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The Achilles tendon resting angle (ATRA) measured with a goniometer
Source publication
Purpose
The aim of this study was to investigate how the Achilles tendon resting angle (ATRA), an indirect measurement of tendon elongation, correlates with ultrasonography (US) measurements of the Achilles tendon length 6 and 12 months after an acute ATR and relates to other clinical outcome measurements such as heel-rise height, jumping ability a...
Context in source publication
Context 1
... The non-injured leg was examined first. The patients were encouraged to relax their ankle joints. The axis of the goniometer (1˚increments) was positioned at the tip of the fibula. One arm of the goniometer was aimed towards the head of the fibula and the other arm of the goniometer was positioned to bisect the head of the fifth metatarsal (Fig. 1). The ATRA has been reliability tested by Carmont et al. [4] and the reported ICC value of the ATRA is 0.91-0.92 ...
Citations
... In comparison, they found that five patients with midsubstance Achilles tendon ruptures unfortunately experienced tendon elongation. Tendon elongation can significantly impact a patient's plantarflexion power and overall satisfaction [34,35]. All patients in the myotendinous group were able to do a single-leg heel raise and had on average 79% the heel-raise ability (HRHI) compared to their contralateral side. ...
Background
Achilles tendon ruptures are the most common lower extremity tendinous rupture. While there has been extensive research into the management of mid-substance Achilles tendon ruptures, there is a paucity of literature on the management of myotendinous Achilles tendon ruptures.
Methods
The aim of this systematic review is to compile all available literature on the treatment of myotendinous Achilles tendon tears. A systematic search of Web of Science, Embase, and Medline databases was performed for all studies published from database inception to April 13, 2024. All publications addressing the treatment of myotendinous Achilles ruptures of all levels of evidence were included. The PRISMA Checklist guided the reporting and data abstraction. Descriptive statistics are presented.
Results
A total of five studies with 70 patients were included for analysis. Sixty-seven patients underwent non-operative management with an average age ranging from 40.8 to 51.0 years. Three patients underwent operative management with ages of 16, 36, and 39. The majority of patients tore their Achilles tendon during sports. For nonoperatively treated patients, one group underwent immobilization for a total of 6 weeks and one study treated patients with functional rehabilitation. All patients were able to perform a single heel-raise, had good reported strength, and returned to work or sport. Nonoperative patients reported statistically significant improvements in subjective outcomes and high rates of satisfaction.
Conclusion
Both nonoperative and operative management of myotendinous Achilles tendon ruptures demonstrated good outcomes after injury, although there is a limited amount of literature on this topic. Given that nonoperative treatment appears to yield good strength and return to activity, it may be preferred for the majority of patients. Operative management may be indicated in high level athletes. Imaging to determine the exact location of injury, quality of remaining tendon, and gap distance may further aid when considering treatment options. Higher level evidence studies are required to determine the optimal treatment of myotendinous Achilles tendon ruptures.
Level of evidence
IV; Systematic review of Level IV-V studies.
... Preoperatively, the contralateral Achilles tendon resting angle (ATRA) is assessed and used as a reference for determining the ATRA after tendon repair. ATRA reflects the position of the ankle joint, measured with the patient positioned prone, the knee flexed at 90°, and the ankle joint fully relaxed [14]. The distal portion of the surgical limb, starting from the knee joint, is disinfected and prepared with sterile draping. ...
... Tendon elongation is a common complication of AATR and may occur at the rehabilitation stage regardless of the chosen treatment, leading to an inferior outcome [23]. Achilles tendon elongation affects foot and ankle biomechanics, plantar flexion strength, maximum calf circumference, and muscular volume [9]. ...
Acute Achilles tendon rupture (AATR) in patients with multimorbidity poses a significant therapeutic challenge to surgeons because of the increased risk for wound-healing-related complications. Thus, nonoperative management has been these individuals' most widely adopted treatment. We report a case of a 66-year-old patient with AATR who was treated with endoscopic flexor hallucis longus (FHL) transfer. His medical history was remarkable for recent stroke, hypertension, prediabetes, pemphigus under oral methylprednisolone, smoking, and recent pneumonia. The patient was evaluated up to two years postoperatively and was satisfied with the outcome since he was able to maintain his pre-traumatic activity level. No complications were noted. The Achilles tendon total rupture score was 92 out of a maximum of 100. This favorable outcome indicates that endoscopic FHL transfer may be a safe alternative treatment option for patients with an increased risk of surgical complications.
... Therefore, our aim was to assess whether early symmetry of AT and triceps surae muscle properties at 2 months after rupture were associated with sideto-side symmetry in isometric plantarflexor maximal voluntary contraction (MVC) and AT nonuniformity at 6 and 12 months. We examined whether participant age [3], sex [3], early symmetry of MG muscle and AT architecture [2,[4][5][6][7], ATRA [8,[15][16][17], or AT shear wave velocity (SWV, m × s −1 ) [7] measured at 2 months postinjury would serve as potential predictors of MVC and AT nonuniformity. We hypothesized that younger age and better structural and mechanical symmetry at 2 months would be related to better symmetry of MVC and AT nonuniformity at 6 and 12 months. ...
... Based on the multiple regression models, a 1% improvement in ATRA LSI would result in a 2.5% improvement in MVC LSI at 6 months and a 1.6% improvement at 12 months. These findings align with previous cross-sectional studies reporting a correlation between ATRA and heel-rise performance after ATR [15][16][17]. Furthermore, Carmont and colleagues [8] found an association between greater intraoperative ATRA and 12 month heel-rise performance in operatively treated patients, supporting our findings. The results of this study show that in addition to heel-rise performance, ATRA is also related to the isometric plantarflexor muscle strength deficit tested with ankle in neutral position, suggesting that ATRA is associated with plantarflexor force production capacity under different conditions. ...
... ATRA measured at 2 months was found to be associated with plantarflexor strength deficit within 1 year after rupture, which aligns with previous studies reporting a relationship between ATRA and heel-rise performance [8,[15][16][17]. The findings suggest that ATRA may be a relevant biomarker of the progression of tendon healing and have potential as a clinical tool for identifying patients at risk of prolonged strength deficits. ...
Purpose
To investigate early structural and mechanical predictors of plantarflexor muscle strength and the magnitude of Achilles tendon (AT) nonuniform displacement at 6 and 12 months after AT rupture.
Methods
Thirty‐five participants (28 males and 7 females; mean ± SD age 41.7 ± 11.1 years) were assessed for isometric plantarflexion maximal voluntary contraction (MVC) and AT nonuniformity at 6 and 12 months after rupture. Structural and mechanical AT and plantarflexor muscle properties were measured at 2 months. Limb asymmetry index (LSI) was calculated for all variables. Multiple linear regression was used with the 6 and 12 month MVC LSI and 12 month AT nonuniformity LSI as dependent variables and AT and plantarflexor muscle properties at 2 months as independent variables. The level of pre‐ and post‐injury sports participation was inquired using Tegner score at 2 and 12 months (scale 0–10, 10 = best possible score). Subjective perception of recovery was assessed with Achilles tendon total rupture score (ATRS) at 12 months (scale 0–100, 100=best possible score).
Results
Achilles tendon resting angle (ATRA) symmetry at 2 months predicted MVC symmetry at 6 and 12 months after rupture (β = 2.530, 95% CI 1.041–4.018, adjusted R² = 0.416, p = 0.002; β = 1.659, 95% CI 0.330–2.988, adjusted R² = 0.418, p = 0.016, respectively). At 12 months, participants had recovered their pre‐injury level of sports participation (Tegner 6 ± 2 points). The median (IQR) ATRS score was 92 (7) points at 12 months.
Conclusion
Greater asymmetry of ATRA in the early recovery phase may be a predictor of plantarflexor muscle strength deficits up to 1 year after rupture.
Trial Registration: This research is a part of “nonoperative treatment of Achilles tendon rupture in Central Finland: a prospective cohort study” that has been registered in ClinicalTrials.gov (NCT03704532)
... Previous studies have investigated the impact of these structural alterations on subjective PROMs (Patient-Related Outcome Measures) and objective outcomes (gait analysis) [ that the Achilles Tendon Resting Angle (ATRA) can be indirectly used to assess the length of the Achilles tendon. Contrary to Larsson et al. [20], Carmont et al. [5] found a strong correlation between ATRA and ATRS after surgery. In addition, it has been reported that after ATR, differential elongation of the gastrocnemius relative to the soleus may compromise the ability of athletes to return to competition [16]. ...
Purpose
The aim of this study was to assess whether variances in Achilles tendon elongation are linked to dissimilarities in the plantar pressure distribution following two different surgical approaches for an Achilles tendon rupture (ATR).
Methods
All patients who were treated with open or minimally invasive surgical repair (MIS) and were over 2 years post their ATR were eligible for inclusion. A total of 65 patients with an average age of 43 ± 11 years were included in the study. Thirty‐five patients were treated with open repair, and 30 patients were treated with MIS. Clinical outcomes were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) and ATR Score (ATRS). Achilles tendon elongation was measured using axial and sagittal magnetic resonance imaging scans. Plantar pressure measurements for the forefoot, midfoot and hindfoot during gait were divided into percentages based on total pressure, measured in g/cm ² for each area.
Results
The average AOFAS score was found ‘excellent’ (93 ± 2.8) in the MIS group, while it was found ‘good’ (87.4 ± 5.6) in the open repair group. In addition, the MIS group showed significantly superior ATRS scores (78.8 ± 7.4) compared to the open repair group (56.4 ± 15.4) ( p < 0.001). The average tendon elongation in the MIS group was 11.3 ± 2 mm, while it was 17.3 ± 4.3 mm ( p < 0.001) in the open repair group. While the open repair group showed significantly higher plantar pressure distribution in the initial contact and preswing phases compared to uninjured extremities, there was no significant difference between the uninjured extremities and the MIS group.
Conclusion
In conclusion, the findings of this study demonstrated that minimally invasive surgery was associated with less tendon elongation, more proximity to the plantar pressure distributions of the uninjured extremity and superior clinical outcomes compared to open surgical repair. Therefore, minimally invasive surgery may be considered a more suitable option for acute Achilles tendon repair to achieve overall better outcomes.
Level of Evidence
Level III.
... The regeneration process of the rupture site was assessed using MRI. The Achilles Tendon Total Rupture Score (ATRS) [15], Achilles Tendon Resting Angle (ATRA) [12] and Heel Rise Height Scale (HRHS) [25] were modified to evaluate the clinical outcomes at the final follow-up. In this study, the patient was placed in the prone position with knee flexion at 90°, while the angle between the lateral side of the sole and horizontal plane was measured with a digital protractor. ...
Purpose
The safety and reliability of endoscopic Achilles tendon rupture repair are still concerning aspects. This study's aim is to evaluate an all‐inside endoscopic semiautomatic running locked stitch (Endo‐SARLS) technique.
Methods
Forty cases with acute Achilles tendon rupture were treated with the all‐inside Endo‐SARLS technique between 2020 and 2021. Under endoscopic control, the proximal tendon stumps were stitched with the running locked method using a semiautomatic flexible suture passer. The threads of the high‐strength suture were grasped through the paratenon subspace and then fixed into calcaneal insertion with a knotless anchor. Magnetic resonance imaging (MRI), surgical time and complications were assessed. Achilles Tendon Total Rupture Score (ATRS), Achilles Tendon Resting Angle (ATRA) and Heel Rise Height Scale (HRHS) were utilised to evaluate final outcomes.
Results
The average follow‐up time was 25.4 ± 0.4 (range: 24–32) months. Appropriate tendon regeneration was observed on MRI after 12 months. At the final follow‐up, the median value of ATRS score was 95 (interquartile range: 94, 98). Furthermore, there is no significant difference between the injured and contralateral side in the average ATRA (18.2 ± 1.8 vs. 18.3 ± 1.9°, ns) and median value of HRHS [14.5 (13.3, 15.5) vs. 14.8 (13.5, 15.6) cm, ns]. No infection and nerve injuries were encountered. Thirty‐nine patients reported that they resumed casual sports activity after 6 months. One patient had a slight anchor cut‐out, due to an addition injury, which was removed after 5 months.
Conclusions
An all‐inside Endo‐SARLS technique showed promising clinical results for acute Achilles tendon ruptures. This procedure reduces the risk of sural nerve injuries while establishing a reliable connection between the tendon stumps.
Level of Evidence
Level IV.
... Interestingly, a recent study showed that ATRA detected deficits after an Achilles tendon rupture, but was not a surrogate for direct measurements of tendon elongation, [13]. In future, authors should consider using other methods to measure tendon elongation. ...
Purpose:
Achilles tendon ruptures (ATR) result in loss of strength and function of the gastrosoleus-Achilles tendon complex, probably because of gradual tendon elongation and calf muscle atrophy, even after surgical repair. Flexor hallucis longus (FHL) augmentation not only reinforces the repair and provides new blood supply to the tendon, but also protects the repair, internally splinting the repaired Achilles tendon, maintaining optimal tension. We prospectively compared the clinical outcomes of patients with acute ATR, managed with either percutaneous repair only or percutaneous repair and FHL augmentation.
Methods:
Patients with acute ATR undergoing operative management were divided into two groups. Thirty patients underwent percutaneous repair under local anesthesia, and 32 patients underwent percutaneous repair augmented by FHL tendon, harvested through a 3 cm longitudinal posteromedial incision, and transferred to the calcaneus, under epidural anesthesia. All patients were treated by a single surgeon between 2015 and 2019 and were followed prospectively for 24 months.
Results:
The percutaneous only group was younger than the augmented one (35.4 ± 8.0 vs 40.4 ± 6.6 years, p = 0.01). In the augmented group, 25 patients stayed overnight and only 5 were day cases, whereas in the percutaneous only group 4 patients stayed overnight and 28 of them were day cases (p < 0.001). The duration of the procedure was significantly longer in the augmented group (38.9 ± 5.2 vs 13.2 ± 2.2 min, p < 0.001). At 24 months after repair, the Achilles tendon resting angle (ATRA) was better in the augmented group (-0.5 ± 1.7 vs -4.0 ± 2.7, p < 0.001), as was Achilles tendon rupture score (ATRS) (91.7 ± 2.2 vs 89.9 ± 2.4, p = 0.004). Calf circumference of the injured and the non-injured leg did not differ between the groups, as did the time interval to single toe raise and the time interval to walking in tiptoes. Although plantarflexion strength of the operated leg was significantly weaker than the non-operated leg in both groups, the difference in isometric strength of the operated leg between the groups was not significant at 24 months (435 ± 37.9 vs 436 ± 39.7 N, n.s.).
Conclusion:
Percutaneous repair and FHL tendon augmentation may have a place in the management of acute Achilles tendon ruptures, reducing tendon elongation and improving functional outcome.
Level of evidence:
Level II.
