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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; 32:2184-2193. [PMID: 38796725 DOI: 10.1002/ksa.12240] [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: 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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Wearing SC, Hooper SL, Langton CM, Keiner M, Horstmann T, Crevier-Denoix N, Pourcelot P. The Biomechanics of Musculoskeletal Tissues during Activities of Daily Living: Dynamic Assessment Using Quantitative Transmission-Mode Ultrasound Techniques. Healthcare (Basel) 2024; 12:1254. [PMID: 38998789 PMCID: PMC11241410 DOI: 10.3390/healthcare12131254] [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: 05/22/2024] [Revised: 06/18/2024] [Accepted: 06/19/2024] [Indexed: 07/14/2024] Open
Abstract
The measurement of musculoskeletal tissue properties and loading patterns during physical activity is important for understanding the adaptation mechanisms of tissues such as bone, tendon, and muscle tissues, particularly with injury and repair. Although the properties and loading of these connective tissues have been quantified using direct measurement techniques, these methods are highly invasive and often prevent or interfere with normal activity patterns. Indirect biomechanical methods, such as estimates based on electromyography, ultrasound, and inverse dynamics, are used more widely but are known to yield different parameter values than direct measurements. Through a series of literature searches of electronic databases, including Pubmed, Embase, Web of Science, and IEEE Explore, this paper reviews current methods used for the in vivo measurement of human musculoskeletal tissue and describes the operating principals, application, and emerging research findings gained from the use of quantitative transmission-mode ultrasound measurement techniques to non-invasively characterize human bone, tendon, and muscle properties at rest and during activities of daily living. In contrast to standard ultrasound imaging approaches, these techniques assess the interaction between ultrasound compression waves and connective tissues to provide quantifiable parameters associated with the structure, instantaneous elastic modulus, and density of tissues. By taking advantage of the physical relationship between the axial velocity of ultrasound compression waves and the instantaneous modulus of the propagation material, these techniques can also be used to estimate the in vivo loading environment of relatively superficial soft connective tissues during sports and activities of daily living. This paper highlights key findings from clinical studies in which quantitative transmission-mode ultrasound has been used to measure the properties and loading of bone, tendon, and muscle tissue during common physical activities in healthy and pathological populations.
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Affiliation(s)
- Scott C. Wearing
- School of Medicine and Health, Technical University of Munich, 80992 Munich, Bavaria, Germany
| | - Sue L. Hooper
- School of Health, University of the Sunshine Coast, Sippy Downs, QLD 4556, Australia
| | - Christian M. Langton
- Griffith Centre of Rehabilitation Engineering, Griffith University, Southport, QLD 4222, Australia
| | - Michael Keiner
- Department of Exercise and Training Science, German University of Health and Sport, 85737 Ismaning, Bavaria, Germany
| | - Thomas Horstmann
- School of Medicine and Health, Technical University of Munich, 80992 Munich, Bavaria, Germany
| | | | - Philippe Pourcelot
- INRAE, BPLC Unit, Ecole Nationale Vétérinaire d’Alfort, 94700 Maisons-Alfort, France
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Zhu S, Garofalo J, Abuhantash M, McRae S, MacDonald P, Longstaffe R, Ogborn D. Functional Performance and Tendon Morphology After Operative or Nonoperative Treatment of Achilles Tendon Ruptures. Int J Sports Phys Ther 2024; 19:670-680. [PMID: 38835984 PMCID: PMC11144663 DOI: 10.26603/001c.117549] [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: 01/16/2024] [Accepted: 04/03/2024] [Indexed: 06/06/2024] Open
Abstract
Background While controversy remains as to the relative benefit of operative (OM) versus non-operative management (NOM) of Achilles tendon (AT) ruptures (ATR), few studies have examined the effect on high impact maneuvers such as jumping and hopping. Hypothesis/Purpose The purpose of this study was to determine if functional performance including strength, jumping, and hopping outcomes differed between OM and NOM of acute ATR. The secondary objective was to assess the degree of association between AT morphology and performance outcomes. Study Design Retrospective cohort with a single prospective evaluation. Methods All patients were treated at an institutional secondary care center. Eligible participants (n=12 OM; 12 NOM) who were treated with OM or NOM of ATR within three weeks of injury were evaluated a minimum 20 months following ATR. AT length, thickness and gastrocnemius muscle thickness were assessed with B-mode ultrasound. Isokinetic plantar flexor strength, hop tests and countermovement and drop jumps were completed. Two-way ANOVAS were completed on all tests with unilateral values, independent t-tests were used for bilateral outcomes, and linear regressions were completed to assess the relationship between normalized AT length and performance. Results Affected limb AT was elongated and thickened (p\<0.01), gastrocnemius was atrophied (p\< 0.01) and angle-specific plantar flexor torque was reduced at 120°/s when measured at 20° plantar flexion (p = 0.028). Single leg drop vertical jump was higher in OM (p = 0.015) with no difference for hop and jump tests. AT length was related to plantar flexor torque but had no relationship with hopping performance. Conclusions Hop test performance was maintained despite plantarflexion weakness, gastrocnemius atrophy, and AT elongation. This may be the result of compensatory movement patterns. AT length holds limited explanatory power in plantar flexor strength, although this relationship should be evaluated further. Level of Evidence Level III.
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Affiliation(s)
- Sophie Zhu
- Department of Surgery, Orthopedic SectionUniversity of Manitoba
| | | | | | | | - Peter MacDonald
- Department of Surgery, Orthopedic SectionUniversity of Manitoba
- Pan Am Clinic
| | - Rob Longstaffe
- Department of Surgery, Orthopedic SectionUniversity of Manitoba
- Pan Am Clinic
| | - Dan Ogborn
- Department of Surgery, Orthopedic SectionUniversity of Manitoba
- Pan Am Clinic Foundation
- Faculty of Kinesiology and Recreation ManagementUniversity of Manitoba
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Wegener F, Ritterbusch A, Saal C, Baumgart C, Hoppe MW. Myotonometry and extended field-of-view ultrasound imaging allow reliable quantification of patellar tendon stiffness and length at rest and during maximal load, whereas several restrictions exist for the Achilles tendon. Front Sports Act Living 2024; 6:1379506. [PMID: 38859890 PMCID: PMC11163091 DOI: 10.3389/fspor.2024.1379506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 05/07/2024] [Indexed: 06/12/2024] Open
Abstract
Introduction Stiffness and length are well-established tendon parameters in sports and medicine. Myotonometry and ultrasound imaging are the commonly used methods to quantify these parameters. However, further studies are needed to clarify the reliability of these methods, especially when assessing maximally loaded tendons and when conducted by different experienced investigators. This study aimed to determine the intra- and interrater reliabilities of measuring the stiffness and length of the patellar tendon (PT) and Achilles tendon (AT) using the myotonometry method and the extended field-of-view ultrasound (EFOV-US) technique at rest and maximal load performed by different experienced investigators. Methods Twenty-seven participants were examined on three different days by one experienced investigator and one novice investigator. Primary outcomes were the intraclass correlation coefficient (ICC) and associated 95% confidence interval (95% CI), coefficient of variation (CV), standard error of measurement (SEM), and minimal detectable change (MDC) across the measurement days and investigators. Results For PT measurements at rest and maximal load, the estimated ICCs for stiffness and length were ≥.867 and ≥.970, respectively, with 95% CIs ranging from poor (.306) to excellent (.973) and good (.897) to excellent (.999). The CV, SEM, and MDC for PT stiffness and length were ≤5.2% and ≤2.0%, ≤39.3 N/m and ≤0.9 mm, and ≤108.9 N/m and ≤2.6 mm, respectively. For AT measurements, some restrictions were evident for stiffness at rest and both parameters at maximal load. However, regarding AT length at rest, the estimated ICC was ≥.996, with an excellent 95% CI (.987-.999). The CV, SEM, and MDC for AT length at rest were 2.8%, ≤1.1 mm, and ≤2.9 mm, respectively. Conclusion The estimated ICCs show good to excellent reliability for the myotonometry method and the EFOV-US technique for measuring PT stiffness and length at rest and maximal load for experienced and novice investigators. However, some restrictions are evident for the AT, especially for measurements at maximal load.
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Affiliation(s)
- Florian Wegener
- Movement and Training Science, Faculty of Sport Science, Leipzig University, Leipzig, Germany
| | - Arne Ritterbusch
- Movement and Training Science, Faculty of Sport Science, Leipzig University, Leipzig, Germany
| | - Christian Saal
- Movement and Training Science, Faculty of Sport Science, Leipzig University, Leipzig, Germany
| | - Christian Baumgart
- Department of Movement and Training Science, Faculty of Humanities and Social Sciences, University of Wuppertal, Wuppertal, Germany
| | - Matthias W. Hoppe
- Department of Exercise Science, Institute of Sport Science and Motology, Faculty of Educational Sciences, Philipps University of Marburg, Marburg, Germany
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Leabeater AJ, Clarke AC, James L, Huynh M, Driller M. Under the Gun: Percussive Massage Therapy and Physical and Perceptual Recovery in Active Adults. J Athl Train 2024; 59:310-316. [PMID: 37248364 PMCID: PMC10976339 DOI: 10.4085/1062-6050-0041.23] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
CONTEXT Handheld percussive massage devices (ie, massage guns) are a relatively new and under-researched recovery tool. These tools are intended to increase range of motion and reduce muscle soreness by delivering targeted vibration to soft tissues. Empirical knowledge about the potential influence of these devices on perceptual recovery and the recovery of performance characteristics after exercise is scarce. OBJECTIVE To investigate the effect of a 5-minute massage gun application, using a commercially available device, on physical and perceptual recovery after a strenuous bout of lower body exercise. DESIGN Controlled laboratory study. SETTING Physiology laboratory. PATIENTS OR OTHER PARTICIPANTS A total of 65 active young adults (age = 21.3 ± 1.4 years; age range = 18-30 years; 34 women: height = 165.8 ± 6.1 cm, mass = 66.0 ± 7.4 kg; 31 men: height = 181.1 ± 6.0 cm, mass = 81.5 ± 11.8 kg). INTERVENTION(S) Participants applied a massage gun on the calf muscles of 1 leg after strenuous exercise (massage gun recovery group) for 5 minutes and used no recovery intervention on the other leg (control group). MAIN OUTCOME MEASURE(S) Ankle range of motion, calf circumference, isometric strength, calf endurance, and perceived muscle soreness measures were collected at baseline and at various points after lower body exercise. RESULTS No significant group × time interactions were recorded for any of the performance or perceptual measures (P values > .05). Effect sizes were mostly unclear, except for a small increase in perceived muscle soreness in the massage gun recovery group compared with the control group immediately (d = -0.35) and 4 hours (d = -0.48) postrecovery. CONCLUSIONS Massage guns appeared to have little effect on physical measures when applied for 5 minutes immediately after strenuous calf exercise. Given the small increase in muscle soreness up to 4 hours after their use, caution is recommended when using massage guns immediately after strenuous lower body exercise.
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Affiliation(s)
- Alana J. Leabeater
- Sport, Performance and Nutrition Research Group, School of Allied Health, Human Services, and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Anthea C. Clarke
- Sport, Performance and Nutrition Research Group, School of Allied Health, Human Services, and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Lachlan James
- Sport, Performance and Nutrition Research Group, School of Allied Health, Human Services, and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Minh Huynh
- Sport, Performance and Nutrition Research Group, School of Allied Health, Human Services, and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Matthew Driller
- Sport, Performance and Nutrition Research Group, School of Allied Health, Human Services, and Sport, La Trobe University, Melbourne, Victoria, Australia
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Mashimo S, Nozaki T, Amaha K, Tanaka K, Kubota J, Sato H, Kitamura N. Quantitative Assessment of Calf Muscle Volume, Strength, and Quality After Achilles Tendon Rupture Repair: A 1-Year Prospective Follow-up Study. Am J Sports Med 2023; 51:3781-3789. [PMID: 37960840 DOI: 10.1177/03635465231206391] [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: 11/15/2023]
Abstract
BACKGROUND A number of studies have reported that calf muscle atrophy is a common long-term problem after Achilles tendon repair; however, there is still a lack of data concerning early postoperative morphological changes in the calf muscle after surgery. PURPOSE To investigate changes over time in calf muscle volume and fatty degeneration during 1 year after Achilles tendon repair. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS A prospective 1-year serial magnetic resonance imaging study was carried out with 20 patients who underwent tendon repair for unilateral acute Achilles tendon rupture. The magnetic resonance imaging assessment in addition to clinical and functional evaluations was performed at 1, 3, 6, and 12 months after surgery. The muscle volume of the medial and lateral gastrocnemius, soleus, and flexor hallucis longus (FHL) and fatty degeneration of the medial and lateral gastrocnemius and soleus were measured for the calf muscles, and the relative volume and fatty degeneration changes in the affected leg compared with the healthy contralateral leg were calculated as a percentage ([injured/healthy control] × 100) to assess structural changes over time. RESULTS Muscle volumes of the medial gastrocnemius, lateral gastrocnemius, soleus, and FHL were 92.3%, 92.8%, 84.6%, and 95.9% at 12 months after surgery, respectively. Medial and lateral gastrocnemius and FHL muscle volumes improved over time and recovered to almost equal to that of the healthy side at 12 months after surgery. The soleus muscle volume did not recover significantly over time and was statistically significantly smaller than that of the healthy side at 12 months (P = .029). Fatty degeneration rates of the medial gastrocnemius, lateral gastrocnemius, and soleus were 118.2%, 113.9% and 121.1% at 12 months after surgery, respectively. Fatty degeneration of the medial and lateral gastrocnemius did not change significantly, but there was a statistically significant increase in fatty degeneration of the soleus over time (P < .001). CONCLUSION Within the triceps surae muscle, the soleus was the most negatively affected by injury and repair for both muscle volume and fatty degeneration. Postoperative management to recover the soleus muscle function before a return to sporting activities should be considered in the future.
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Affiliation(s)
- Shota Mashimo
- Department of Rehabilitation, St Luke's International Hospital, Tokyo, Japan
| | - Taiki Nozaki
- Department of Radiology, St Luke's International Hospital, Tokyo, Japan
| | - Kentaro Amaha
- Department of Orthopaedic Surgery, St Luke's International Hospital, Tokyo, Japan
| | - Keita Tanaka
- Department of Rehabilitation, St Luke's International Hospital, Tokyo, Japan
| | - Junya Kubota
- Department of Rehabilitation, St Luke's International Hospital, Tokyo, Japan
| | - Hiroyuki Sato
- Department of Rehabilitation, St Luke's International Hospital, Tokyo, Japan
| | - Nobuto Kitamura
- Department of Rehabilitation, St Luke's International Hospital, Tokyo, Japan
- Department of Orthopaedic Surgery, St Luke's International Hospital, Tokyo, Japan
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Blemker SS. In vivo imaging of skeletal muscle form and function: 50 years of insight. J Biomech 2023; 158:111745. [PMID: 37579605 DOI: 10.1016/j.jbiomech.2023.111745] [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: 03/21/2023] [Revised: 07/22/2023] [Accepted: 07/27/2023] [Indexed: 08/16/2023]
Abstract
Skeletal muscle form and function has fascinated scientists for centuries. Our understanding of muscle function has long been driven by advancements in imaging techniques. For example, the sliding filament theory of muscle, which is now widely leveraged in biomechanics research, stemmed from observations made possible by scanning electron microscopy. Over the last 50 years, advancing in medical imaging, combined with ingenuity and creativity of biomechanists, have provide a wealth of new and important insights into in vivo human muscle function. Incorporation of in vivo imaging has also advanced computational modeling and allowed our research to have an impact in many clinical populations. While this review does not provide a comprehensive or meta-analysis of the all the in vivo muscle imaging work over the last five decades, it provides a narrative about the past, present, and future of in vivo muscle imaging.
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Affiliation(s)
- Silvia S Blemker
- Departments of Biomedical Engineering, Mechanical & Aerospace Engineering, Ophthalmology, and Orthopedic Surgery, University of Virginia, Charlottesville, VA, United States; Springbok Analytics, Charlottesville, VA, United States
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Lu Z, Sun D, Kovács B, Radák Z, Gu Y. Case study: The influence of Achilles tendon rupture on knee joint stress during counter-movement jump - Combining musculoskeletal modeling and finite element analysis. Heliyon 2023; 9:e18410. [PMID: 37560628 PMCID: PMC10407047 DOI: 10.1016/j.heliyon.2023.e18410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 07/15/2023] [Accepted: 07/17/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Presently, the current research concerning Achilles tendon rupture repair (ATR) is predominantly centered on the ankle joint, with a paucity of evidence regarding its impact on the knee joint. ATR has the potential to significantly impede athletic performance and increase tibiofemoral contact forces in athletes. The purpose of this study was to prognosticate the distribution of stress within the knee joint during a countermovement jump through the use of a simulation method that amalgamated a musculoskeletal model of a patient who underwent Achilles tendon rupture repair with a finite element model of the knee joint. METHODS A male elite badminton player who had suffered an acute Achilles tendon rupture in his right leg one year prior was selected as our study subject. In order to analyze his biomechanical data, we employed both the OpenSim musculoskeletal model and finite element model to compute various parameters such as joint angles, joint moments, joint contact forces, and the distribution of knee joint stress. RESULTS During the jumping phase, a significantly lower knee extension angle (p < 0.001), ankle dorsiflexion angle (p = 0.002), peak vertical ground reaction force (p < 0.001), and peak tibiofemoral contact force (p = 0.009) were observed on the injured side than on the uninjured side. During the landing phase, the ankle range of motion (ROM) was significantly lower on the injured side than on the uninjured side (p = 0.009), and higher peak vertical ground reaction forces were observed (p = 0.012). Additionally, it is logical that an injured person will put higher load on the uninjured limb, but the finite element analysis indicated that the stresses on the injured side of medial meniscus and medial cartilage were significantly greater than the uninjured side. CONCLUSIONS An Achilles tendon rupture can limit ankle range of motion and lead to greater joint stress on the affected area during countermovement jumps, especially during the landing phase. This increased joint stress may also transfer more stress to the soft tissues of the medial knee, thereby increasing the risk of knee injury. It is worth noting that this study only involves the average knee flexion angle and load after ATR in one athlete. Caution should be exercised when applying the conclusions, and in the future, more participants should be recruited to establish personalized knee finite element models to validate the results.
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Affiliation(s)
- Zhenghui Lu
- Faculty of Sports Science, Ningbo University, Ningbo, 315211, China
| | - Dong Sun
- Faculty of Sports Science, Ningbo University, Ningbo, 315211, China
| | - Bálint Kovács
- Faculty of Sports Science, Ningbo University, Ningbo, 315211, China
- Research Institute of Sport Science, Hungarian University of Sport Science, Budapest, 1123, Hungary
| | - Zsolt Radák
- Research Institute of Sport Science, Hungarian University of Sport Science, Budapest, 1123, Hungary
| | - Yaodong Gu
- Faculty of Sports Science, Ningbo University, Ningbo, 315211, China
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Hoeffner R, Svensson RB, Dietrich-Zagonel F, Schefte D, Kjær M, Eliasson P, Magnusson SP. Muscle fascicle and sarcomere adaptation in response to Achilles tendon elongation in an animal model. J Appl Physiol (1985) 2023; 135:326-333. [PMID: 37348011 DOI: 10.1152/japplphysiol.00040.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 06/16/2023] [Accepted: 06/16/2023] [Indexed: 06/24/2023] Open
Abstract
Permanent loss of muscle function seen after an Achilles tendon rupture may partly be explained by tendon elongation and accompanying shortening of the muscle. Muscle fascicle length shortens, serial sarcomere number is reduced, and the sarcomere length is unchanged after Achilles tendon transection (ATT), and these changes are mitigated with suturing. The method involved in this study was a controlled laboratory study. Two groups of rats underwent ATT on one side with a contralateral control (CTRL): A) ATT with 3 mm removal of the Achilles tendon and no suturing (substantial tendon elongation), and B) ATT with suture repair (minimal tendon elongation). The operated limb was immobilized for 2 wk to reduce load. Four weeks after surgery the rats were euthanized, and hindlimbs were analyzed for tendon length, gastrocnemius medialis (GM) muscle mass, length, fascicle length, sarcomere number and length. No differences were observed between the groups, and in both groups the Achilles tendon length was longer (15.2%, P < 0.001), GM muscle mass was smaller (17.5%, P < 0.001), and muscle length was shorter (8.2%, P < 0.001) on the ATT compared with CTRL side. GM fascicle length was shorter (11.2%, P < 0.001), and sarcomere number was lower (13.8%, P < 0.001) on the ATT side in all regions. Sarcomere length was greater in the proximal (5.8%, P < 0.001) and mid (4.2%, P = 0.003), but not distal region on the ATT side. In this animal model, regardless of suturing, ATT resulted in tendon elongation, loss of muscle mass and length, and reduced serial sarcomere number, which resulted in an "overshoot" lengthening of the sarcomeres.NEW & NOTEWORTHY Following acute Achilles tendon rupture, patients are often left with functional deficits. The specific reason remains largely unknown. The shortened muscle leads to reduced fascicle length, in turn leading to adaptation by reduced serial sarcomere numbers. Surprisingly, this adaptation appears to "overshoot" and lead to increased sarcomere length. The present animal model advances understanding of how muscle sarcomeres, which are difficult to measure in humans, are affected when undue elongation takes place after tendon rupture.
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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
| | - Franciele Dietrich-Zagonel
- Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Science, Linköping University, Linköping, Sweden
| | - Daniel Schefte
- Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Science, Linköping University, Linköping, Sweden
| | - Michael Kjær
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Pernilla Eliasson
- Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Science, Linköping University, Linköping, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - S Peter Magnusson
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Physical and Occupational Therapy, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
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10
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Nakamura G, Yasuda T, Shima H, Togei K, Hirai Y, Neo M. Morphology of the asymptomatic Αchilles tendon: Measurement of tendon length and shape using magnetic resonance imaging, and investigation of related factors. J Orthop Sci 2023; 28:204-211. [PMID: 34756633 DOI: 10.1016/j.jos.2021.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 08/27/2021] [Accepted: 09/20/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND One of the severe complications of Achilles tendon (AT) rupture is muscle weakness due to tendon lengthening. It is very important to prevent tendon lengthening during treatment; however, data on the length, thickness, and width of normal ATs are scarce. Furthermore, no studies have investigated the factors related to the AT length and shape. We aimed to determine the normal AT length and shape and to investigate any correlating factors. METHODS We measured the AT length, thickness, and width of 100 asymptomatic patients using magnetic resonance imaging. We also investigated the correlation between the AT length, thickness, and width and factors including age, sex, height, body weight, body mass index, history of sports activities, and the area of Kager's fat pad. RESULTS The mean AT length was 42.1 ± 12.9 mm. The AT length in 73% of the patients was within the range of 30-55 mm. Individual differences in the tendon length were large, but there was no correlation between the tendon length and patient height (P = 0.505). There was a strong correlation between the AT length and area of Kager's fat pad on magnetic resonance imaging (r = 0.734, P < 0.001). Furthermore, the correlation coefficient between the area of Kager's fat pad on magnetic resonance imaging and the area of Kager's triangle on radiography was extremely high (r = 0.851, P < 0.001). CONCLUSIONS The AT length can be predicted based on the area of Kager's triangle of the unaffected ankle on radiography. If the AT length is > 55 mm or longer than the length measured directly or calculated from the estimated area of Kager's triangle, tendon lengthening should be suspected. Our findings could provide an important indicator for the evaluation of AT lengthening not only in daily clinical situations but also in clinical studies.
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Affiliation(s)
- Gen Nakamura
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, 2-7, Daigaku-machi, Takatsuki City, Osaka 569-8686 Japan
| | - Toshito Yasuda
- Faculty of Nursing, Osaka Medical and Pharmaceutical University, 7-6 Hatchonishi-machi, Takatsuki City, Osaka 569-0095, Japan.
| | - Hiroaki Shima
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, 2-7, Daigaku-machi, Takatsuki City, Osaka 569-8686 Japan
| | - Kosho Togei
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, 2-7, Daigaku-machi, Takatsuki City, Osaka 569-8686 Japan
| | - Yoshihiro Hirai
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, 2-7, Daigaku-machi, Takatsuki City, Osaka 569-8686 Japan
| | - Masashi Neo
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, 2-7, Daigaku-machi, Takatsuki City, Osaka 569-8686 Japan
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Boksh K, Elbashir M, Thomas O, Divall P, Mangwani J. Platelet-Rich Plasma in acute Achilles tendon ruptures: A systematic review and meta-analysis. Foot (Edinb) 2022; 53:101923. [PMID: 36037774 DOI: 10.1016/j.foot.2022.101923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 03/13/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Platelet Rich Plasma (PRP) is known to exert multi-directional biological effects favouring tendon healing. However, conclusions drawn by numerous studies on its clinical efficacy for acute Achilles tendon rupture are limited. We performed a systematic review and meta-analysis to investigate this and to compare to those without PRP treatment. METHODS The Cochrane Controlled Register of Trials, Pubmed, Medline and Embase were used and assessed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following search terms: ('plasma' OR 'platelet-rich' OR 'platelet-rich plasma' or 'PRP') AND ('Achilles tendon rupture/tear' OR 'calcaneal tendon rupture/tear' OR 'tendo calcaneus rupture/tear'). Data pertaining to biomechanical outcomes (heel endurance test, isokinetic strength, calf-circumference and range of motion), patient-reported outcome measures (PROMs) and incidence of re-ruptures were extracted. Meta-analysis was performed for same outcomes measured in at least three studies. Pooled outcome data were analysed by random- and fixed-effects models. RESULTS After abstract and full-text screening, 6 studies were included. In total there were 510 patients of which 256 had local PRP injection and 254 without. The average age was 41.6 years, mean time from injury to treatment 5.9 days and mean follow-up at 61 weeks. Biomechanically, there was similar heel endurance, isokinetic strength, calf circumference and range of motion between both groups. In general, there were no differences in patient reported outcomes from all scoring systems used in the studies. Both groups returned to their pre-injured level at a similar time and there were no differences on the incidence of re-rupture (OR 1.13, 95% CI, 0.46-2.80, p = 0.79). CONCLUSION PRP injections for acute Achilles tendon ruptures do not improve medium to long-term biomechanical and clinical outcomes. However, future studies incorporating the ideal application and biological composition of PRP are required to investigate its true clinical efficacy.
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Affiliation(s)
- Khalis Boksh
- Academic Team of Musculoskeletal Surgery, Department of Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, UK.
| | - Mohamed Elbashir
- Academic Team of Musculoskeletal Surgery, Department of Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Owain Thomas
- Academic Team of Musculoskeletal Surgery, Department of Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Pip Divall
- Academic Team of Musculoskeletal Surgery, Department of Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Jitendra Mangwani
- Academic Team of Musculoskeletal Surgery, Department of Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, UK
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12
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Kastoft R, Barfod K, Bencke J, Speedtsberg MB, Hansen SB, Penny JØ. 1.7 cm elongated Achilles tendon did not alter walking gait kinematics 4.5 years after non-surgical treatment. Knee Surg Sports Traumatol Arthrosc 2022; 30:3579-3587. [PMID: 35234975 DOI: 10.1007/s00167-022-06874-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 01/12/2022] [Indexed: 12/19/2022]
Abstract
PURPOSE The aim of the present study was to evaluate Achilles tendon length after non-surgical treatment of acute Achilles tendon rupture (aATR), and to evaluate indirect effects of possible persistent elongation on kinematics. METHODS The study was performed as a cross-sectional study based on a population of patients from an RCT regarding non-operative treatment of aATR. Thirty-seven patients out of the 56 in the original RCT participated with at a follow up of 4-5 years after aATR. Primary outcome was Achilles tendon elongation. Additional outcomes were Achilles tendon resting angle (ATRA), calf circumference, passive ankle plantar and dorsiflexion and loading pattern. Foot pressure mapping was performed to measure plantar loading distribution pattern; medial and lateral forefoot peak pressure, heel peak pressure, medial versus lateral loading pattern and timing of heel lift during roll over process. The healthy leg was used as a control. RESULTS The injured Achilles tendon was significantly elongated by 1.7 (SD 1.6) cm compared to the non-injured leg. A slight delay of 2.6% (SD 6.0) was measured in heel lift in the injured side compared to the non-injured leg. We found no significant difference in forefoot peak pressure, medial and lateral peak pressure as well as heel peak pressure, and no correlation was found between Achilles tendon length and pressure measurements. Finally, dorsiflexion was 1.9°(SD1.28) larger, ATRA 8.1°(SD6.7) larger, and calf circumference 1.6 cm (SD1.1) lower on the injured leg. CONCLUSION The Achilles tendon was 1.7 cm elongated 4.5 years after the initial injury and significant changes in ATRA, calf circumference and passive dorsiflexion was present. Except for a slight delay in heel lift-off, kinematics during walking was symmetrical between injured and healthy leg, even with an elongated tendon on the injured leg. The clinical relevance of the Achilles tendon elongation is uncertain. LEVEL OF EVIDENCE II. CLINICAL TRIALS IDENTIFIER NCT02760784.
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Affiliation(s)
- Rasmus Kastoft
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark.
| | - Kristoffer Barfod
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark
| | - Jesper Bencke
- Laboratory of Human Movement Analysis, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager, Hvidovre, Denmark
| | - Merete B Speedtsberg
- Laboratory of Human Movement Analysis, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager, Hvidovre, Denmark
| | - Sanja Bay Hansen
- Department of Radiology, Center for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital, Hvidovre, Denmark
| | - Jeannette Ø Penny
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark
- Department of Orthopaedic Surgery, Zealand University Hospital, Koege, Denmark
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13
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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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14
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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: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/03/2022] [Accepted: 06/15/2022] [Indexed: 04/26/2024]
Abstract
Persistent muscle weakness, tendon elongation, and incomplete return to preinjury level are frequent sequelae after acute Achilles tendon rupture, and evidence-based knowledge of how to best rehabilitate the injury is largely absent in the literature. The objective of this review is to illuminate and discuss to what extent an Achilles tendon rupture affects muscle, tendon, and function when assessed with the Achilles tendon total rupture score (ATRS), muscle strength, muscle cross-sectional area, tendon length, and the heel-rise test. The patient-reported outcome measures (PROM) data in the literature suggest that the recovery takes longer than 6 months (ATRS, 70 out of 100), that one-year postinjury, the ATRS only reaches 82, and that this does not appear to noticeably improve thereafter. Loss of muscle mass, strength, and function can in some cases be permanent. Over the first 6 months postinjury, the tendon undergoes elongation, which appears to be negatively correlated to heel-rise function. More recently, there has been some interest in how muscle length and excursion is related to the reduced function. The available literature indicates that further research is highly warranted and that efforts to restore normal tendon length may improve the likelihood of returning to preinjury level after an Achilles tendon rupture.
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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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15
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Mansur H, Estanislau G, Noronha MD, Marqueti RDC, Fachin-Martins E, Durigan JLQ. Intra- and inter-rater reliability for the measurement of the cross-sectional area of ankle tendons assessed by magnetic resonance imaging. Acta Radiol 2022; 63:481-488. [PMID: 34247515 DOI: 10.1177/02841851211003284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The cross-sectional area (CSA) records make an essential measurement for determining the mechanical properties of tendons, such as stress and strength. However, there is no consensus regarding the best method to record the CSA from different tendons. PURPOSE To determine intra- and inter-rater reliability for CSA measures from magnetic resonance imaging (MRI) of the following tendons: tibialis anterior; tibialis posterior; fibularis longus and brevis; and Achilles. MATERIAL AND METHODS We designed an observational study with repeated measures taken from a convenience sample of 20 participants diagnosed with acute or chronic ankle sprain. Two independent raters took three separate records from the CSA of ankle tendon images of each MRI slice. The intra-class correlation coefficient (ICC) and 95% limits of agreement (LoA) defined the quality (associations) and magnitude (differences), respectively, of intra- and inter-rater reliability on the measures plotted by the Bland-Altman method. RESULTS Data showed very high intra- and inter-rater correlations for measures taken from all tendons analyzed (ICC 0.952-0.999). It also revealed an excellent agreement between raters (0.12%-2.3%), with bias no higher than 2 mm2 and LoA in the range of 4.4-7.9 mm2. The differences between repeated measures recorded from the thinnest tendons (fibularis longus and brevis) revealed the lowest bias and narrowest 95% LoA. CONCLUSION Reliability for the CSA of ankle tendons measured from MRI taken by independent rates was very high, with the smallest differences between raters observed when the thinnest tendon was analyzed.
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Affiliation(s)
- Henrique Mansur
- Graduate Program in Physical Education Sciences, University of Brasília (UnB), Brasília, Brazil
- Department of Orthopaedics, Hospital das Forças Armadas (HFA), Brasília, Brazil
| | | | | | - Rita de Cassia Marqueti
- Graduate Program in Rehabilitation Sciences, University of Brasília (UnB), Ceilândia, Brazil
| | - Emerson Fachin-Martins
- Graduate Program in Rehabilitation Sciences, University of Brasília (UnB), Ceilândia, Brazil
| | - João Luiz Quagliotti Durigan
- Graduate Program in Physical Education Sciences, University of Brasília (UnB), Brasília, Brazil
- Graduate Program in Rehabilitation Sciences, University of Brasília (UnB), Ceilândia, Brazil
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16
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Samy AM. Intra-operative ultrasound: does it improve the results of percutaneous repair of acute Achilles tendon rupture? Eur J Trauma Emerg Surg 2022; 48:4061-4068. [PMID: 35275242 PMCID: PMC9532319 DOI: 10.1007/s00068-022-01926-x] [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: 11/01/2021] [Accepted: 02/20/2022] [Indexed: 12/03/2022]
Abstract
Purpose Percutaneous repair is a good option for acute Achilles tendon rupture. Although it overcomes the complications of open technique, it carries the risk of sural nerve injury and inadequate repair. In this study, we explore if the use of intra-operative ultrasound with percutaneous technique has any advantageous effect on final results of repair. Methods This is a prospective randomized study done between May 2014 and December 2020. It included 91 patients with complete acute Achilles tendon rupture distributed in 2 groups with homogenous clinical and demographic data. Group A (n = 47) included those managed by percutaneous repair with assistant of an intra-operative ultrasound. Group B (n = 44) included those done without the assistant of ultrasound. Post-operative evaluation was done clinically by the American Orthopedic Foot and Ankle Society score, calf muscle circumference and single heel rise test and radiologically by Magnetic Resonance Image. Results Patients of both groups reported continuous improvement of the American Orthopedic Foot and Ankle Society score with time. However, patient of group A recorded better functional outcome score at 3 months postoperatively. We recorded longer operative time in group A than those in group B. Continuous improvement of maximum calf circumference was observed in both groups. Satisfactory healing was noticed to happen faster in patients of group A than those of group B. We recorded two cases of re-rupture and two cases of sural nerve injury in group B with no reported complication in group A. Conclusion The use of an intra-operative ultrasound with percutaneous repair of acute rupture of Achilles tendon can improve the quality of repair as evidenced by quicker satisfactory healing and earlier regain of activity. Also, it can help in proper localization of sural nerve in relation to lateral edge of Achilles tendon. Trial registration Clinical Trials.gov Identifier: NCT04935281.
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Muscular and Tendon Degeneration after Achilles Rupture: New Insights into Future Repair Strategies. Biomedicines 2021; 10:biomedicines10010019. [PMID: 35052699 PMCID: PMC8773411 DOI: 10.3390/biomedicines10010019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 12/10/2021] [Accepted: 12/19/2021] [Indexed: 11/17/2022] Open
Abstract
Achilles tendon rupture is a frequent injury with an increasing incidence. After clinical surgical repair, aimed at suturing the tendon stumps back into their original position, the repaired Achilles tendon is often plastically deformed and mechanically less strong than the pre-injured tissue, with muscle fatty degeneration contributing to function loss. Despite clinical outcomes, pre-clinical research has mainly focused on tendon structural repair, with a lack of knowledge regarding injury progression from tendon to muscle and its consequences on muscle degenerative/regenerative processes and function. Here, we characterize the morphological changes in the tendon, the myotendinous junction and muscle belly in a mouse model of Achilles tendon complete rupture, finding cellular and fatty infiltration, fibrotic tissue accumulation, muscle stem cell decline and collagen fiber disorganization. We use novel imaging technologies to accurately relate structural alterations in tendon fibers to pathological changes, which further explain the loss of muscle mechanical function after tendon rupture. The treatment of tendon injuries remains a challenge for orthopedics. Thus, the main goal of this study is to bridge the gap between clinicians’ knowledge and research to address the underlying pathophysiology of ruptured Achilles tendon and its consequences in the gastrocnemius. Such studies are necessary if current practices in regenerative medicine for Achilles tendon ruptures are to be improved.
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18
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Meulenkamp B, Woolnough T, Cheng W, Shorr R, Stacey D, Richards M, Gupta A, Fergusson D, Graham ID. What Is the Best Evidence to Guide Management of Acute Achilles Tendon Ruptures? A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials. Clin Orthop Relat Res 2021; 479:2119-2131. [PMID: 34180874 PMCID: PMC8445578 DOI: 10.1097/corr.0000000000001861] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 05/26/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Uncertainty exists regarding the best treatment for acute Achilles tendon ruptures. Simultaneous comparison of the multiple treatment options using traditional study designs is problematic; multiarm clinical trials often are logistically constrained to small sample sizes, and traditional meta-analyses are limited to comparisons of only two treatments that have been compared in head-to-head trials. Network meta-analyses allow for simultaneous comparison of all existing treatments utilizing both direct (head-to-head comparison) and indirect (not previously compared head-to-head) evidence. QUESTIONS/PURPOSES We performed a network meta-analysis of randomized controlled trials (RCTs) to answer the following questions: Considering open repair, minimally invasive surgery (MIS) repair, functional rehabilitation, or primary immobilization for acute Achilles tendon ruptures, (1) which intervention is associated with the lowest risk of rerupture? (2) Which intervention is associated with the lowest risk of complications resulting in surgery? METHODS This study was conducted with methods guided by the Cochrane Handbook for Systematic Reviews of Interventions and is reported in adherence with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension statement for incorporating network meta-analysis. Five databases and grey literature sources (such as major orthopaedic meeting presentation lists) were searched from inception to September 30, 2019. Included studies were RCTs comparing treatment of acute Achilles tendon ruptures using two or more of the following interventions: primary immobilization, functional rehabilitation, open surgical repair, or MIS repair. We excluded studies enrolling patients with chronic ruptures, reruptures, and preexisting Achilles tendinopathy as well as studies with more than 20% loss to follow-up or less than 6 months of follow-up. Nineteen RCTs (1316 patients) were included in the final analysis. The mean number of patients per study treatment arm was 35 ± 16, mean age was 41 ± 5 years, mean sex composition was 80% ± 10% males, and mean follow-up was 22 ± 12 months. The four treatment groups were compared for the main outcomes of rerupture and complications resulting in operation. The analysis was conducted using random-effects Bayesian network meta-analysis with vague priors. Evidence quality was evaluated using Grades of Recommendation, Assessment, Development, and Evaluation methodology. We found risk of selection, attrition, and reporting bias to be low across treatments, and we found the risk of performance and detection bias to be high. Overall risk of bias between treatments appeared similar. RESULTS We found that treatment with primary immobilization had a greater risk of rerupture than open surgery (odds ratio 4.06 [95% credible interval {CrI} 1.47 to 11.88]; p < 0.05). There were no other differences between treatments for risk of rerupture. Minimally invasive surgery was ranked first for fewest complications resulting in surgery and was associated with a lower risk of complications resulting in surgery than functional rehabilitation (OR 0.16 [95% CrI 0.02 to 0.90]; p < 0.05), open surgery (OR 0.22 [95% CrI 0.04 to 0.93]; p < 0.05), and primary immobilization (OR < 0.01 [95% CrI < 0.01 to 0.01]; p < 0.05). Risk of complications resulting in surgery was no different between primary immobilization and open surgery (OR 1.46 [95% CrI 0.35 to 5.36]). Data for patient-reported outcome scores and return to activity were inappropriate for pooling secondary to considerable clinical heterogeneity and imprecision associated with small sample sizes. CONCLUSION Faced with acute Achilles tendon rupture, patients should be counseled that, based on the best-available evidence, the risk of rerupture likely is no different across contemporary treatments. Considering the possibly lower risk of complications resulting in surgery associated with MIS repair, patients and surgeons must balance any benefit with the potential risks of MIS techniques. As treatments continue to evolve, consistent reporting of validated patient-reported outcome measures is critically important to facilitate analysis with existing RCT evidence. Infrequent but serious complications such as rerupture and deep infection should be further explored to determine whether meaningful differences exist in specific patient populations. LEVEL OF EVIDENCE Level I, therapeutic study.
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Affiliation(s)
| | - Taylor Woolnough
- Division of Orthopaedic Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Wei Cheng
- Centre for Practice-Changing Research, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Risa Shorr
- The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Dawn Stacey
- Centre for Practice-Changing Research, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
| | - Megan Richards
- Division of Orthopaedic Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Arnav Gupta
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Dean Fergusson
- Centre for Practice-Changing Research, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Ian D. Graham
- Centre for Practice-Changing Research, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
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19
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Eken G, Misir A, Tangay C, Atici T, Demirhan N, Sener N. Effect of muscle atrophy and fatty infiltration on mid-term clinical, and functional outcomes after Achilles tendon repair. Foot Ankle Surg 2021; 27:730-735. [PMID: 33272750 DOI: 10.1016/j.fas.2020.09.007] [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: 07/18/2020] [Revised: 08/30/2020] [Accepted: 09/14/2020] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Muscle atrophy is one of the most common problems after Achilles tendon repair. The aim of this study was to evaluate the effect of gastrosoleus muscle atrophy and fatty infiltration on clinical, and functional outcomes after Achilles tendon repair. MATERIAL AND METHODS A total of 46 patients (mean age = 39.3 ± 7.4 years) who underwent open Achilles tendon repair were included in the study. During the clinical evaluation of muscle atrophy, ipsilateral and contralateral calf circumference (CC), maximum heel rise (HR), and ankle range of motion measurements were recorded. Functional outcomes were assessed via The Achilles tendon Total Rupture Score (ATRS), the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, and the Leppilahti score. Muscle volume (MV), cross-sectional area (CSA), and percent of fatty infiltration (FI) were measured via magnetic image resonance. RESULTS The functional outcome scores were excellent: ATRS = 98.1 ± 2.2; AOFAS = 97.3 ± 4.1; Leppilahti score = 95.8 ± 5.1. There were significant differences detected between injured and non-injured legs regarding CC, HR, MV, CSA, and FI. Additionally, there were significant negative correlations between CSA and MV loss with all functional outcome scores. FI was correlated with only the AOFAS ankle-hindfoot score. CONCLUSIONS Significant muscle atrophy was measured after a mean follow-up period of 7.4 (range 2.0-12.6) years post-surgery and negatively correlated with clinical outcomes. CC is an easy and cost-effective measurement method to predict MV during the follow-up of Achilles tendon repairs.
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Affiliation(s)
- Gökay Eken
- Bursa Acibadem Hospital, Orthopedics and Traumatology Department, FSM Bulvarı, Sumer Sokak No:1 16110 Nilufer Bursa, Turkey.
| | - Abdulhamit Misir
- Basaksehir Pine and Sakura City Hospital, Başakşehir Olimpiyat Bulvarı Yolu, 34480 Başakşehir, İstanbul, Turkey.
| | - Cem Tangay
- Bursa Acibadem Hospital, Orthopedics and Traumatology Department, FSM Bulvarı, Sumer Sokak No:1 16110 Nilufer Bursa, Turkey.
| | - Teoman Atici
- Uludag University Faculty of Medicine, Orthopedics and Traumatology Department, 16059 Gorukle Nilufer Bursa, Turkey.
| | - Nevzat Demirhan
- Bursa Acibadem Hospital, Radiology Department, FSM Bulvarı, Sumer Sokak No:1, Nilufer, Bursa, Turkey.
| | - Nadir Sener
- Bursa Acibadem Hospital, Orthopedics and Traumatology Department, FSM Bulvarı, Sumer Sokak No:1 16110 Nilufer Bursa, Turkey.
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Hyer CF, Berlet G, Philbin T, Bull P, Brandão R, Prissel M, Malay DS. Does Functional Neuromuscular Electrical Stimulation (NMES) Influence Calf Atrophy Following Achilles Tendon Surgery? Prospective Double-Blind Randomized Controlled Trial on the Use of Immediate Postoperative Electrical Muscle Stimulation to Preserve Muscle Function and Volume. J Foot Ankle Surg 2021; 60:683-688. [PMID: 33736944 DOI: 10.1053/j.jfas.2020.12.005] [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: 02/22/2020] [Revised: 12/11/2020] [Accepted: 12/18/2020] [Indexed: 02/03/2023]
Abstract
Surgical repair of the Achilles tendon can lead to prolonged calf atrophy and functional limitations, even with early weightbearing. The use of neuromuscular electrical stimulation (NMES) has been studied in muscle rehabilitation programs following anterior cruciate ligament repair. Accelerated recovery and pain reduction were noted. The aim of the present study was to evaluate the use of electrical stimulation on maintaining calf muscle cross-sectional area volume and improving patient reported outcome measures following Achilles tendon surgery. Randomized controlled clinical trial. Forty patients were enrolled. All patients had undergone repair of the Achilles tendon. A 4 lead NMES device was applied at time of surgery with both patient and surgeon blinded to activity of the device. All patients followed a standardized postoperative protocol. Group 1 consisted of 20 patients who received protocol specific NMES. Group 2 was the "sham device" control group, receiving subtherapeutic electrical stimulation. Preoperative and postoperative calf circumference (2, 6, 12 weeks) and magnetic resonance imaging (MRI) scans (2, 6 weeks) were conducted. Patient-reported functional outcome scores were measured. Of the 40 patients, 23 (57.5%) were male and 17 (42.5%) were female. The mean age was 48.9 years (11.1 standard deviation [SD]) with a mean body mass index of 32.2 kg/m2 (5.7 SD). Calf measurements for Group 1 (39.3 cm and 39.7 cm) were slightly higher compared Group 2 (38.4 cm and 39.2 cm) at 6 and 12 weeks postoperative. Functional scores were similar between Groups 1 and 2 at final follow-up. Foot/Ankle Computer Adaptive Test scores were 55.1 (6.9 SD) versus 58.4(8.6 SD), and American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scores were 82.3 (8.2 SD) and 83.9 (9.3 SD), respectively. The visual analog scale at 12-week visit for Groups 1 and 2 was 8.4 (9.3 SD) and 8.4 (9.1 SD), respectively. This prospective randomized controlled trial was undertaken to quantify and validate the effect and ability of NMES to minimize calf atrophy after acute or chronic repair. No statistically significant difference was found between active NMES and sham control group. There was a trend showing some maintenance of calf volume per MRI study.
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Affiliation(s)
| | - Gregory Berlet
- Attending Physician, Orthopedic Foot and Ankle Center, Worthington, OH
| | - Terry Philbin
- Attending Physician, Orthopedic Foot and Ankle Center, Worthington, OH
| | - Patrick Bull
- Attending Physician, Orthopedic Foot and Ankle Center, Worthington, OH
| | - Roberto Brandão
- Fellow Foot and Ankle Surgery, Orthopedic Foot and Ankle Center, Worthington, OH
| | - Mark Prissel
- Attending Physician, Orthopedic Foot and Ankle Center, Worthington, OH
| | - D Scot Malay
- Director of Podiatric Research and Staff Surgeon, Penn Presbyterian Medical Center, Philadelphia, PA
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21
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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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22
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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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23
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Wearing SC, Kuhn L, Pohl T, Horstmann T, Brauner T. Transmission-Mode Ultrasound for Monitoring the Instantaneous Elastic Modulus of the Achilles Tendon During Unilateral Submaximal Vertical Hopping. Front Physiol 2020; 11:567641. [PMID: 33343380 PMCID: PMC7744658 DOI: 10.3389/fphys.2020.567641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 11/11/2020] [Indexed: 11/30/2022] Open
Abstract
Submaximal vertical hopping capitalizes on the strain energy storage-recovery mechanism associated with the stretch-shortening cycle and is emerging as an important component of progressive rehabilitation protocols in Achilles tendon injury and a determinant of readiness to return to sport. This study explored the reliability of transmission mode ultrasound in quantifying the instantaneous modulus of elasticity of human Achilles tendon during repetitive submaximal hopping. A custom-built ultrasound transmission device, consisting of a 1 MHz broadband emitter and four regularly spaced receivers, was used to measure the axial velocity of ultrasound in the Achilles tendon of six healthy young adults (mean ± SD; age 26 ± 5 years; height 1.78 ± 0.11 m; weight 79.8 ± 13.6 kg) during steady-state unilateral hopping (2.5 Hz) on a piezoelectric force plate. Vertical ground reaction force and lower limb joint kinematics were simultaneously recorded. The potential sensitivity of the technique was further explored in subset of healthy participants (n = 3) that hopped at a slower rate (1.8 Hz) and a patient who had undergone Achilles tendon rupture-repair (2.5 Hz). Reliability was estimated using the mean-within subject coefficient of variation calculated at each point during the ground-contact phase of hopping, while cross-correlations were used to explore the coordination between lower limb kinematics ground reaction forces and ultrasound velocity in the Achilles tendon. Axial velocity of ultrasound in the Achilles tendon was highly reproducible during hopping, with the mean within-subject coefficient of variation ranging between 0.1 and 2.0% across participants. Ultrasound velocity decreased immediately following touch down (−19 ± 13 ms–1), before increasing by 197 ± 81 ms–1, on average, to peak at 2230 ± 87 ms–1 at 67 ± 3% of ground contact phase in healthy participants. Cross-correlation analysis revealed that ultrasound velocity in the Achilles tendon during hopping was strongly associated with knee (mean r = 0.98, range 0.95–1.00) rather than ankle (mean r = 0.67, range 0.35–0.79) joint motion. Ultrasound velocity was sensitive to changes in hopping frequency in healthy adults and in the surgically repaired Achilles tendon was characterized by a similar peak velocity (2283 ± 13 ms–1) but the change in ultrasound velocity (447 ± 21 ms–1) was approximately two fold that of healthy participants (197 ± 81 ms–1). Although further research is required, the technique can be used to reliably monitor ultrasound velocity in the Achilles tendon during hopping, can detect changes in the instantaneous elastic modulus of tendon with variation in hopping frequency and tendon pathology and ultimately may provide further insights into the stretch-shortening cycle and aid clinical decision concerning tendon rehabilitation protocols and readiness to return to sport.
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Affiliation(s)
- Scott C Wearing
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia.,Faculty of Sports and Health Sciences, Technical University of Munich, Munich, Germany
| | - Larissa Kuhn
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Torsten Pohl
- Faculty of Sports and Health Sciences, Technical University of Munich, Munich, Germany
| | - Thomas Horstmann
- Faculty of Sports and Health Sciences, Technical University of Munich, Munich, Germany
| | - Torsten Brauner
- Department of Sport Science, German University of Health and Sport, Ismaning, Germany
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24
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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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25
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Agres AN, Arampatzis A, Gehlen T, Manegold S, Duda GN. Muscle Fascicles Exhibit Limited Passive Elongation Throughout the Rehabilitation of Achilles Tendon Rupture After Percutaneous Repair. Front Physiol 2020; 11:746. [PMID: 32792966 PMCID: PMC7385380 DOI: 10.3389/fphys.2020.00746] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 06/08/2020] [Indexed: 12/28/2022] Open
Abstract
Achilles tendon rupture (ATR) results in long-term functional and structural deficits, characterized by reduced ankle mobility and plantarflexor muscle atrophy. However, it remains unclear how such functional impairments develop after surgical repair. While it is known that this injury negatively affects the tendon’s function, to date, limited work has focused on the short-term effect of ATR on the structure of the muscles in series. The aim of this study was to characterize changes in medial gastrocnemius architecture and its response to passive lengthening during the post-surgical rehabilitative period following ATR. Both injured and contralateral limbs from 10 subjects (1 female, BMI: 27.2 ± 3.9 kg/m2; age: 46 ± 10 years) with acute, unilateral ATR were assessed at 8, 12, and 16 weeks after percutaneous surgical repair. To characterize the component tissues of the muscle-tendon unit, resting medial gastrocnemius muscle thickness, fascicle length, and pennation angle were determined from ultrasound images with the ankle in both maximal plantarflexion and dorsiflexion. The ankle range of motion (ROM) was determined using motion capture; combined ultrasound and motion capture determined the relative displacement of the musculotendinous junction (MTJ) of the AT with the medial gastrocnemius. The ATR-injured gastrocnemius muscle consistently exhibited lower thickness, regardless of time point and ankle angle. Maximal ankle plantarflexion angles and corresponding fascicle lengths were lower on the injured ankle compared to the contralateral throughout rehabilitation. When normalized to the overall ankle ROM, both injured fascicles and MTJ displacement exhibited a comparably lower change in length when the ankle was passively rotated. These results indicate that when both ankles are passively exposed to the same ROM following ATR surgery, both ipsilateral Achilles tendon and gastrocnemius muscle fascicles exhibit limited lengthening compared to the contralateral MTU tissues. This appears to be consistent throughout the rehabilitation of gait, suggesting that current post-operative rehabilitative exercises do not appear to induce muscle adaptations in the affected MTU.
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Affiliation(s)
- Alison N Agres
- Julius Wolff Institute, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Adamantios Arampatzis
- Department of Training and Movement Sciences, Humboldt University of Berlin, Berlin, Germany
| | - Tobias Gehlen
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sebastian Manegold
- Department for Foot and Ankle Surgery, BG Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
| | - Georg N Duda
- Julius Wolff Institute, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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26
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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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27
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Makulavičius A, Mazarevičius G, Klinga M, Urmanavičius M, Masionis P, Oliva XM, Uvarovas V, Porvaneckas N. Outcomes of open "crown" type v. percutaneous Bunnell type repair of acute Achilles tendon ruptures. Randomized control study. Foot Ankle Surg 2020; 26:580-584. [PMID: 31548150 DOI: 10.1016/j.fas.2019.07.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 07/26/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND The optimal treatment of acute Achilles tendon ruptures (AATR) is still under debate. The purpose of this study was to evaluate outcomes of open repair comparing with percutaneous procedure for AATR. METHODS 100 patients with AATR were randomized in two groups: open "crown" type (group A) and percutaneous Bunnell type repair (group B). 87 patients were available for the mean follow up of 27months RESULTS: No statistically significant difference was observed between groups in ATRS score, leg circumference, single heel rise, Achilles resting angle, time back to work and sports and overall patient satisfaction. Percutaneous technique was much faster. Overall 13 complications occurred in both groups (5 and 8 respectively). No deep infection occurred, no revisions were needed. CONCLUSIONS Both techniques showed to be effective and safe when using absorbable suture material with a high patient satisfaction and a low complication rate, but percutaneous repair was significantly faster.
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Affiliation(s)
- Aleksas Makulavičius
- Vilnius University, Faculty of Medicine, Clinic of Rheumatology, Traumatology Orthopaedic and Reconstructive Surgery, Centre of Orthopedics and Traumatology, Republican Vilnius University Hospital, Šiltnamių g. 29, LT-04130 Vilnius, Lithuania.
| | - Giedrius Mazarevičius
- Vilnius University, Faculty of Medicine, Clinic of Rheumatology, Traumatology Orthopaedic and Reconstructive Surgery, Centre of Orthopedics and Traumatology, Republican Vilnius University Hospital, Šiltnamių g. 29, LT-04130 Vilnius, Lithuania
| | - Mindaugas Klinga
- Vilnius University, Faculty of Medicine, Clinic of Rheumatology, Traumatology Orthopaedic and Reconstructive Surgery, Centre of Orthopedics and Traumatology, Republican Vilnius University Hospital, Šiltnamių g. 29, LT-04130 Vilnius, Lithuania
| | - Matas Urmanavičius
- Vilnius University, Faculty of Medicine, Clinic of Rheumatology, Traumatology Orthopaedic and Reconstructive Surgery, Centre of Orthopedics and Traumatology, Republican Vilnius University Hospital, Šiltnamių g. 29, LT-04130 Vilnius, Lithuania
| | - Povilas Masionis
- Vilnius University, Faculty of Medicine, Clinic of Rheumatology, Traumatology Orthopaedic and Reconstructive Surgery, Centre of Orthopedics and Traumatology, Republican Vilnius University Hospital, Šiltnamių g. 29, LT-04130 Vilnius, Lithuania
| | - Xavier Martin Oliva
- Barcelona University, Faculty of Medicine, Department of Embriology and Human Anatomy, Barcelona, Spain
| | - Valentinas Uvarovas
- Vilnius University, Faculty of Medicine, Clinic of Rheumatology, Traumatology Orthopaedic and Reconstructive Surgery, Centre of Orthopedics and Traumatology, Republican Vilnius University Hospital, Šiltnamių g. 29, LT-04130 Vilnius, Lithuania
| | - Narūnas Porvaneckas
- Vilnius University, Faculty of Medicine, Clinic of Rheumatology, Traumatology Orthopaedic and Reconstructive Surgery, Centre of Orthopedics and Traumatology, Republican Vilnius University Hospital, Šiltnamių g. 29, LT-04130 Vilnius, Lithuania
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28
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Sun D, Fekete G, Baker JS, Mei Q, István B, Zhang Y, Gu Y. A Pilot Study of Musculoskeletal Abnormalities in Patients in Recovery from a Unilateral Rupture-Repaired Achilles Tendon. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17134642. [PMID: 32605170 PMCID: PMC7369810 DOI: 10.3390/ijerph17134642] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 11/16/2022]
Abstract
The purpose of this study was to compare the inter-limb joint kinematics, joint moments, muscle forces, and joint reaction forces in patients after an Achilles tendon rupture (ATR) via subject-specific musculoskeletal modeling. Six patients recovering from a surgically repaired unilateral ATR were included in this study. The bilateral Achilles tendon (AT) lengths were evaluated using ultrasound imaging. The three-dimensional marker trajectories, ground reaction forces, and surface electromyography (sEMG) were collected on both sides during self-selected speed during walking, jogging and running. Subject-specific musculoskeletal models were developed to compute joint kinematics, joint moments, muscle forces and joint reaction forces. AT lengths were significantly longer in the involved side. The side-to-side triceps surae muscle strength deficits were combined with decreased plantarflexion angles and moments in the injured leg during walking, jogging and running. However, the increased knee extensor femur muscle forces were associated with greater knee extension degrees and moments in the involved limb during all tasks. Greater knee joint moments and joint reaction forces versus decreased ankle joint moments and joint reaction forces in the involved side indicate elevated knee joint loads compared with reduced ankle joint loads that are present during normal activities after an ATR. In the frontal plane, increased subtalar eversion angles and eversion moments in the involved side were demonstrated only during jogging and running, which were regarded as an indicator for greater medial knee joint loading. It seems after an ATR, the elongated AT accompanied by decreased plantarflexion degrees and calf muscle strength deficits indicates ankle joint function impairment in the injured leg. In addition, increased knee extensor muscle strength and knee joint loads may be a possible compensatory mechanism for decreased ankle function. These data suggest patients after an ATR may suffer from increased knee overuse injury risk.
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Affiliation(s)
- Dong Sun
- Faculty of Sports Science, Ningbo University, Ningbo 315211, China; (D.S.); (Q.M.); (Y.Z.)
| | - Gusztáv Fekete
- Savaria Institute of Technology, Eötvös Loránd University, 9700 Szombathely, Hungary;
| | - Julien S. Baker
- Department of Sport and Physical Education, Hong Kong Baptist University, Hong Kong 999077, China;
| | - Qichang Mei
- Faculty of Sports Science, Ningbo University, Ningbo 315211, China; (D.S.); (Q.M.); (Y.Z.)
| | - Bíró István
- Department of Technology, Faculty of Engineering, University of Szeged, 6727 Szeged, Hungary;
| | - Yan Zhang
- Faculty of Sports Science, Ningbo University, Ningbo 315211, China; (D.S.); (Q.M.); (Y.Z.)
| | - Yaodong Gu
- Faculty of Sports Science, Ningbo University, Ningbo 315211, China; (D.S.); (Q.M.); (Y.Z.)
- Correspondence: ; Tel.: +86-574-87600208
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29
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Zellers JA, Pohlig RT, Cortes DH, Grävare Silbernagel K. Achilles tendon cross-sectional area at 12 weeks post-rupture relates to 1-year heel-rise height. Knee Surg Sports Traumatol Arthrosc 2020; 28:245-252. [PMID: 31267192 PMCID: PMC6939153 DOI: 10.1007/s00167-019-05608-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 06/26/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE Achilles tendon rupture leads to long-term plantar flexor deficits, but some patients recover functional performance better than others. Early indicators of tendon healing could be helpful in establishing patient prognosis and making individualized decisions regarding rehabilitation progression. The purpose of this study was to investigate relationships between early tendon morphology and mechanical properties to long-term heel-rise and jumping function in individuals after Achilles tendon rupture. METHODS Individuals after Achilles tendon rupture were assessed at 4, 8, 12, 24, and 52 weeks post-injury. Tendon cross-sectional area, length, and mechanical properties were measured using ultrasound. Heel-rise and jump tests were performed at 24 and 52 weeks. Correlation and regression analysis were used to identify relationships between tendon structural variables in the first 12 weeks to functional outcomes at 52 weeks, and determine whether the addition of tendon structural characteristics at 24 weeks strengthened relationships between functional performance at 24 and 52 weeks. Functional outcomes of individuals with < 3 cm of elongation were compared to those with > 3 cm of elongation using a Mann-Whitney U test. RESULTS Twenty-two participants [mean (SD) age = 40 (11) years, 17 male] were included. Tendon cross-sectional area at 12 weeks was the strongest predictor of heel-rise height (R2 = 0.280, p = 0.014) and work symmetry (R2 = 0.316, p = 0.008) at 52 weeks. Jumping performance at 52 weeks was not significantly related to any of the tendon structural measures in the first 12 weeks. Performance of all functional tasks at 24 weeks was positively related to performance on the same task at 52 weeks (r = 0.456-0.708, p < 0.05). The addition of tendon cross-sectional area improved the model for height LSI (R2 = 0.519, p = 0.001). Tendon elongation > 3 cm significantly reduced jumping symmetry (p < 0.05). CONCLUSION Tendon cross-sectional area and excessive elongation related to plantar flexor performance on functional testing after Achilles tendon rupture. Once an individual is able to perform function-based testing, tendon structural measures may inform long-term prognosis. Ultrasound-based measures of tendon structure early in recovery seem to relate to later performance on functional testing. Clinically, assessing tendon structure has the potential to be used as a biomarker of tendon healing early in recovery and better predict patients at risk of negative functional outcome. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Jennifer A Zellers
- Program in Physical Therapy, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Ryan T Pohlig
- College of Health Sciences biostatistics Core Facility, University of Delaware, Newark, DE, USA
| | - Daniel H Cortes
- Department of Mechanical and Nuclear Engineering, Penn State University, State College, PA, USA
| | - Karin Grävare Silbernagel
- Department of Physical Therapy, University of Delaware, 540 South College Ave, Newark, DE, 19713, USA.
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Modified Percutaneous Achilles Tendon Lengthening by Triple Hemisection for Achilles Tendon Contracture. BIOMED RESEARCH INTERNATIONAL 2019; 2019:1491796. [PMID: 31781592 PMCID: PMC6874878 DOI: 10.1155/2019/1491796] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 08/10/2019] [Indexed: 01/04/2023]
Abstract
Background Both percutaneous Achilles tendon lengthening by triple hemisection and the traditional open Z-lengthening are effective methods for Achilles tendon contracture. This study aims to evaluate the efficacy and safety of this new therapeutic method, which is based on the percutaneous sliding technique with three hemi-cuts in the tendon, as compared with the traditional open Z-lengthening. Methods Retrospective analysis of the Achilles tendon contracture cases in our hospital between January 2010 and September 2016 was conducted. Twenty-five cases received percutaneous Achilles tendon lengthening (group A), and 30 patients who underwent open Z-lengthening during the same period were in the control group (group B). Operative time and hospital stay were statistically analyzed. Incision complication, equinus recurrence rate and Achilles tendon rupture morbidity were recorded. The function was assessed by American Orthopaedic Foot & Ankle Society (AOFAS) score. All cases in group A received Magnetic Resonance Imaging (MRI) of ankle preoperatively and in the follow-ups. Results The mean follow-up period was 42.04 months in group A and 61.7 months in group B. The entire operative time and the mean hospitalization days were lower in group A than in group B. No incision and infection complication occurred in group A. The infection rate in group B was 3.3%. Equinus recurrence rate was 4% in group A and the equinus recurrence rate in group B was 21.4%. In group A, the mean AOFAS score increased from 64 ± 10.16 points preoperatively to 96.08 ± 3.17 at final follow-up, while the score in group B increased from 63.48 ± 6.2 points to 85.4 ± 10.3. MRI showed continuity of the Achilles tendon and homogeneous signal in group A. Conclusion Modified surgery can significantly reduce the risk of Achilles tendon rupture, provide better balance in soft tissue strength between ankle dorsiflexion and ankle plantarflexion, helping to avoid recurrence of the deformity.
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Zellers JA, Parker S, Marmon A, Silbernagel KG. Muscle activation during maximum voluntary contraction and m-wave related in healthy but not in injured conditions: Implications when normalizing electromyography. Clin Biomech (Bristol, Avon) 2019; 69:104-108. [PMID: 31326725 PMCID: PMC6823141 DOI: 10.1016/j.clinbiomech.2019.07.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 07/03/2019] [Accepted: 07/04/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Electromyography signal amplitude is influenced by a variety of factors. Normalization strategies aimed at decreasing signal variability include using peak electromyography signal during a maximum voluntary contraction and peak-to-peak M-wave amplitude. However, whether these normalization methods are comparable has not been investigated in injured populations. This study investigated the relationship between peak signal during maximum voluntary contraction and M-wave amplitude in individuals with a unilateral Achilles tendon rupture. Secondarily, we observed whether the two normalizations strategies would yield similar results when evaluating between limb differences in muscle activity during a jump task. METHODS Eleven individuals 1-3 years after a unilateral Achilles tendon rupture were included in this study. Surface electromyography was used on the medial and lateral gastrocnemii bilaterally. Peak maximum voluntary contraction, M-wave amplitude, and electromyography during a jumping task were collected. FINDINGS A strong relationship was observed between peak maximum voluntary contraction and M-wave amplitude on the uninjured (r = 0.71-0.88, P < 0.05) but not on the ruptured side (r = 0.41-0.44, P > 0.05). The two normalization techniques did not produce different results when comparing the uninjured and ruptured sides. INTERPRETATION The findings of this study suggest that M-wave normalization yields similar results as peak maximum voluntary contraction-normalized electromyography in uninjured conditions. M-wave normalization may be a useful strategy in an injured population where a maximal muscle contraction is unsafe or impaired.
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Affiliation(s)
- Jennifer A. Zellers
- Department of Physical Therapy, University of Delaware, 540 S. College Ave, Newark, DE, 19713, USA
| | - Sheridan Parker
- Department of Biomechanics, University of Nebraska at Omaha, 6160 University Drive South, Omaha, NE, 68182, USA,Department of Biomedical Engineering, 540 S. College Ave, University of Delaware, Newark, DE, 19713, USA
| | - Adam Marmon
- Department of Physical Therapy, University of Delaware, 540 S. College Ave, Newark, DE, 19713, USA
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Early weight-bearing in nonoperative treatment of acute Achilles tendon rupture did not influence mid-term outcome: a blinded, randomised controlled trial. Knee Surg Sports Traumatol Arthrosc 2019; 27:2781-2788. [PMID: 30030579 DOI: 10.1007/s00167-018-5058-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 07/11/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE Acute Achilles tendon rupture leads to impaired outcome at short term, but little is known concerning medium-term results. The aim of the present study was to investigate the influence of early weight-bearing on clinical outcome 4.5 years after nonoperative treatment of acute Achilles tendon rupture. METHOD The study was performed as a medium-term follow-up on patients included in a randomised controlled trial. Both groups were treated with nonoperative management and controlled early motion. The intervention group was allowed full weight-bearing from day 1, and the control group was non-weight-bearing for 6 weeks. 60 patients were randomised 1:1. Of those, 56 were eligible for inclusion in the medium-term follow-up and 37 participated (18 control, 19 intervention). The outcomes were Achilles tendon Total Rupture Score (ATRS) and heel raise work performed at an average of 4.5 years after the initial injury. Statistical analysis was performed using paired t tests and linear regression. RESULTS No differences were found between control and intervention groups at 4.5 years. ATRS scores consistently improved in both the intervention and the control groups from 0.5 to 1 year and from 1 to 4.5 years, ending up at 80.5 on average after 4.5 years. Heel raise height kept improving from 0.5 to 4.5 years, reaching a limb symmetry index of 82.4%. The heel raise work improvement from 0.5 to 1 year did not continue. No significant change was found from 1 to 4.5 years, ending at a limb symmetry index of 60%. CONCLUSION Early weight-bearing did not influence outcome 4.5 years after nonoperative treatment of acute Achilles tendon rupture. The calf muscle of the injured limb performs 40% less work, when compared to the healthy limb, though lifting height recovers better. LEVEL OF EVIDENCE II. CLINICAL TRIALS IDENTIFIER NCT02760784.
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Zellers JA, Cortes DH, Pohlig RT, Silbernagel KG. Tendon morphology and mechanical properties assessed by ultrasound show change early in recovery and potential prognostic ability for 6-month outcomes. Knee Surg Sports Traumatol Arthrosc 2019; 27:2831-2839. [PMID: 30415387 PMCID: PMC6510650 DOI: 10.1007/s00167-018-5277-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 10/29/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE Optimizing tendon structural recovery during the first 12 weeks after Achilles tendon rupture is a prime target to improve patient outcomes, but a comprehensive understanding of biomarkers is needed to track early healing. The purpose of this study was to observe healing of tendon structure over time using ultrasound-based, tendon-specific measures and to identify relationships between tendon structural characteristics and clinical measures of gait and strength. METHODS Twenty-seven participants (21 males, mean (SD) age 39 (11) years) were assessed at 4, 8, 12, and 24 weeks after injury or surgery using ultrasound imaging techniques. Gait analysis and strength testing were added at the later time points. RESULTS Ruptured tendons had significantly lower dynamic shear modulus (p < 0.001), greater tendon cross-sectional area (p < 0.001), and greater length (p < 0.001) than the uninjured side. Dynamic shear modulus, cross-sectional area, and length were found to increase over time (p < 0.01). Tendon structure at 4 weeks post-injury [cross-sectional area symmetry (r = 0.737, p = 0.002) and dynamic shear modulus (r = 0.518, p = 0.040)] related to stance phase walking symmetry at 24 weeks. CONCLUSIONS Tendon structure assessed by ultrasound imaging changes over the first 24 weeks of healing after Achilles tendon rupture, suggesting it could be used as a biomarker to track tendon healing early in recovery. Additionally, tendon structure within the first 12 weeks relates to later walking gait and heel-rise symmetry, which may indicate that tendon structure could have prognostic value in the care of these patients. This study's clinical relevance is in its support for using ultrasound imaging to assess early patient healing and prognosticate later patient outcomes after Achilles tendon rupture. LEVEL OF EVIDENCE Level 2, prospective cohort prognostic study.
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Affiliation(s)
- Jennifer A Zellers
- Department of Physical Therapy, University of Delaware, 540 South College Ave, Newark, DE, 19713, USA
| | - Daniel H Cortes
- Department of Mechanical and Nuclear Engineering, Penn State University, State College, PA, USA
| | - Ryan T Pohlig
- College of Health Sciences Biostatistics Core Facility, University of Delaware, Newark, DE, USA
| | - Karin Grävare Silbernagel
- Department of Physical Therapy, University of Delaware, 540 South College Ave, Newark, DE, 19713, USA.
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Svensson RB, Couppé C, Agergaard A, Ohrhammar Josefsen C, Jensen MH, Barfod KW, Nybing JD, Hansen P, Krogsgaard M, Magnusson SP. Persistent functional loss following ruptured Achilles tendon is associated with reduced gastrocnemius muscle fascicle length, elongated gastrocnemius and soleus tendon, and reduced muscle cross‐sectional area. TRANSLATIONAL SPORTS MEDICINE 2019. [DOI: 10.1002/tsm2.103] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- René B. Svensson
- Department of Orthopedic Surgery, Institute of Sports Medicine Copenhagen, Bispebjerg‐Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences University of Copenhagen Copenhagen Denmark
| | - Christian Couppé
- Department of Orthopedic Surgery, Institute of Sports Medicine Copenhagen, Bispebjerg‐Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences University of Copenhagen Copenhagen Denmark
- Department of Physical Therapy Bispebjerg‐Frederiksberg Hospital Copenhagen Denmark
| | - Anne‐Sofie Agergaard
- Department of Orthopedic Surgery, Institute of Sports Medicine Copenhagen, Bispebjerg‐Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences University of Copenhagen Copenhagen Denmark
- Department of Physical Therapy Bispebjerg‐Frederiksberg Hospital Copenhagen Denmark
| | - Christian Ohrhammar Josefsen
- Department of Orthopedic Surgery, Institute of Sports Medicine Copenhagen, Bispebjerg‐Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences University of Copenhagen Copenhagen Denmark
| | - Mikkel Holm Jensen
- Department of Orthopedic Surgery, Institute of Sports Medicine Copenhagen, Bispebjerg‐Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences University of Copenhagen Copenhagen Denmark
| | - Kristoffer Weisskirchner Barfod
- Department of Orthopedic Surgery, Sports Orthopedic Research Center–Copenhagen Copenhagen University Hospital Amager‐Hvidovre Denmark
| | - Janus D. Nybing
- Department of Radiology, Musculoskeletal Imaging Research Unit Bispebjerg‐Frederiksberg Hospital Copenhagen Denmark
| | - Philip Hansen
- Department of Radiology, Musculoskeletal Imaging Research Unit Bispebjerg‐Frederiksberg Hospital Copenhagen Denmark
| | - Michael Krogsgaard
- Section for Sports Traumatology, Department of Orthopedic Surgery Bispebjerg‐Frederiksberg Hospital Copenhagen Denmark
| | - S. Peter Magnusson
- Department of Orthopedic Surgery, Institute of Sports Medicine Copenhagen, Bispebjerg‐Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences University of Copenhagen Copenhagen Denmark
- Department of Physical Therapy Bispebjerg‐Frederiksberg Hospital Copenhagen Denmark
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Manegold S, Tsitsilonis S, Gehlen T, Kopf S, Duda GN, Agres AN. Alterations in structure of the muscle-tendon unit and gait pattern after percutaneous repair of Achilles tendon rupture with the Dresden instrument. Foot Ankle Surg 2019; 25:529-533. [PMID: 30321951 DOI: 10.1016/j.fas.2018.04.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Revised: 04/05/2018] [Accepted: 04/09/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Functional deficits after Achilles tendon (AT) ruptures are observed. The relationship between musculotendinous structural alterations and functional outcome is not clear. METHODS Kinematic analyses (level walking, stair climbing), patient-reported outcome measures (PROMs), calf atrophy (maximum calf circumference (MCC)), and AT length were evaluated in patients after percutaneous AT repair with the Dresden instrument (n=20min. FOLLOW-UP 24 months). RESULTS Patients achieved good results in PROMs. However, MCC decreased significantly and AT length increased significantly postoperatively. Side-to-side MCC differences over 2cm resulted in significantly lower PROMs. AT lengthening correlated with increased dorsiflexion and decreased plantarflexion. CONCLUSION Calf atrophy and AT lengthening after minimally invasive AT repair resulted in inferior ankle kinematics and PROMs.
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Affiliation(s)
- Sebastian Manegold
- Charité - University Medicine Berlin, Center for Musculoskeletal Surgery, Campus Virchow Clinic, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Serafim Tsitsilonis
- Charité - University Medicine Berlin, Center for Musculoskeletal Surgery, Campus Virchow Clinic, Augustenburger Platz 1, 13353, Berlin, Germany; Berlin-Brandenburg Center for Regenerative Therapies/BSRT, Charité - University Medicine Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Tobias Gehlen
- Charité - University Medicine Berlin, Center for Musculoskeletal Surgery, Campus Virchow Clinic, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Sebastian Kopf
- Charité - University Medicine Berlin, Center for Musculoskeletal Surgery, Campus Virchow Clinic, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Georg N Duda
- Berlin-Brandenburg Center for Regenerative Therapies/BSRT, Charité - University Medicine Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Alison N Agres
- Berlin-Brandenburg Center for Regenerative Therapies/BSRT, Charité - University Medicine Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
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Skypala J, Jandacka D, Hamill J. Reliability of a measurement technique for achilles tendon length. J Sports Sci 2019; 37:2389-2395. [PMID: 31238805 DOI: 10.1080/02640414.2019.1635375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Recently, there has been an increasing amount of literature dealing with new methods of Achilles tendon (AT) length measurement. However, most of these studies measured the AT length between the calcaneus and medial head of the gastrocnemius and the reliability of such a measurement has not been satisfactorily presented. The purpose of this study was to determine the reliability of the measurement of AT length within and between sessions. AT length was measured by using a combination of ultrasound imaging and optoelectronic stereophotogrammetry. Nineteen healthy athletes visited the lab on six different days where the AT length was measured on both lower extremities: 1) from the calcaneus to the mid-point of the medial and lateral heads of the gastrocnemius; and 2) from the calcaneus to the soleus musculotendinous attachment. The reliability results indicated high intraclass correlation coefficients (ICC > 0.8), a low typical error (< 0.6) and a standard error of measurement (SEM < 5.5 mm) for all measured AT lengths on within and between sessions. This non-invasive reliable measurement method may be recommended for sport science research purposes.
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Affiliation(s)
- Jiri Skypala
- a Department of Human Movement Studies, Human Motion Diagnostics Center, University of Ostrava , Ostrava , Czech Republic
| | - Daniel Jandacka
- a Department of Human Movement Studies, Human Motion Diagnostics Center, University of Ostrava , Ostrava , Czech Republic
| | - Joseph Hamill
- a Department of Human Movement Studies, Human Motion Diagnostics Center, University of Ostrava , Ostrava , Czech Republic.,b Department of Kinesiology, University of Massachusetts , Amherst , USA
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Hullfish TJ, O’Connor KM, Baxter JR. Gastrocnemius fascicles are shorter and more pennate throughout the first month following acute Achilles tendon rupture. PeerJ 2019; 7:e6788. [PMID: 31065459 PMCID: PMC6485203 DOI: 10.7717/peerj.6788] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 03/14/2019] [Indexed: 12/28/2022] Open
Abstract
The purpose of this study was to characterize the short-term effects of Achilles tendon ruptures on medial gastrocnemius. We hypothesized that the fascicles of the medial gastrocnemius muscle of the injured Achilles tendon would be shorter and more pennate immediately following the injury and would persist throughout 4 weeks post-injury. B-mode longitudinal ultrasound images of the medial gastrocnemius were acquired in 10 adults who suffered acute Achilles tendon ruptures and were treated non-operatively. Ultrasound images were acquired during the initial clinical visit following injury as well as 2 and 4 weeks following this initial clinical visit. Resting muscle structure was characterized by measuring fascicle length, pennation angle, muscle thickness, and muscle echo intensity in both the injured and contralateral (control) limbs. Fascicle length was 15% shorter (P < 0.001) and pennation angle was 21% greater (P < 0.001) in the injured muscle compared to the uninjured (control) muscle at the presentation of injury (week 0). These differences in fascicle length persisted through 4 weeks after injury (P < 0.002) and pennation angle returned to pre-injury levels. Muscle thickness changes were not detected at any of the post-injury visits (difference < 4%, P > 0.026). Echo intensity of the injured limb was 8% lower at the presentation of the injury but was not different compared to the contralateral muscle at 2 and 4 weeks post-injury. Our results suggest that Achilles tendon ruptures elicit rapid changes in the configuration of the medial gastrocnemius, which may explain long-term functional deficits.
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Affiliation(s)
- Todd J. Hullfish
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Kathryn M. O’Connor
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Josh R. Baxter
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
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Zellers JA, Marmon AR, Ebrahimi A, Silbernagel KG. Lower extremity work along with triceps surae structure and activation is altered with jumping after Achilles tendon repair. J Orthop Res 2019; 37:933-941. [PMID: 30816587 PMCID: PMC6470019 DOI: 10.1002/jor.24260] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 02/12/2019] [Indexed: 02/04/2023]
Abstract
Achilles tendon rupture leads to long term plantar flexor deficits. The purpose of this study was to describe changes in jumping biomechanics along with triceps surae structure and activation in individuals after Achilles repair. Eleven individuals 1-3 years following Achilles repair and 10 healthy controls were included. Kinetics and kinematics, analyzed using a constituent lower extremity work (CLEW) approach, and muscle activity using surface electromyography (EMG) were collected during a unilateral hopping task. Triceps surae myotendinous structure was assessed using ultrasound imaging. There were no differences in jump height, absolute limb work, or cost of transport between groups. During takeoff, the knee did more (p < 0.001) and ankle did less concentric work (p < 0.001), and lateral gastrocnemius rate of rise was higher (p = 0.02) on the ruptured side. During landing, the knee did more eccentric work (p = 0.033) and lateral gastrocnemius (p = 0.003) and soleus (p = 0.02) activation amplitude prior to landing was higher on the ruptured side. Individuals after Achilles tendon repair shift work toward the knee and alter muscle recruitment. Differences in lateral gastrocnemius activity may indicate that it is well-situated to generate power during takeoff and assist in landing with the soleus. The lack of change in muscle activity and decreased cross sectional area of the medial gastrocnemius may suggest that this muscle atrophies and does not accommodate to the hopping task. Clinical Significance: Proximal lower extremity strengthening along with emphasizing medial gastrocnemius and soleus activation during the recovery of patients with Achilles tendon repair may be rehabilitative targets for improved jumping performance. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.
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Affiliation(s)
- Jennifer A. Zellers
- Department of Physical Therapy, University of Delaware, 540 S. College Ave, Newark, DE 19713, USA,
| | - Adam R. Marmon
- Department of Physical Therapy, University of Delaware, 540 S. College Ave, Newark, DE 19713, USA,
| | - Anahid Ebrahimi
- Department of Mechanical Engineering, University of Wisconsin-Madison, 1513 University Ave, Madison, WI, 53706, USA,
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El-Akkawi AI, Joanroy R, Barfod KW, Kallemose T, Kristensen SS, Viberg B. Effect of Early Versus Late Weightbearing in Conservatively Treated Acute Achilles Tendon Rupture: A Meta-Analysis. J Foot Ankle Surg 2018; 57:346-352. [PMID: 28974345 DOI: 10.1053/j.jfas.2017.06.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Indexed: 02/03/2023]
Abstract
Achilles tendon ruptures can be either surgically or conservatively treated with either early functional mobilization or cast immobilization. The purpose of the present study was to conduct a meta-analysis comparing the effect of early versus late weightbearing in conservatively treated adult patients, including only randomized controlled trials (RCTs). The primary endpoint was rerupture, and the secondary endpoints were strength, quality of life during treatment, range of motion, deep venous thrombosis, return to sports, and return to work. The search for studies was conducted using PubMed, EMBASE, and the Cochrane Central Register of Controlled trials. A search was performed, and 2 reviewers independently screened the studies by title, abstract, and, finally, by reading the full text. Four studies met the inclusion criteria. The reference lists of the included studies were scanned and 1 additional RCT study was included. The critical appraisal skills program checklist was applied for study appraisal. A statistician performed the data management and analysis. No statistically significant differences were found between the 2 treatment groups concerning rerupture (p = .796), return to sports (p = .455), or return to work (p = .888). One RCT found 1 case of deep venous thrombosis in the late weightbearing group. One RCT reported significant improvement in quality of life and one reported a significantly improved range of dorsiflexion in the early weightbearing group. No statistically significant difference was found between early and late weightbearing with conservative treatment regarding the rerupture rate. The results of the other outcomes were limited by the low number of studies included in the present meta-analysis. Larger randomized studies are needed to investigate these outcomes. From the results in the present study, we would recommend early weightbearing when an Achilles tendon rupture is treated conservatively.
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Affiliation(s)
- Ali Imad El-Akkawi
- Junior Doctor, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark.
| | - Rajzan Joanroy
- Junior Doctor, Fellowship in Orthopedic Surgery, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
| | - Kristoffer Weisskirchner Barfod
- Doctor, Fellowship in Orthopedic Surgery, Clinical Orthopedic Research Hvidovre, Department of Orthopedics, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Thomas Kallemose
- Scientific Statistician, Clinical Research Centre, Clinical Orthopedic Research Hvidovre, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Søren Skydt Kristensen
- Senior Doctor and Chief Physician, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
| | - Bjarke Viberg
- Doctor, Fellowship in Orthopedic Surgery, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark; Doctor, Fellowship in Orthopedic Surgery, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Manegold S, Tsitsilonis S, Schumann J, Gehlen T, Agres AN, Keller J, Gesslein M, Wichlas F. Functional outcome and complication rate after percutaneous suture of fresh Achilles tendon ruptures with the Dresden instrument. J Orthop Traumatol 2018; 19:19. [PMID: 30229505 PMCID: PMC6143488 DOI: 10.1186/s10195-018-0511-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 07/19/2018] [Indexed: 11/10/2022] Open
Abstract
Background The aim of this study was to evaluate the outcome of patients with a rupture of the Achilles tendon (ATR) treated percutaneously with the Dresden instrument in the hands of surgeons others than its inventors. Materials and methods 118 patients (FU rate: 77.1%) with an acute ATR treated with the Dresden instrument were retrospectively evaluated. The following data were evaluated: pain intensity, functional limitation, Hannover score, Achilles tendon total rupture score (ATRS), AOFAS ankle-hindfoot score, Tegner activity score, complications, maximum calf circumference (MCC) on both sides, and the Matles test for tendon lengthening. The effect of the time point of the surgery after trauma was examined. Results Hannover scores and ATRSs were good; AOFAS scores were excellent. Almost all patients returned to sporting activities postoperatively, and 66.1% were able to return to their previous level. The Tegner activity score revealed a slight posttraumatic decrease (p = 0.009) in the level of physical activity overall (pre-injury: 5.37 ± 0.15; postoperatively: 4.77 ± 0.15). The re-rupture rate was 2%. No sural nerve lesions and no infections were reported. Even after 3 years, there was still a difference in MCC that was correlated with inferior clinical score and AT lengthening. Patients treated within the first 2 days after ATR showed inferior clinical outcomes in terms of AOFAS score, ATRS, and functional limitations. Conclusions Percutaneous ATR suture with the Dresden instrument is a safe and reliable method. Low complication and re-rupture rates, good clinical results, and a high rate of return to play support this fact. The time point of the operation may influence the outcome.
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Affiliation(s)
- Sebastian Manegold
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Campus Virchow Clinic, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Serafim Tsitsilonis
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Campus Virchow Clinic, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Jakob Schumann
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Campus Virchow Clinic, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Tobias Gehlen
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Campus Virchow Clinic, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Alison N Agres
- Julius Wolff Institute, Charité-University Medicine Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Johannes Keller
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Campus Virchow Clinic, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Markus Gesslein
- Clinic for Orthopaedics and Traumatology, Klinikum Nürnberg Süd, Paracelsus University, Breslauer Str. 201, 90471, Nuremberg, Germany
| | - Florian Wichlas
- Clinic for Orthopaedics and Traumatology, University of Salzburg, Müllner Hauptstraße 48, Salzburg, Austria
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Lower material stiffness in rupture-repaired Achilles tendon during walking: transmission-mode ultrasound for post-surgical tendon evaluation. Knee Surg Sports Traumatol Arthrosc 2018; 26:2030-2037. [PMID: 28660438 DOI: 10.1007/s00167-017-4624-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 06/19/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE This cross-sectional study used transmission-mode ultrasound to evaluate dynamic tendon properties during walking in surgically repaired and contralateral Achilles tendon (AT), with a median (range) post-operative period of 22 (4-58) months. It was hypothesised that the axial transmission speed of ultrasound (TSOU) during walking would be slower, indicating lower material stiffness in repaired compared with contralateral AT. METHODS Ten patients [median (range) age 47 (37-69) years; height 180 (170-189) cm; weight 93 (62-119) kg], who had undergone open surgical repair of the AT and were clinically recovered according to their treating clinicians, walked barefoot on a treadmill at self-selected speed (1.0 ± 0.2 m/s). Synchronous measures of TSOU, sagittal ankle motion, vertical ground reaction force (GRF), and spatiotemporal gait parameters were recorded during 20 s of steady-state walking. Paired t tests were used to evaluate potential between-limb differences in TSOU, GRF, ankle motion, and spatiotemporal gait parameters. RESULTS TSOU was significantly lower (≈175 m/s) in the repaired than in the contralateral AT over the entire gait cycle (P < 0.05). Sagittal ankle motion was significantly greater (≈3°) in the repaired than in the contralateral limb (P = 0.036). There were no significant differences in GRF or spatiotemporal parameters between limbs. CONCLUSIONS Repaired AT was characterised by a lower TSOU, reflecting a lower material stiffness in the repaired tendon than in the contralateral tendon. A lower material stiffness may underpin greater ankle joint motion of the repaired limb during walking and long-term deficits in the muscle-tendon unit reported with AT repair. Treatment and rehabilitation approaches that focus on increasing the material stiffness of the repaired AT may be clinically beneficial. Transmission-mode ultrasound would seem useful for quantifying tendon properties post AT rupture repair and may have the potential to individually guide rehabilitation programmes, thereby aiding safer return to physical activity. LEVEL OF EVIDENCE II.
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Jandacka D, Plesek J, Skypala J, Uchytil J, Silvernail JF, Hamill J. Knee Joint Kinematics and Kinetics During Walking and Running After Surgical Achilles Tendon Repair. Orthop J Sports Med 2018; 6:2325967118779862. [PMID: 29977947 PMCID: PMC6024538 DOI: 10.1177/2325967118779862] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Despite the increasing incidence of Achilles tendon (AT) ruptures, there is a lack of information on the possible risks associated with regular running and walking for exercise after an injury. There are some known kinematic gait changes after an AT rupture, especially at the knee. However, it is not clear whether runners with AT ruptures may be at risk for secondary knee injuries during shod or barefoot running/walking. PURPOSE/HYPOTHESIS The purpose of this study was to compare the kinematics and kinetics of barefoot walking and barefoot and shod running between athletes with a history of AT ruptures and a healthy control group. We hypothesized that there would be increased knee joint loads in the affected limb of the AT rupture group, especially during shod running. STUDY DESIGN Controlled laboratory study. METHODS Ten patients who had undergone surgical treatment of a unilateral acute AT rupture (6.1 ± 3.7 years postoperatively ) and 10 control participants were matched according to age, sex, physical activity, weight, height, and footfall type. The kinematics and kinetics of barefoot walking and barefoot and shod running were recorded using a high-speed motion capture system synchronized with force platforms. RESULTS The main outcome measures were lower extremity joint angles and moments during the stance phase of walking and running. After AT repair, athletes had increased internal knee abduction moments during shod and barefoot running compared with the healthy control group (P < .05, η2 > 0.14). There were no significant differences in kinematics and kinetics during walking between the AT rupture and healthy control groups (P ≥ .05). CONCLUSION After an AT rupture, athletes had increased internal knee abduction moments during running compared with the healthy control group. CLINICAL RELEVANCE The increased abduction loads on the knee in patients with an AT rupture could lead to further running-related injuries. However, barefoot walking may be used as a proprioceptive exercise without an increased risk of overuse injuries in these patients.
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Affiliation(s)
- Daniel Jandacka
- Human Motion Diagnostic Centre, Department of Human Movement Studies, University of Ostrava, Ostrava, Czech Republic
| | - Jan Plesek
- Human Motion Diagnostic Centre, Department of Human Movement Studies, University of Ostrava, Ostrava, Czech Republic
| | - Jiri Skypala
- Human Motion Diagnostic Centre, Department of Human Movement Studies, University of Ostrava, Ostrava, Czech Republic
| | - Jaroslav Uchytil
- Department of Kinesiology and Nutrition Sciences, University of Nevada, Las Vegas, Las Vegas, Nevada, USA
| | - Julia Freedman Silvernail
- Department of Kinesiology and Nutrition Sciences, University of Nevada, Las Vegas, Las Vegas, Nevada, USA
| | - Joseph Hamill
- Human Motion Diagnostic Centre, Department of Human Movement Studies, University of Ostrava, Ostrava, Czech Republic
- Department of Kinesiology, University of Massachusetts Amherst, Amherst, Massachusetts, USA
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Zellers JA, Carmont MR, Silbernagel KG. Achilles Tendon Resting Angle Relates to Tendon Length and Function. Foot Ankle Int 2018; 39:343-348. [PMID: 29272160 PMCID: PMC6047896 DOI: 10.1177/1071100717742372] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Following Achilles tendon rupture, tendon elongation leads to long term deficits in calf function. A surrogate measure of Achilles tendon length, Achilles tendon resting angle (ATRA), has been described but has not been validated against length measured using ultrasound. Therefore, the purpose of this study was to validate the ATRA against ultrasound. Secondarily, this study aimed to identify the relationship of other factors (tendon mechanical properties, heel-rise test performance) to the ATRA. METHODS Individuals following unilateral Achilles tendon rupture were included. ATRA was measured in knee flexed and extended positions. Tendon elongation was measured using extended field of view ultrasound imaging. Continuous shear wave elastography quantified tendon mechanical properties. The relationship between variables was tested using Spearman's ρ. Subgroup analysis was used to compare subjects with less then or greater than 1 year following rupture. A total of 42 participants (with a mean of 18.2 months following rupture [SD = 35.9]) were included. RESULTS Tendon elongation related with relative ATRA with knee flexed (ρ = .491, P = .001) and knee extended (ρ = 0.501, P = .001) positions. In individuals greater than 1 year following rupture, relative ATRA with the knee flexed related to shear modulus (ρ = .800, P = .01) and total work on the heel-rise test (ρ = -.782, P = .008) relative to the uninjured side. CONCLUSION Relative ATRA in both knee flexed and knee extended positions has a moderate relationship to tendon elongation within the first year following rupture. After 1 year, the relative ATRA with knee flexed may be a better indicator of tendon elongation and also related to tendon mechanical properties and heel-rise test performance. LEVEL OF EVIDENCE Level III, case-control study.
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Affiliation(s)
| | - Michael R. Carmont
- University of Gothenburg, Gothenburg, Sweden,Princess Royal Hospital, Shropshire, United Kingdom
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Hansen MS, Barfod KW, Kristensen MT. Development and reliability of the Achilles Tendon Length Measure and comparison with the Achilles Tendon Resting Angle on patients with an Achilles tendon rupture. Foot Ankle Surg 2017; 23:275-280. [PMID: 29202987 DOI: 10.1016/j.fas.2016.08.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 05/04/2016] [Accepted: 08/08/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND There is a need for a valid, reliable, and easily applicable clinical measure of the length of the Achilles tendon (AT) after rupture. This study examines the reliability of a new ruler based measurement, the Achilles Tendon Length Measure (ATLM) in comparison with the goniometer-based Achilles Tendon Resting Angle (ATRA). METHODS Measurements were performed by two independent physiotherapists eight weeks after AT rupture on 28 patients treated non-operatively. RESULTS The mean (SD) injured ATLM was 56.5 (2.3)cm, ICC2.1 0.91(CI [0.72-0.97]), SEM 0.7cm (SEM% 1.2), MDC 1.9cm (MDC% 3.4). Corresponding data for the injured ATRA was mean 64.4° (3.9°), ICC2.1 0.84 (CI [0.68-0-92]), SEM 1.5° (SEM% 2.4), MDC 4.3° (MDC% 6.6). CONCLUSION Both ATLM and ATRA showed excellent inter-rater reliability with low measurement error. Both measurements seem easy to use in clinical practice and potentially providing an indirect measure of the length of the AT after rupture.
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Affiliation(s)
- Maria Swennergren Hansen
- Physical Medicine and Rehabilitation Research-Copenhagen (PMR-C), Copenhagen University Hospital, Hvidovre, Kettegård allé 30, Hvidovre 2650, Denmark; Department of Physiotherapy, Copenhagen University Hospital, Hvidovre, Kettegård allé 30, Hvidovre 2650, Denmark.
| | | | - Morten Tange Kristensen
- Physical Medicine and Rehabilitation Research-Copenhagen (PMR-C), Copenhagen University Hospital, Hvidovre, Kettegård allé 30, Hvidovre 2650, Denmark; Department of Physiotherapy, Copenhagen University Hospital, Hvidovre, Kettegård allé 30, Hvidovre 2650, Denmark; Department of Orthopaedic Surgery, Clinical Orthopaedic Research Hvidovre, Kettegård allé 30, Hvidovre 2650, Denmark.
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Jandacka D, Zahradnik D, Farana R, Uchytil J, Hamill J. Footfall patterns of a runner with an Achilles tendon rupture. JOURNAL OF SPORT AND HEALTH SCIENCE 2017; 6:498-502. [PMID: 30356660 PMCID: PMC6189259 DOI: 10.1016/j.jshs.2016.05.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 07/28/2015] [Accepted: 03/07/2016] [Indexed: 06/08/2023]
Abstract
PURPOSE This study aims to compare the load and the length of previously ruptured and healthy Achilles tendon (AT) of a recreational runner who used different footfall patterns on each limb during running. METHODS A 41-year-old recreational athlete with a ruptured AT participated in this report. Two force plates and a high-speed motion capture system were used to collect ground reaction force and kinematic data in shod and barefoot running conditions. AT length was measured using ultrasonography and an infrared camera system. AT force was estimated as the active plantar flexion moment divided by AT moment arm during stance phase. RESULTS The participant used a rearfoot pattern on the affected limb and a forefoot/midfoot pattern on the unaffected limb during shod running, and a forefoot/midfoot pattern during barefoot running. There was no difference between the length of the affected and the unaffected AT. During shod running, the maximal AT force and loading rate were lower in the affected AT versus the unaffected AT. During barefoot running, the affected maximal AT force and loading rate were greater than the unaffected AT. CONCLUSION Footfall patterns can be an adaptation to reduce the loading on a previously injured AT. It appears that runners may consider using a rearfoot footfall pattern during running to reduce the stress on the AT.
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Affiliation(s)
- Daniel Jandacka
- Department of Human Movement Studies, Human Motion Diagnostic Center, University of Ostrava, Ostrava 70200, Czech Republic
| | - David Zahradnik
- Department of Human Movement Studies, Human Motion Diagnostic Center, University of Ostrava, Ostrava 70200, Czech Republic
| | - Roman Farana
- Department of Human Movement Studies, Human Motion Diagnostic Center, University of Ostrava, Ostrava 70200, Czech Republic
| | - Jaroslav Uchytil
- Department of Human Movement Studies, Human Motion Diagnostic Center, University of Ostrava, Ostrava 70200, Czech Republic
| | - Joseph Hamill
- Department of Human Movement Studies, Human Motion Diagnostic Center, University of Ostrava, Ostrava 70200, Czech Republic
- Department of Kinesiology, University of Massachusetts, Amherst, MA 01003, USA
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Jandacka D, Silvernail JF, Uchytil J, Zahradnik D, Farana R, Hamill J. Do athletes alter their running mechanics after an Achilles tendon rupture? J Foot Ankle Res 2017; 10:53. [PMID: 29209417 PMCID: PMC5704504 DOI: 10.1186/s13047-017-0235-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 11/20/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Over the past thirty years, there has been dramatic increase in incidence of Achilles tendon rupture in the athletic population. The purpose of this study was to compare the lower extremity mechanics of Achilles tendon ruptured runners with healthy controls. METHODS The participants with a past history of an Achilles tendon repair (n = 11) and healthy control (n = 11) subgroups were matched on sex, age, type of regular physical activity, mass, height, footfall pattern and lateral dominancy. Running kinetics and kinematics of the ankle, knee and hip were recorded using a high-speed motion capture system interfaced with a force platform. Achilles tendon length was measured using ultrasonography. Main outcome measures were lower extremity joint angles and moments during stance phase of running and Achilles tendon lengths. RESULTS Athletes from Achilles tendon group had an affected gastro-soleus complex. Athletes with history of Achilles tendon rupture had reduced ankle range of motion during second half of the stance phase of running (Δ7.6°), an overextended knee during initial contact (Δ5.2°) and increased affected knee range of motion (Δ4.4°) during the first half of stance phase on their affected limb compared to the healthy control group. There was a 22% increase in the maximal hip joint moment on contralateral side of the Achilles tendon group compared to the healthy controls. CONCLUSION These results suggest a compensation mechanism, relatively extended knee at initial ground contact against the deficit in the muscle-tendon complex of the triceps surae. Overextension during sporting activities may place the knee at risk for further injury. Avoidance of AT lengthening and plantarflexion strength deficit after surgery and during rehabilitation might help to manage AT rupture since these factors may be responsible for altered running kinematics.
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Affiliation(s)
- Daniel Jandacka
- Department of Human Movement Studies, Human Motion Diagnostic Center, University of Ostrava, Varenska 40 A, 70200 Ostrava, Czech Republic
| | | | - Jaroslav Uchytil
- Department of Human Movement Studies, Human Motion Diagnostic Center, University of Ostrava, Varenska 40 A, 70200 Ostrava, Czech Republic
| | - David Zahradnik
- Department of Human Movement Studies, Human Motion Diagnostic Center, University of Ostrava, Varenska 40 A, 70200 Ostrava, Czech Republic
| | - Roman Farana
- Department of Human Movement Studies, Human Motion Diagnostic Center, University of Ostrava, Varenska 40 A, 70200 Ostrava, Czech Republic
| | - Joseph Hamill
- Department of Human Movement Studies, Human Motion Diagnostic Center, University of Ostrava, Varenska 40 A, 70200 Ostrava, Czech Republic
- Department of Kinesiology, University of Massachusetts, Amherst, USA
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Brorsson A, Willy RW, Tranberg R, Grävare Silbernagel K. Heel-Rise Height Deficit 1 Year After Achilles Tendon Rupture Relates to Changes in Ankle Biomechanics 6 Years After Injury. Am J Sports Med 2017; 45:3060-3068. [PMID: 28783473 DOI: 10.1177/0363546517717698] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND It is unknown whether the height of a heel-rise performed in the single-leg standing heel-rise test 1 year after an Achilles tendon rupture (ATR) correlates with ankle biomechanics during walking, jogging, and jumping in the long-term. PURPOSE To explore the differences in ankle biomechanics, tendon length, calf muscle recovery, and patient-reported outcomes at a mean of 6 years after ATR between 2 groups that, at 1-year follow-up, had less than 15% versus greater than 30% differences in heel-rise height. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Seventeen patients with less than 15% (<15% group) and 17 patients with greater than 30% (>30% group) side-to-side difference in heel-rise height at 1 year after ATR were evaluated at a mean (SD) 6.1 (2.0) years after their ATR. Ankle kinematics and kinetics were sampled via standard motion capture procedures during walking, jogging, and jumping. Patient-reported outcome was evaluated with Achilles tendon Total Rupture Score (ATRS), Physical Activity Scale (PAS), and Foot and Ankle Outcome Score (FAOS). Tendon length was evaluated by ultrasonography. The Limb Symmetry Index (LSI = [Injured Side ÷ Healthy Side] × 100) was calculated for side differences. RESULTS The >30% group had significantly more deficits in ankle kinetics during all activities compared with patients in the <15% group at a mean of 6 years after ATR (LSI, 70%-149% and 84%-106%, respectively; P = .010-.024). The >30% group, compared with the <15% group, also had significantly lower values in heel-rise height (LSI, 72% and 95%, respectively; P < .001) and heel-rise work (LSI, 58% and 91%, respectively; P < .001) and significantly larger side-to-side difference in tendon length (114% and 106%, respectively; P = .012). Achilles tendon length correlated with ankle kinematic variables ( r = 0.38-0.44; P = .015-.027) whereas heel-rise work correlated with kinetic variables ( r = -0.57 to 0.56; P = .001-.047). LSI tendon length correlated negatively with LSI heel-rise height ( r = -0.41; P = .018). No differences were found between groups in patient-reported outcome ( P = .143-.852). CONCLUSION Height obtained during the single-leg standing heel-rise test performed 1 year after ATR related to the long-term ability to regain normal ankle biomechanics. Minimizing tendon elongation and regaining heel-rise height may be important for the long-term recovery of ankle biomechanics, particularly during more demanding activities such as jumping.
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Affiliation(s)
- Annelie Brorsson
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Richard W Willy
- Department of Physical Therapy, College of Allied Health Sciences, East Carolina University, Greenville, North Carolina, USA
| | - Roy Tranberg
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Karin Grävare Silbernagel
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Physical Therapy, University of Delaware, Newark, Delaware, USA
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Dams OC, Reininga IHF, Gielen JL, van den Akker-Scheek I, Zwerver J. Imaging modalities in the diagnosis and monitoring of Achilles tendon ruptures: A systematic review. Injury 2017; 48:2383-2399. [PMID: 28943056 DOI: 10.1016/j.injury.2017.09.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 09/10/2017] [Accepted: 09/11/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the role of imaging in the diagnosis and monitoring of the Achilles tendon rupture (ATR). STUDY DESIGN Systematic review. DATA SOURCES PubMed and EMBASE in November 2016. ELIGIBILITY CRITERIA Clinical studies providing information on the methods and role of imaging in the diagnosis and monitoring of the ATR were included. RESULTS Fifty-six studies were included, most concerning the use of ultrasound (n=37) or MRI (n=18). Seven studies provided data on the diagnostic accuracy of imaging. Most ultrasound studies used a 7.5MHz probe (19/32 studies) and scanned the patient bilaterally in prone position, with recent studies tending to use higher frequency probes (r=0.42). Sensitivity [for detecting a rupture] ranged from 79.6 to 100%; the spread in specificity was large but two studies showed perfect (100%) data. Negative and positive likelihood ratios ranged from 0 to 0.23 and 1.0 to 10 respectively. MRI examination was generally performed with 1.5Tesla (T) MRI (6/12 studies) with a strong trend for higher T strength in more recent studies (r=0.71). One study reported a sensitivity of 90.9% and one a specificity of 100%. Although imaging can visualize structure and healing, these results were generally not related to the clinical picture. Overall, ultrasound was recommended over MRI for diagnosis and monitoring. Results of other imaging modalities remain inconclusive. CONCLUSION The adjunct role of imaging, especially of ultrasound and MRI, in the diagnosis and monitoring of ATRs was established. It is therefore recommended to rely primarily on the clinical examination and evaluation and to use imaging for ruling out other injuries and providing additional clinical information. More high-quality research is warranted into the diagnostic accuracy of imaging as well as less conventional imaging modalities' diagnostic and monitoring capabilities.
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Affiliation(s)
- Olivier C Dams
- University of Groningen, University Medical Center Groningen, Department of Sport and Exercise Medicine, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
| | - Inge H F Reininga
- University of Groningen, University Medical Center Groningen, Department of Trauma Surgery, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Jan L Gielen
- Antwerp University Hospital, S.P.O.R.T.S., Wilrijkstraat 10, Edegem-Antwerp, 2650, Belgium
| | - Inge van den Akker-Scheek
- University of Groningen, University Medical Center Groningen, Department of Sport and Exercise Medicine, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Johannes Zwerver
- University of Groningen, University Medical Center Groningen, Department of Sport and Exercise Medicine, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
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Heikkinen J, Lantto I, Piilonen J, Flinkkilä T, Ohtonen P, Siira P, Laine V, Niinimäki J, Pajala A, Leppilahti J. Tendon Length, Calf Muscle Atrophy, and Strength Deficit After Acute Achilles Tendon Rupture: Long-Term Follow-up of Patients in a Previous Study. J Bone Joint Surg Am 2017; 99:1509-1515. [PMID: 28926379 DOI: 10.2106/jbjs.16.01491] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND In this prospective study, we used magnetic resonance imaging (MRI) to assess long-term Achilles tendon length, calf muscle volume, and muscle fatty degeneration after surgery for acute Achilles tendon rupture. METHODS From 1998 to 2001, 60 patients at our center underwent surgery for acute Achilles tendon rupture followed by early functional postoperative rehabilitation. Fifty-five patients were reexamined after a minimum duration of follow-up of 13 years (mean, 14 years), and 52 of them were included in the present study. Outcome measures included Achilles tendon length, calf muscle volume, and fatty degeneration measured with MRI of both the affected and the uninjured leg. The isokinetic plantar flexion strength of both calves was measured and was correlated with the structural findings. RESULTS The Achilles tendon was, on average, 12 mm (95% confidence interval [CI] = 8.6 to 15.6 mm; p < 0.001) longer (6% longer) in the affected leg than in the uninjured leg. The mean volumes of the soleus and medial and lateral gastrocnemius muscles were 63 cm (13%; p < 0.001), 30 cm (13%; p < 0.001), and 16 cm (11%; p < 0.001) lower in the affected leg than in the uninjured leg, whereas the mean volume of the flexor hallucis longus (FHL) was 5 cm (5%; p = 0.002) greater in the affected leg, indicating FHL compensatory hypertrophy. The median plantar flexion strength for the whole range of motion ranged from 12% to 18% less than that on the uninjured side. Finally, the side-to-side difference in Achilles tendon length correlated substantially with the strength deficit (ρ = 0.51, p < 0.001) and with medial gastrocnemius (ρ = 0.46, p = 0.001) and soleus (ρ = 0.42, p = 0.002) muscle atrophy. CONCLUSIONS Increased Achilles tendon length is associated with smaller calf muscle volumes and persistent plantar flexion strength deficits after surgical repair of Achilles tendon rupture. Strength deficits and muscle volume deficits are partly compensated for by FHL hypertrophy, but 11% to 13% deficits in soleus and gastrocnemius muscle volumes and 12% to 18% deficits in plantar flexion strength persist even after long-term follow-up. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Juuso Heikkinen
- 1Division of Orthopaedic and Trauma Surgery, Department of Surgery (J.H., I.L., J.P., T.F., P.O., A.P., and J.L.), Department of Physical Medicine and Rehabilitation (P.S. and V.L.), and Department of Diagnostic Radiology, Institute of Diagnostics (J.N.), Oulu University Hospital, Medical Research Center, University of Oulu, Oulu, Finland
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Ho G, Tantigate D, Kirschenbaum J, Greisberg JK, Vosseller JT. Increasing age in Achilles rupture patients over time. Injury 2017; 48:1701-1709. [PMID: 28457569 DOI: 10.1016/j.injury.2017.04.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 04/11/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND The changing demographics of Achilles tendon rupture (ATR) patients have not fully been investigated. However, there has been a general suspicion that this injury is occurring in an increasingly older population, in terms of mean age. The aim of this study was to objectively show an increase in age in Achilles tendon rupture patients over time. METHODS Published literature on Achilles tendon ruptures was searched for descriptive statistics on the demographics of patients in the studies, specifically mean and median age of Achilles tendon rupture patients, gender ratio, percentage of athletics-related injuries, percentage of smokers, and BMI. Linear regression analyses were performed to determine the trend of patient demographics over time. A Welch one-way ANOVA was carried out to identify any possible differences in data obtained from different types of studies. RESULTS The patient demographics from 142 studies were recorded, with all ATR injuries occurring between the years 1953 and 2014. There was no significant difference in the mean age data reported by varying study types, i.e. randomized controlled trial, cohort study, case series, etc. (P=0.182). There was a statistically significant rise in mean age of ATR patients over time (P<0.0005). There was also a statistically significant drop in percentage of male ATR patients (P=0.02). There is no significant trend for percentage of athletics-related injuries, smoking or BMI. CONCLUSION Since 1953 to present day, the mean age at which ATR occurs has been increasing by at least 0.721 years every five years. In the same time period, the percentage of female study patients with ATR injuries has also been increasing by at least 0.6% every five years. LEVEL OF EVIDENCE Level III; Retrospective cohort study.
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Affiliation(s)
- Gavin Ho
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States
| | - Direk Tantigate
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States
| | - Josh Kirschenbaum
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States
| | - Justin K Greisberg
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States
| | - J Turner Vosseller
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States.
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