Postoperative Rehabilitation Protocols for Achilles Tendon Ruptures

ABSTRACTAchilles tendon ruptures are common injuries that lead to functional deficits in two-thirds of patients. Progressively loading the healing tendon has been associated with superior outcomes, but the loading profiles that patients experience throughout rehabilitation have not yet been established. In this study, we developed and calibrated an instrumented immobilizing boot paradigm that is aimed at longitudinally quantifying patient loading biomechanics to develop personalized rehabilitation protocols. We used a 3-part instrumented insole to quantify the ankle loads generated by the Achilles tendon and secured a load cell in-line with the posterior strut of the immobilizing boot to quantify boot loading. We then collected gait data from five healthy young adults to demonstrate the validity of this instrumented immobilizing boot paradigm to assess Achilles tendon loading during ambulation. We developed a simple calibration procedure to improve the measurement fidelity of the instrumented insole needed to quantify Achilles tendon loading while ambulating with an immobilizing boot. By assessing Achilles tendon loading with the ankle constrained to 0 degrees and 30 degrees plantar flexion, we confirmed that walking with the foot supported in plantar flexion decreased Achilles tendon loading by 60% (P < 0.001). This instrumented immobilizing boot paradigm leverages commercially available sensors and logs data using a small microcontroller secured to the boot and a handheld device, making our paradigm capable of continuously monitoring biomechanical loading outside of the lab or clinic.

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Acute Achilles Tendon Rupture in Badminton Players

The American Journal of Sports Medicine ◽

10.1177/03635465980260032201 ◽

1998 ◽

Vol 26 (3) ◽

pp. 467-470 ◽

Cited By ~ 36

Author(s):

Martin Fahlström ◽

Ulf Björnstig ◽

Ronny Lorentzon

Keyword(s):

Achilles Tendon ◽

Achilles Tendon Rupture ◽

Specific Treatment ◽

Treated Group ◽

Activity Level ◽

University Hospital ◽

Long Term Results ◽

Postoperative Rehabilitation ◽

Sports Activity ◽

Tendon Ruptures

All patients with badminton-related acute Achilles tendon ruptures registered during 1990 to 1994 at the University Hospital of Umeå were retrospectively followed up using a questionnaire. Thirty-one patients (mean age, 36.0 years), 27 men and 4 women, were included. Thirty patients (97%) described themselves as recreational players or beginners. The majority of the injuries (29 of 31, 94%) happened at the middle or end of the planned game. Previous local symptoms had been noticed by five patients (16%). Long-term results showed that patients treated with surgery had a significantly shorter sick leave absence than patients treated without surgery (50 versus 75 days). There was no obvious selection favoring any treatment modality. None of the surgically treated patients had reruptures, but two reruptures occurred in the nonsurgically treated group. There seemed to be fewer remaining symptoms and a higher sports activity level after the injury in the surgically treated group. Our results indicate that local muscle fatigue may interfere with strength and coordination. Preventive measures such as specific treatment of minor injuries and adequate training of strength, endurance, and coordination are important. Our findings also indicate that surgical treatment and careful postoperative rehabilitation is of great importance among badminton players of any age or sports level with Achilles tendon ruptures.

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Biomechanical Head-to-Head Comparison of 2 Sutures and the Giftbox Versus Bunnell Techniques for Midsubstance Achilles Tendon Ruptures

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967117707477 ◽

2017 ◽

Vol 5 (5) ◽

pp. 232596711770747 ◽

Cited By ~ 8

Author(s):

Rufus O. Van Dyke ◽

Sejul A. Chaudhary ◽

Gregory Gould ◽

Roman Trimba ◽

Richard T. Laughlin

Keyword(s):

Cyclic Loading ◽

Achilles Tendon ◽

Biomechanical Testing ◽

Gap Formation ◽

Postoperative Rehabilitation ◽

Repair Technique ◽

Significant Difference ◽

Load To Failure ◽

Tendon Ruptures ◽

To Receive

Background: Acute midsubstance Achilles tendon ruptures are a common orthopaedic problem for which the optimal repair technique and suture type remain controversial. Head-to-head comparisons of current fixation constructs are needed to establish which stitch/suture combination is most biomechanically favorable. Hypothesis: Of the tested fixation constructs, Giftbox repairs with Fiberwire will exhibit superior stiffness and strength during biomechanical testing. Study Design: Controlled laboratory study. Methods: Two biomechanical trials were performed, isolating stitch technique and suture type, respectively. In trial 1, 12 transected fresh-frozen cadaveric Achilles tendon pairs were randomized to receive either the Giftbox-modified Krackow or the Bunnell stitch with No. 2 Fiberwire suture. Each repair underwent cyclic loading, oscillating between 10 and 100 N at 2 Hz for 1000 cycles, with repair gapping measured at 500 and 1000 cycles. Load-to-failure testing was then performed, and clinical and catastrophic failure values were recorded. In trial 2, 10 additional paired cadaveric Achilles tendons were randomized to receive a Giftbox repair with either No. 2 Fiberwire or No. 2 Ultrabraid. Testing and data collections protocols in trial 2 replicated those used in trial 1. Results: In trial 1, the Bunnell group had 2 failures during cyclic loading while the Giftbox had no failures. The mean tendon gapping after cyclic loading was significantly lower in the Giftbox repairs (0.13 vs 2.29 mm, P = .02). Giftbox repairs were significantly stiffer than Bunnell (47.5 vs 38.7 N/mm, P = .019) and showed more tendon elongation (5.9 ± 0.8 vs 4.5 ± 1.0 mm, P = .012) after 1000 cycles. Mean clinical load to failure was significantly higher for Giftbox repairs (373 vs 285 N, P = .02), while no significant difference in catastrophic load to failure was observed (mean, 379 vs 336 N; P = .61). In trial 2, there were no failures during cyclic loading. The Giftbox + Fiberwire repairs recorded higher clinical load-to-failure values compared with Giftbox + Ultrabraid (mean, 361 vs 239 N; P = .005). No other biomechanical differences were observed in trial 2. Conclusion: Simulated early rehabilitation biomechanical testing showed that Giftbox-modified Krackow Achilles repair technique with Fiberwire suture was stronger and more resistant to gap formation at the repair site than combinations that incorporated the Bunnell stitch or Ultrabraid suture. Clinical Relevance: A more in-depth understanding of the biomechanical properties of the Giftbox repair will help inform surgical decision making because stronger repairs are less likely to fail during accelerated postoperative rehabilitation.

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Biomechanical Evaluation of Achilles Tendon Midsubstance Repair: The Effects of Anchor Angle and Position

Foot & Ankle Specialist ◽

10.1177/19386400211009360 ◽

2021 ◽

pp. 193864002110093

Author(s):

Ingrid K. Stake ◽

Jon W. Miles ◽

Brenton W. Douglass ◽

Grant J. Dornan ◽

Thomas O. Clanton

Keyword(s):

Achilles Tendon ◽

Sagittal Plane ◽

Repair System ◽

Suture Anchors ◽

Postoperative Rehabilitation ◽

Repair Technique ◽

Significant Difference ◽

Failure Loads ◽

Ultimate Failure ◽

Tendon Ruptures

Background The percutaneous knotless repair technique for Achilles tendon ruptures utilizes a Percutaneous Achilles Repair System (PARS) device for suturing the proximal tendon and 2 suture anchors for fixing the sutures into the calcaneus. Determining the best position of the suture anchors may optimize the strength of this repair. Methods Twelve pairs of human ankle cadaveric specimens were randomly assigned to receive suture anchors placed at 45°, 90°, or 135° from the sagittal plane. The anchors were tensioned according to a protocol representing progressive, postoperative rehabilitation. Load, number of loading cycles, displacement, and mode of failure were recorded. Results With the anchors placed at 45°, 90°, and 135°, the ultimate failure loads were mean 265 ± 64 N, 264 ± 75 N, and 279 ± 40 N, and the total number of loading cycles were mean 459 ± 166, 466 ± 158, and 469 ± 110, respectively. The effect of anchor angle on failure load, number of loading cycles, and displacement was not statistically significant. Visually, the anchors at 45° and 90° demonstrated sutures cutting through the bone. Conclusion We found no statistically significant difference in pullout strength between the 3 different anchor angles. Sutures cutting through the bone may be a concern with acute anchor angles. This suggests that a 135° anchor angle may result in a lower risk of tendon elongation with the percutaneous knotless repair technique. Levels of Evidence Cadaveric laboratory study

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Suture-Only Repair Versus Suture Anchor–Augmented Repair for Achilles Tendon Ruptures With a Short Distal Stump

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967116678722 ◽

2017 ◽

Vol 5 (1) ◽

pp. 232596711667872 ◽

Cited By ~ 1

Author(s):

Michael A. Boin ◽

Matthew A. Dorweiler ◽

Christopher J. McMellen ◽

Gregory C. Gould ◽

Richard T. Laughlin

Keyword(s):

Achilles Tendon ◽

Suture Anchor ◽

Achilles Tendon Rupture ◽

Peak Load ◽

Tendon Repair ◽

Distal Stump ◽

Rehabilitation Protocols ◽

Load To Failure ◽

Tendon Ruptures ◽

Active Rehabilitation

Background: Chronic noninsertional Achilles tendinosis can result in an acute Achilles tendon rupture with a short distal stump. In such tendon ruptures, there is a limited amount of adequate tissue that can hold suture, thus presenting a challenge for surgeons who elect to treat the rupture operatively. Hypothesis: Adding suture anchors to the repair construct may result in biomechanically stronger repairs compared with a suture-only technique. Study Design: Controlled laboratory study. Methods: Nine paired Achilles-calcaneus complexes were harvested from cadavers. An artificial Achilles rupture was created 2 cm proximal to the insertion on the calcaneus. One specimen from each cadaver was assigned to a suture-only or a suture anchor–augmented repair. The contralateral specimen of the same cadaver received the opposing repair. Cyclic testing was then performed at 10 to 100 N for 2000 cycles, and load-to-failure testing was performed at 0.2 mm/s. This was followed by analysis of repair displacement, gapping at repair site, peak load to failure, and failure mode. Results: The suture anchor–augmented repair exhibited a 116% lower displacement compared with the suture-only repair (mean ± SD, 1.54 ± 1.13 vs 3.33 ± 1.47 mm, respectively; P < .03). The suture anchor–augmented repair also exhibited a 45% greater load to failure compared with the suture-only repair (303.50 ± 102.81 vs 209.09 ± 48.12 N, respectively; P < .04). Conclusion: Suture anchor–augmented repairs performed on acute Achilles tendon ruptures with a short distal stump are biomechanically stronger than suture-only repairs. Clinical Relevance: Our results support the use of suture anchor–augmented repairs for a biomechanically stronger construct in Achilles tendon ruptures with a short distal stump. Biomechanically stronger repairs may lead to less tendon repair gapping and failure, increasing the ability to start early active rehabilitation protocols and thus improving patient outcomes.

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The Achilles Heel of Rehabilitation: Communication: A First Look at a National Research Survey

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00231 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0023

Author(s):

David Jenkins ◽

Daniel Urness ◽

Austin Thompson ◽

James Meeker

Keyword(s):

Physical Therapy ◽

Achilles Tendon ◽

Weight Bearing ◽

Years Of Experience ◽

Good Communication ◽

Research Survey ◽

Successful Recovery ◽

Rehabilitation Protocols ◽

Tendon Ruptures ◽

Communication Modalities

Category: Hindfoot, Rehabilitation Introduction/Purpose: For decades, there has been much debate over the proper treatment and rehabilitation protocols regarding the management of Achilles tendon ruptures (ATRs). With so much controversy, communication between physical therapists (PTs) and orthopaedic surgeons could prove to be paramount in ensuring successful recovery and return to post- morbid activities. Little research has been done in identifying effective communication modalities between surgeons and PTs and it remains unclear how this dynamic impacts the rehabilitation course. We examined the frequency of how common it is for PTs to receive rehabilitation protocols from referring orthopedic surgeons in patients who suffered Achilles tendon ruptures. Methods: A blinded national research survey was conducted of PTs who had treated ATR from 2012-2017. Researchers sought to create a generalizable sample of US PTs by selecting physical therapy clinics located in rural and urban areas of randomly selected states. Those who were actively practicing as a PTs and held a corresponding degree (DPT, MPT, and MSPT) were included. Non-practicing PTs, and those without a degree in physical therapy were excluded. A total of 56 respondents took part in the survey. Results: PTs practicing for 10 or more years were more likely to promote slower rehabilitation for non-surgical patients, while PTs with less than 10 years of experience preferred slower progress for operative patients (p=0.04). PTs with 10 or more years of experience were significantly more likely to have patients full weight bearing (FWB) after 6 weeks (p=0.01). PTs were also asked what factor was most important for good ATR outcomes. Three themes emerged, one was good communication between PTs and doctors. One respondent wrote “better communication between MD and PT for best outcomes.” The second theme was timing and implementation of proper clinical techniques such as ”early ROM and weight bearing.” A final theme centered on patient education, especially physicians educating patients on mobility restrictions. Conclusion: Despite belief that protocol driven approach improves outcomes, it remains unclear how well applied this is in practice. One of the most common responses given by PTs when asked what the most important factor is to ensure good outcomes in ATRs was good communication between PTs and doctors. This insight juxtaposed with 49% of PTs stating most of their recent patients arrived with no protocol, suggests one way to help improve patient outcomes might be to focus on improving communication between doctors and PTs.

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