1
|
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.
Collapse
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
| |
Collapse
|
2
|
Abstract
The Achilles tendon has a high incidence of ruptures often occurring in weekend warriors and the aging population. Based on anatomic studies of the Achilles tendon, ruptures are commonly found in the watershed area proximal to the insertion site. Traditionally, treatment options included conservative therapy with immobilization and a prolonged non-weight-bearing phase versus surgical treatment. Surgical treatment can vary between open, minimally invasive, or percutaneous approaches. In more recent years, early functional rehabilitation with or without surgery has shown to have successful results.
Collapse
Affiliation(s)
- Varsha Salunkhe Ivanova
- Kaiser Permanente Foot and Ankle Surgery, 700 Lawrence Expressway, Santa Clara, CA 95051, USA.
| | - Khanh Phuong Sieu Tong
- Kaiser Permanente Foot and Ankle Surgery, 700 Lawrence Expressway, Santa Clara, CA 95051, USA
| | - Cristian Neagu
- Kaiser Permanente Santa Clara Foot and Ankle Surgery, 700 Lawrence Expressway, Santa Clara, CA 95051, USA
| | - Christy M King
- Kaiser Permanente, Department of Foot & Ankle Surgery, 3600 Broadway, Clinic 17, Oakland, CA 94611, USA; Kaiser San Francisco Bay Area Foot & Ankle Residency Program, Oakland, CA, USA
| |
Collapse
|
3
|
Kastoft R, Barfod K, Bencke J, Speedtsberg MB, Hansen SB, Penny JØ. 1.7 cm elongated Achilles tendon did not alter walking gait kinematics 4.5 years after non-surgical treatment. Knee Surg Sports Traumatol Arthrosc 2022; 30:3579-3587. [PMID: 35234975 DOI: 10.1007/s00167-022-06874-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 01/12/2022] [Indexed: 12/19/2022]
Abstract
PURPOSE The aim of the present study was to evaluate Achilles tendon length after non-surgical treatment of acute Achilles tendon rupture (aATR), and to evaluate indirect effects of possible persistent elongation on kinematics. METHODS The study was performed as a cross-sectional study based on a population of patients from an RCT regarding non-operative treatment of aATR. Thirty-seven patients out of the 56 in the original RCT participated with at a follow up of 4-5 years after aATR. Primary outcome was Achilles tendon elongation. Additional outcomes were Achilles tendon resting angle (ATRA), calf circumference, passive ankle plantar and dorsiflexion and loading pattern. Foot pressure mapping was performed to measure plantar loading distribution pattern; medial and lateral forefoot peak pressure, heel peak pressure, medial versus lateral loading pattern and timing of heel lift during roll over process. The healthy leg was used as a control. RESULTS The injured Achilles tendon was significantly elongated by 1.7 (SD 1.6) cm compared to the non-injured leg. A slight delay of 2.6% (SD 6.0) was measured in heel lift in the injured side compared to the non-injured leg. We found no significant difference in forefoot peak pressure, medial and lateral peak pressure as well as heel peak pressure, and no correlation was found between Achilles tendon length and pressure measurements. Finally, dorsiflexion was 1.9°(SD1.28) larger, ATRA 8.1°(SD6.7) larger, and calf circumference 1.6 cm (SD1.1) lower on the injured leg. CONCLUSION The Achilles tendon was 1.7 cm elongated 4.5 years after the initial injury and significant changes in ATRA, calf circumference and passive dorsiflexion was present. Except for a slight delay in heel lift-off, kinematics during walking was symmetrical between injured and healthy leg, even with an elongated tendon on the injured leg. The clinical relevance of the Achilles tendon elongation is uncertain. LEVEL OF EVIDENCE II. CLINICAL TRIALS IDENTIFIER NCT02760784.
Collapse
Affiliation(s)
- Rasmus Kastoft
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark.
| | - Kristoffer Barfod
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark
| | - Jesper Bencke
- Laboratory of Human Movement Analysis, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager, Hvidovre, Denmark
| | - Merete B Speedtsberg
- Laboratory of Human Movement Analysis, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager, Hvidovre, Denmark
| | - Sanja Bay Hansen
- Department of Radiology, Center for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital, Hvidovre, Denmark
| | - Jeannette Ø Penny
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark
- Department of Orthopaedic Surgery, Zealand University Hospital, Koege, Denmark
| |
Collapse
|
4
|
Rendek Z, Bon Beckman L, Schepull T, Dånmark I, Aspenberg P, Schilcher J, Eliasson P. Early Tensile Loading in Nonsurgically Treated Achilles Tendon Ruptures Leads to a Larger Tendon Callus and a Lower Elastic Modulus: A Randomized Controlled Trial. Am J Sports Med 2022; 50:3286-3298. [PMID: 36005394 PMCID: PMC9527451 DOI: 10.1177/03635465221117780] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Early tensile loading improves material properties of healing Achilles tendon ruptures in animal models and in surgically treated human ruptures. However, the effect of such rehabilitation in patients who are nonsurgically treated remains unknown. HYPOTHESIS In nonsurgically treated Achilles tendon ruptures, early tensile loading would lead to higher elastic modulus 19 weeks after the injury compared with controls. STUDY DESIGN Randomized controlled trial; Level of evidence, 2. METHODS Between October 2015 and November 2018, a total of 40 nonsurgically treated patients with acute Achilles tendon rupture were randomized to an early tensile loading (loaded group) or control group. Tantalum bead markers were inserted percutaneously into the tendon stumps 2 weeks after the injury to allow high-precision measurements of callus deformation under mechanical testing. The loaded group used a training pedal twice daily to produce a gradual increase in tensile load during the following 5 weeks. Both groups were allowed full weightbearing in an ankle orthosis and unloaded range of motion exercises. Patients were followed clinically and via roentgen stereophotogrammetric analysis and computed tomography at 7, 19, and 52 weeks after the injury. RESULTS The mean ± standard deviation elastic modulus at 19 weeks was 95.6 ± 38.2 MPa in the loaded group and 108 ± 45.2 MPa in controls (P = .37). The elastic modulus increased in both groups, although it was lower in the loaded group at all time points. Tendon cross-sectional area increased from 7 weeks to 19 weeks, from 231 ± 99.5 to 388 ± 142 mm2 in the loaded group and from 188 ± 65.4 to 335 ± 87.2 mm2 in controls (P < .001 for the effect of time). Cross-sectional area for the loaded group versus controls at 52 weeks was 302 ± 62.4 mm2 versus 252 ± 49.2 mm2, respectively (P = .03). Gap elongation was 7.35 ± 13.9 mm in the loaded group versus 2.86 ± 5.52 mm in controls (P = .27). CONCLUSION Early tensile loading in nonsurgically treated Achilles tendon ruptures did not lead to higher elastic modulus in the healing tendon but altered the structural properties of the tendon via an increased tendon thickness. REGISTRATION NCT0280575 (ClinicalTrials.gov identifier).
Collapse
Affiliation(s)
- Zlatica Rendek
- Orthopedic Department, Linköping University Hospital, Linköping, Sweden
| | - Leo Bon Beckman
- Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Science, Linköping University, Linköping, Sweden
| | - Thorsten Schepull
- Orthopedic Department, Linköping University Hospital, Linköping, Sweden
| | - Ida Dånmark
- Orthopedic Department, Linköping University Hospital, Linköping, Sweden
| | - Per Aspenberg
- Author deceased,Orthopedic Department, Linköping University Hospital, Linköping, Sweden,Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Science, Linköping University, Linköping, Sweden
| | - Jörg Schilcher
- Orthopedic Department, Linköping University Hospital, Linköping, Sweden,Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Science, Linköping University, Linköping, Sweden
| | - Pernilla Eliasson
- Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Science, Linköping University, Linköping, Sweden,Pernilla Eliasson, MSc, PhD, Department of Biomedical and Clinical Sciences, Division of Cell Biology, Linköping University, Cell Biology Building Floor 10, Linköping, SE-58183, Sweden ()
| |
Collapse
|
5
|
The epidemiology of Achilles tendon re-rupture and associated risk factors: male gender, younger age and traditional immobilising rehabilitation are risk factors. Knee Surg Sports Traumatol Arthrosc 2022; 30:2457-2469. [PMID: 35018477 DOI: 10.1007/s00167-021-06824-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 11/25/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE The aim of this study was to describe the epidemiology of Achilles tendon re-rupture. Secondary aims were to identify factors predisposing to increased Achilles tendon re-rupture risk, at the time of primary Achilles tendon rupture. METHODS A retrospective review of all patients with primary Achilles tendon rupture and Achilles tendon re-rupture was undertaken. Two separate databases were compiled: the first included all Achilles tendon re-ruptures presenting during the study period and described epidemiology, mechanisms and nature of the re-rupture; the second was a case-control study analysing differences between patients with primary Achilles tendon rupture during the study period, who did, or did not, go on to develop re-rupture, with minimum review period of 1.5 years. RESULTS Seven hundred and eighty-three patients (567 males, 216 females) attended with primary Achilles tendon rupture and 48 patients (41 males, 7 females) with Achilles tendon re-rupture. Median time to re-rupture was 98.5 days (IQR 82-122.5), but 8/48 re-ruptures occurred late (range 3 to 50 years) after primary Achilles tendon rupture. Males were affected more commonly (OR = 7.40, 95% CI 0.91-60.15; p = 0.034). Mean Achilles tendon re-rupture incidence was 0.94/100,000/year for all ages and 1.16/100,000/year for adults (≥ 18 years). Age distribution was bimodal for both primary Achilles tendon rupture and re-rupture, peaking in the fifth decade, with secondary peaks in older age. Incidence of re-rupture was higher in less socioeconomically deprived sub-populations (OR = 2.01, 95%CI 1.01-3.97, p = 0.04). The majority of re-ruptures were low-energy injuries. Greater risk of re-rupture was noted for patients with primary rupture aged < 45 years [adjusted odds ratio (aOR) 1.96; p = 0.037] and those treated with traditional cast immobilisation (aOR 2.20; p = 0.050). CONCLUSION The epidemiology of Achilles tendon re-rupture is described and known trends (e.g. male predilection) are confirmed, while other novel findings are described, including incidence of a small but significant number of late re-ruptures, occurring years after the primary injury and an increased incidence of re-rupture in less socioeconomically deprived patients. Younger age and traditional immobilising cast treatment of primary Achilles tendon rupture were independently associated with Achilles tendon re-rupture. LEVEL OF EVIDENCE III.
Collapse
|
6
|
Achilles tendon resting angle is able to detect deficits after an Achilles tendon rupture, but it is not a surrogate for direct measurements of tendon elongation, function or symptoms. Knee Surg Sports Traumatol Arthrosc 2022; 30:4250-4257. [PMID: 36087127 PMCID: PMC9463053 DOI: 10.1007/s00167-022-07142-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 08/23/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE The aim of this study was to investigate how the Achilles tendon resting angle (ATRA), an indirect measurement of tendon elongation, correlates with ultrasonography (US) measurements of the Achilles tendon length 6 and 12 months after an acute ATR and relates to other clinical outcome measurements such as heel-rise height, jumping ability and patient-reported outcome measurements (PROMs). METHODS Patients were included following acute Achilles tendon rupture (ATR). Achilles tendon length, ATRA, heel-rise height (HRH), drop countermovement jump (Drop CMJ) and PROMs (Achilles tendon total rupture score (ATRS) and physical activity scale (PAS)) were evaluated 6 and 12 months after injury. Achilles tendon length was evaluated using US, while the ATRA was measured with a goniometer. RESULTS Sixty patients (13 women, 47 men), mean (SD) age 43 (9) years, with an acute ATR undergoing either surgical (35%) or non-surgical (65%) treatment were evaluated. A negative correlation (r = - 0.356, p = 0.010) between relative ATRA and tendon elongation was seen at 12 months after ATR. There were also significant positive correlations at 6 and 12 months between relative ATRA and HRH (r = 0.330, p = 0.011 and r = 0.379, p = 0.004). There were no correlations between ATRA and ATRS or ATRA and Drop CMJ, at either 6 or 12 months after the injury. CONCLUSION In combination with other clinical evaluations such as HRH and US, ATRA could be a clinical tool for indirect measurements of tendon elongation. However, ATRA cannot be recommended as a direct surrogate for US for determining Achilles tendon length. LEVEL OF EVIDENCE III.
Collapse
|