Career Outlook and Performance of Professional Athletes After Achilles Tendon Rupture: A Systematic Review

Tendon Elongation and Function After Delayed or Standard Loading of Surgically Repaired Achilles Tendon Ruptures: A Randomized Controlled Trial

BACKGROUND

Achilles tendon ruptures often result in long-term functional deficits despite accelerated (standard) rehabilitation.

PURPOSE/HYPOTHESIS

The purpose of this study was to investigate if delayed loading would influence functional, clinical, and structural outcomes of the muscles and tendon 1 year after a surgical repair. It was hypothesized that delaying the loading would reduce the heel-rise height deficit 1 year after Achilles tendon rupture.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

In total, 48 patients with a surgically repaired Achilles tendon rupture were randomized to 2 groups: the standard group received the currently accepted rehabilitation, and the delayed group received the same rehabilitation except that initial loading was delayed by 6 weeks. The primary outcome was the heel-rise height difference between the injured and uninjured sides at 1 year. The secondary outcomes were (1) tendon length measured with magnetic resonance imaging, (2) muscle fascicle length and pennation angle of the gastrocnemius medialis muscle, (3) Doppler activity measured with ultrasonography, (4) Achilles tendon Total Rupture Score (ATRS), and (5) isometric muscle strength.

RESULTS

The mean heel-rise height deficits for the standard and delayed groups were -2.2 cm and -2.1 cm, respectively (P = .719). The soleus part of the tendon was already elongated 1 week after surgery in both groups without a between-group difference (side-to-side difference: standard, 16.3 mm; delayed, 17.5 mm; P = .997) and did not change over 52 weeks. The gastrocnemius tendon length was unchanged at 1 week but elongated over time without a between-group difference (side-to-side difference at 52 weeks: standard, 10.5 mm; delayed, 13.0 mm; P = .899). The delayed group had less Doppler activity at 12 weeks (P = .006) and a better ATRS (standard, 60 points; delayed, 72 points; P = .032) at 52 weeks.

CONCLUSION

Delayed loading was not superior to standard loading in reducing the heel-rise height difference at 1 year. The data indirectly suggested reduced inflammation in the initial months and a better patient-reported outcome at 1 year in the delayed group. The soleus part of the tendon was already markedly elongated (35%) 1 week after surgery, while the length of the gastrocnemius tendon was unchanged at 1 week but was 6% elongated at 1 year. Together, these data indirectly suggest that the delayed group fared better, although this finding needs to be confirmed in future investigations.

REGISTRATION

NCT04263493 (ClinicalTrials.gov identifier).

Surgical management of chronic Achilles tendon rupture: evidence-based guidelines

BACKGROUND

Chronic Achilles tendon ruptures (CATR) often require surgical intervention to restore function. Despite numerous treatment modalities available, the optimal management strategy remains controversial given the limited high-quality evidence available. This article aims to provide evidence-based guidelines for the surgical management of CATR through a comprehensive systematic review of the available data. The consensus reached by synthesizing the findings will assist clinicians in making informed decisions and improving patient outcomes.

METHODS

A group of 9 foot surgeons in three continents was consulted to gather their expertise on guidelines regarding the surgical management of CATR. Following the proposal of 9 clinical topics, a thorough and comprehensive search of relevant literature published since 1980 was conducted for each topic using electronic databases, including PubMed, MEDLINE, and Cochrane Library, to identify relevant studies published until 1 October 2023. All authors collaborated in drafting, discussing, and finalizing the recommendations and statements. The recommendations were then categorized into two grades: grade a (strong) and grade b (weak), following the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) concept. Additionally, feedback from 21 external specialists, who were independent from the authors, was taken into account to further refine and finalize the clinical guidelines.

RESULTS

Nine statements and guidelines were completed regarding surgical indications, surgical strategies, and postoperative rehabilitation protocol.

CONCLUSION

Based on the findings of the systematic review, this guideline provides recommendations for the surgical management of CATR. We are confident that this guideline will serve as a valuable resource for physicians when making decisions regarding the surgical treatment of patients with CATR.

Reliability and validation of the German Achilles tendon Total Rupture Score

PURPOSE

Patient-related outcome measures (PROMs) are important instruments to evaluate efficacy of orthopaedic procedures. The Achilles tendon Total Rupture Score (ATRS) is a PROM developed to evaluate outcomes after treatment of Achilles tendon ruptures (ATRs). Purpose of this study is to develop and culturally adapt the German version of the ATRS and to evaluate reliability and validity.

METHODS

The ATRS was translated by forward-backward translation based on common guidelines. In this retrospective study, 48 patients with a surgical intervention after ATR were recruited. Reliability was evaluated by intraclass correlation coefficient (ICC) and Cronbach's alpha. Construct validity was valued by determining Pearson correlation coefficient with the German version of the Foot and Ankle Outcome Score (FAOS) and the Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A).

RESULTS

The German Version of the ATRS has an excellent internal consistency (Cronbach's alpha 0.96) as well as an excellent test-retest-reliability (ICC 0.98). It has a moderately strong correlation with the VISA-A (r = 0.73) as well as with the FAOS subclasses (r = 0.6-0.79).

CONCLUSION

The German version of the ATRS demonstrated good psychometric properties. It proofed to be a valid and reliable instrument for use in patients with Achilles tendon Rupture.

LEVEL OF EVIDENCE

Level II.

The ALR-RSI score can be used to evaluate psychological readiness to return to sport after acute Achilles tendon tear

PURPOSE

The return to sport is one of the main goals following Achilles tendon tear repair. Several psychological factors influence the return to sport after a sports injury. The traditional tools to assess the return to sport do not take into account psychological factors. The ankle ligament reconstruction-return to sport injury (ALR-RSI), validated for ankle instability, is a score to evaluate psychological readiness to return to sport. The goal of this study was to validate the ALR-RSI score for the assessment of the readiness to return to sport after Achilles tendon repair.

METHODS

The ALR-RSI score, adapted from the anterior cruciate ligament-return to sport injury (ACL-RSI) score used following knee ligament reconstruction, was validated according to the international COSMIN methodology. Patients operated for Achilles tendon repair responded to the questionnaire during the rehabilitation period. The EFAS, FAAM and VISA-A scores were used as reference questionnaires.

RESULTS

A total of 50 patients were included. The ALR-RSI score was strongly (r > 0.5) correlated to the EFAS score: r = 0.68 [0.50-0.80] the FAMM sport score: r = 0.7 [0.52-0.84] the FAAM AVQ score (r = 0.6 [0.35-0.78]), and the VISA-A score (r = 0.54 [0.26-0.76]). The discriminant validity was good with the ALR-RSI, which was significantly lower in the patients that did not return to sport: 60.7 (40-81.4) compared to those that did: 83.2 (64.3-100) p = 0.001. Reproducibility was excellent with an intra-class correlation coefficient ρ of 0.99 [097-1.00]. The internal consistency was excellent (alpha coefficient = 0.95).

CONCLUSION

The ALR-RSI score provides a valid, reproducible assessment of the psychological readiness to return to sport in patients who undergo surgical Achilles tendon suture repair.

LEVEL OF EVIDENCE

III.

Bilateral Achilles Tendon Ruptures in the NFL

Background: Achilles tendon ruptures (ATR) can have devastating results for athletes in the National Football League (NFL). While many studies have examined the effects of an ipsilateral ATR, there are no reports on the impact of bilateral ATRs on NFL athlete performance. Methods: Publicly available online injury data for NFL athletes who sustained bilateral ATRs between the start of the 2007 season and the start of the 2021 season were queried using online news and sports analysis web sources. Results: After applying inclusion and exclusion criteria, 5 NFL athletes were identified. The findings demonstrated a significant difference in age at the time of each rupture (27.8 vs 30.4 years, P < .01) along with a decreasing trend in the number of Pro Bowl nominations following successive ATRs (P = .027). There were no differences reported for the duration and number of games missed during either rehabilitation period following an ATR. Upon analyzing defensive NFL athletes, forced fumbles was the only performance metric that significantly changed across successive ATRs. Conclusion: Overall, bilateral ATRs can adversely impact an NFL player's performance and further research should be performed to continue analyzing the effects of bilateral ATRs on these athletes.Level of Evidence: 4.

Return to Play Following Achilles Tendon Rupture in NFL Players Based on Position

BACKGROUND

The purpose of this study was to determine the return-to-play (RTP) rate and postinjury performance after Achilles tendon (AT) ruptures in National Football League (NFL) skill position players.

METHODS

The study included NFL skill positions with an AT rupture between the 2009-2010 and 2015-2016 seasons. Performance data were collected and compared against a matched control group. RTP was defined as playing in at least 1 game after repair.

RESULTS

RTP rate was 57% for the study cohort. The tight ends (TEs) had the highest RTP rate at 71% while the wide receivers (WRs) had the lowest RTP rate at 38%. Compared with the control group, WRs with successful RTP had significantly less receptions per game (P = .01). For defensive players with RTP there were significant decreases in postrepair performance in tackles, passes defended, and fumbles forced/recovered compared with the control group.

CONCLUSION

A total of 57% of players achieved RTP with WRs and running backs (RBs) having the lowest RTP rates and TEs and linebackers (LBs) having the highest RTP rates. RBs, defensive backs (DBs), and LBs with successful RTP had decreased performance in all categories. This updated information may be helpful for athletes, physicians, scouts, and coaches in evaluating players with a history of AT rupture.

LEVELS OF EVIDENCE

Analytic, level 3, retrospective cohort study, Epidemiologic study.

Outcomes Following Repair of Achilles Midsubstance Tears: Percutaneous Knotless Repair vs Open Repair

BACKGROUND

Optimum treatment for acute Achilles tendon rupture results in high mechanical strength, low risk of complications, and return to preinjury activity level. Percutaneous knotless repair is a minimally invasive technique with promising results in biomechanical studies, but few comparison clinical studies exist. Our study purpose was to compare functional outcomes and revision rates following acute Achilles tendon rupture treated between percutaneous knotless repair and open repair techniques.

METHODS

Patients 18 years or older with an acute Achilles tendon rupture, treated by a single surgeon with either open repair or percutaneous knotless repair, and more than 2 years after surgery were assessed for eligibility. Prospective clinical data were obtained from the data registry and standard electronic medical record. Additionally, the patients were contacted to obtain current follow-up questionnaires. Primary outcome measure was Foot and Ankle Ability Measure (FAAM) activities of daily living (ADL). Secondary outcome measures were FAAM sports, 12-Item Short Form Health Survey (SF-12), Tegner activity scale, patient satisfaction with outcome, complications, and revisions. Postoperative follow-up closest to 5 years was used in this study.

RESULTS

In total, 61 patients were included in the study. Twenty-four of 29 patients (83%) in the open repair group and 28 of 32 patients (88%) in the percutaneous knotless repair group completed the questionnaires with average follow-up of 5.8 years and 4.2 years, respectively. We found no significant differences in patient-reported outcomes or patient satisfaction between groups (FAAM ADL: 99 vs 99 points, P = .99). Operative time was slightly longer in the percutaneous knotless repair group (46 vs 52 minutes, P = .02). Two patients in the open group required revision surgery compared to no patients in the percutaneous group.

CONCLUSION

In our study, we did not find significant differences in patient-reported outcomes or patient satisfaction by treating Achilles tendon midsubstance ruptures with percutaneous knotless vs open repair.

LEVEL OF EVIDENCE

Level IlI, retrospective cohort study.

Bioinductive Collagen Implant Augmentation for Myotendinous Achilles Rupture in a Teenage Competitive Gymnast: A Case Report

CASE

A 16-year-old female competitive gymnast presented to our orthopaedic clinic with an acute Achilles tendon rupture at the myotendinous junction. Direct end-to-end repair was performed and augmented with a bioinductive collagen patch. The patient had increased tendon thickness at 6 months postoperatively, as well as significant improvements in strength and range of motion at 12 months.

CONCLUSION

Bioinductive collagen patch augmentation of Achilles tendon repair may be a useful adjunct for myotendinous junction Achilles ruptures, particularly in high-demand patients including competitive gymnasts.

Validity and reliability of the Thai version of the Achilles tendon total rupture score

PURPOSE

The purpose of this study was to translate and cross-culturally adapt the Achilles Tendon Total Rupture Score (ATRS), a patient-reported outcome measurement (PROM) designed specifically to assess outcomes in patients with Achilles tendon rupture, into the Thai language and then determine its validity and reliability.

METHODS

The ATRS was translated into the Thai version (Thai-ATRS) according to internationally recognized guidelines. The study included 50 patients with Achilles tendon rupture from 2003 to 2017. The web-based online assessments were conducted two weeks apart. Construction validity was determined by assessing the correlation between the Thai-ATRS and the Thai version of the Foot and Ankle Outcome Score (Thai-FAOS). Reliability was determined with Cronbach's alpha and intraclass correlation coefficients (ICC).

RESULTS

The validity test displayed a strong correlation between the Thai-ATRS and the Thai-FAOS (r = 0.87). The reliability test showed good internal consistency with a Cronbach's alpha of 0.95 and excellent internal consistency with an ICC of 0.95, which represented excellent test-retest reliability. The MDC was 10.7 at the individual level and 1.5 at the group level.

CONCLUSION

The Thai-ATRS was demonstrated to be valid and reliable for assessing functional outcomes in Thai patients with Achilles tendon rupture.

LEVEL OF EVIDENCE

II.

Interest of platelet rich plasma in Achilles tendon rupture management: a systematic review

OBJECTIVES

Acute Achilles tendon rupture (ATR) is a disabling sport-related injury. Its management involves conservative treatment with early weight-bearing or surgical treatment. Platelet-rich plasma (PRP) has raised interest as an adjuvant for treatment, given its properties on tendon repair and its anti-inflammatory effect. We aimed to assess clinical impact of PRP use in surgical or non-surgical treatment of acute ATR: range of motion, muscle strength, function, return to sport and adverse events.

METHOD

A systematic literature research was performed using PubMed, ScienceDirect, and Google Scholar databases to collect studies reporting clinical outcomes after acute ATR treated with PRP.

RESULTS

Eight studies were eligible and included 543 acute ATR. Four were randomized comparative studies. A total of 128 patients were treated surgically and 415 were treated conservatively, 271 received PRP injection. Five studies described the type of PRP used, which was variable. Only one study including 12 patients found significant outcomes in favor of the PRP group, with a 4-week earlier recovery of a normal range of motion and a 7-week earlier return to running. No difference in clinical or morphological evaluations, strength measurement, and functional outcomes was found in other studies both at short and long-term. PRP did not seem to modify the frequency of adverse events.

CONCLUSIONS

Data are not clearly in favor of a significant effect of the PRP use for treatment of ATR. There might be a slight effect on evolution during the first months. Its interest should be assessed in future studies with strong methodology.

Performance of wild animals with “broken” traits: Movement patterns in nature of moose with leg injuries

Organismal traits are presumed to be well suited for performance in the tasks required for survival, growth, and reproduction. Major injuries to such traits should therefore compromise performance and prevent success in the natural world; yet some injured animals can survive for long periods of time and contribute to future generations. We here examine 3 years of camera trap observations along a remote trail through old‐growth forest in northern British Columbia, Canada. The most common observations were of moose (2966), wolves (476), and brown bears (224). The moose overwhelmingly moved in one direction along the trail in the late fall and early winter and in the other direction in the spring. This movement was clustered/contagious, with days on which many moose traveled often being interspersed with days on which few moose traveled. On the video recordings, we identified 12 injured moose, representing 1.4% of all moose observations. Seven injuries were to the carpus, three were to the antebrachium, and two were to the tarsus—and they are hypothesized to reflect damage to ligaments, tendons, and perhaps bones. The injured moose were limping in all cases, sometimes severely; and yet they did not differ noticeably from uninjured moose in the direction, date, contagiousness, or speed of movement along the trail. We discuss the potential relevance of these findings for the action of natural selection in the evolution of organismal traits important for performance.

Achilles Tendon Ruptures and Repair in Athletes-a Review of Sports-Related Achilles Injuries and Return to Play

PURPOSE OF REVIEW

Achilles tendon ruptures (ATR) are detrimental to sports performance, and optimal treatment strategy and guidelines on return to play (RTP) remain controversial. This current review investigates the recent literature surrounding nonoperative versus operative management of ATR, clinical outcomes, and operative techniques to allow the athlete a successful return to their respective sport.

RECENT FINDINGS

The Achilles tendon (AT) is crucial to the athlete, as it is essential for explosive activities such as running and jumping. Athletes that sustain an ATR play in fewer games and perform at a lower level of play compared to age-matched controls. Recent studies also theorize that ATRs occur due to elongation of the tendon with fatigue failure. Biomechanical studies have focused on comparing modes of fixation under dynamic loading to recreate this mechanism. ATRs can be career-ending injuries. Fortunately, the recent incorporation of early weight-bearing and functional rehabilitation programming for non-operative and operative patients alike proves to be beneficial. Especially for those treated nonoperatively, with the incorporation of functional rehabilitation, the risk of re-rupture among non-operative patients is beginning to approach the historical lower risk of re-rupture observed among patients treated operatively. Despite this progress in decreasing risk of re-rupture particularly among non-operative patients, operative managements are associated with unique benefits that may be of particular interest for athletes and active individuals. Recent studies demonstrate that operative intervention improves strength and functional outcomes with more efficacy compared to nonoperative management with rehabilitation. The current literature supports operative intervention in elite athletes to improve performance and shorten the duration to RTP. However, we acknowledge that surgical intervention does have inherent risks. Ultimately, most if not all young and/or high-level athletes with an ATR benefit from surgical repair, but it is crucial to take a stepwise algorithmic approach and consider other factors, which may lead towards nonoperative intervention. These factors include age, chronicity of injury, gap of ATR, social factors, and medical history amongst others in this review.

Endoscopic Flexor Hallucis Longus Transfer for the Management of Acute Achilles Tendon Ruptures in Professional Soccer Players

BACKGROUND

Acute Achilles tendon ruptures (AATRs) that occur in athletes can be a career-ending injury. The aim of this study was to describe return to play and clinical outcomes of isolated endoscopic flexor hallucis longus (FHL) transfer in active soccer players with AATR.

METHODS

Twenty-seven active male soccer players who underwent endoscopically assisted FHL tendon transfer for acute Achilles tendon ruptures were included in this study. Follow up was 46.2 (±10.9) months after surgery. Return to play criteria and clinical outcome measures were evaluated.

RESULTS

All players returned to playing professional competitive soccer games. Return to active team training was at a mean of 5.8 (±1.1) months postoperatively. However, return to active competitive match play occurred at a mean of 8.3 (±1.4) months. Twenty-two players (82%) were able to return to their preinjury levels and performances and resumed their professional careers at the same soccer club as their preinjury state. One player (3.7%) shifted his career to professional indoor soccer. At 26 months postoperatively, the mean Tegner activity scale score was 9.7 (±0.4), the mean Achilles tendon total rupture score was 99 (±2), and the mean American Orthopaedic Foot & Ankle Society ankle-hindfoot score was 99 (±3). No patients reported any great toe complaints or symptomatic deficits of flexion strength.

CONCLUSION

The current study demonstrated satisfactory and comparable return to play criteria and clinical results with minimal complications when using an advanced endoscopically assisted technique involving FHL tendon transfer to treat acute Achilles tendon ruptures in this specific subset of patient cohort.

LEVEL OF EVIDENCE

Level II, prospective cohort case series study.

Factors Associated With Achilles Tendon Rupture in Women's Collegiate Gymnastics

BACKGROUND

Achilles injury risk in women's collegiate gymnastics is 10-fold higher than in all other collegiate sports. This study aims to identify risk factors for Achilles tendon ruptures in collegiate female gymnasts.

HYPOTHESIS

Gymnasts with Achilles tendon ruptures will be more likely to report early gymnastics specialization, elite-level training before college, and performance of high-difficulty skills on floor and vault.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 4.

METHODS

Anonymous surveys were distributed to current and former collegiate female gymnasts, aged 18 to 30 years, via coaches, athletic trainers, Twitter, and ResearchMatch. Information about Achilles tendon ruptures, gymnastics-related injuries, sport specialization, event/skills participation, and medication use were collected.

RESULTS

A total of 581 gymnasts were included. One hundred gymnasts (17.2%; 95% CI: 14.1%-20.3%) reported Achilles tendon ruptures during collegiate training or competition. Most ruptures (91%) occurred on floor exercise; 85.7% of these occurred during back tumbling-take-off. Compared with gymnasts without ruptures during college, a greater percentage of gymnasts with ruptures competed at a Division I program, trained elite, competed difficult vaults and floor passes before and during college, competed in all 4 events during college, identified as Black/African American, and used retinoid medications.

CONCLUSION

Achilles tendon ruptures are more common in women's collegiate gymnastics than other sports. Competing at the elite level, performing difficult floor and vault skills, and competing in all 4 events may increase the risk for an Achilles tendon rupture. Potential nontraining risk factors include retinoid exposure and Black/African American race. Future studies regarding the mechanisms of Achilles tendon ruptures in female collegiate gymnasts are warranted.

CLINICAL RELEVANCE

Collegiate gymnasts who compete at the elite level, perform high levels of difficulty on floor and vault, and compete in all 4 events may be at increased risk for Achilles tendon ruptures.

Achilles Tendon Rupture: Mechanisms of Injury, Principles of Rehabilitation and Return to Play

The Achilles tendon is the thickest, strongest and largest tendon in the human body, but despite its size and tensile strength, it frequently gets injured. Achilles tendon ruptures (ATRs) mainly occur during sports activities, and their incidence has increased over the last few decades. Achilles tendon tears necessitate a prolonged recovery time, sometimes leaving long-term functional limitations. Treatment options include conservative treatment and surgical repair. There is no consensus on which is the best treatment for ATRs, and their management is still controversial. Limited scientific evidence is available for optimized rehabilitation regimen and on the course of recovery after ATRs. Furthermore, there are no universally accepted outcomes regarding the return to play (RTP) process. Therefore, the aim of this narrative review is to give an insight into the mechanism of injuries of an ATR, related principles of rehabilitation, and RTP.