The Sheffield splint for controlled early mobilisation after rupture of the calcaneal tendon. A prospective, randomised comparison with plaster treatment

Return to Play and Functional Outcomes Following Treatment of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-Analysis

Return to play (RTP) and functional outcomes are critical to treatment success for acute Achilles tendon rupture (AATR). This systematic review and meta-analysis explored treatment superiority essential in optimal treatment selection concerning individual patients and their expectations regarding RTP and functional outcomes. This study was in accordance with the preferred reporting items for systematic reviews and meta-analyses guidelines. The included studies were assessed regarding the level and quality of evidence. Fixed-effects models were employed for I2 < 25% and random-effects models for I2 ≥ 25%. The RTP rate meta-analysis of surgical vs conservative treatment revealed no significant difference. This was similar to the subgroup analysis of open repair and conservative treatment. The RTP rate and Achilles Tendon Total Rupture Score (ATRS) meta-analysis of open repair + earlier rehabilitation (ER) vs + later rehabilitation (LR) also revealed no significant differences. The mean time to RTP meta-analysis of open repair + ER vs + LR showed that open repair + ER was significantly favored (-4.19 weeks; p = .002). The ATRS meta-analysis of conservative treatment with ER vs with LR revealed no significant difference. This meta-analysis has revealed that the RTP rates following treatment of AATR are high. Therefore, the decision for surgical vs conservative treatment or open repair + ER vs + LR for AATR should not be selected based on the expectation of RTP. However, open repair + ER can be advocated over + LR for reduced mean time to RTP.

The Acute Achilles Tendon Rupture: An Evidence-Based Approach from the Diagnosis to the Treatment

Background and Objective: Acute Achilles tendon rupture (AATR) is a common injury with a significant impact on daily living. Although various systematic reviews and meta-analyses have been written on the topic, no actual consensus exists on the best treatment. We aimed to collect the highest quality of evidence on the subject and to produce a document to which to refer, from the diagnosis to the final treatment. Material and Methods: Inclusion criteria were systematic reviews discussing Achilles tendon rupture, concerning either diagnostic criteria, classification, or treatment; English language; clearly stated inclusion and exclusion criteria for patients’ selection. Results: Thirteen systematic reviews were included in the study. A strong consensus exists about the higher risk of re-rupture associated with non-operative treatment and a higher risk of complications associated with surgical repair. Conclusions: The combination of minimally invasive repair and accelerated functional rehabilitation seems to offer the best results in the treatment of Achilles tendon rupture.

Early versus late weightbearing in conservative management of acute achilles tendon rupture: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Achilles tendon rupture (ATR) is one of the most frequently encountered injuries in Sports Medicine. ATR can be managed surgically or conservatively followed by early functional rehabilitation or cast immobilization. The aim of the present systematic review and meta-analysis was to provide an update about the role of early weightbearing (WB) versus late WB on the clinical outcomes of adults with acute ATR.

METHODS

We performed a systematic literature search in Web of Science, Ovid, Medline/PubMed, and CENTRAL. We included randomized controlled trials (RCTs) that compared early WB, defined as weight-bearing within 4 weeks of treatment, to late WB for individuals with acute (<14 days) ATR. We sought to evaluate the following outcomes: re-rupture rate, Achilles Tendon Rupture Score (ATRS), return to pre-injury sport activity, time to return to work, and adverse event rate. The standardized mean difference (SMD) was used to represent continuous outcomes while the risk ratio (RR) was used to represent dichotomous outcomes.

RESULTS

A total of 9 RCTs that enrolled 1046 participants were deemed eligible. There was no significant difference between early WB and late WB in terms of re-rupture rate (RR=0.75, 95% CI 0.49 to 1.16), ATRS (SMD=0.06, 95% CI -0.03 to 0.16), return to pre-injury sport activity (RR=1.05, 95% CI 0.86 to 1.28), time to return to work (SMD=0.03, 95% CI -0.20 to 0.26), or adverse event rate (RR=1.87, 95% CI 0.53 to 6.63).

CONCLUSION

This meta-analysis shows no difference in the functional outcomes and patient-reported outcomes between early functional rehabilitation and cast immobilization for conservatively treat individuals with acute ATR.

Accelerated Rehabilitation in Non-operative Management of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis

The optimal treatment and rehabilitation strategy for Achilles tendon ruptures is still under debate. There is a paradigm shift toward early mobilization and weightbearing. We examined the treatment effect of accelerated functional rehabilitation in nonoperative management of acute Achilles tendon ruptures. A systematic search of PubMed, EMBASE, and Web of Science databases for articles comparing accelerated versus delayed rehabilitation in the nonoperative management of acute Achilles tendon rupture was performed. Outcomes of interest were Achilles tendon rupture score (ATRS) (standardized patient-reported instrument related to symptoms and physical activity after treatment of an acute Achilles tendon rupture), rerupture rate, strength, range of motion, return to work, and sports. A total of 2001 articles were identified using our search strategy. We included 6 randomized controlled trials of interest. Although the concept of accelerated rehabilitation has gained popularity in recent years, no statistically significant differences could be revealed in any of the outcomes of interest. We performed a meta-analysis on the following outcomes: ATRS (mean difference -0.93 95% confidence interval [CI] -6.01 to 4.14), Rerupture rate (odds ratio [OR] 0.97, 95% CI: 0.46-2.03), Return to sports (OR 1.31, 95% CI 0.76-2.25), Return to work (mean difference 5.24, 95% CI to -12.04 to 22.51). The treatment effect of accelerated rehabilitation in nonoperatively treated patients seems to be small. However, we recommend accelerated rehabilitation for all conservatively treated patients, because it is a safe option and no detrimental effects have been described in the literature. Furthermore, many patients prefer this type of rehabilitation to avoid the practical disadvantages of prolonged immobilization.

Treatment of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis of Complication Rates With Best- and Worst-Case Analyses for Rerupture Rates

BACKGROUND

An acute Achilles tendon rupture (AATR) is a common injury. The controversy that has surrounded the optimal treatment options for AATRs warrants an updated meta-analysis that is comprehensive, accounts for loss to follow-up, and utilizes the now greater number of available studies for data pooling.

PURPOSE

To meta-analyze the rates of all complications after the treatment of AATRs with a "best-case scenario" and "worst-case scenario" analysis for rerupture rates that assumes that all patients lost to follow-up did not or did experience a rerupture, respectively.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 1.

METHODS

Two authors performed a systematic review of the PubMed and Embase databases according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines on February 17, 2020. The included studies were assessed in terms of the level of evidence, quality of evidence, and quality of the literature. A meta-analysis by fixed-effects models was performed if heterogeneity was low (I² < 25%) and by random-effects models if heterogeneity was moderate to high (I²≥ 25%).

RESULTS

Surgical treatment was significantly favored over nonsurgical treatment for reruptures. Nonsurgical treatment was significantly favored over surgical treatment for complications other than reruptures, notably infections. Minimally invasive surgery was significantly favored over open repair for complications other than reruptures (no difference for reruptures), in particular for minor complications.

CONCLUSION

This meta-analysis demonstrated that surgical treatment was superior to nonsurgical treatment in terms of reruptures. However, the number needed to treat analysis produced nonmeaningful values for all treatment options, except for surgical versus nonsurgical treatment and minimally invasive surgery versus open repair. No single treatment option was revealed to be profoundly favorable with respect to every complication. The results of this meta-analysis can guide clinicians and patients in their treatment decisions that should be made jointly and on a case-by-case basis.

Is Early Controlled Motion and Weightbearing Recommended for Nonoperatively Treated Acute Achilles Tendon Rupture? A Systematic Review and Meta-analysis

Background

There is disagreement as to whether early controlled motion and weightbearing confer a beneficial effect for nonoperatively treated acute Achilles tendon rupture (ATR) compared with immobilization and late weightbearing.

Purpose

To conduct a meta-analysis of randomized controlled trials (RCTs) to determine whether early controlled motion and weightbearing results in different outcomes compared with immobilization and late weightbearing for nonoperatively treated patients with acute ATR.

Study Design

Systematic review; Level of evidence, 1.

Methods

We conducted a search in the PubMed, Web of Science, and EMBASE databases for relevant RCTs in humans from January 1981 to August 2020. The primary outcome was the Achilles Tendon Total Rupture Score (ATRS) at 1-year follow-up. The secondary outcomes were the rerupture rate, return to sports activity and work, and the heel-rise work (limb symmetry index [LSI]). Study quality was assessed using the Cochrane Collaboration risk of bias tool.

Results

Included were 7 RCTs involving 424 participants (n = 215 treated with early controlled motion and weightbearing [early group], n = 209 treated with immobilization and late weightbearing [late group]). The quality assessment indicated a low risk of bias in all included RCTs. There was no difference between the early and late groups regarding the ATRS (mean difference [MD], -0.220; 95% CI, -4.489 to 4.049; P = .920). Likewise, we found no difference between the 2 groups in terms of the rerupture rate (odds ratio [OR], 1.107; 95% CI, 0.552 to 2.219; P = .775), the number of patients who returned to sports (OR, 0.766; 95% CI, 0.438 to 1.341; P = .351) and returned to work (OR, 0.706; 95% CI, 0.397 to 1.253; P = .234), the time to return to work (MD, -2.802 days; 95% CI, -6.525 to 0.921 days; P = .140), or the heel-rise work LSI (MD, -0.135; 95% CI, -6.243 to 5.973; P = .965).

Conclusion

No significant differences were found between early controlled motion and weightbearing compared with immobilization and late weightbearing regarding the ATRS, the rerupture rate, return to sports activity and work, and the heel-rise work in nonoperatively treated patients with acute ATR.

The Influence of Early Weightearing, Controlled Motion, and Timing of Orthosis Removal on the Nonoperative Management of Achilles Tendon Rupture: A Systematic Review

This is a systematic review of the non-operative treatment for Achilles tendon rupture aimed at assessing the effect of early weightbearing, controlled motion and orthosis removal on 5 outcome measures. The literature was searched for relevant RCTs and prospective cohort studies. The primary outcome measure was the re-rupture rate. The secondary outcome measures were the rates for DVT, duration before return to work (RTW), return to sports (RTS) and the mean Achilles Tendon Rupture Score (ATRS). Eighteen publications reporting a total of 1068 patients were reviewed. The pooled rates were: re-rupture: 7.3%, DVT: 5.5%, RTW: 10.3 weeks, RTS: 47.7% and ATRS: 78.7. Early compared to late weightbearing was associated with significantly lower rates of DVT, RTW and ATRS but no difference in the rates of re-rupture and RTS. Early controlled motion compared to no motion was associated with significantly lower rates of re-rupture, RTW and ATRS but no difference in the rates of DVT and RTS. Early compared to late orthosis removal was associated with significantly higher rates of re-rupture and ATRS as well as a lower rate of RTW but no difference in the rates of DVT and RTS. The findings relating to re-rupture, DVT, RTW and RTS support the adoption of early weightbearing and controlled motion in the non-operative treatment for Achilles tendon rupture. Early removal of orthosis is not advisable due to an increased risk of re-rupture. The ATRS results were considered inconclusive probably due to inconsistencies in the reporting or heterogeneity in the study population.

Multiple comparisons of the efficacy and safety for six treatments in Acute Achilles Tendon Rupture patients: A systematic review and network meta-analysis

BACKGROUND

The choice of the best therapeutic regimen for Acute Achilles Tendon Rupture (AATR) remains controversial. Our study aims to evaluate the efficacy and safety of therapeutic regimens in AATR patients using a network meta-analysis of data from clinical randomized controlled trials.

MATERIAL/METHODS

The studies were abstracted from Medline, Embase, Web of Science, Google Scholar and the Cochrane Central Register of Controlled Trials. RCTs meeting the inclusion and exclusion criteria were selected. Statistical analyses were conducted using Stata software, version 14.0 (Stata Corporation, College Station, Texas, USA).

RESULTS

38 randomized controlled trials involving 2480 participants were included. The studies were published between 1981 and 2019. A total of 6 therapeutic regimens -open repair (OR), minimally invasive repair (MIR) and nonoperative treatment (non) combined with traditional standard rehabilitation (TSR) and accelerated functional rehabilitation (AFR) - were included in the literature. The treatments were ranked based on the Surface Under the Cumulative Ranking Curve (SUCRA) probability. In terms of the re-rupture rate, the therapeutic regimens were ranked as follows: OR&AFR, OR&TSR, MIR&AFR, MIR&TSR, nonoperative treatment &AFR and nonoperative treatment &TSR. In terms of the wound-related complication, the therapeutic regimens were ranked as follows: MIR&AFR, nonoperative treatment &AFR, MIR&TSR, nonoperative treatment &TSR, OR&AFR and OR&TSR. In terms of the sural nerve injury, the therapeutic regimens were ranked as follows: non, OR and MIR. In terms of the deep venous thrombosis, the therapeutic regimens were ranked as follows: MIR&AFR, OR&AFR, nonoperative treatment &AFR, OR&TSR, MIR&TSR and nonoperative treatment &TSR. In terms of the returning back to sport, the therapeutic regimens were ranked as follows: MIR&TSR, OR&AFR, OR&TSR, nonoperative treatment &AFR, nonoperative treatment &TSR and MIR&AFR.

CONCLUSIONS

MIR can repair the ruptured Achilles tendon and narrow the tendon gap with low risk of complications. AFR is superior to TSR without increasing the risk of rerupture. MIR&AFR is the best therapeutic regime for AATR. More RCTs focused on AATR are needed to further indicate this conclusion.

Surgical Management of Chronic Tendoachilles Tear in Elderly Patients - A Case Series

Introduction:

Chronic tendoachilles (TA) tears are commonly missed injuries in elderly population with associated comorbidities and they usually occur as low-energy injuries. Appropriate surgical management helps in getting a better functional outcome in elderly patients.

Case Series:

We present a series of three cases of chronic TA tear in elderly patients managed surgically. Two patients had an insertional tear and they were managed with flexor hallucis longus (FHL) transfer and fixed with interference screw in the calcaneum. Another patient was managed with end-to-end suturing using fiber wire. All the patients are having good functional outcome without any wound complication or re rupture.

Conclusion:

Early diagnosis, meticulous repair, and handling of soft tissues and TA tear help in getting a better outcome in elderly patients. The final functional outcome depends on intraoperative stability of the repair, ankle physiotherapy, and wisely selection of the treatment method, which mainly depends on the location of the tear. Reconstruction with FHL tendon using interference screw in calcaneum helps to repair the insertional tears in elderly patients.

Plaster cast versus functional bracing for Achilles tendon rupture: the UKSTAR RCT

BACKGROUND

Achilles tendon rupture affects > 11,000 people each year in the UK, leading to prolonged periods away from work, sports and social activities. Traditionally, the ruptured tendon is held still in a plaster cast for ≥ 8 weeks. Functional bracing is an alternative treatment that allows patients to mobilise earlier, but there is little evidence about how bracing affects patients' recovery.

OBJECTIVES

To measure the Achilles Tendon Rupture Score, quality of life, complications and resource use of patients receiving non-operative treatment for an Achilles tendon rupture treated with plaster cast compared with those treated with functional bracing.

DESIGN

This was a multicentre, randomised, pragmatic, two-group superiority trial.

SETTING

The setting was 39 NHS hospitals.

PARTICIPANTS

A total of 540 adult patients treated non-operatively for Achilles tendon rupture were randomised from July 2016 to May 2018. Exclusion criteria included presenting after 14 days, having had previous rupture and being unable to complete questionnaires.

INTERVENTIONS

A total of 266 participants had a plaster cast applied, with their toes initially pointing to the floor. The cast was changed over 8 weeks to bring the foot into a walking position. A total of 274 patients had a functional brace that facilitated immediate weight-bearing. The foot position was adjusted within the brace over the same 8-week period.

MAIN OUTCOME MEASURES

Achilles Tendon Rupture Score is patient reported and assesses symptoms and physical activity related to the Achilles tendon (score 0-100, with 100 being the best possible outcome). The secondary outcomes were quality of life, complications and resource use at 8 weeks and at 3, 6 and 9 months.

RESULTS

Participants had a mean age of 48.7 years, were predominantly male (79%) and had ruptured their tendon during sports (70%). Over 93% of participants completed follow-up. There was no statistically significant difference in Achilles Tendon Rupture Score at 9 months post injury (-1.38, 95% confidence interval -4.9 to 2.1). There was a statistically significant difference in Achilles Tendon Rupture Score at 8 weeks post injury in favour of the functional brace group (5.53, 95% confidence interval 2.0 to 9.1), but not at 3 or 6 months post injury. Quality of life showed the same pattern, with a statistically significant difference at 8 weeks post injury but not at later time points. Complication profiles were similar in both groups. Re-rupture of the tendon occurred 17 times in the plaster cast group and 13 times in the functional brace group. There was no difference in resource use.

CONCLUSIONS

This trial provides strong evidence that early weight-bearing in a functional brace provides similar outcomes to traditional plaster casting and is safe for patients receiving non-operative treatment of Achilles tendon rupture. The probability that functional bracing is cost-effective exceeds 95% for the base-case imputed analysis, assuming a cost-effectiveness threshold of £20,000 per quality-adjusted life-year. On average, functional brace is associated with lower costs (-£103, 95% confidence interval -£290 to £84) and more quality-adjusted life-years (0.015, 95% confidence interval -0.0013 to 0.030) than plaster cast.

LIMITATIONS

Some patients declined to participate in the trial, but only a small proportion of these declined because they had a preference for one treatment or another. Overall, 58% of eligible patients agreed to participate, so the participants are broadly representative of the population under investigation.

FUTURE WORK

Although the UK Study of Tendo Achilles Rehabilitation provides guidance with regard to early management, rehabilitation following Achilles tendon rupture is prolonged and further research is required to define the optimal mode of rehabilitation after the initial cast/brace has been removed.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN62639639.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 8. See the NIHR Journals Library website for further project information.

Acute Achilles Tendon Ruptures

There is an ever-evolving debate about the best treatment option for Achilles tendon ruptures. There was a relative consensus that operative treatment yielded the best outcomes. Much of this is based on results in athletic populations. Conservative treatment was considered only for the elderly and those with very inactive lifestyles. There has been an evolution, however, with more surgeons utilizing an aggressive functional rehabilitation with conservative management. Surgical intervention still is the treatment of choice for elite-level athletes. The treatment of choice for patient populations other than elite athletes remains an individual choice between patient and physician.

Clinical Outcomes and Complications Following Limited Open Achilles Repair Without an Instrumented Guide

BACKGROUND

We report the clinical outcomes and complications following our limited open incision Achilles tendon repair technique without instrument guides.

METHODS

A total of 33 patients were included in this study. We recorded pre- and postoperative scores on the Foot and Ankle Disability Index (FADI), visual analog scale (VAS), and the Foot and Ankle Outcome Score (FAOS). Subgroup analyses were performed for acute (<2 weeks) and subacute (2-6 weeks) Achilles tendon repairs. A P value <.05 was considered significant for all statistical analyses.

RESULTS

The median time from injury to surgery was 10.0 days (range, 1-45 days). At a median follow-up of 3.7 years (range, 1.0-9.8 years), the average pre- and postoperative outcome scores improved significantly for the following: FADI index (49.1-98.4, P < .001), VAS (4.8-0.2, P < .001), FAOS Pain (54.8-99.2, P < .001), FAOS Symptoms (84.6-97.0, P < .001), FAOS activities of daily living (61.4-97.2, P < .001), FAOS Sports and Recreational Activity (39.5-98.5, P < .001), and FAOS quality of life (39.7-88.7, P < .001). There were no significant differences between pre- and postoperative outcome scores between the acute and subacute Achilles repair groups. There were no wound complication, reruptures, or reoperations in the entire cohort.

CONCLUSION

Patients showed improvements in postoperative patient-reported outcome scores with minimal complications. There was no significant difference in outcomes for acute vs subacute repairs. Our limited open incision Achilles tendon repair, which required no additional targeting instrumentation, had favorable midterm results.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

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.

Rehabilitation regimen for non-surgical treatment of Achilles tendon rupture: A systematic review and meta-analysis of randomised controlled trials

OBJECTIVES

To compare re-rupture rate, functional and quality-of-life outcomes, return to sports and work, complications, and resource use in patients treated non-surgically with different rehabilitation regimens for Achilles tendon rupture.

DESIGN

Systematic review and meta-analysis.

METHODS

We performed a systematic literature search in PubMed, Embase, Scopus and the Cochrane Library through May 2020 to identify randomized controlled trials (RCTs) that included patients treated non-surgically for Achilles tendon rupture. All analyses were stratified according to rehabilitation protocols.

RESULTS

Eight RCTs with a total of 978 patients were included. There was no significant difference about re-rupture rate (P=0.38), return to sports (P=0.85) and work (P=0.33), functional outcome (P=0.34), quality of life (P=0.50), and complication rate (P=0.29) between early weight bearing with functional ankle motion and traditional ankle immobilisation with non-weight bearing. Similarly, no significant difference in re-rupture rate (P=0.88), return to sports (P=0.45) and work (P=0.20), functional outcome (P=0.26), and complication rate (P=0.49) was seen between ankle immobilisation with non-weight bearing and early weight bearing without functional ankle motion.

CONCLUSIONS

Traditional ankle immobilisation with non-weight bearing was not found to be superior to early weight bearing with or without functional ankle motion for patients treated non-surgically for Achilles tendon rupture. Clinicians may consider early weight bearing in functional brace as a safe and cost-effective alternative to non-weight bearing with plaster casting.

Resistance Exercises in Early Functional Rehabilitation for Achilles Tendon Ruptures Are Poorly Described: A Scoping Review

OBJECTIVES

To (1) describe which resistance exercises are used in the first 8 weeks of treatment for acute Achilles tendon rupture and (2) assess the completeness of reporting of the exercise descriptions.

DESIGN

Scoping review.

LITERATURE SEARCH

We searched the MEDLINE, Embase, CINAHL, Cochrane Library, and Physiotherapy Evidence Database (PEDro) databases.

STUDY SELECTION CRITERIA

Randomized controlled trials, cohort studies, and case series (10 or more participants) that reported using resistance exercise in the immobilization period in the first 8 weeks of treatment for acute Achilles tendon rupture were included.

DATA SYNTHESIS

Completeness of exercise description was assessed with the Consensus on Exercise Reporting Template (CERT) and the Toigo and Boutellier exercise descriptor framework.

RESULTS

Thirty-eight studies were included. Fifty-one resistance exercises were extracted and categorized as isometric exercises (n = 20), heel raises (n = 6), strengthening with external resistance (n = 13), or unspecified (n = 12). A median of 8 (interquartile range, 6-10) of a possible 19 CERT items was reported. The amount of items described of the 13 Toigo and and Boutellier exercise descriptors ranged from 0 to 11.

CONCLUSION

A variety of resistance exercises targeted at the ankle plantar flexors were used as part of early functional rehabilitation after Achilles tendon rupture. However, most studies provided inadequate description of resistance exercise interventions. J Orthop Sports Phys Ther 2020;50(12):681-691. Epub 23 Oct 2020. doi:10.2519/jospt.2020.9463.

Systematic Review of Nonoperative Functional Protocols for Acute Achilles Ruptures Utilizing a Formal Rehabilitation Protocol Showing Lowest Rerupture Rates

AIM

To lay out a comprehensive protocol for practitioners and physical therapists that has the lowest rerupture rates for nonoperative treatment of acute Achilles ruptures.

METHOD

Relevant articles were searched in PubMed, CINAHL Plus, and Cochrane Library using keyword combinations: nonoperative AND/OR Achilles rupture AND functional AND/OR protocol or functional AND/OR rehabilitation. To be included in the full analysis, the studies had to have detailed functional protocols with physical therapy program details and outcome scores of rupture rates and/or Achilles Tendon Rupture Score (ATRS). We ultimately found 7 articles that fit our inclusion criteria for analysis. All of them had rerupture rates, and 4 had ATRS scores and functional protocols with mention of formal physical therapy programs.

RESULTS

Lowest rerupture rates were found in strict functional rehabilitation protocols that were full weightbearing in boot immediately at full equinus or 30° plantar flexed. They started active range of motion at 5 to 8 weeks and started formal physical therapy at 10 weeks.Levels of Evidence: Level III: Evidence obtained from well-designed non-experimental descriptive studies.

Unusual Presentation of a Swelling in the Achilles Tendon After an Acute Rupture: A Case Report

Introduction

Achilles tendon rupture is common and most cases heal with appropriate treatment. However, complications in the treatment of this condition can be debilitating, especially for young, active individuals.

Case Report

We present the case of a 37-year-old man who presented with ongoing pain on weight-bearing and swelling in the left Achilles tendon area8 months after acute rupture treated with functional bracing and early rehabilitation. Magnetic resonance imaging showed intrasubstance thickening of the tendon with a large swelling. Successful decompression of the swelling was achieved using an arthroscopic technique and the patient returned to normal activities.

Conclusion

Physiotherapy and return to normal activities were limited in our patient due to high levels of discomfort and pain. Prolonged immobility following tendon rupture has been shown to cause increased scar tissue proliferation. This may have hindered functional rehabilitation progress and negatively impacted on the reparative process.

Identifying Instruments to Assess Care Quality for Individuals With Custom Ankle Foot Orthoses: A Scoping Review

OBJECTIVES

We conducted 2 complementary scoping reviews to identify instruments that assess the experience and outcomes of custom ankle-foot orthosis (AFO) care in individuals with neurologic and traumatic conditions and to determine to what extent they might be psychometrically sound for AFO users. A stakeholder advisory committee considered to what extent the identified and psychometrically sound instruments might be feasible for use in developing quality measures for custom AFO users.

DATA SOURCES

Both scoping reviews were conducted using PubMed, the Cumulative Index to Nursing and Allied Health Literature, Embase, and Cochrane Systematic Reviews. The following were used for the first scoping review only: Cochrane Central Register of Controlled Trials and the Physiotherapy Evidence Database.

STUDY SELECTION

The initial scoping review yielded 79 articles with 82 instruments, 16 of which were used in 4 or more studies. The second scoping review yielded 57 articles reporting psychometric properties.

DATA EXTRACTION

Psychometric properties for populations who use AFOs were summarized for 15 of the 16 instruments. The advisory committee eliminated 2 insrtruments, noted overlap between 4 instruments in terms of the constructs measured, and suggested 6 potential contemporary substitutes.

DATA SYNTHESIS

Most instruments assessed activity (specifically mobility) and pertained to the National Quality Forum domain of "Health-Related Quality of Life." The 10-meter walk test, 6-minute walk test, Berg Balance Scale, Timed Up and Go, and Rivermead Mobility Index were reported to have adequate reliability and validity, and were considered feasible for administration in a clinical setting.

CONCLUSIONS

Complementary scoping reviews demonstrated that some instruments with reasonable psychometric properties are available that are feasible to use in developing quality measures for custom AFO care. However, experience of care instruments suitable for this population were not identified but are needed for a comprehensive evaluation of care quality for AFO users.

Treatment of Acute Achilles Tendon Rupture

There is no clear consensus on the optimal treatment of acute Achilles tendon rupture. Recently, studies have demonstrated the critical role of functional rehabilitation in the treatment of ruptured Achilles tendons. Hence, conservative treatment is preferred by a growing number of surgeons seeking to treat the condition without the risk of complications from surgery. However, operative treatment is still considered as a more reliable treatment option for acute Achilles tendon rupture. In this review article, we provide an overview of recent treatment strategies for acute rupture of the Achilles tendon.

Defining Components of Early Functional Rehabilitation for Acute Achilles Tendon Rupture: A Systematic Review

Background:

Early functional rehabilitation is frequently discussed in treating Achilles tendon rupture. A consistent definition of what constitutes early functional rehabilitation has not been established across the literature, despite studies supporting its efficacy. A standardized definition would be helpful to pool data across studies, allow for between-study comparisons, and ultimately work toward developing clinical guidelines.

Purpose:

To define early functional rehabilitation (including when it is initiated and what it entails) when used to treat Achilles tendon rupture and to identify outcome measures for evaluating the effect of treatment.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

Ovid MEDLINE, EMBASE, PEDro, CINAHL, and Cochrane databases were searched for relevant studies. Eligibility criteria for selecting studies consisted of randomized controlled trials, cohort studies, and case series (≥10 participants) including weightbearing or exercise-based interventions within 8 weeks after Achilles tendon rupture.

Results:

A total of 174 studies published between 1979 and 2018 were included. Studies were rated a median (interquartile range [IQR]) of 17 (15-20) on the Downs & Black checklist and included 9098 participants. Early functional rehabilitation incorporated weightbearing (95%), range of motion (73%), and isometric/strengthening exercises (50%). Weightbearing was initiated within the first week, whereas exercise (eg, ankle range of motion, strengthening, whole-body conditioning) was initiated in the second week. Initiation of exercises varied based on whether treatment was nonsurgical (mean, 3.0 weeks; IQR, 2.0-4.0 weeks) or simple (mean, 2.0 weeks; IQR, 0.0-2.3 weeks) or augmented surgical repair (mean, 0.5 weeks; IQR, 0.0-2.8 weeks) (P = .017). Functional outcomes including ankle range of motion (n = 84) and strength (n = 76) were reported in 130 studies. Other outcome domains included patient-reported outcomes (n = 89), survey-based functional outcomes (n = 50), and tendon properties (n = 53).

Conclusion:

Early functional rehabilitation includes weightbearing and a variety of exercise-based interventions initiated within the first 2 weeks after acute Achilles tendon rupture/repair. Because early functional rehabilitation has lacked a standardized definition, interventions and outcome measures are highly variable, and pooling data across studies should be done with attention paid to what was included in the intervention and how treatment was assessed.

Efficacy of early controlled motion of the ankle compared with immobilisation in non-operative treatment of patients with an acute Achilles tendon rupture: an assessor-blinded, randomised controlled trial

Background

Early controlled motion (ECM) of the ankle is widely used in the non-operative treatment of acute Achilles tendon rupture, although its safety and efficacy have not been investigated properly in a randomised set-up.

Purpose/Aim of the study

To investigate if ECM of the ankle was superior to immobilisation in the treatment of acute Achilles tendon rupture.

Materials and methods

This was an assessor-blinded, randomised controlled trial with patients allocated in a 1:1 ratio to one of two parallel groups. Patients aged 18–70 years were eligible for inclusion. The ECM group performed movements of the ankle five times a day from week 3 to week 8 after rupture. The control group was immobilised for 8 weeks. The primary outcome was the Achilles tendon Total Rupture Score (ATRS) evaluated at 1-year postinjury. The secondary outcomes were heel-rise work test (HRW), Achilles tendon elongation and rate of rerupture. Analysis was conducted as intention-to-treat using inverse probability weighting.

Findings/Results

189 patients were assessed for eligibility and 130 were included from February 2014 to December 2016. There were 64 patients in the ECM group and 58 in the immobilisation group. There were no statistically significant differences (p>0.3) between the ECM and the immobilisation groups at 1 year: mean (SD) ATRS was 74 (18) and 75 (18), respectively. HRW was 60% (21) and 60% (21) of the uninjured limb, and elongation was 18 mm (13) and 16 mm (11), respectively. Correspondingly, there were six and seven reruptures.

Conclusions

ECM revealed no benefit compared with immobilisation in any of the investigated outcomes.

Trial registration number

NCT02015364

Minimally Invasive Treatments of Acute Achilles Tendon Ruptures

Achilles tendon rupture is a common injury to the lower extremity that requires appropriate treatment to minimize functional deficit. Available treatments of Achilles tendon ruptures include nonoperative, open surgical repair, percutaneous repair, and minimally invasive repair. Open surgical repair obtains favorable functional outcomes with significant potential for deep soft tissue complications, calling into question the value of open repair. Percutaneous repair is an alternative option with comparable functional results and minimal soft tissue complications; however, sural nerve injury is a complication. Minimally invasive Achilles repair offers optimal results with superior functional outcomes with minimal soft tissue complications and sural nerve injury.

Comparison Between Early Functional Rehabilitation and Cast Immobilization After Minimally Invasive Repair for an Acute Achilles Tendon Rupture

The purpose of the present study was to compare the outcomes of patients with Achilles tendon rupture treated with minimally invasive repair and early functional rehabilitation with the outcomes of similar patients treated with cast immobilization. After undergoing minimally invasive surgery, a below-knee splint with the foot in 30° of plantarflexion was applied to each patient for the first week. Patients were then assigned to a cast immobilization group (IG; n = 25) or a functional group (FG; n = 16). Data were collected during outpatient checks at 6 weeks, 3 months, 6 months, and 1 year. Outcomes of interest included range of motion (ROM), heel height, calf circumference, pain and functional score, return to work and light sports activity, and complications. The time interval for return to work in the FG was faster than that in the IG (p = .026). There was no clinically important difference between the 2 groups with regard to heel height, ROM, return to sports, calf circumference, visual analog scale, American Orthopaedic Foot and Ankle Society score, or Achilles tendon Total Rupture Score at every outpatient check except ROM difference at 6 weeks and heel height at 3 months. Rerupture occurred in 2 patients (1 [4%] in the IG and 1 [6.25%] in the FG). Early functional rehabilitation seemed to be as safe as traditional postoperative immobilization with a similar functional result and complications, but it was advantageous for the early phase of rehabilitation only.

Surgical Versus Non-Surgical Methods for Acute Achilles Tendon Rupture: A Meta-Analysis of Randomized Controlled Trials

We performed a meta-analysis to (1) compare surgical and non-surgical treatment methods for repair of acute rupture of the Achilles tendon, in terms of the re-rupture rate, incidence of complications other than re-rupture, functional outcomes, and proportion of patients returning to previous levels of sporting activities, and (2) explore the difference in the re-rupture rate if proven early functional rehabilitation protocols were followed. PubMed, EMBASE, Medline, and Cochrane Central Register of Controlled Trials databases were searched to identify randomized clinical trials. The quality of included studies was assessed by the Cochrane risk-of-bias tool. The random-effects model or subgroup analysis would be chosen to perform the meta-analysis if the data were heterogeneous; otherwise, the fixed-effect model would be selected. Ten randomized clinical trials with a total of 934 randomized patients were included. Patients in the non-surgical group underwent higher re-ruptures than patients in the surgical group (p = .0002), but the re-rupture rates were equivalent in the non-surgical group and the surgical group (p = .08) if an early range of motion exercises protocol was performed. Lower incidence of complications excluding re-rupture was found in non-surgical patients (p = .006). However, the surgical group had better results in functional outcomes when evaluated by 2 different jump tests (drop counter-movement jump [p = .002], Hopping [p = .004]) and 1 muscular endurance test (Heel-rise work [p = .01]). The 2 groups had no significant difference in the proportion of patients returning to previous levels of sporting activities (p = 0.87). The risk of re-rupture after surgical or non-surgical treatment was equivalent if a functional rehabilitation protocol with early range of motion was performed, but the risk of other complications happening after surgical treatment was higher than in non-surgical treatment.

Acute Achilles tendon rupture: Do cast boots produce adequate equinus when used for functional rehabilitation?

Acute Achilles tendon rupture is frequently treated conservatively using functional rehabilitation protocols in which the ankle is held in equinus. Equinus is achieved using a variety of means including equinus casts and rigid boots with heel wedges. Concerns have been raised that rigid boots with heel wedges do not achieve adequate equinus. Patients presenting to our institutions with an acute Achilles tendon rupture were randomised to treatment with an equinus cast or rigid boot with heel wedges. After application of these lateral radiographs of the hindfoot and ankle were taken, and these used to measure tibiotalar angle (TTA), tibio-1st metatarsal angle (TMA) and posterior malleolar to calcaneal tip height (PCH). 15 patients were randomised to a rigid boot and 14 to an equinus cast. The mean TTA was 124° in the rigid boot group and 136° in the equinus cast group (p<0.001). The mean TMA was 134° in the rigid boot group and 147° in the equinus cast group (p<0.001). The mean PCH was 25mm in the rigid boot group and 15mm in the equinus cast group (p<0.05). Our results demonstrate that the rigid boots with heel wedges used in our institutions produce significantly less equinus than an equinus cast. Whilst the clinical relevance of this remains uncertain, clinicians should be aware that rigid boots with wedges and equinus casts may not achieve the same degree of Achilles tendon shortening.

Effect of Early Versus Late Weightbearing in Conservatively Treated Acute Achilles Tendon Rupture: A Meta-Analysis

Achilles tendon ruptures can be either surgically or conservatively treated with either early functional mobilization or cast immobilization. The purpose of the present study was to conduct a meta-analysis comparing the effect of early versus late weightbearing in conservatively treated adult patients, including only randomized controlled trials (RCTs). The primary endpoint was rerupture, and the secondary endpoints were strength, quality of life during treatment, range of motion, deep venous thrombosis, return to sports, and return to work. The search for studies was conducted using PubMed, EMBASE, and the Cochrane Central Register of Controlled trials. A search was performed, and 2 reviewers independently screened the studies by title, abstract, and, finally, by reading the full text. Four studies met the inclusion criteria. The reference lists of the included studies were scanned and 1 additional RCT study was included. The critical appraisal skills program checklist was applied for study appraisal. A statistician performed the data management and analysis. No statistically significant differences were found between the 2 treatment groups concerning rerupture (p = .796), return to sports (p = .455), or return to work (p = .888). One RCT found 1 case of deep venous thrombosis in the late weightbearing group. One RCT reported significant improvement in quality of life and one reported a significantly improved range of dorsiflexion in the early weightbearing group. No statistically significant difference was found between early and late weightbearing with conservative treatment regarding the rerupture rate. The results of the other outcomes were limited by the low number of studies included in the present meta-analysis. Larger randomized studies are needed to investigate these outcomes. From the results in the present study, we would recommend early weightbearing when an Achilles tendon rupture is treated conservatively.

Cast versus functional brace in the rehabilitation of patients treated non-operatively for a rupture of the Achilles tendon: protocol for the UK study of tendo achilles rehabilitation (UK STAR) multi-centre randomised trial

INTRODUCTION

Achilles tendon rupture affects over 11 000 people yearly in the UK, and the incidence is increasing. Controversy remains with regard to the best rehabilitation strategy for these patients. In operatively treated patients, functional bracing provides better outcomes compared with plaster casts. However, the role of functional bracing in non-operatively managed patients is unclear. This is the protocol for a multicentre randomised trial of plaster cast immobilisation versus functional bracing for patients with a non-operatively managed Achilles tendon rupture.

METHODS AND ANALYSIS

All adults presenting with a primary rupture of the Achilles tendon will be screened. Non-operatively treated patients will be eligible to take part in the trial. Broad eligibility criteria will ensure that the results of the study can be generalised to the wider patient population. Randomisation will be on a 1:1 basis. Both rehabilitation strategies are widely used within the National Health Service. Standardised protocols will be followed, and details of plaster material and brace will be as per the site's usual practice.A minimum of 330 patients will be randomised to obtain 90% power to detect a difference of 8 points in Achilles Tendon Total Rupture Score at 9 months. Quality of life and resource use will be collected at 3, 6 and 9 months. The differences between treatment groups will be assessed on an intention-to-treat basis. The results of the trial-based economic evaluation will be expressed in terms of incremental cost per quality-adjusted life-year gained.

ETHICS AND DISSEMINATION

The National Research Ethic Committee approved this study on 18 March 2016 (16/SC/0109).The National Institute for Health Research Health Technology Assessment monograph and a manuscript to a peer-reviewed journal will be submitted on completion of the trial (summer 2019). The results of this trial will substantially inform clinical practice on the clinical and cost-effectiveness of the treatment of this injury. This study has been registered on the International Standard Randomised Controlled Trial Number registry with reference no ISRCTN62639639.

Increasing age in Achilles rupture patients over time

BACKGROUND

The changing demographics of Achilles tendon rupture (ATR) patients have not fully been investigated. However, there has been a general suspicion that this injury is occurring in an increasingly older population, in terms of mean age. The aim of this study was to objectively show an increase in age in Achilles tendon rupture patients over time.

METHODS

Published literature on Achilles tendon ruptures was searched for descriptive statistics on the demographics of patients in the studies, specifically mean and median age of Achilles tendon rupture patients, gender ratio, percentage of athletics-related injuries, percentage of smokers, and BMI. Linear regression analyses were performed to determine the trend of patient demographics over time. A Welch one-way ANOVA was carried out to identify any possible differences in data obtained from different types of studies.

RESULTS

The patient demographics from 142 studies were recorded, with all ATR injuries occurring between the years 1953 and 2014. There was no significant difference in the mean age data reported by varying study types, i.e. randomized controlled trial, cohort study, case series, etc. (P=0.182). There was a statistically significant rise in mean age of ATR patients over time (P<0.0005). There was also a statistically significant drop in percentage of male ATR patients (P=0.02). There is no significant trend for percentage of athletics-related injuries, smoking or BMI.

CONCLUSION

Since 1953 to present day, the mean age at which ATR occurs has been increasing by at least 0.721 years every five years. In the same time period, the percentage of female study patients with ATR injuries has also been increasing by at least 0.6% every five years.

LEVEL OF EVIDENCE

Level III; Retrospective cohort study.

Rehabilitation of Achilles tendon ruptures: is early functional rehabilitation daily routine?

INTRODUCTION

Ruptures of the Achilles tendon are the most common tendon injuries of the lower extremities. Besides the initial operative or non-operative treatment, rehabilitation of patients plays a crucial role for tendon healing and long-term outcome. As only limited evidence is available for optimized rehabilitation regimen and guidelines for the initial (e.g., first 6 weeks) rehabilitation are limited, this study investigated the current rehabilitation concepts after Achilles tendon rupture.

MATERIALS AND METHODS

We analyzed 213 written rehabilitation protocols that are provided by orthopedic and trauma surgery institutions throughout Germany in terms of recommendations for weight-bearing, range of motion (ROM), physiotherapy, and choice of orthosis. All protocols for operatively and non-operatively treated Achilles tendon ruptures were included. Descriptive analysis was carried out and statistical analysis applied where appropriate.

RESULTS

Of 213 institutions, 204 offered rehabilitation protocols for Achilles tendon rupture and, therefore, 243 protocols for operative and non-operative treatment could be analyzed. While the majority of protocols allowed increased weight-bearing over time, significant differences were found for durations of fixed plantar flexion between operative (o) and non-operative (n) treatments [fixed 30° (or 20)° to 15° (or 10)°: 3.6 weeks (±0.1; o) vs 4.7 weeks (±0.3; n) (p ≤ 0.0001) and fixed 15° (or 10)° to 0°: 5.8 weeks (±0.1; o) vs 6.6 weeks (±0.2; n) (p ≤ 0.001)]. The mean time of the recommended start of physiotherapy is at 2.9 weeks (±0.2; o) vs 3.3 weeks (±0.4; n), respectively.

CONCLUSION

Our study shows that a huge variability in rehabilitation after Achilles tendon rupture exists. This study shows different strategies in rehabilitation of Achilles tendon ruptures using a convertible vacuum brace system. To improve patient care, further clinical as well as biomechanical studies need to be conducted. This study might serve as basis for prospective randomized controlled trials to optimize rehabilitation for Achilles tendon ruptures.

Achilles tendon injuries

PURPOSE OF REVIEW

The purpose of this study is to review the current literature of Achilles tendon injuries, specifically chronic tendinopathy and acute ruptures in regard to etiology, diagnosis, treatment options, and outcomes.

RECENT FINDINGS

The incidence of Achilles tendon injuries is increasing, but the necessity for surgical intervention is decreasing due to improved conservative therapies, which may provide comparable outcomes without the implied surgical risk. If surgery is undertaken, no difference has been noted between open and minimally invasive techniques. The majority of patients are able to return to pre-injury level of activity, with the elite athlete as an unfortunate exception. Achilles injuries can be devastating injuries, but if addressed early and appropriately, most patients have good self-reported long-term outcomes regardless of the treatment modality implemented. Further research is needed into the etiology, potential preventative measures, and longer-term outcomes of the different treatment options for wide range of Achilles pathology.

Acute Achilles Tendon Ruptures: An Update on Treatment

Acute rupture of the Achilles tendon is common and seen most frequently in people who participate in recreational athletics into their thirties and forties. Although goals of treatment have not changed in the past 15 years, recent studies of nonsurgical management, specifically functional bracing with early range of motion, demonstrate rerupture rates similar to those of tendon repair and result in fewer wound and soft-tissue complications. Satisfactory outcomes may be obtained with nonsurgical or surgical treatment. Newer surgical techniques, including limited open and percutaneous repair, show rerupture rates similar to those of open repair but lower overall complication rates. Early research demonstrates no improvement in functional outcomes or tendon properties with the use of platelet-rich plasma, but promising results with the use of bone marrow-derived stem cells have been seen in animal models. Further investigation is necessary to warrant routine use of biologic adjuncts in the management of acute Achilles tendon ruptures.

Non-surgical treatment of Achilles rupture: Does duration in functional weight bearing orthosis matter?

BACKGROUND

The treatment of acute Achilles tendon ruptures is continually being debated. The success of non-surgical regimes is now evident yet there remains a high rate of surgery in the United States of America and Scandinavia. Recent studies have investigated functional outcome rather than complication rates as primary outcome but the current data are still sparse. We aimed to investigate whether there is any difference in functional outcomes between two dynamic regimes of differing durations for acute Achilles tendon ruptures.

METHODS

The patients in the two groups were matched for age, gender, follow-up duration and mechanism of injury. Forty-four patients were managed in a regime of 11 weeks and another 44 patients for 8 weeks. Demographics, injury details, complications and functional outcome were recorded. The validated Achilles Tendon Rupture Score (ATRS) was used to assess functional outcomes. Minimum follow-up was 1 year.

RESULTS

The 11-week group had a mean age of 50.8 years (range: 27-80) with 36 (82%) males. The 8-week group had a mean age of 52.0 years (range: 32-77) with 36 (82%) males. The mean ATRS for the 11-week group was 76.0 (range: 8-100). The mean ATRS for the 8-week group was 76.1 (range: 30-100). There were no re-ruptures in the 11-week group and one in the 8-week group. There were three episodes of venous thromboembolism in the 11-week group and four in the 8-week group.

CONCLUSION

A reduction in duration of dynamic rehabilitation for non-operative treatment of Achilles tendon rupture from 11 weeks to 8 weeks does not lead to a significant detriment in functional outcomes or complication rates.

Efficacy of early controlled motion of the ankle compared with no motion after non-operative treatment of an acute Achilles tendon rupture: study protocol for a randomized controlled trial

BACKGROUND

Early controlled ankle motion is widely used in the non-operative treatment of acute Achilles tendon rupture, though its safety and efficacy have never been investigated in a randomized setup. The objectives of this study are to investigate if early controlled motion of the ankle affects functional and patient-reported outcomes.

METHODS/DESIGN

The study is performed as a blinded, randomized, controlled trial with patients allocated in a 1:1 ratio to one of two parallel groups. Patients aged from 18 to 70 years are eligible for inclusion. The intervention group performs early controlled motion of the ankle in weeks 3-8 after rupture. The control group is immobilized. In total, 130 patients will be included from one big orthopedic center over a period of 2½ years. The primary outcome is the patient-reported Achilles tendon Total Rupture Score evaluated at 12 months post-injury. Secondary outcome measures are the heel-rise work test, Achilles tendon elongation, and the rate of re-rupture. The primary analysis will be conducted as intention-to-treat analyses.

DISCUSSION

This trial is the first to investigate the safety and efficacy of early controlled motion in the treatment of acute Achilles tendon rupture in a randomized setup. The study uses the patient-reported outcome measure, the Achilles tendon Total Rupture Score, as the primary endpoint, as it is believed to be the best surrogate measure for the tendon's actual capability to function in everyday life.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02015364 . Registered on 13 December 2013.

Functional rehabilitation of patients with acute Achilles tendon rupture: a meta-analysis of current evidence

PURPOSE

The optimal treatment for acute Achilles tendon rupture (ATR) is continuously debated. Recent studies have proposed that the choice of either operative or non-operative treatment may not be as important as rehabilitation, suggesting that functional rehabilitation should be preferred over traditional immobilization. The purpose of this meta-analysis of randomized controlled trials (RCTs) was to compare functional rehabilitation to immobilization in the treatment of ATR.

METHOD

This meta-analysis was conducted using the databases: PubMed, EMBASE, Rehabilitation and Sports Medicine Source, AMED, CINAHL, Cochrane Library and PEDro using the search terms: "Achilles tendon," "rupture," "mobilization" and "immobilization". Seven RCTs involving 427 participants were eligible for inclusion, with a total of 211 participants treated with functional rehabilitation and 216 treated with immobilization.

RESULTS

Re-rupture rate, other complications, strength, range of motion, duration of sick leave, return to sport and patient satisfaction were examined. There were no statistically significant differences between groups. A trend favoring functional rehabilitation was seen regarding the examined outcomes.

CONCLUSION

Functional rehabilitation after acute Achilles tendon rupture does not increase the rate of re-rupture or other complications. A trend toward earlier return to work and sport, and increased patient satisfaction was found when functional rehabilitation was used. The present literature is of low-to-average quality, and the basic constructs of the examined treatment and study protocols vary considerably. Larger, randomized controlled trials using validated outcome measures are needed to confirm the findings.

LEVEL OF EVIDENCE

II.

Prospective Use of a Standardized Nonoperative Early Weightbearing Protocol for Achilles Tendon Rupture: 17 Years of Experience

BACKGROUND

Acute traumatic rupture of the Achilles tendon can be treated operatively or nonoperatively. Throughout the literature, there is no consensus regarding the optimal treatment protocol.

PURPOSE

To report on 17 years of experience with treating this injury with a standardized nonoperative treatment protocol.

STUDY DESIGN

Case Series; Level of evidence, 4.

METHODS

The treatment protocol was based on a combination of an equinus cast and rehabilitation boot, which promoted immediate full weightbearing and early functional rehabilitation. A total of 171 patients were consecutively treated and prospectively followed from 1996 to 2013. Assessed were subjective parameters such as pain, loss of strength, return to previous activity level, meteosensitivity, and general satisfaction with the treatment outcome. Clinical assessment included testing of plantar flexion strength and endurance, calf circumference, and tendon length. Subjective and clinical parameters were then used to calculate a modified Thermann score. The correlation between tendon lengthening and function was calculated using the Pearson correlation coefficient.

RESULTS

A total of 114 patients were followed for a minimum of 12 months (mean, 27 ± 20 months; range, 12-88 months). The mean Thermann score was 82 ± 13 (range, 41-100), and subjective satisfaction was rated "very good" and "good" in 90%. An inverse correlation was found between tendon length and muscle strength (R = -0.3). There were 11 reruptures (8 with and 3 without an adequate trauma). General complications were 5 deep venous thromboses, 1 complex regional pain syndrome, and minor problems such as transient heel pain (n = 3), heel numbness (n = 1), and cast-associated skin abrasions (n = 4).

CONCLUSION

Seventeen years of experience with a nonoperative treatment protocol for acute rupture of the Achilles tendon confirmed good functional outcome and patient satisfaction. Reruptures mostly occurred with new traumatic events in the vulnerable phase from 6 to 12 weeks after the initial injury. Muscle strength correlated to tendon length, making its assessment a crucial follow-up parameter. The protective equinus cast and boot can protect against excessive tendon lengthening during the healing process.

Rehabilitation after anatomical ankle ligament repair or reconstruction

The selection, implementation of and adherence to a post-operative regimen are all essential in order to achieve the best outcomes after ankle ligament surgery. The purpose of this paper is to present a best-evidence approach to this, with grounding in basic science and a consensus opinion from the members of the ESSKA-AFAS Ankle Instability Group. Basic science and clinical evidence surrounding tissue healing after surgical repair or reconstruction of the ligaments as well as around the re-establishment of sensorimotor control are reviewed. A consensus opinion based on this evidence as to the recommended rehabilitation protocol after ankle ligament surgery was then obtained from the members of the ESSKA-AFAS Ankle Instability Group. Rehabilitation recommendations are presented for the initial post-operative period, the early recovery phase and a goal-orientated late rehabilitation and return-to-sport phase. This paper presents practical, evidenced-based guidelines for rehabilitation and return to activity after lateral ankle ligament surgery.

Rehabilitation after anatomical ankle ligament repair or reconstruction

The selection, implementation of and adherence to a post-operative regimen are all essential in order to achieve the best outcomes after ankle ligament surgery. The purpose of this paper is to present a best-evidence approach to this, with grounding in basic science and a consensus opinion from the members of the ESSKA-AFAS Ankle Instability Group. Basic science and clinical evidence surrounding tissue healing after surgical repair or reconstruction of the ligaments as well as around the re-establishment of sensorimotor control are reviewed. A consensus opinion based on this evidence as to the recommended rehabilitation protocol after ankle ligament surgery was then obtained from the members of the ESSKA-AFAS Ankle Instability Group. Rehabilitation recommendations are presented for the initial post-operative period, the early recovery phase and a goal-orientated late rehabilitation and return-to-sport phase. This paper presents practical, evidenced-based guidelines for rehabilitation and return to activity after lateral ankle ligament surgery.

Early functional rehabilitation or cast immobilisation for the postoperative management of acute Achilles tendon rupture? A systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

To determine which postoperative rehabilitation regime is superior following surgical repair of acute Achilles tendon rupture. The primary outcomes were patient safety and satisfaction.

DESIGN

Intervention meta-analysis.

DATA SOURCES

The MEDLINE and CINAHL electronic databases were searched from their date of inception until June 2015 using keywords related to acute Achilles tendon rupture, surgical repair and rehabilitation. The electronic database search was supplemented with forward citation tracking using the Web of Science.

ELIGIBILITY CRITERIA

Randomised controlled trials comparing clinical and/or patient-reported outcomes between patients receiving early functional postoperative ankle motion and weight bearing (bracing group), and traditional ankle immobilisation with a non-weight bearing rigid cast (cast group) were eligible for inclusion. Fourteen articles were identified as potentially eligible; 10 sufficient-quality randomised controlled trials involving 570 patients were included for meta-analysis.

MAIN RESULTS

A high proportion of patients were able to return to prior employment and sporting activity in both groups. Five of the six trials measuring the time interval showed a faster return to prior sporting level in the bracing group. Subjective patient outcomes were significantly better in the bracing group (for good and excellent results, p=0.01; OR, 3.13; 95% CI 1.30 to 7.53). There was no difference in major complications between the two groups (p=0.21; RD, -0.03; 95% CI -0.06 to 0.01). Dynamometry and anthropometry measurements favoured functional rehabilitation at 6-12 weeks postoperation; however, by 6 months postoperative, the differences were negligible.

CONCLUSIONS

Compared to traditional ankle immobilisation, with a non-weight bearing cast following surgical repair of acute Achilles tendon rupture, early dynamic functional rehabilitation is as safe with higher patient satisfaction.

Weight bearing the same day versus non-weight bearing for 4 weeks in Achilles tendon rupture

INTRODUCTION

Achilles tendon rupture (ATR) often occurs in 40- to 50-year-old men. Multiple studies discuss the correct treatment strategy based on surgical or nonsurgical intervention, including early mobilization. We aimed to compare the outcomes of bearing weight on the same day with non-weight bearing over a 4-week period of ATR patients.

MATERIALS AND METHOD

Forty-seven ATR patients were conservatively treated and entered into our study. Group 1 consisted of 23 patients treated with partial weight bearing beginning the same day of conservative treatment; Group 2 consisted of 24 patients treated with non-weight bearing after a 4-week period. Patients were at least 18 years old and were followed for 12 months. Evaluation criteria were mechanism of injury, admission time to our clinic, complication rate, and time to return to work. Symptoms and physical activity levels of all patients were assessed on 6 and 12 months after treatment began, according to the Achilles Tendon Total Rupture Score (ATRS), Physical Activity Scale (PAS), and American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score.

RESULTS

Rerupture rates were rate 17.4% (4 patients) in Group 1 and 12.5% (3 patients) in Group 2 (p = 0.81). Time to return to work was shorter in Group 1 compared with Group 2, but it was not statistically significant (p = 0.86). AOFAS, ATRS, and PAS scores at 6 and 12 months showed no significant differences between groups (p = 0.69, p = 0.59, p = 0.89, p = 0.77, p = 0.94, p = 0.66, respectively).

CONCLUSION

This study showed that a well-conducted early-weight-bearing treatment has good clinical outcomes, with a complication rate no higher than non-weight-bearing treatment.

Achilles tendon rupture rehabilitation: a mixed methods investigation of current practice among orthopaedic surgeons in the United Kingdom

OBJECTIVES

The evidence base to inform the management of Achilles tendon rupture is sparse. The objectives of this research were to establish what current practice is in the United Kingdom and explore clinicians' views on proposed further research in this area. This study was registered with the ISRCTN (ISRCTN68273773) as part of a larger programme of research.

METHODS

We report an online survey of current practice in the United Kingdom, approved by the British Orthopaedic Foot and Ankle Society and completed by 181 of its members. A total of ten of these respondents were invited for a subsequent one-to-one interview to explore clinician views on proposed further research in this area.

RESULTS

The survey showed wide variations in practice, with patients being managed in plaster cast alone (13%), plaster cast followed by orthoses management (68%), and orthoses alone (19%). Within these categories, further variation existed regarding the individual rehabilitation facets, such as the length of time worn, the foot position within them and weight-bearing status. The subsequent interviews reflected this clinical uncertainty and the pressing need for definitive research.

CONCLUSIONS

The gap in evidence in this area has resulted in practice in the United Kingdom becoming varied and based on individual opinion. Future high-quality randomised trials on this subject are supported by the clinical community. Cite this article: Bone Joint Res 2015;4:65-9.

Nonoperative dynamic treatment of acute achilles tendon rupture: the influence of early weight-bearing on clinical outcome: a blinded, randomized controlled trial

BACKGROUND

Dynamic rehabilitation has been suggested to be an important part of nonoperative treatment of acute Achilles tendon rupture that results in functional outcome and rerupture rates comparable with those of operative treatment. However, the optimal role of weight-bearing during early rehabilitation remains unclear. The purpose of this study was to compare immediate weight-bearing with non-weight-bearing in a nonoperative dynamic treatment protocol for Achilles tendon rupture.

METHODS

The study was conducted as a blinded, randomized, controlled, parallel superiority trial. Patients eighteen to sixty years of age were eligible for inclusion. Both groups were treated nonoperatively with controlled early motion. The intervention group was allowed full weight-bearing from day one, and the control group was non-weight-bearing for six weeks. The primary outcome was the Achilles tendon Total Rupture Score (ATRS) after one year. Secondary outcomes included heel-rise work, health-related quality of life, and the rerupture rate. Outcome assessors were blinded to the intervention.

RESULTS

Thirty patients were randomized to each group; twenty-nine in the weight-bearing group and twenty-seven in the control group were analyzed. The only significant difference between the groups was better health-related quality of life in the weight-bearing group at twelve months (p = 0.009). The mean ATRS at twelve months was 73 in the weight-bearing group and 74 in the control group (p = 0.81). At twelve months, the total heel-rise work performed by the injured limb relative to that by the uninjured limb was 53% in the weight-bearing group and 58% in the control group (p = 0.37). There were three reruptures in the weight-bearing group and two in the control group (p = 1.0).

CONCLUSIONS

The ATRS and heel-rise work results did not differ significantly between the groups. The rerupture rate was 9% overall, and both groups had substantial functional deficits in the injured limb compared with the uninjured limb. Immediate weight-bearing can be recommended as an option in the nonoperative treatment of Achilles tendon rupture.

A retrospective comparative study with historical control to determine the effectiveness of platelet-rich plasma as part of nonoperative treatment of acute achilles tendon rupture

PURPOSE

The aim of this study was to evaluate the effectiveness of platelet-rich plasma (PRP) in the nonoperative treatment of acute Achilles tendon rupture.

METHODS

This was a comparative study that included a prospective cohort and a historical control group. The control group was formed from a randomized trial in which one arm of the trial underwent nonoperative treatment, including accelerated functional rehabilitation after acute Achilles tendon rupture identical to that performed in the prospective treatment group. Patients in the prospective group were recruited consecutively and were administered 2 injections of PRP during the first 2 weeks after the injury. The primary outcome was isokinetic plantar flexion strength at 1 and 2 years after injury. Secondary outcomes included range of motion (ROM), calf circumference, and Leppilahti score. The ankle-hindfoot scale (American Orthopedic Functional Ankle Scale [AOFAS]) was administered to patients who received the PRP injection in the prospective group but was not measured for the historical group.

RESULTS

A total of 73 patients participated in the prospective PRP study group and were compared with a retrospective control group of 72 patients from a previous randomized controlled trial (RCT). The mean difference between groups in isokinetic plantar flexion strength (injured/uninjured) at 1 year after injury was -4.3% (95% confidence interval [CI], -15.9 to 7.3; P = .5) and 2.4% (95% CI, -8.6 to 13.5; P = .7) at 30°/s and 60°/s, respectively. Results at 2 years after injury were -3.1% (95% CI, -13.5 to 7.2; P = .6) and 4.8% (95% CI, -3.5 to 13.1; P = .3) at 30°/s and 60°/s, respectively. All secondary outcomes were also not statistically different.

CONCLUSIONS

The results of this study suggest that there is no measurable clinical benefit to the addition of PRP to the treatment regimen for nonoperatively treated acute Achilles tendon rupture.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.