The recovery after Achilles tendon rupture: a protocol for a multicenter prospective cohort study

Comparison of different immobilisation durations following open surgery for acute achilles tendon rupture: a prospective cohort study

BACKGROUND

In recent decades, early rehabilitation after Achilles tendon rupture (ATR) repair has been proposed. The aim of this prospective cohort study was to compare different immobilisation durations in order to determine the optimal duration after open surgery for ATR repair.

METHODS

This study included 1088 patients (mean age, 34.9 ± 5.9 years) who underwent open surgery for acute ATR repair. The patients were categorised into four groups (A, B, C, and D) according to postoperative immobilisation durations of 0, 2, 4, and 6 weeks, respectively. All patients received the same suture technique and a similar rehabilitation protocol after brace removal,; they were clinically examined at 2, 4, 6, 8, 10, 12, 14, and 16 weeks postoperatively, with a final follow-up at a mean of 19.0 months. The primary outcome was the recovery time for the one-leg heel-rise height (OHRH). Secondary outcomes included the time required to return to light exercise (LE) and the recovery times for the range of motion (ROM). Data regarding the surgical duration, complications, the visual analogue scale (VAS) score for pain, the Achilles tendon Total Rupture Score (ATRS), and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale score were also collected.

RESULTS

The recovery times for OHRH, LE, and ROM were significantly shorter in groups A and B than in groups C and D (P < 0.001). The VAS scores decreased over time, reaching 0 in all groups by 10 weeks. The mean scores in groups A and B were higher than those in the other groups at 2 and 4 weeks (P < 0.001), whereas the opposite was true at 8 weeks (P < 0.001). ATRS and the AOFAS Ankle-Hindfoot scale score increased across all groups over time, showing significant between-group differences from weeks 6 to 16 (P < 0.001) and weeks 6 to 12 (P < 0.001). The mean scores were better in groups A and B than in groups C and D. Thirty-eight complications (3.5%) were observed, including 20 re-ruptures and 18 superficial infections. All complications were resolved at the last follow-up, with no significant between-group differences.

CONCLUSIONS

Immobilisation for 2 weeks after open surgery for ATR repair may be the optimal strategy for early rehabilitation with relatively minimal pain and other complications.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT04663542).

Free tendon grafts for surgical management of chronic tears of the main body of the Achilles tendon: a systematic review

PURPOSE

After four weeks from injury, tears of the Achilles tendon are considered chronic. Their management is challenging, and the use of a graft is suggested when the gap between proximal and distal stumps is greater than 6 cm. The present study systematically reviews the outcome of free tendon grafts in chronic ruptures of the Achilles tendon, evaluating clinical outcomes, complications and return to sport.

METHODS

The present study was conducted according to the PRISMA 2020 guidelines. PubMed, Google Scholar, Embase, and Web of Science databases were accessed in February 2023. All the published clinical studies reporting clinical outcome, return to sport and complications of free tendon grafts used the treatment of chronic rupture of the midportion of the Achilles Tendon were accessed. The mean CMS (Coleman Methodology Score) of 65.7 suggested an overall good quality of the available published articles, attesting to the low risk of bias.

RESULTS

Data from 22 articles (368 patients with a mean age of 47 years) were retrieved. The average time from rupture to surgery was 25.1 week. At last follow-up, the AOFAS (American Orthopaedic Foot and Ankle Surgery) and ATRS (Achilles Tendon Total Rupture Score) scores improved of 33.8 (P = 0.0004), and 45.1 points (P = 0.0001) respectively. Return to activity was reported in 105 patients, and 82 (78.1%) had no activity limitations, while 19 (18.1%) had limited recreational but not daily activity limitations, and 4 (3.8%) reported limitations in daily activities. Return to sport data was reported in six studies, and 45 of 93 (48.4%) patients returned to sport at an average of 22.6 weeks.

CONCLUSION

In chronic tears of the Achilles tendon, with a gap of at least 6 cm, free tendon grafts allow predictable return to sport and acceptable recovery function.

LEVEL OF EVIDENCE

Level IV.

Fast Functional Rehabilitation Protocol versus Plaster Cast Immobilization Protocol after Achilles Tendon Tenorrhaphy: Is It Different? Clinical, Ultrasonographic, and Elastographic Comparison

BACKGROUND

the incidence of Achilles tendon (AT) rupture is rising; however, there is no clear consensus regarding the optimal treatment. The aim of this retrospective study was to compare instrumental and patient-reported outcome scores after fast functional rehabilitation (group A) versus plaster cast immobilization (group B) programs in patients who underwent AT tenorrhaphy.

METHODS

33 patients, with similar clinical and demographic features, underwent open AT tenorrhaphy between January and July 2018. Of these, 15 patients were treated with fast functional rehabilitation program (group A), and 18 patients were treated with plaster cast immobilization protocol (group B). Sural triceps hypotrophy and functional scores (American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score, and Achilles tendon Total Rupture Score (ATRS)) were recorded at a 12-month follow-up. Ultrasonography (US) and elastosonography (ES) were used to compare the characteristics of the tendons after surgery.

RESULTS

At 12 months, no significant differences in any of the patient-reported outcomes or the instrumental measurement tests were seen between the two groups.

CONCLUSIONS

fast functional rehabilitation after AT surgical repair is safe, effective, and may be the first choice of treatment, especially in young, collaborative, and active patients.

Current Consensus for Rehabilitation Protocols of the Surgically Repaired Acute Mid-Substance Achilles Rupture: A Systematic Review and Recommendations From the "GAIT" Study Group

Surgical repair of acute mid-substance Achilles tendon ruptures is performed in active patients, but the postoperative rehabilitation program is often based on the experience of the surgeon or therapist, rather than on evidence-based protocols. The aim of the study is to establish an evidence-based protocol for rehabilitation. This study is a consensus statement. The "GAIT" study group (German, American, and Italian Tendon), an informal collection of 4 experienced foot and ankle surgeons, met to address the question of what items they felt were important relative to rehabilitate a surgically repaired Achilles tendon acute rupture. Thirty-three statements were formulated. A value of 100% agreement by all the members was set to produce a proposed consensus statement. A value of 80% consensus was set to produce "strong recommendation." A systematic review of the literature was also performed. The GAIT group reach 100% agreement on the average postoperative non-weightbearing for 2.3 weeks, the foot in plantarflexion for the first 4 weeks, avoiding ROM exercises beyond neutral, and both stretching and eccentric exercise, not started before 12 weeks. Concentric bilateral heel raises should be performed after 6 weeks, and the average return to initiate sports, was 24.4 weeks. The use of a 1/8^th-1/4^th inch heel cushions in daily shoes after 8 weeks, the use of an antigravity treadmill for rehabilitation, and the return to sports based on heel raise repetitions is strongly recommended. Given lack of established verified protocols, the recommendations by our experienced panel should be considered. These proposed consensus statements could be used as a basis for larger controlled trials, and develop best practices.

Ground Reaction Forces during Vertical Hops Are Correlated with the Number of Supervised Physiotherapy Visits after Achilles Tendon Surgery

The objective of this study was to assess the effectiveness of, and the correlation between, an average of 42 supervised physiotherapy (SVPh) visits for the vertical ground reaction forces component (vGRF) using ankle hops during two- and one-legged vertical hops (TLH and OLH, respectively), six months after the surgical suturing of the Achilles tendon using the open method (SSATOM) via Keesler’s technique. Hypothesis: Six months of supervised physiotherapy with a higher number of visits (SPHNVs) was positively correlated with higher vGRF values during TLH and OLH. Group I comprised male patients (n = 23) after SSATOM (SVPh x = 42 visits), and Group II comprised males (n = 23) without Achilles tendon injuries. In the study groups, vGRF was measured during TLH and OLH in the landing phase using two force plates. The vGRF was normalized to the body mass. The limb symmetry index (LSI) of vGRF values was calculated. The ranges of motion of the foot and circumferences of the ankle joint and shin were measured. Then, 10 m unassisted walking, the Thompson test, and pain were assessed. A parametric test for dependent and independent samples, ANOVA and Tukey’s test for between-group comparisons, and linear Pearson’s correlation coefficient calculations were performed. Group I revealed significantly lower vGRF values during TLH and OLH for the operated limb and LSI values compared with the right and left legs in Group II (p ≤ 0.001). A larger number of visits correlates with higher vGRF values for the operated limb during TLH (r = 0.503; p = 0.014) and OLH (r = 0.505; p = 0.014). An average of 42 SVPh visits in 6 months was insufficient to obtain similar values of relative vGRF and their LSI during TLH and OLH, but the hypothesis was confirmed that SPHNVs correlate with higher relative vGRF values during TLH and OLH in the landing phase.

Psychological Factors Change During the Rehabilitation of an Achilles Tendon Rupture: A Multicenter Prospective Cohort Study

OBJECTIVE

The authors sought to gain insight into the changes in psychological factors during rehabilitation after Achilles tendon rupture (ATR) and to explore the association between psychological factors during rehabilitation and functional outcome 12 months after ATR.

METHODS

Fifty patients clinically diagnosed with ATR were invited to visit the hospital 3, 6, and 12 months after injury for data collection. They completed questionnaires assessing psychological factors: psychological readiness to return to sport (Injury Psychological Readiness to Return to Sport Questionnaire); kinesiophobia (Tampa Scale for Kinesiophobia); expectations, motivation, and outcome measures related to symptoms and physical activity (Achilles Tendon Total Rupture Score); and sports participation and performance (Oslo Sports Trauma Research Centre Overuse Injury Questionnaire). To determine whether psychological factors changed over time, generalized estimating equation analyses were performed. Multivariate regression analyses were used to study the association between psychological factors at 3, 6, and 12 months and outcome measures at 12 months after ATR.

RESULTS

Psychological readiness to return to sport improved, and kinesiophobia decreased significantly during rehabilitation. Psychological readiness at 6 and 12 months showed significant associations with sports participation and performance. Kinesiophobia at 6 months was significantly associated with symptoms and physical activity. Motivation remained high during rehabilitation and was highly associated with symptoms and physical activity, sports participation, and performance.

CONCLUSION

Psychological factors change during rehabilitation after ATR. Patients with lower motivation levels during rehabilitation, low psychological readiness to return to sports, and/or high levels of kinesiophobia at 6 months after ATR need to be identified.

IMPACT

According to these results, psychological factors can affect the rehabilitation of patients with ATR. Physical therapists can play an important role in recognizing patients with low motivation levels and low psychological readiness for return to sport and patients with high levels of kinesiophobia at 6 months post-ATR. Physical therapist interventions to enhance motivation and psychological readiness to return to sport and to reduce kinesiophobia need to be developed and studied in the post-ATR population.

LAY SUMMARY

With Achilles tendon rupture, level of motivation, psychological readiness for return to sport, and fear of movement can affect rehabilitation outcome. A physical therapist can help recognize these factors.

Mental Health in Patients Undergoing Orthopaedic Surgery: Diagnosis, Management, and Outcomes

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Mental health and psychosocial factors play a critical role in clinical outcomes in orthopaedic surgery.

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The biopsychosocial model of disease defines health as a product of physiology, psychology, and social factors and, traditionally, has not been as emphasized in the care of musculoskeletal disease.

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Improvement in postoperative outcomes and patient satisfaction is incumbent upon the screening, recognition, assessment, and possible referral of patients with high-risk psychosocial factors both before and after the surgical procedure.

Fit to Burst: Toward Noninvasive Estimation of Achilles Tendon Load Using Burst Vibrations

OBJECTIVE

Tendons are essential components of the musculoskeletal system and, as with any mechanical structure, can fail under load. Tendon injuries are common and can be debilitating, and research suggests that a better understanding of their loading conditions could help mitigate injury risk and improve rehabilitation. To that end, we present a novel method of noninvasively assessing parameters related to mechanical load in the Achilles tendon using burst vibrations.

METHODS

These vibrations, produced by a small vibration motor on the skin superficial to the tendon, are sensed by a skin-mounted accelerometer, which measures the tendon's response to burst excitation under varying tensile load. In this study, twelve healthy subjects performed a variety of everyday tasks designed to expose the Achilles tendon to a range of loading conditions. To approximate the vibration motor-tendon system and provide an explanation for observed changes in tendon response, a 2-degree-of-freedom mechanical systems model was developed.

RESULTS

Reliable, characteristic changes in the burst response profile as a function of Achilles tendon tension were observed during all loading tasks. Using a machine learning-based approach, we developed a regression model capable of accurately estimating net ankle moment-which captures general trends in tendon tension-across a range of walking speeds and across subjects (R² = 0.85). Simulated results of the mechanical model accurately recreated behaviors observed in vivo. Finally, preliminary, proof-of-concept results from a fully wearable system demonstrated trends similar to those observed in experiments conducted using benchtop equipment.

CONCLUSION

These findings suggest that an untethered, unobtrusive system can effectively assess tendon loading during activities of daily life.

SIGNIFICANCE

Access to such a system would have broad implications for injury recovery and prevention, athletic training, and the study of human movement.

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.

Epidemiology of Achilles tendon injuries in collegiate level athletes in the United States

BACKGROUND

Achilles injuries are devastating injuries, especially for competitive athletes. No studies have examined the outcomes of Achilles injuries in NCAA athletes. Therefore, a better characterization and understanding of the epidemiology is crucial.

METHODS

Achilles injuries across 16 sports among NCAA men and women during the 2004-2005 to 2013-2014 academic years were analyzed using the NCAA Injury Surveillance Program (NCAA-ISP). Achilles tendon injury rate (IR) per 100,000 athlete-exposures (AEs), operative rate, annual injury rate trends, reinjury rates, mechanism of injury, in-season status (pre/regular/post season), and time loss distributions were compiled and calculated. A sub-analysis of comparing gender and injury mechanism was also performed for both all injuries and severe injuries.

RESULTS

Overall, N = 255 Achilles injuries were identified with an injury rate (IR) of 2.17 (per 100,000 AEs). These injuries occurred most often in women's gymnastics (IR = 16.73), men's basketball (IR = 4.26), and women's basketball (IR = 3.32), respectively. N = 52 injuries were classified as severe injuries which have higher median time loss (48 days) and higher operative rate (65.4%). For severe Achilles injuries, female athletes had higher operative (77.8% vs. 58.8%) and higher time loss compared to male athletes (96 days vs. 48 days). Contact mechanisms were associated with a higher season-ending injury rate.

CONCLUSION

Overall, 20.4% of Achilles injuries were considered severe with 65.6% operative rate. About 73.1% were season-ending injuries, and the remaining athletes have a median time loss of 48 days. Severe Achilles injuries create significant impact on playing time and career for NCAA athletes.

The Achilles tendon Total Rupture Score is a responsive primary outcome measure: an evaluation of the Dutch version including minimally important change

PURPOSE

Aim of this study was to evaluate the responsiveness of the Dutch version of the Achilles tendon Total Rupture Score (ATRS-NL).

METHODS

Patients (N = 47) completed the ATRS-NL at 3 and 6 months after Achilles tendon rupture (ATR). Additionally, they filled out the Euroqol-5D-5L (EQ-5D-5L) and Global Rating of Change Score (GRoC). Effect sizes (ES) and standardized response means (SRM) were calculated. The anchor-based method for determining the minimally important change (MIC) was used. GRoC and improvement on the items mobility and usual activities on the EQ-5D-5L served as external criteria. The scores on these anchors were used to categorize patients' physical functioning as improved or unchanged between 3 and 6 months after ATR. Receiver operating curve (ROC) analysis was performed, with the calculation of the area under the ROC curve (AUC) and the estimation of MIC values using the optimal cut-off points.

RESULTS

There was a large change (ES: 1.58) and good responsiveness (SRM: 1.19) of the ATRS-NL between 3 and 6 months after ATR. Using ROC analysis, the MIC values ranged from 13.5 to 28.5 for reporting improvement on EQ-5D-5L mobility and GRoC, respectively. The AUC of improvement on mobility and improvement on GRoC were > 0.70.

CONCLUSION

The ATRS-NL showed good responsiveness in ATR patients between 3 and 6 months after injury. Use of this questionnaire is recommended in clinical follow-up and longitudinal research of ATR patients. MIC values of 13.5 and 28.5 are recommended to consider ATR patients as improved and greatly improved between 3 and 6 months after ATR.

LEVEL OF EVIDENCE

II.