Does Early Functional Mobilization Affect Long-Term Outcomes After an Achilles Tendon Rupture? A Randomized Clinical Trial

Background: Functional deficits and health-related impairments are common after an Achilles tendon rupture (ATR). Rehabilitation protocols vary greatly, and few studies have allowed loading in combination with ankle motion immediately after surgery (ie, early functional mobilization [EFM]). It is unclear whether EFM may counteract the negative impact of ankle immobilization after an ATR. Purpose: The primary aim of this study was to assess the efficacy of EFM compared with standard treatment (ie, 2 weeks of unloading in a plaster cast followed by 4 weeks of weightbearing in an orthosis) regarding patient-reported and functional outcomes in patients with an ATR after acute operative repair. The secondary aim was to explore whether the occurrence of deep venous thrombosis (DVT) during the 2 postoperative treatments affected outcomes. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 135 patients who underwent ATR repair, randomized to either EFM, including immediate postoperative loading and ankle motion, or standard treatment, were evaluated with functional tests and 5 self-administered outcome questionnaires at 6 and 12 months postoperatively. Results: At 6 months, the EFM group scored higher on the RAND 36-Item Health Survey (RAND-36) questionnaire subscales of general health and vitality ( P < .05) compared with the control group. No significant differences between the groups were found on disease-specific questionnaires (Achilles tendon Total Rupture Score [ATRS] and Foot and Ankle Outcome Score [FAOS]). At 12 months, no significant differences on any of the patient-reported outcome measures or the functional heel-rise test were seen between the groups. The RAND-36 subscale of general health, however, exhibited higher values in the EFM group (82.6 ± 16.9) than the control group (77.1 ± 17.0) ( P = .051) at 12 months after the injury. Patients sustaining DVT postoperatively had lower self-reported outcomes on the ATRS, FAOS, and RAND-36 questionnaires at 6 and 12 months compared with patients not having sustained DVT (all P < .05). Conclusion: This study demonstrated that an accelerated postoperative protocol with immediate loading and ankle motion resulted in better general health and vitality at 6 months. However, there were no differences between the groups in the recovery of heel-rise function. Future studies should focus on the means to reduce the risk of DVT to improve patient outcomes after ATR. Registration: NCT02318472 (ClinicalTrials.gov identifier).

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Early mobilization does not reduce the risk of deep venous thrombosis after Achilles tendon rupture: a randomized controlled trial

Knee Surgery Sports Traumatology Arthroscopy ◽

10.1007/s00167-019-05767-x ◽

2019 ◽

Vol 28 (1) ◽

pp. 312-319 ◽

Cited By ~ 8

Author(s):

Susanna Aufwerber ◽

Annette Heijne ◽

Gunnar Edman ◽

Karin Grävare Silbernagel ◽

Paul W. Ackermann

Keyword(s):

Venous Thrombosis ◽

Deep Venous Thrombosis ◽

Achilles Tendon ◽

Tendon Rupture ◽

Controlled Trial ◽

Achilles Tendon Rupture ◽

Control Group ◽

Level Of Evidence ◽

Treatment As Usual ◽

Patient Reported

Abstract Purpose The hypothesis was that early functional mobilization would reduce the incidence of deep venous thrombosis (DVT) during leg immobilization after Achilles tendon rupture surgery. A secondary aim was to evaluate if the amount of weightbearing and daily steps influenced the risk of sustaining a DVT. Methods One-hundred and fifty patients with Achilles tendon rupture repair were randomized to treatment with early functional mobilization, encouraging full weightbearing and ankle motion in orthosis, or treatment-as-usual, i.e., 2 weeks of unloading in plaster cast followed by 4 weeks weightbearing in orthosis. At 2 and 6 weeks postoperatively, all patients were screened for DVT using compression duplex ultrasound. During the first 2 weeks postoperatively, patient-reported loading, pain and step counts were assessed. Results At 2 weeks, 28/96 (29%) of the patients in early functional mobilization group and 15/49 (31%) in the control group (n.s) had sustained a DVT. At 6 weeks, the DVT rate was 35/94 (37%) in the early functional mobilization and 14/49 (29%) in the control group (n.s). During the first postoperative week, the early functional mobilization group reported low loading and higher experience of pain vs. the control group (p = 0.001). Low patient-reported loading ≤ 50% (OR = 4.3; 95% CI 1.28–14.3) was found to be an independent risk factor for DVT, in addition to high BMI and higher age. Conclusions Early functional mobilization does not prevent the high incidence of DVT during leg immobilization in patients with Achilles tendon rupture as compared to treatment-as-usual. The low efficacy of early functional mobilization is mainly explained by postoperative pain and subsequent low weightbearing. To minimize the risk of DVT, patients should be encouraged to load at least 50% of body weight on the injured leg 1 week after surgery. Level of evidence Therapeutic, level 1

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Kinematic and Neuromuscular Changes of the Gait Pattern After Achilles Tendon Rupture

Foot & Ankle International ◽

10.1177/107110079701800605 ◽

1997 ◽

Vol 18 (6) ◽

pp. 339-341 ◽

Cited By ~ 11

Author(s):

Daniela Neumann ◽

Lutz Vogt ◽

Winfried Banzer ◽

Udo Schreiber

Keyword(s):

Achilles Tendon ◽

Gastrocnemius Muscle ◽

Tendon Rupture ◽

Achilles Tendon Rupture ◽

Gait Pattern ◽

Control Group ◽

Motor Patterns ◽

Lateral Gastrocnemius ◽

Functional Movement ◽

Ankle Motion

After long immobilization periods in equinovalgus with operated Achilles tendon rupture, long-lasting changes of motor patterns in functional movement can be expected. In the present study, possible alterations in gait pattern have been analyzed based on kinematic and neuromuscular parameters. Ten patients 1 year after surgery and a healthy control group performed 10 gait cycles in natural walking cadence. Ankle motion, pressure distribution, and electromyographic data were recorded and analyzed in defined phases. Kinematic and neuromuscular changes are still evident 1 year after surgery with a temporal phase shift and a neuromuscular deficit of the lateral gastrocnemius muscle. The objective of rehabilitation should be the facilitation of the temporal innervation pattern of the lateral gastrocnemius muscle in the functional movement.

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Individualized treatment for acute Achilles tendon rupture based on the Copenhagen Achilles Rupture Treatment Algorithm (CARTA): a study protocol for a multicenter randomized controlled trial

10.21203/rs.3.rs-19305/v2 ◽

2020 ◽

Author(s):

Maria Swennergren Hansen ◽

Marianne Toft Vestermark ◽

Per Hölmich ◽

Morten Tange Kristensen ◽

Kristoffer Weisskirchner Barfod

Keyword(s):

Randomized Controlled Trial ◽

Achilles Tendon ◽

Tendon Rupture ◽

Controlled Trial ◽

Achilles Tendon Rupture ◽

Treatment Algorithm ◽

Intervention Group ◽

Individualized Treatment ◽

Control Group ◽

Randomized Controlled

Abstract Background: An individualized treatment algorithm (Copenhagen Achilles Rupture Treatment Algorithm - CARTA) based on the ultrasonographic appearance of an acute Achilles tendon rupture has been developed aiming to select the correct patients for operative and non-operative treatment. The objective of this study is to investigate if this individualized treatment algorithm gives a better functional outcome than treating all patients either operatively or non-operatively per default. Methods: This study is conducted as a multicenter three-armed randomized controlled trial. Participants are included from four hospitals in Denmark and randomized 1:1:1 to one of three parallel groups: 1) Intervention group: Participants are treated according to an individualized treatment algorithm, 2) Control group A: Participants are treated non-operative, 3) Control group B: Participants are treated operative. The individualized treatment algorithm for the intervention group is based on an ultrasonographic examination; tendon overlap and elongation below 7% is to be treated non-operative, while no tendon overlap and and/or elongation above 7% will be treated operative. 300 participants will be included over a period of 3 years. The primary outcome is the heel-rise work test at 12 months post-injury. Secondary outcomes are tendon elongation, the Achilles tendon Total Rupture Score (ATRS), the rate of re-ruptures and other complications. The primary analysis will be conducted as intention-to-treat analysis.Discussion: This trial will indicate if treatment of acute Achilles tendon rupture can be individualized based on the elongation and tendon overlap. It is hypothesized that different patients will benefit from different treatment instead of offering all the same treatment. Trial registration: ClinicalTrials.gov Identifier: NCT03525964. Registered 16 May 2018.

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3 Platelet rich plasma for acute achilles tendon rupture: a double-blind, multicentre, randomised, placebo-controlled trial

British Journal of Sports Medicine ◽

10.1136/bjsports-2019-basemabs.3 ◽

2019 ◽

Vol 53 (13) ◽

pp. 843.3-844

Author(s):

DJ Keene ◽

J Alsousou ◽

P Harrison ◽

P Hulley ◽

S Wagland ◽

...

Keyword(s):

Achilles Tendon ◽

Goal Attainment ◽

Tendon Rupture ◽

Platelet Rich Plasma ◽

Controlled Trial ◽

Achilles Tendon Rupture ◽

Soft Tissue Injuries ◽

Double Blind ◽

Patient Reported ◽

Secondary Outcomes

AimSlow recovery and disability after Achilles tendon rupture are major challenges. Platelet Rich Plasma (PRP) is an autologous supraphysiological concentration of platelets from whole blood that has demonstrated positive cellular and physiological effects on healing in the laboratory and is widely used in musculoskeletal treatments. However, evidence from adequately powered, robust clinical trials is lacking. We aimed to determine the clinical efficacy of PRP for treatment of acute Achilles tendon rupture.Methods230 adults starting Achilles rupture non-surgical management within 12 days of injury were randomised to PRP injection or dry needle insertion to the rupture gap, under local anaesthetic. Participants were blinded to study treatment and received standardised rehabilitation. Blinded outcome assessments were at 4, 7, 13, and 24 weeks. The primary outcome was muscle-tendon function assessed by work performed during the heel-rise endurance test (HRET), measured with the Limb Symmetry Index (LSI) (0–100%; 100% denotes full recovery) at 24 weeks. Secondary outcomes were the Achilles Tendon Rupture Score (ATRS), quality of life (SF-12), pain and goal attainment. The trial was prospectively registered.ResultsOf 230 participants, 114 were allocated to PRP injection (103 received PRP), 116 were allocated to and received placebo. At 24 weeks, 201/230 (87%) completed the HRET and 214/230 (93%) completed patient reported outcomes. Participant characteristics between the groups were similar. There was no difference between groups at 24 weeks in LSI (mean difference = -4.373; 95% CI −11.217 to 2.471; p=0.195). There were no differences in the secondary outcomes and adverse event rates.ConclusionThis trial design and standardised PRP preparation secure the first robust clinical trial evidence for PRP in managing Achilles tendon rupture, and suggest that PRP offers no patient benefit. The use of PRP in soft tissue injuries must be questionable unless supported by equally robust evidence indicating positive outcomes.

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The Ruptured Achilles Tendon Elongates for 6 Months After Surgical Repair Regardless of Early or Late Weightbearing in Combination With Ankle Mobilization: A Randomized Clinical Trial

The American Journal of Sports Medicine ◽

10.1177/0363546518781826 ◽

2018 ◽

Vol 46 (10) ◽

pp. 2492-2502 ◽

Cited By ~ 32

Author(s):

Pernilla Eliasson ◽

Anne-Sofie Agergaard ◽

Christian Couppé ◽

René Svensson ◽

Rikke Hoeffner ◽

...

Keyword(s):

Achilles Tendon ◽

Tendon Rupture ◽

Surgical Repair ◽

Controlled Trial ◽

Achilles Tendon Rupture ◽

Home Exercise ◽

Full Weightbearing ◽

Tendon Elongation ◽

Patient Reported ◽

Functional Scores

Background: Treatment strategies for Achilles tendon rupture vary considerably, and clinical outcome may depend on the magnitude of tendon elongation after surgical repair. The aim of this project was to examine whether tendon elongation, mechanical properties, and functional outcomes during rehabilitation of surgically repaired acute Achilles tendon ruptures were influenced by different rehabilitation regimens during the early postsurgical period. Hypothesis: Restricted early weightbearing that permits only limited motion about the ankle in the early phase of tendon healing limits tendon elongation and improves functional outcome. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: 75 consecutive patients with an acute Achilles tendon rupture were included. They underwent surgical repair, and tantalum beads were placed in the distal and proximal parts of the tendon; thereafter, the patients were randomized into 3 groups. The first group was completely restricted from weightbearing until week 7. The second group was completely restricted from weightbearing until week 7 but performed ankle joint mobilization exercises. The first and second groups were allowed full weightbearing after week 8. The third group was allowed partial weightbearing from day 1 and full weightbearing from week 5. All patients received the same instructions in home exercise guidelines starting from week 9. Results: The rehabilitation regimen in the initial 8 weeks did not significantly influence any of the measured outcomes including tendon elongation. Achilles tendon elongation and tendon compliance continued for up to 6 months after surgery, and muscle strength, muscle endurance, and patient-reported functional scores did not reach normal values at 12 months. Conclusion: Differences in rehabilitation loading pattern in the initial 8 weeks after the repair of an Achilles tendon rupture did not measurably alter the outcome. The time to recover full function after an Achilles tendon rupture is at least 12 months. Registration: NCT02422004 ( ClinicalTrials.gov identifier).

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A Prospective Study of Platelet-Rich Plasma as Biological Augmentation for Acute Achilles Tendon Rupture Repair

BioMed Research International ◽

10.1155/2016/9364170 ◽

2016 ◽

Vol 2016 ◽

pp. 1-8 ◽

Cited By ~ 27

Author(s):

Jian Zou ◽

Xiaolian Mo ◽

Zhongmin Shi ◽

Tanzhu Li ◽

Jianfeng Xue ◽

...

Keyword(s):

Achilles Tendon ◽

Tendon Rupture ◽

Platelet Rich Plasma ◽

Controlled Trial ◽

Achilles Tendon Rupture ◽

Control Group ◽

Sf 36 ◽

Study Results ◽

A Prospective Study ◽

Biological Augmentation

Acute Achilles tendon rupture is one of the most common tendon injuries in adults. We hypothesized that Platelet-Rich Plasma (PRP) can be used as biological augmentation for surgical treatment of acute Achilles tendon rupture. Our study is a prospective randomized controlled trial. Patients with acute Achilles tendon rupture undergoing surgical repair were randomly assigned into either control group or PRP group. End-to-end modified Krackow suture was performed in both groups. In the PRP group, PRP was injected into the paratenon sheath and around the ruptured tissue after the tendon was repaired. Postoperatively we evaluated isokinetic muscle strength at 3, 6, 12, and 24 months. In addition, ankle ROM, calf circumference, Leppilahti score, and the SF-36 score were evaluated at 6, 12, and 24 months after operation. At 3 months, the PRP group had better isokinetic muscle. The PRP group also achieved higher SF-36 and Leppilahti scores at 6 and 12 months. At 24 months, the PRP group had an improved ankle range of motion compared to the control group. Our study results suggest that PRP can serve as a biological augmentation to acute Achilles tendon rupture repair and improves both short and midterm functional outcomes.

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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

British Journal of Sports Medicine ◽

10.1136/bjsports-2019-100709 ◽

2019 ◽

Vol 54 (12) ◽

pp. 719-724 ◽

Cited By ~ 8

Author(s):

Kristoffer Weisskirchner Barfod ◽

Maria Swennergren Hansen ◽

Per Hölmich ◽

Morten Tange Kristensen ◽

Anders Troelsen

Keyword(s):

Randomised Controlled Trial ◽

Achilles Tendon ◽

Operative Treatment ◽

Tendon Rupture ◽

Controlled Trial ◽

Achilles Tendon Rupture ◽

Control Group ◽

Intention To Treat ◽

Controlled Motion ◽

Randomised Controlled

BackgroundEarly 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 studyTo investigate if ECM of the ankle was superior to immobilisation in the treatment of acute Achilles tendon rupture.Materials and methodsThis 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/Results189 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.ConclusionsECM revealed no benefit compared with immobilisation in any of the investigated outcomes.Trial registration numberNCT02015364

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Individualized treatment for acute Achilles tendon rupture based on the Copenhagen Achilles Rupture Treatment Algorithm (CARTA): a study protocol for a multicenter randomized controlled trial

10.21203/rs.3.rs-19305/v1 ◽

2020 ◽

Author(s):

Maria Swennergren Hansen ◽

Marianne Toft Vestermark ◽

Per Hölmich ◽

Morten Tange Kristensen ◽

Kristoffer Weisskirchner Barfod

Keyword(s):

Randomized Controlled Trial ◽

Achilles Tendon ◽

Tendon Rupture ◽

Controlled Trial ◽

Achilles Tendon Rupture ◽

Treatment Algorithm ◽

Intervention Group ◽

Individualized Treatment ◽

Control Group ◽

Randomized Controlled

Abstract Background: An individualized treatment algorithm (Copenhagen Achilles Rupture Treatment Algorithm - CARTA) based on the ultrasonographic appearance of an acute Achilles tendon rupture has been developed aiming to select the correct patients for operative and non-operative treatment. The objective of this study is to investigate if this individualized treatment algorithm gives a better functional outcome than treating all patients either operatively or non-operatively per default. Methods: This study is conducted as a multicenter three-armed randomized controlled trial. Participants are included from four hospitals in Denmark and randomized 1:1:1 to one of three parallel groups: 1) Intervention group: Participants are treated according to an individualized treatment algorithm,2) Control group A: Participants are treated non-operative, 3) Control group B: Participants are treated operative. The individualized treatment algorithm for the intervention group is based on an ultrasonographic examination; tendon overlap and elongation below 7% is to be treated non-operative, while no tendon overlap and and/or elongation above 7% will be treated operative. 300 participants will be included over a period of 3 years. The primary outcome is the heel-rise work test at 12 months post-injury. Secondary outcomes are tendon elongation, the Achilles tendon Total Rupture Score (ATRS), the rate of re-ruptures and other complications. The primary analysis will be conducted as intention-to-treat analysis. Discussion: This trial will indicate if treatment of acute Achilles tendon rupture can be individualized based on the elongation and tendon overlap. It is hypothesized that different patients will benefit from different treatment instead of offering all the same treatment. Trial registration: ClinicalTrials.gov Identifier: NCT03525964. Registered 16 May 2018. Keywords: Achilles tendon, Achilles tendon rupture, individualized treatment, ultrasound.

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Effect of Achilles Tendon Rupture on Player Performance and Longevity in Women’s National Basketball Association Players

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967121989982 ◽

2021 ◽

Vol 9 (3) ◽

pp. 232596712198998

Author(s):

Joseph S. Tramer ◽

Lafi S. Khalil ◽

Patrick Buckley ◽

Alexander Ziedas ◽

Patricia A. Kolowich ◽

...

Keyword(s):

Achilles Tendon ◽

Tendon Rupture ◽

Achilles Tendon Rupture ◽

National Basketball Association ◽

Return To Play ◽

Control Group ◽

Healthy Controls ◽

Career Longevity ◽

Women's National Basketball Association ◽

Player Performance

Background:Women’s National Basketball Association (WNBA) players have a greater incidence of lower extremity injury compared with male players, yet no data exist on functional outcomes after Achilles tendon rupture (ATR).Purpose:To evaluate the effect of Achilles tendon repair on game utilization, player performance, and career longevity in WNBA athletes.Study Design:Cohort study; Level of evidence, 3.Methods:WNBA players from 1997 to 2019 with a history of ATR (n = 12) were matched 1:2 to a healthy control group. Player characteristics, game utilization, and in-game performance data were collected for each athlete, from which the player efficiency rating (PER) was calculated. Statistical analysis was performed comparing postinjury data to preinjury baseline as well as cumulative career data. Changes at each time point relative to the preinjury baseline were also compared between groups.Results:Of the 12 players with ATR, 10 (83.3%) returned to play at the WNBA level at a mean (±SD) of 12.5 ± 3.3 months. Four players participated in only 1 WNBA season after injury. There were no differences in characteristics between the 10 players who returned to play after injury and the control group. After return to play, the WNBA players demonstrated a significant decrease in game utilization compared with preinjury, playing in 6.0 ± 6.9 fewer games, starting in 12.7 ± 15.4 fewer games, and playing 10.2 ± 9.1 fewer minutes per game ( P < .05 for all). After the index date of injury, the players with Achilles repair played 2.1 ± 1.2 more years in the WNBA, while control players played 5.35 ± 3.2 years ( P < .01) Additionally, the players with Achilles repair had a significant decrease in PER in the year after injury compared with preinjury (7.1 ± 5.3 vs 11.0 ± 4.4; P = .02). The reduction in game utilization and decrease in PER in these players was maintained when compared with the matched controls ( P < .05 for both).Conclusion:The majority of WNBA players who sustained ATR were able to return to sport after their injury; however, their career longevity was shorter than that of healthy controls. There was a significant decrease in game utilization and performance in the year after return to play compared with healthy controls.

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