Recovery of calf muscle endurance 3 months after an Achilles tendon rupture

Feasibility of an early progressive resistance exercise program for acute Achilles tendon rupture

BACKGROUND

Long-term strength deficits are common after Achilles tendon ruptures. Early use of progressive resistance exercises may help reduce strength deficits, but the feasibility of this approach is unknown. The aim was to investigate the feasibility of early progressive resistance exercises regarding patient acceptability and compliance with the intervention.

METHODS

We recruited patients with an acute Achilles tendon rupture treated non-surgically. During 9 weeks of immobilisation with a walking boot, participants attended weekly supervised physiotherapy sessions of progressive resistance exercises and performed home exercises, consisting of isometric ankle plantarflexion, seated heel-rise, and elastic band exercises. Acceptability was evaluated using a 7-point Likert scale (1 = very unacceptable and 7 = very acceptable) with feasibility threshold at 80% of the participants rating ≥ 4. Adherence to the exercises was defined as 80% of the participants performing at least 50% of the home exercises. During the intervention, tendon healing and adverse events were monitored.

RESULTS

Sixteen participants (mean age 46 (range 28-61), male/female = 13/3) completed the intervention. Pre-injury Achilles tendon total rupture score was 98 (SD 8). All participants rated the acceptability of the exercises ≥ 5 (moderate acceptable to very acceptable) at 9- and 13-week follow-up and 9/16 rated 7 points (very acceptable). Participants performed 74% (range 4-117) of the total prescribed home exercises and 15/16 performed > 50%. One participant was not compliant with the home exercises due to feeling uncomfortable performing these independently. There were no re-ruptures, but one case of deep venous thrombosis.

CONCLUSIONS

The early progressive resistance exercise program for treatment of non-surgically treated Achilles tendon rupture was feasible. Future studies should investigate the efficacy of the progressive intervention.

TRIAL REGISTRATION

The study was registered at Clinical Trials (NCT04121377) on 29 September 2019.

CLINICALTRIALS

NCT04121377 .

Devices to measure calf raise test outcomes: A narrative review

BACKGROUND

The calf raise test (CRT) is commonly administered without a device in clinics to measure triceps surae muscle function. To standardise and objectively quantify outcomes, researchers use research-grade or customised CRT devices. To incorporate evidence-based practice and apply testing devices effectively in clinics, it is essential to understand their design, applicability, psychometric properties, strengths, and limitations. Therefore, this review identifies, summarises, and critically appraises the CRT devices used in science.

METHODS

Four electronic databases were searched in April 2022. Studies that used devices to measure unilateral CRT outcomes (i.e., number of repetitions, work, height) were included.

RESULTS

Thirty-five studies met inclusion, from which seven CRT devices were identified. Linear encoder (n = 18) was the most commonly used device, followed by laboratory equipment (n = 6) (three-dimensional motion capture and force plate). These measured the three CRT outcomes. Other devices used were electrogoniometer, Häggmark and Liedberg light beam device, Ankle Measure for Endurance and Strength (AMES), Haberometer, and custom-made. Devices were mostly used in healthy populations or Achilles tendon pathologies. AMES, Haberometer, and custom-made devices were the most clinician-friendly, but only quantified repetitions were completed. In late 2022, a computer vision mobile application appeared in the literature and offered clinicians a low-cost, research-grade alternative.

CONCLUSION

This review details seven devices used to measure CRT outcomes. The linear encoder is the most common in research and quantifies all three CRT outcomes. Recent advances in computer-vision provide a low-cost research-grade alternative to clinicians and researchers via a n iOS mobile application.

A systematic review of the patient reported outcome measures utilized in level 1 randomized controlled trials involving achilles tendon ruptures

BACKGROUND

Patient Reported Outcome Measures (PROMs) are utilized in level 1 randomized controlled trials involving Achilles tendon ruptures. However, the characteristics of these PROMs and current practices has not yet been reported. We hypothesize that there will be heterogeneous PROM usage in this context.

METHODS

A PubMed and Embase systematic review was performed including all dates up to July 27th, 2022, assessing Achilles tendon ruptures in level 1 studies using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines where applicable. Inclusion criteria were all randomized controlled clinical studies involving Achilles tendon injuries. Studies that: (1) were not level 1 evidence (including editorial, commentary, review, or technique articles), (2) omitted outcome data or PROMs, (3) included injuries aside from Achilles tendon ruptures, (4) involved non-human or cadaveric subjects, (5) were not written in English, and (6) were duplicates were excluded. Demographics and outcome measures were assessed in the studies included for final review.

RESULTS

Out of 18,980 initial results, 46 studies were included for final review. The average number of patients per study was 65.5. Mean follow up was 25 months. The most common study design involved comparing two different rehabilitation interventions (48 %). Twenty different outcome measures were reported including the Achilles tendon rupture score (ATRS) (48 %), followed by the American Orthopedic Foot and Ankle score Ankle-Hindfoot score (AOFAS-AH) (46 %), the Leppilahti score (20 %), and the RAND-36/Short Form (SF) - 36/SF-12 scores (20 %). An average of 1.4 measures were reported per study.

CONCLUSION

Significant heterogeneity exists in PROM usage among level 1 studies involving Achilles tendon ruptures, which prevents meaningful interpretation of these data across multiple studies. We advocate for usage of at least the disease-specific Achilles Tendon Rupture score and a global, quality of life (QOL) survey such as the SF-36/12/RAND-36. Future literature should provide more evidence-based guidelines for PROM usage in this context.

LEVEL OF EVIDENCE

Level IV; Systematic Review.

Achilles Tendon Repairs: Identification of Risk Factors for and Economic Impact of Complications and Reoperation

BACKGROUND

Compared with nonoperative management, Achilles tendon repair is associated with increased rates of complications and increased initial healthcare cost. However, data are currently lacking on the risk factors for these complications and the added healthcare cost associated with common preoperative comorbidities.

HYPOTHESIS

Identify the independent risk factors for complications and reoperation after acute Achilles tendon repair and calculate the added cost of care associated with having each preoperative risk factor.

STUDY DESIGN

Retrospective cohort study.

LEVEL OF EVIDENCE

Level 3.

METHODS

A retrospective review of a large commercial claims database was performed to identify patients who underwent primary operative management for Achilles tendon rupture between 2007 and 2016. The primary outcome measures of the study were risk factors for (1) postoperative complications, (2) revision surgery, and (3) increased healthcare resource utilization.

RESULTS

A total of 50,279 patients were included. The overall complication rate was 2.7%. The most common 30-day complication was venous thromboembolism (1.2%). The rate of revision surgery was 2.5% at 30 days and 4.3% at 2 years. Independent risk factors for 30-day complications in our cohort included increasing age, hyperlipidemia, hypertension, female sex, obesity, and diabetes. Independent risk factors for revision surgery within 2 years included female sex, tobacco use, hypertension, obesity, and the presence of any postoperative complication. The average 5-year cost of operative intervention was $17,307. The need for revision surgery had the largest effect on 5-year overall cost, increasing it by $6776.40. This was followed by the presence of a postoperative complication ($3780), female sex ($3207.70), and diabetes ($3105).

CONCLUSION

Achilles tendon repair is a relatively low-risk operation. Factors associated with postoperative complications include increasing age, hyperlipidemia, hypertension, female sex, obesity, and diabetes. Factors associated with the need for revision surgery include female sex, hypertension, obesity, and the presence of any postoperative complication. Female sex, diabetes, the presence of any complication, and the need for revision surgery had the largest added costs associated with them.

CLINICAL RELEVANCE

Surgeons can use this information for preoperative decision-making and during the informed consent process.

Return-to-play and performance after operative treatment of Achilles tendon rupture in elite male athletes: a scoping review

OBJECTIVE

To examine the current evidence regarding return-to-play (RTP) and performance after Achilles tendon rupture in elite athletes treated with operative intervention.

DESIGN

Scoping review.

DATA SOURCES

Published sources identified through a PubMed search of elite athletes, defined as professional or division one collegiate athletes in baseball, basketball, American football or soccer.

METHODS

Our search yielded a total of 2402 studies, with 13 studies fulfilling the study criteria of reporting elite athletes with objective measures of their athletic performance. A total of 709 elite athletes were included from the NBA, NFL, Major League Baseball (MLB), National Collegiate Athletic Association (NCAA) football and professional soccer.

RESULTS AND DISCUSSION

Overall, 61%-100% of elite male athletes RTP after Achilles tendon rupture and operative repair. NBA players had inferior performance compared with their preoperative status as well as controls of non-injured players. Studies did not show significantly different performance after Achilles injury for MLB players. Professional soccer, NFL and NCAA football studies reported varying performance after injury.

CONCLUSIONS

Evidence suggests that sports with explosive plantarflexion demands, such as basketball, may be associated with a greater decrease in performance despite operative intervention after Achilles rupture.

Reliability and usefulness of the single leg heel raise balance test in patients with chronic ankle instability

We aimed to analyze the differences in static (including conventional and modified [single-leg heel-raise balance]) and dynamic postural stability and muscle endurance between patients with chronic ankle instability (CAI) and healthy controls, and to determine the reliability and usefulness of the single-leg heel-raise balance test in patients with CAI. In total, 26 patients with CAI and 26 healthy controls were enrolled. Postural stability was assessed using a postural stabilometry system. Muscle endurance was measured in dorsiflexion and plantarflexion using an isokinetic device. Modified static postural stability (P < 0.001) and dynamic postural stability (P < 0.001) were significantly poorer in the affected ankles of patients with CAI than in the controls. Plantarflexion endurance was significantly lower in the affected ankles of the patients with CAI than in the controls (P = 0.023). Modified static postural stability significantly correlated with plantarflexion endurance in both groups (CAI group: r = - 0.470, P = 0.015; healthy controls group: r = - 0.413, P = 0.036). Plantarflexion endurance was a significant risk factor for modified static postural stability in both the CAI group (R² = 0.221, P = 0.015) and healthy controls (R² = 0.170, P = 0.036). Given the reliability of the modified static postural stability test, clinicians and therapists should consider using it to assess improvements in postural stability and muscle endurance in patients with CAI before and after rehabilitation.

A Brief Review on the Sensor Measurement Solutions for the Ten-Meter Walk Test

The wide-spread use of wearables and the adoption of the Internet of Things (IoT) paradigm provide an opportunity to use mobile-device sensors for medical applications. Sensors available in the commonly used devices may inspire innovative solutions for physiotherapy striving for accurate and early identification of various pathologies. An essential and reliable performance measure is the ten-meter walk test, which is employed to determine functional mobility, gait, and vestibular function. Sensor-based approaches can identify the various test phases and their segmented duration, among other parameters. The measurement parameter primarily used is related to the tests’ duration, and after identifying patterns, a variety of physical treatments can be recommended. This paper reviews multiple studies focusing on automated measurements of the ten-meter walk test with different sensors. Most of the analyzed studies measure similar parameters as traditional methods, such as velocity, duration, and other involuntary and dangerous patients’ movements after stroke. That provides an opportunity to measure different parameters that can be later fed into machine learning models for analyzing more complex patterns.

Analysis of the Results of Heel-Rise Test with Sensors: A Systematic Review

Strokes are a constant concern for people and pose a major health concern. Tests that allow detection and the rehabilitation of patients have started to become more important and essential. There are several tests used by physiotherapists to speed up the recovery process of patients. This article presents a systematic review of existing studies using the Heel-Rise Test and sensors (i.e., accelerometers, gyroscopes, pressure and tilt sensors) to estimate the different levels and health statuses of individuals. It was found that the most measured parameter was related to the number of repetitions, and the maximum number of repetitions for a healthy adult is 25 repetitions. As for future work, the implementation of these methods with a simple mobile device will facilitate the different measurements on this subject.

Impact of seated and standing positions on triceps surae muscle activation in unilateral Achilles tendon rupture

Heel-rises are commonly used in the rehabilitation of individuals following Achilles tendon rupture, however, the impact of tendon elongation on triceps surae activation in seated versus standing positions has not been investigated. The purpose of this study was to investigate changes in triceps surae activation during seated compared to standing heel-rises in individuals with Achilles tendon rupture and its relationship to tendon elongation. Ten individuals with a history of Achilles tendon rupture were included in this study. Muscle activity using electromyography was examined during a heel-rise task in seated (unilateral) and standing (bilateral) positions. Soleus activity was not significantly different between sitting and standing on both the ruptured and uninjured side. On the ruptured, side there were no differences in medial or lateral gastrocnemius activity between sitting and standing; however, on the uninjured side medial and lateral gastrocnemius activity was lower in sitting compared to standing. The results of this study suggest that neuromuscular changes in triceps surae activation occur following Achilles tendon rupture. The seated heel-rise position can be used to strengthen all muscles of the triceps surae and is useful when the patient is unable to perform a standing heel-rise.

Performance of the Achilles Tendon Total Rupture Score Over Time in a Large National Database: Development of an Instruction Manual for Accurate Use

BACKGROUND

The Achilles tendon Total Rupture Score (ATRS) is a commonly used patient-reported outcome measure for patients with an acute Achilles tendon rupture. The score consists of 10 questions, the last 3 of which include activities that some patients cannot or do not do. No instruction manual has been developed for the ATRS.

HYPOTHESIS/PURPOSE

The purpose was to evaluate the ATRS at 4, 12, and 24 months after a rupture. The hypothesis was that the results at 4 months would be inconsistent when compared with the results at 1 year and 2 years. We also aimed to develop a manual that explains how to use the ATRS.

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 3.

METHODS

This was a mixed-methods study. The first section was a registry study, where prospectively collected data were analyzed. Data were collected 4, 12, and 24 months after rupture. The original score based on 10 items was compared with a score based on the first 7 items adjusted to the same scale as the original score. Density plots and scatterplots were made and differences between the scores were tested using the Mann-Whitney U test. The second section of the study consisted of discussions among the authors, which resulted in a manual for the ATRS.

RESULTS

In total, 2790 complete ATRSs were included. The 7-item score significantly overestimated the value of the 10-item score at all time points (P < .001), but only at 4 months was the difference clinically relevant (9.7 points).

CONCLUSION

When the ATRS is used for short-term evaluation, there is a risk of results being inconsistent because of the last 3 questions. A manual explaining how to use the ATRS was therefore developed. We recommend that the full ATRS together with the manual should be used in future research rather than eliminating the 3 last questions.

Achilles tendon cross-sectional area at 12 weeks post-rupture relates to 1-year heel-rise height

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.

Strength Measurement After Achilles Tendon Repair

The goal of treatment after Achilles tendon rupture (ATR) is to restore appropriate tension to the tendon, so that normal baseline strength and functional soft-tissue length can be achieved. The assessment of plantarflexion strength has shown widespread variability. The purpose of this study is to document variations in strength assessment after the treatment of ATR in the literature. A comprehensive literature review was performed. In total, 2758 articles were found on Achilles tendon rupture and Achilles tendon strength measurement. The full text of articles including strength as a functional outcome measurement in the abstract were assessed. All objective strength measurements performed were reviewed and recorded for comparison. One-hundred articles were included in our study. In 78 articles, a dynamometer was used to measure strength, whereas in 22 articles, an endurance test (n=14) or formal gait assessment (n=8) was applied. When a dynamometer was used, there was wide variability in the various methods used including the incorporation of both isokinetic (n = 65) and isometric (n = 29) exercises utilizing varying degrees of knee flexion and patient testing position. Furthermore, the number of measurements at certain angular velocities varied. This study illustrates that no general consensus exists regarding an optimal method for measuring strength after ATR. The variability creates difficulty and challenges medical professionals' ability to formulate consistent conclusions when determining functional performance outcomes. A more uniform way of measuring strength after ATR may allow for better comparisons between studies in the literature, potentially leading to a better understanding of strength. Levels of Evidence: Therapeutic, Level II.

Lower extremity work along with triceps surae structure and activation is altered with jumping after Achilles tendon repair

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.

Achilles Tendon Resting Angle Relates to Tendon Length and Function

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.

Side-to-side differences in Achilles tendon geometry and mechanical properties following achilles tendon rupture

Background

Recovery of tendon structure has been suggested to play a role in clinical success following Achilles tendon rupture. The purpose of this study was to identify side-to-side differences in tendon geometry and mechanical properties following Achilles tendon rupture and investigate the relationship of tendon structure with clinical outcomes.

Methods

Participants within 1 year post complete rupture were included. Tendon geometry and mechanical properties were quantified using B-mode ultrasound imaging and continuous shear wave elastography (cSWE). Clinical outcomes included the heel-rise test. Participant self-reported function was measured using the Achilles tendon Total Rupture Score, Foot and Ankle Outcome Score - quality of life subscale, and the Physical Activity Scale.

Results

Twenty participants [mean (SD) age: 42.7(13.6) years, 13 managed surgically] were included. Tendon thickness was greater on the ruptured side (p <0.001) [median (IQR) rupture: 1.38(1.21-1.56) cm, non-rupture: 0.49(0.40-0.52)]. Tendon length to the gastrocnemius was longer (p <0.001) on ruptured [22.8 (21.71-24.31) cm] than non-ruptured [21.66(20.74-23.62) cm] sides. Viscosity was lower on the ruptured side (p <0.001) [median (IQR) rupture: 37.7(30.6-43.3) Pa*s, non-rupture: 53.5(48.4-59.6) Pa*s]. Shear modulus was not different between sides. Tendon thickness (rho = 0.675, p = 0.002) and shear modulus (rho = -0.791, p = 0.001) related to total work on the heel-rise test.

Conclusion

Ultrasound imaging, including cSWE, can be used to detect side-to-side differences in tendon structure in individuals with Achilles tendon rupture and tendon structure relates to clinical performance.

Level of evidence

III b.

Heel-Rise Height Deficit 1 Year After Achilles Tendon Rupture Relates to Changes in Ankle Biomechanics 6 Years After Injury

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.

Clinical failure after Dresden repair of mid-substance Achilles tendon rupture: human cadaveric testing

PURPOSE

The purpose of this study was to describe the angle of clinical failure during cyclical mobilization exercises in the Achilles tendon of human cadaveric specimens that were repaired using the Dresden technique and FiberWire^® No. 2. The secondary aim was to identify the secure limit of mobilization, the type of failure, and the type of apposition.

METHODS

The lower limbs of eight males (mean age: 60.3 ± 6.3 years) were repaired with the Dresden technique following complete, percutaneous mid-substance Achilles tendon rupture. A basal tension of 10 N at 30° of plantarflexion was placed on each specimen. The angle of the ankle during clinical failure (tendon ends separation >5 mm) was then tested via cyclical exercises (i.e. 100 cycles between 30° and 15° of plantarflexion; 100 cycles between 15° of plantarflexion and 0°; 100 cycles between 0° and 15° of dorsiflexion; and 100 cycles between 15° of dorsiflexion and full dorsiflexion). Clinical failure was determined using the Laplacian edge detection filter, and the angle of clinical failure was obtained using a rotatory potentiometer aligned in relation to the intermalleolar axis of each foot specimen. The type of failure (knot, tendon, or suture) and apposition (termino-terminal or non-termino-terminal) were determined. Descriptive statistics were used to obtain the mean; standard deviation; 95 % confidence interval; 1st, 25th, 50th, 75th, and 100th percentiles; and the standard error of the mean for angle data. Proportions were used to describe the type of failure and apposition.

RESULTS

The main results were a mean angle of clinical failure equal to 12.5° of plantarflexion, a limit of mobilization equal to 14.0° of plantarflexion, tendon failure type, and non-termino-terminal apposition in all specimens.

CONCLUSIONS

While the mean angle of clinical failure in human cadaveric models was 12.5° of plantarflexion, after 14.0° of plantarflexion, the percutaneous Dresden technique was found insecure for cyclical mobilization exercises, with a 5 % range of error. These findings are clinically relevant as they provide mechanical limits for diminishing the risk of Achilles lengthening during immediate rehabilitation.

Mechanical, histological, and functional properties remain inferior in conservatively treated Achilles tendons in rodents: Long term evaluation

Conservative treatment (non-operative) of Achilles tendon ruptures is suggested to produce equivalent capacity for return to function; however, long term results and the role of return to activity (RTA) for this treatment paradigm remain unclear. Therefore, the objective of this study was to evaluate the long term response of conservatively treated Achilles tendons in rodents with varied RTA. Sprague Dawley rats (n=32) received unilateral blunt transection of the Achilles tendon followed by randomization into groups that returned to activity after 1-week (RTA1) or 3-weeks (RTA3) of limb casting in plantarflexion, before being euthanized at 16-weeks post-injury. Uninjured age-matched control animals were used as a control group (n=10). Limb function, passive joint mechanics, tendon properties (mechanical, histological), and muscle properties (histological, immunohistochemical) were evaluated. Results showed that although hindlimb ground reaction forces and range of motion returned to baseline levels by 16-weeks post-injury regardless of RTA, ankle joint stiffness remained altered. RTA1 and RTA3 groups both exhibited no differences in fatigue properties; however, the secant modulus, hysteresis, and laxity were inferior compared to uninjured age-matched control tendons. Despite these changes, tendons 16-weeks post-injury achieved secant stiffness levels of uninjured tendons. RTA1 and RTA3 groups had no differences in histological properties, but had higher cell numbers compared to control tendons. No changes in gastrocnemius fiber size or type in the superficial or deep regions were detected, except for type 2x fiber fraction. Together, this work highlights RTA-dependent deficits in limb function and tissue-level properties in long-term Achilles tendon and muscle healing.

A Prospective Randomized Trial Comparing Surgical and Nonsurgical Treatments of Acute Achilles Tendon Ruptures

BACKGROUND

The optimal treatment of acute Achilles tendon ruptures for active patients is under debate.

PURPOSE

To compare clinical outcomes and calf muscle strength recovery after the nonsurgical treatment and open surgical repair of acute Achilles tendon ruptures with identical accelerated rehabilitation programs.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

From 2009 to 2013, a total of 60 patients with an acute Achilles tendon rupture were randomized to surgery or nonsurgical treatment. Nonsurgical treatment included first a week of cast immobilization, followed by a functional orthosis for 6 weeks, allowing full weightbearing after week 1 and active plantar flexion after week 5. Surgery was simple end-to-end open repair, and postoperative treatment was identical to nonsurgical treatment. Outcome measures included the Leppilahti Achilles tendon performance score, isokinetic calf muscle strength, and RAND 36-Item Health Survey at 18-month follow-up.

RESULTS

At 18-month follow-up, the mean Leppilahti score was 79.5 and 75.7 for the surgically and nonsurgically treated groups, respectively (mean difference, 3.8; 95% CI, -1.9 to 9.5; P = .19). Angle-specific peak torque results of affected legs showed that surgery resulted in faster and better recovery of calf muscle strength over the entire range of motion of the ankle joint: at 6 months, the difference varied from 16% to 24% (P = .016), favoring the surgically treated group, whereas at 18 months, surgically treated patients had 10% to 18% greater strength results (P = .037). At 18 months, a 14% difference in the peak torque of the affected leg favored the surgical group versus the nonsurgical group (mean peak torque, 110.3 vs 96.5 N·m, respectively; mean difference, 13.6 N·m; 95% CI, 2.0-25.1 N·m; P = .022). The RAND 36-Item Health Survey indicated better results in the domains of physical functioning (P = .006) and bodily pain (P = .037) for surgically treated patients.

CONCLUSION

Surgical and nonsurgical treatments of acute Achilles tendon ruptures have similar results in terms of the Achilles tendon performance score, but surgery restores calf muscle strength earlier over the entire range of motion of the ankle joint, with a 10% to 18% strength difference favoring surgery at 18 months. Surgery may also result in better health-related quality of life in the domains of physical functioning and bodily pain compared with nonsurgical treatment.

REGISTRATION

NCT02012803 (ClinicalTrials.gov).

Return to play post-Achilles tendon rupture: a systematic review and meta-analysis of rate and measures of return to play

AIM

This systematic review and meta-analysis sought to identify return to play (RTP) rates following Achilles tendon rupture and evaluate what measures are used to determine RTP.

DESIGN

A systematic review and meta-analysis were performed. Studies were assessed for risk of bias and grouped based on repeatability of their measure of RTP determination.

DATA SOURCES

PubMed, CINAHL, Web of Science and Scopus databases were searched to identify potentially relevant articles.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies reporting RTP/sport/sport activity in acute, closed Achilles tendon rupture were included.

RESULTS

108 studies encompassing 6506 patients were included for review. 85 studies included a measure for determining RTP. The rate of RTP in all studies was 80% (95% CI 75% to 85%). Studies with measures describing determination of RTP reported lower rates than studies without metrics described, with rates being significantly different between groups (p<0.001).

CONCLUSIONS

80 per cent of patients returned to play following Achilles tendon rupture; however, the RTP rates are dependent on the quality of the method used to measure RTP. To further understand RTP after Achilles tendon rupture, a standardised, reliable and valid method is required.