnaires, and (4) quantitative sensory testing. Participants with Achilles tendinopathy received a local anesthetic injection before repeat testing and controls did not. Mixed-effects analyses of variance examined the effects of group, time, and group by time. RESULTS The Achilles tendinopathy group had movement-evoked pain, motor dysfunction, and higher pain psychological factors (pain catastrophizing, kinesiophobia) compared to controls (P<.05). The Achilles tendinopathy group did not have indicators of nociplastic pain with quantitative sensory testing (P>.05). In those with Achilles tendinopathy, local anesthetic injection eliminated pain and normalized the observed deficits in heel-raise performance and pain catastrophizing (group-by-time effect, P<.01), but not in kinesiophobia (P = .45). Injection did not affect measures of nociplastic pain (P>.05). CONCLUSION People with Achilles tendinopathy had elevated pain psychological factors and motor dysfunction but no signs of nociplastic pain with quantitative sensory testing. Removal of nociceptive input normalized movement-evoked pain and some indicators of altered central processing (motor dysfunction, pain catastrophizing), but not kinesiophobia. J Orthop Sports Phys Ther 2020;50(6):334-343. Epub 29 Apr 2020. doi:10.2519/jospt.2020.9242.
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