Functional Ankle Range of Motion but Not Peak Achilles Tendon Force Diminished With Heel-Rise and Jumping Tasks After Achilles Tendon Repair

Effects of tendon elongation on plantar pressure and clinical outcomes: A comparative analysis between open repair and minimally invasive surgery

PURPOSE

The aim of this study was to assess whether variances in Achilles tendon elongation are linked to dissimilarities in the plantar pressure distribution following two different surgical approaches for an Achilles tendon rupture (ATR).

METHODS

All patients who were treated with open or minimally invasive surgical repair (MIS) and were over 2 years post their ATR were eligible for inclusion. A total of 65 patients with an average age of 43 ± 11 years were included in the study. Thirty-five patients were treated with open repair, and 30 patients were treated with MIS. Clinical outcomes were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) and ATR Score (ATRS). Achilles tendon elongation was measured using axial and sagittal magnetic resonance imaging scans. Plantar pressure measurements for the forefoot, midfoot and hindfoot during gait were divided into percentages based on total pressure, measured in g/cm2 for each area.

RESULTS

The average AOFAS score was found 'excellent' (93 ± 2.8) in the MIS group, while it was found 'good' (87.4 ± 5.6) in the open repair group. In addition, the MIS group showed significantly superior ATRS scores (78.8 ± 7.4) compared to the open repair group (56.4 ± 15.4) (p < 0.001). The average tendon elongation in the MIS group was 11.3 ± 2 mm, while it was 17.3 ± 4.3 mm (p < 0.001) in the open repair group. While the open repair group showed significantly higher plantar pressure distribution in the initial contact and preswing phases compared to uninjured extremities, there was no significant difference between the uninjured extremities and the MIS group.

CONCLUSION

In conclusion, the findings of this study demonstrated that minimally invasive surgery was associated with less tendon elongation, more proximity to the plantar pressure distributions of the uninjured extremity and superior clinical outcomes compared to open surgical repair. Therefore, minimally invasive surgery may be considered a more suitable option for acute Achilles tendon repair to achieve overall better outcomes.

LEVEL OF EVIDENCE

Level III.

Differential elongation of the gastrocnemius after Achilles tendon rupture: a novel technique of selective shortening to treat push-off weakness with case series and literature review

PURPOSE

Differential elongation of the gastrocnemius after Achilles tendon rupture (ATR) may compromise the ability of athletes to return to competition. Recognition of this differential elongation of the gastrocnemius relative to the soleus is vital to treat patients with weakness in push-off. This paper describes a novel technique performed for selective shortening of the gastrocnemius to treat push-off weakness.

METHODS

Three patients with differential proximal retraction of the gastrocnemius greater than 20 mm after treatment for ATR with inability to run and jump underwent surgical correction with this novel technique and were followed-up for 2 years. A novel selective shortening of the gastrocnemius with autologous hamstring graft was performed in these patients. The Achilles Tendon Total Rupture Score (ATRS) and American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score were recorded preoperatively and at the final follow-up.

RESULTS

All three patients were able to return to running and jumping at final follow-up. The ATRS improved significantly in the strength, fatigue, running and jumping domains but there appeared to be a less notable improvement in activities of daily living domain. The AOFAS score showed improvement with the greatest margin in the domain of activity limitation.

CONCLUSION

This procedure is the first described selective shortening method of the gastrocnemius tendons after differential elongation following ATR. It is a safe and reliable technique providing improved ATRS and AOFAS scores in three patients who were all able to return to running and jumping sports at 2-year follow-up.

LEVEL OF EVIDENCE

IV.

Comparable Recovery and Compensatory Strategies in Heel-Rise Performance After a Surgically Repaired Acute Achilles Tendon Rupture: An In Vivo Kinematic Analysis Comparing Early Functional Mobilization and Standard Treatment

BACKGROUND

Deficits in calf muscle function and heel-rise performance are common after an Achilles tendon rupture (ATR) and are related to tendon elongation and calf muscle atrophy. Whether early functional mobilization (EFM) can improve calf muscle function compared with standard treatment (ST) with 2 weeks of immobilization and unloading in a plaster cast is unknown.

HYPOTHESIS

EFM would lead to superior recovery of heel-rise performance, as demonstrated by more symmetrical side-to-side ankle and knee joint kinematics, compared with ST.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

In total, 47 patients with an ATR were prospectively included and treated with open surgical repair and randomized 2:1 postoperatively to either EFM or ST. Overall, 29 patients were treated with a dynamic orthosis (EFM), and 18 underwent ST. At 8 weeks and 6 months after ATR repair, 3-dimensional motion analysis of heel-rise performance was conducted. At 6 months, tendon length and muscle volume were assessed with ultrasound imaging, calf muscle function with the heel-rise test, and patient-reported outcomes with the Achilles tendon Total Rupture Score.

RESULTS

At 8 weeks and 6 months, there were no significant group differences between the EFM and ST groups in heel-rise performance, but significant side-to-side differences in ankle and knee kinematics were detected. At 8 weeks and 6 months, both the EFM and ST groups showed a significantly decreased peak ankle plantarflexion angle and increased knee flexion angle on the injured limb compared with the uninjured limb during bilateral heel raises. Linear regression demonstrated that greater atrophy of the medial gastrocnemius muscle (P = .008) and higher body weight (P < .001) were predictors of a decreased maximum peak ankle plantarflexion angle on the injured limb at 6 months.

CONCLUSION

EFM after an ATR repair did not lead to superior recovery of calf muscle function, as assessed by heel-rise performance, compared with ST. Increased knee flexion seemed to be a compensatory strategy for decreased ankle plantarflexion. Medial gastrocnemius atrophy and increased body weight were additional factors associated with a decreased ankle plantarflexion angle.

REGISTRATION

NCT02318472 (ClinicalTrials.gov identifier).

Persistent Deficits after an Achilles Tendon Rupture: A Narrative Review

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.