ArticlePDF AvailableLiterature Review

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

Authors:

Abstract and Figures

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.
Content may be subject to copyright.
Review
Defining Components of Early Functional
Rehabilitation for Acute Achilles
Tendon Rupture
A Systematic Review
Jennifer A. Zellers,* DPT, PhD, Marianne Christensen,
†‡§
PT, MHSc, Inge Lunding Kjær,
MD,
Michael Skovdal Rathleff,
PT, PhD, and Karin Gra
¨vare Silbernagel,
k{
PT, PhD, ATC
Investigation performed at Aalborg University Hospital, Aalborg, Denmark
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 effi-
cacy. 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) (P¼.017). Functional out-
comes including ankle range of motion (n ¼84) and strength (n ¼76) were reported in 130 studies. Other outcome domains
included patient-reported outcomes (n ¼89), survey-based functional outcomes (n ¼50), and tendon properties (n ¼53).
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.
Keywords: Achilles; mobilization; weightbearing; ankle; outcomes
The yearly incidence of Achilles tendon rupture is up to 37
per 100,000 individuals.
61,105,160
There is ongoing debate
regarding optimal treatment, as attention has shifted away
from outcomes such as rerupture rates and toward
function-based outcomes.
74
Plantar flexor weakness
22,72,103
and biomechanical asymmetries with running and jumping
activities
23,200
persist in the long term. These may limit
performance capacity or predispose these individuals to
other orthopaedic conditions such as patellofemoral joint
pain.
200
It is important that patients recover within the
first year after injury, as 1-year outcomes predict whether
individuals will be left with long-term disabilities.
23,69
Early functional rehabilitation has become a buzz phrase
in treating Achilles tendon rupture. A consistent definition
of what constitutes early functional rehabilitation has not
been established across the literature, despite studies iden-
tifying that early functional rehabilitation was safe,
resulted in higher patient satisfaction, improved function,
The Orthopaedic Journal of Sports Medicine, 7(11), 2325967119884071
DOI: 10.1177/2325967119884071
ªThe Author(s) 2019
1
This open-access article is published and distributed under the Creative Commons Attribution - NonCommercial - No Derivatives License (http://creativecommons.org/
licenses/by-nc-nd/4.0/), which permits the noncommercial use, distribution, and reproduction of the article in any medium, provided the original author and source are
credited. You may not alter, transform, or build upon this article without the permission of the Author(s). For article reuse guidelines, please visit SAGE’s website at
http://www.sagepub.com/journals-permissions.
and led to faster return to work and sport in some
instances.
24,67,99,117,193
Systematic reviews have supported
the use of early functional rehabilitation to optimize patient
outcomes regardless of whether a participant is managed
nonsurgically
55
or surgically.
21,24,78,128
A standardized def-
inition would be helpful to pool data across studies, allow
for between-study comparison, and ultimately work toward
developing clinical guidelines.
The components in defining early functional rehabilita-
tion include establishing what types of treatment recom-
mendations comprise early functional rehabilitation and
when they are initiated. Prior systematic reviews investigat-
ing the efficacy of early functional rehabilitation
21,24,55,78, 128
have provided limited guidance as to the working definition
of this term, relying on author-delineated, inconsistent
definitions of early. For example, Brumann et al
24
limited
studies to those including weightbearing or ankle mobiliza-
tion in the first 3 weeks, McCormack and Bovard
128
included only studies that included any type of rehabilita-
tion by 2 weeks, and El-Akkawi et al
55
limited study inclu-
sion to those that initiated rehabilitation by 4 weeks.
Variations between systematic review–level evidence point
to the lack of uniform definition of early functional
rehabilitation.
The standardization of outcomes used to assess patient
response to intervention is another critical piece in under-
standing the effectiveness of early functional rehabilitation.
As part of the Core Outcome Measures in Effectiveness
Trials (COMET) Initiative, core outcome sets are being
developed and applied in an effort to improve direct compar-
isons across studies.
198
This is in response to the challenge of
pooling literature with large variability in reported out-
comes
13
as well as substantial problems with missing data
for primary outcomes.
198
A first step in the development of
a core outcome set is to identify the outcome measures
used in clinical trials. A core outcome set is being dis-
cussed for Achilles tendinopathy
114,176
; however, to date,
an Achilles tendon rupture–specific set has not been initi-
ated in the literature.
The purpose of this study was to comprehensively define
early functional rehabilitation in terms of what types of
interventions are delivered to patients with Achilles tendon
rupture and when. We hypothesized that treatment was
initiated earlier in more recent studies, so we investigated
changes in trends of early functional rehabilitation onset
over time. Secondarily, we sought to identify the outcome
measures that have been used to assess patient response to
these rehabilitative protocols as a first step in identifying a
core outcome set for this patient population.
METHODS
This study was a systematic review of the literature on early
functional rehabilitation for Achilles tendon rupture. The
study was performed according to the PRISMA (Preferred
Reporting Items for Systematic Reviews and Meta-Analyses)
guidelines and was registered on the Prospero database (reg-
istration ID: CRD42017062300). Due to the size of the study,
we are reporting results for the definition of early functional
rehabilitation portion of the Prospero protocol, and work
regarding specific rehabilitation protocols is ongoing. The
search was completed on May 9, 2018.
Search Strategy
The search strategy was based on the PICO (Patient, Inter-
vention, Comparator, and Outcome) model. Development of
the search string and conduct of the search were done with
the assistance of a research librarian. The complete search
string is included in Appendix Table A1. Databases
included in the search were Ovid MEDLINE, EMBASE,
PEDro, CINAHL, and the Cochrane Database.
Study Inclusion and Exclusion
For the purposes of this review, we broadly defined early
functional rehabilitation as having weightbearing and/or
ankle-focused exercises beginning within the first 8 weeks
and while the patient is still using an immobilization device
(ie, orthosis, cast, specialized treatment boot). In the event
that no immobilization device was used during the course of
treatment, early functional rehabilitation was defined as
weightbearing and exercises started within the first 8
weeks after injury or surgery.
Included studies needed to involve patients at least 18
years of age treated with early functional rehabilitation
after acute (defined as treated within 2 weeks) Achilles
tendon rupture. Studies needed to be randomized con-
trolled trials (RCTs), cohort studies, or case series with a
minimum of 10 participants. Narrative reviews, systematic
reviews and meta-analyses, and case studies were
excluded. Studies were excluded if participants with diabe-
tes, neurological conditions, or only chronic or delayed
treatment were included. In studies including participants
{
Address correspondence to Karin Gra
¨vare Silbernagel, PT, PhD, ATC, University of Delaware, Department of Physical Therapy, 540 South College Ave,
Newark, DE 19713 USA (email: kgs@udel.edu).
*Program in Physical Therapy, Washington University School of Medicine in St Louis, St Louis, Missouri, USA.
Physiotherapy and Occupational Therapy, Aalborg University Hospital, Aalborg, Denmark.
Orthopaedic Research Unit, Aalborg University Hospital, Aalborg, Denmark.
§
Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
k
Department of Physical Therapy, University of Delaware, Newark, Delaware, USA.
One or more of the authors has declared the following potential conflict of interest or source of funding: The project received financial support from the
Danish Physiotherapy Research Foundation (to M.C.). This study was also funded by the Foundation for Physical Therapy (to K.G.S. and J.A.Z.) and National
Institutes of Health under award numbers 1R01AR072034-01A1 (to K.G.S. and J.A.Z.) and T32HD007434 (to J.A.Z.). Funding sources had no role in
describing the protocol, planning the project, performing analyses, or interpreting the results. AOSSM checks author disclosures against the Open Payments
Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
2Zellers et al The Orthopaedic Journal of Sports Medicine
with acute and delayed ruptures, only data pertaining to
the acute rupture group were included in the review. Due to
the limitations of languages spoken by the investigatory
team and access to translators, only studies in English,
Danish, Swedish, Norwegian, German, French, Spanish,
or Portuguese were included.
Data Extraction: Defining
Early Functional Rehabilitation
Study inclusion and exclusion were determined by 2 inde-
pendent reviewers (J.A.Z., M.C.) using Covidence system-
atic review software (Veritas Health Innovation) for
citation management. In the event that consensus regard-
ing inclusion could not be met, a third reviewer was con-
sulted (K.G.S.). Data extraction was completed by 2
independent reviewers (J.A.Z., M.C.) using a REDCap
database,
70
with the exception of non-English studies. Dis-
agreements between reviewers were resolved through dis-
cussion, and if consensus could not be met, a third reviewer
was consulted (K.G.S.). For non-English studies, a single
reviewer completed data extraction due to language com-
prehension constraints among the study team.
Data extraction included study design (RCT, cohort study,
or case series), number of participants, treatment type (sur-
gical, nonsurgical, or both), and, when applicable, surgery
type (simple repair or augmented repair). Type of early func-
tional rehabilitation was categorized as follows: weightbear-
ing, range of motion (exercises or as allowed by an orthosis
permitting some movement), strength exercise with resis-
tance and progression, isometric exercise, cardiovascular-
based exercise (eg, stationary bike), general and core
strengthening, balance, and other. All rehabilitation strate-
gies used during the first 8 weeks and while participants
were still using some form of immobilization were included.
Timing of exercise and weightbearing onset was recorded. In
cases where 2 or more groups with different rehabilitative
protocols were used, the content of these protocols was com-
bined for the purposes of describing type of rehabilitation,
and the earliest onset time across groups was recorded.
Methodological Quality Assessment
Studies were assessed for methodological quality through
use of the modified Downs & Black
79,98,145
checklist, in
which 26 or above indicates excellent, 20-25 good, 15-19 fair,
and 14 or less poor quality. Studies in English were scored by
2 independent reviewers. If there were inconsistencies in
reviewer response, a third reviewer (J.A.Z. or M.C. ) was
consulted. Similar to data extraction, non–English
language studies were scored by a single reviewer.
Data Extraction: Outcome Measures Data
Outcome measures used in each study were noted and sub-
grouped by domain (patient-reported outcome, survey-
based functional outcome, functional outcome, and tendon
properties). Time of outcomes assessment was recorded as
0-3 months, 4-6 months, 7-12 months, >1-5 years, and >5
years. All time points were extracted. If a study did not
have predetermined time points for assessment, the mean
or median time of assessment was recorded.
In cases where 2 or more studies analyzed the same
group of participants, the studies were combined for the
purposes of extracting outcome types and timing of out-
comes assessment, and the primary study was used for
total number of participants, rehabilitation strategy, and
quality assessment. This was done to maximize the number
of outcomes reported while not artificially inflating partic-
ipant numbers.
Data Analysis
Data failed the assumptions of parametric statistics based
on the Shapiro-Wilk test, so nonparametric tests were used
for analysis. Descriptive statistics used are frequencies,
medians, and interquartile ranges (IQRs). To better under-
stand the types of studies included in this review, the rela-
tionship of study publication year and study quality was
assessed by Spearman correlation.
To investigate timing ofearly functional rehabilitation, the
onset of weightbearing and exercise (in weeks, with 0 indicat-
ing days 0-6, 1 indicating days 7-13, etc) is reported as fre-
quencies of studies using a given start time. Time of
weightbearing and exercise onset was also investigated by
treatment intervention subgroup (nonsurgical, simple
repair, or augmented repair), and differences intime of onset
were compared between groups through use of an
independent-samples Kruskal-Wallis test. Studies investi-
gating only 1 type of treatment were included in the subgroup
analysis. This is because it is possible that information from
both treatment groups would have been listed together in
studies comparing 2 different initial treatment strategies.
To identify changes in early functional rehabilitation
over time, time of weightbearing and exercise onset was
compared with publication year by use of Spearman corre-
lation. Because not all studies included in the review were
included in the individual analyses (eg, a study involving
only early exercise would not be included in the weightbear-
ing analyses), for each analysis the total number of primary
studies included along with their median Downs & Black
checklist score is reported.
RESULTS
Search Results and Study Inclusion
The results of the search and study inclusion are shown in
Figure 1. Of the 174 included studies, 157 studies
#
were
found to be primary studies, and 17 studies
**
were found
to have overlapping populations and were included only in
the reporting of additional outcomes and outcome
#
References 1-12, 14, 16-18, 25-28, 30-36, 38-40, 42-46, 48, 50-54,
57, 58, 60, 62-68, 72, 73, 75-77, 80-86, 88-97, 99-103, 106-113, 115-117,
119-127, 129, 131-134, 137-144, 146, 150-159, 161-175, 179-187, 189-
196, 199, 201-204.
**References 15, 19, 20, 41, 47, 71, 87, 104, 118, 130, 135, 136, 147-
149, 188, 197.
The Orthopaedic Journal of Sports Medicine Early Rehabilitation for Achilles Rupture 3
assessment timeframes. We included 16 non-English stud-
ies: 12 in German, 2 in Portuguese, 1 in Danish, and 1 in
Spanish (see Appendix Tables A2 and A3).
Descriptive Analysis of Included Studies
Included primary studies were published between 1979
and 2018 (median [IQR], 2010 [2002-2015]), consisting of
38 RCTs and 119 cohort studies or case series. Studies
rated a median [IQR] (range) of 17 [15-20] (4-25) on the
Downs & Black checklist for quality assessment (see
Appendix Table A2).
Included studies had a median [IQR] (range) of 40
[25-66] (10-363) participants, with a total of 9098 partici-
pants included in this systematic review. The included
RCTs contained significantly more participants versus the
cohort studies (median [IQR], range: RCTs, 52 [39-74],
14-156; cohort/case series, 35 [22-66], 10-363; P¼.011)
(Figure 2). Participants were managed surgically in 112
studies and nonsurgically in 20 studies (see Appendix
Tables A2 and A3). A total of 24 studies included both
surgical and nonsurgical groups, and 1 study had treat-
ment described as “other” (open fibrin gluing without end-
to-end repair). Surgery type was a simple repair in 114
studies and augmented repair in 33 studies.
Onset of weightbearing was a median [IQR] of 2 weeks
[0-3 weeks] after injury (Figure 3). Onset of exercise was
a median (IQR) of 2 weeks (0-3 weeks) after injury
(Figure 3).
Type of Early Functional Rehabilitation
Type of early functional rehabilitation is depicted in
Figure 4. Interventions that were categorized as “other”
(number of studies in parentheses) included massage (8),
stretching (8), proprioception (8), electrical stimulation (5),
cryotherapy (4), coordination (3), aqua therapy (3), propri-
oceptive neuromuscular facilitation (2), joint mobilization
(1), ankle self-mobilization (1), neuromuscular exercise (1),
night splint (1), and laser (1).
Descriptive Analysis of Early Functional
Rehabilitation Onset by Treatment Subgroup
Distribution of the timing of weightbearing onset was not
significantly different between groups (median [IQR]
Figure 1. Search results and study inclusion-exclusion
flowchart.
Figure 2. (A) Year of publication positively relates to study
quality. (B) Distribution of number of participants to study
quality by study design.
4Zellers et al The Orthopaedic Journal of Sports Medicine
nonsurgical, 0.0 [0.0-2.0]; simple surgical, 1.0 [0.0-3.0]; aug-
mented surgical, 2.5 [0.0-3.0] weeks; P¼.060) (Figure 5).
Distribution of the timing of exercise onset was signifi-
cantly different between groups (median [IQR] nonsurgical,
3.0 [2.0-4.0]; simple surgical, 2.0 [0.0-2.3]; augmented sur-
gical, 0.5 [0.0-2.8 weeks]; P¼.017) (Figure 5).
No differences were found in year of publication
(P¼.530) or study quality (P¼.148) between studies based
on initial intervention (nonsurgery, primary repair, or aug-
mented repair) (nonsurgery: n ¼20, median [IQR] year of
publication ¼2008 [1998-2016], study quality ¼17 [14-20];
primary repair: n ¼82, year of publication ¼2011 [2003-
2015], study quality ¼17 [15-19]; augmented repair: n ¼
20, year of publication ¼2007 [2001-2012], study quality ¼
15 [13-18]).
Change in Study Quality Over Time
Study quality improved with year of publication (r
sp
¼0.33;
P<.001) (Figure 2). In studies where exercise was initiated
within the first 8 weeks (n ¼127) (Downs & Black checklist
score median [IQR], 17 [15-20]), time of exercise onset sig-
nificantly increased with year of publication (r
sp
¼0.198;
P¼.026) but was not significantly related to study quality
(r
sp
¼–0.016; P¼.862). In studies where weightbearing
was initiated within the first 8 weeks (n ¼144, Downs &
Black checklist score median[IQR],18[15-20]),timeof
weightbearing onset was not significantly related to year
of publication (r
sp
¼–0.079; P¼.344) or study quality
(r
sp
¼0.047; P¼.572).
Outcome Measures
Common outcome measures are shown in Figure 4 and
Table 1. General outcomes categorized as “other” (number
of studies in parentheses) in multiple studies included
satisfaction (40), pain (29), time to a selected milestone
(12), metrics regarding hospital stay or length (9), opera-
tive time (8), number of office or physical therapy visits (5),
footwear restrictions (5), cost (4), Thompson/Matles test
(4), Achilles tendon resting angle (3), Hannover scale (3),
Boyden scale (3), aesthetics of surgical site (4), scale
devised by the authors (2), Achilles tendon repair score
(2), and pain medication use (2). A total of 4 studies
included general “other” outcomes that were not used in
any other study.
For the patient-reported outcomes domain, outcomes cat-
egorized as “other” in multiple studies included self-rating
of specified functional activity (8), Victorian Institute of
Sport Assessment – Achilles questionnaire (VISA-A) (6),
EuroQol-5D (4), RAND 36-Item Health Survey (RAND-
36) (3), Grimby Physical Activity Scale (4), Tegner Scale
(3), Functional Index for Lower Leg (2), and 12-Item Short
Form Health Survey (SF-12) (2). There were 9 studies that
included outcomes not used by any other study.
For the functional outcomes domain, outcomes catego-
rized as “other” in multiple studies included jump or hop
testing (15), heel-toe walking (12), ankle circumference (4),
pedobarography (3), ankle passive stiffness (3), muscle
activity or electromyography (3), single-legged balance
(3), and quadriceps circumference (2). For tendon-level out-
comes, 2 studies reported other outcomes not used in any
other study. Tendon-level outcomes categorized as “other”
in multiple studies included tendon appearance on ultraso-
nography (11), tendon appearance on magnetic resonance
imaging (7), tendon mechanical properties (7), gap distance
(4), tendon adhesions (4), and muscle appearance on diag-
nostic imaging (3). We found that 7 studies reported out-
comes that were not used in any other study.
Study outcomes were assessed between 0 and 3 months
in 52 studies, between 4 and 6 months in 58 studies,
between 7 and 12 months in 60 studies, between 1 and 5
years in 75 studies, and longer than 5 years in 8 studies (see
Appendix Table A3).
DISCUSSION
This systematic review is the first to comprehensively eval-
uate the available literature to define early functional reha-
bilitation after Achilles tendon rupture with regard to type
and timing of rehabilitative treatment. Early functional
rehabilitation in the treatment of Achilles tendon rupture
is commonly used (>150 publications) but still lacks a con-
sistent definition. Lack of standardization of content and
timing when this intervention is initiated hampers
Figure 3. (A) Timing of weightbearing onset in entire group. (B)
Timing of exercise onset in entire group.
The Orthopaedic Journal of Sports Medicine Early Rehabilitation for Achilles Rupture 5
evidence synthesis and implementation into clinical prac-
tice. Based on our comprehensive overview of the available
literature, we define early functional rehabilitation as
starting in the first 2 weeks after an acute Achilles tendon
rupture. Such rehabilitation consists of a variety of weight-
bearing and exercise-based interventions.
Early functional rehabilitation tends to begin within the
first 2 weeks after injury or surgery; however, there are
subtleties in timing of weightbearing and exercise compo-
nents based on initial treatment strategy (Figure 3). After
surgical repair, both weightbearing and exercises tend to
begin simultaneously—either immediately or 2 weeks after
surgical repair. With nonsurgical management, the ten-
dency is to initiate weightbearing immediately but delay
initiation of exercise. Differences in trends of exercise onset
between surgically and nonsurgically managed partici-
pants may result from clinical decision making aimed at
approximating the tendon ends
37
and avoiding complica-
tions
29,49
while simultaneously providing enough tensile
load to promote tendon healing.
59,174
Early functional rehabilitation protocols incorporated
a variety of different exercise-based intervention. Ankle
range of motion was the most commonly included inter-
vention. The goal of range of motion is likely to assist in
tendon gliding and to prevent deep adhesion. In the con-
text of this study, range of motion included both tradi-
tional ankle range of motion outside of the orthosis and
use of a hinged orthosis. After ankle range of motion,
strengthening was the next most common intervention.
Despite mechanistic studies supporting the role of gradual
tensile loading in order to promote tendon recovery,
6,59,174
only 52%(66/127) of studies with exercise-based inter-
ventions included isometric or other strengthening exer-
cise. Less frequently did exercise interventions address
more holistic concerns such as cardiovascular and global
strengthening.
Timing of rehabilitation onset did not decrease relative
to study year as we had hypothesized. Exercises were
started later in more recent studies, and no relationship
was observed between publication year and weightbearing
onset. These findings could be explained by our inclusion
criteria. A higher number of studies from more recent
years were included, which may reflect more studies ini-
tiating rehabilitation within the first 8 weeks and when
participants were still using an orthosis. Studies pub-
lished less recently may have been excluded, skewing
relationships between publication year and timing of
rehabilitation onset.
A variety of outcome measures are used to assess patient
response to treatment after Achilles tendon rupture.
Broadly, these measures can be described in 2 groups:
population-specific outcomes and general outcomes. Spe-
cific to this patient population, a variety of functional mea-
sures are commonly used along with tendon morphology
and diagnosis-specific outcome measures, such as the
Achilles tendon Total Rupture Score (ATRS). When looking
at general outcomes, the American Orthopedic Foot and
Ankle Score (AOFAS) was used in several studies as were
numerous other patient-reported outcomes, such as patient
satisfaction. From a research standpoint, it would be bene-
ficial to develop a core outcome set that uses a combination
of general and population-specific measures to allow com-
parison between populations of individuals with varying
diagnoses as well as measures that more comprehensively
assess the concerns of this particular patient population.
The data from this study can be used as a first step in
developing a core outcome set, as we have compiled fre-
quencies of commonly used outcomes across multiple
domains of patient assessment.
The available literature poses a variety of challenges
regarding early functional rehabilitation after Achilles ten-
don rupture. Looking across the included literature, we find
Figure 4. Type of early functional rehabilitation and outcome measures used.
6Zellers et al The Orthopaedic Journal of Sports Medicine
that studies are primarily cohort studies or case series.
Although RCTs had significantly more participants on
average, 73%of studies presenting data from 100 or more
individuals were case series or cohort studies. The majority
of research has been done on individuals undergoing simple
surgical repair (73%of studies), whereas 28%of studies
investigated individuals managed nonsurgically. It seems
that little research is available on rehabilitative strategies
for nonsurgically managed individuals, which is potentially
concerning given trends of increasing numbers of patients
managed without surgery.
61,177,178
Moving forward, it
seems that tensile loading could be an area for rehabilita-
tion protocol improvement. We found that only 1 in 2 stud-
ies included tensile-type loading, which has been suggested
in basic science and mechanistic studies
6,7,59,174
to be of
importance in the recovery of this patient population. Addi-
tionally, a variety of orthoses are used in immobilizing
patients—casts, unhinged walking boots with wedging,
hinged walking boots—and the effect of these devices on
tendon healing from a mechanistic standpoint is not well-
described, with 1 study comparing foot position between
strategies.
56
The area of early functional rehabilitation con-
tinues to have great research potential, but standardizing
outcomes and clearly stating rehabilitative protocols
should be a focus moving forward.
Studies aimed at improving Achilles tendon rupture out-
comes have used early functional rehabilitation, but this
term has been applied without a well-established
Figure 5. Timing of (A) weightbearing and (B) exercise onset in nonsurgically and surgically managed (primary and augmented
repair) patients.
The Orthopaedic Journal of Sports Medicine Early Rehabilitation for Achilles Rupture 7
definition. Without a standardized definition, caution
should be used when comparing outcomes between studies
or pooling data from multiple studies, as the intervention
could be very different even if treatment is labeled “early
functional rehabilitation.” This study was intended to
describe trends across the literature regarding type and
timing of early rehabilitation to synthesize an explicit def-
inition. Therefore, the results of this study cannot be
taken in a prescriptive sense, because efficacy of treat-
ment protocols was not assessed. We intentionally took a
broad approach to study inclusion, and it is important to
consider that the Downs & Black checklist can substan-
tially favor RCTs over even very large cohort studies and
case series.
Clinically, the findings of this systematic review suggest
that in most cases, early functional rehabilitation begins
within the first 2 weeks after treatment initiation in indi-
viduals with Achilles tendon rupture. Weightbearing and
range of motion are commonly used intervention strategies;
however, a growing body of literature is using additional
rehabilitative strategies such as strengthening interven-
tions and general conditioning. Although general foot and
ankle functional scores are regularly reported, several out-
comes more specific to this patient population could be con-
sidered to assess patient response to treatment.
ACKNOWLEDGMENT
The authors thank Tyler Tice and Jordan Denesik for their
assistance in scoring studies for risk of bias assessment and
Anne Thielecke, Camilla Rams Rathleff, Barbara C. Brocki,
Kathryn Wiser, and Susan Wiser for translation of foreign
studies.
REFERENCES
1. Agres AN, Gehlen TJ, Arampatzis A, Taylor WR, Duda GN, Manegold
S. Short-term functional assessment of gait, plantarflexor strength,
and tendon properties after Achilles tendon rupture. Gait Posture.
2018;62:179-185.
2. Aisaiding A, Wang J, Maimaiti R, et al. A novel minimally invasive
surgery combined with early exercise therapy promoting tendon
regeneration in the treatment of spontaneous Achilles tendon rupture.
Injury. 2018;49(3):712-719.
3. Aktas S, Kocaoglu B, Nalbantoglu U, Seyhan M, Guven O. End-to-end
versus augmented repair in the treatment of acute Achilles tendon
ruptures. J Foot Ankle Surg. 2007;46(5):336-340.
4. Al-Mouazze n L, Rajakulendran K, Najefi A, Ahad N. Percutaneous
repair followed by accelerated rehabilitation for acute Achilles tendon
ruptures. J Orthop Surg (Hong Kong). 2015;23(3):352-356.
5. Alviti F, Gurz`ı M, Santilli V, et al. Achilles tendon open surgical treat-
ment with platelet-rich fibrin matrix augmentation: biomechanical
evaluation. J Foot Ankle Surg. 2017;56(3):581-585.
6. Andersson T, Eliasson P, Aspenberg P. Tissue memory in healing
tendons: short loading episodes stimulate healing. J Appl Physiol.
2009;107:417-421.
7. Andersson T, Eliasson P, Hammerman M, Sandberg O, Aspenberg P.
Low-level mechanical stimulation is sufficient to improve tendon heal-
ing in rats. J Appl Physiol. 2012;113(9):1398-1402.
8. Aoki M, Ogiwara N, Ohta T, Nabeta Y. Early active motion and weight-
bearing after cross-stitch Achilles tendon repair. Am J Sports Med.
1998;26(6):794-800.
9. Aspenberg P, Schepull T. Substantial creep in healing human Achilles
tendons: a pilot study. Muscles Ligaments Tendons J. 2015;5(3):
151-155.
10. Assal M, Jung M, Stern R, Rippstein P, Delmi M, Hoffmeyer P. Limited
open repair of Achilles tendon ruptures. J Bone Joint Surg. 2002;
84(2):161-170.
11. Aujla R, Kumar A, Bhatia M. Non-surgical treatment of Achilles rup-
ture: does duration in functional weight bearing orthosis matter? Foot
Ankle Surg. 2016;22(4):254-258.
12. Aujla R, Patel S, Jones A, Bhatia M. Predictors of functional outcome
in non-operatively managed Achilles tendon ruptures. Foot Ankle
Surg. 2018;24(4):336-341.
13. Ba
¨cker HC, Yenchak AJ, Trofa DP, Vosseller JT. Strength mea-
surement after Achilles tendon repair. Foot Ankle Spec. 2019;12(5):
471-479.
14. Barfod KW, Bencke J, Lauridsen HB, Ban I, Ebskov L, Troelsen A.
Nonoperative dynamic treatment of acute Achilles tendon rupture: the
influence of early weight-bearing on clinical outcome: a blinded, ran-
domizedcontrolledtrial.JBoneJointSurgAm. 2014;96(18):
1497-1503.
15. Barfod KW, Bencke J, Lauridsen HB, Dippmann C, Ebskov L, Troel-
sen A. Nonoperative, dynamic treatment of acute Achilles tendon
rupture: influence of early weightbearing on biomechanical properties
of the plantar flexor muscle-tendon complex—a blinded, randomized,
controlled trial. J Foot Ankle Surg. 2015;54(2):220-226.
16. Baumfeld D, Baumfeld T, Spiezia F, Nery C, Zambelli R, Maffulli N.
Isokinetic functional outcomes of open versus percutaneous repair
following Achilles tendon tears. Foot Ankle Surg. 2019;25(4):503-506.
17. Bevoni R, Angelini A, D’Apote G, et al. Long term results of acute
Achilles repair with triple-bundle technique and early rehabilitation
protocol. Injury. 2014;45(8):1268-1274.
18. Bhattacharyya M, Gerber B. Mini-invasive surgical repair of the Achil-
les tendon—does it reduce post-operative morbidity? Int Orthop.
2009;33:151-156.
19. Bhattacharyya M, Gerber B. Minimally-invasive surgical repair of rup-
tured Achilles tendon as a day case procedure with early full weight
bearing. Journal of One-day Surgery. 17(3):70-75.
20. Bostick GP, Jomha NM, Suchak AA, Beaupr ´
e LA. Factors associated
with calf muscle endurance recovery 1 year after Achilles tendon
rupture repair. J Orthop Sports Phys Ther. 2010;40(6):345-351.
TABLE 1
Outcome Measures Used
a
Outcome Measure No. of Studies
Patient-reported outcome (total) 89
Achilles tendon Total Rupture Score 27
Foot and Ankle Outcome Score 3
No information provided 1
Other patient-reported outcome 43
Survey-based functional outcome (total) 50
AOFAS 33
Leppilahti score 12
Thermann score 12
Functional outcome (total) 130
Ankle range of motion 84
Strength 76
Calf circumference 69
Heel-rise 56
Biomechanics/gait analysis 21
Other 39
Tendon properties (total) 53
Morphology 43
Biology (cellular studies) 1
Other 32
a
AOFAS, American Orthopedic Foot and Ankle Score.
8Zellers et al The Orthopaedic Journal of Sports Medicine
21. Braunstein M, Baumbach SF, Boecker W, Carmont MR, Polzer H.
Development of an accelerated functional rehabilitation protocol
following minimal invasive Achilles tendon repair. Knee Surg Sports
Traumatol Arthrosc. 2018;26(3):846-853.
22. Brorsson A, Silbernagel KG, Olsson N, Helander KN. Calf muscle
performance deficits remain 7 years after an Achilles tendon rupture.
Am J Sports Med. 2017;46(2):470-477.
23. Brorsson A, Willy RW, Tranberg R, Gra
¨vare Silbernagel K. Heel-rise
height deficit 1 year after Achilles tendon rupture relates to changes in
ankle biomechanics 6 years after injury. Am J Sports Med. 2017;
45(13):3060-3068.
24. Brumann M, Baumbach SF, Mutschler W, Polzer H. Accelerated
rehabilitation following Achilles tendon repair after acute rupture—
development of an evidence-based treatment protocol. Injury. 2014;
45(11):1782-1790.
25. Buchgraber A, Pa
¨ssler HH. Percutaneous repair of Achilles tendon
rupture: immobilization versus functional postoperative treatment.
Clin Orthop Relat Res. 1997;341:113-122.
26. Calder JDF, Saxby TS. Early, active rehabilitation following mini-open
repair of Achilles tendon rupture: a prospective study. Br J Sports
Med. 2005;39:857-859.
27. Carmont MR, Gra
¨vare Silbernagel K, Brorsson A, Olsson N, Maffulli
N, Karlsson J. The Achilles tendon resting angle as an indirect meas-
ure of Achilles tendon length following rupture, repair, and rehabili-
tation. Asia Pac J Sports Med Arthrosc Rehabil Technol. 2015;2(2):
49-55.
28. Carmont MR, Zellers JA, Brorsson A, et al. Functional outcomes of
Achilles tendon minimally invasive repair using 4- and 6-strand non-
absorbable suture: a cohort comparison study. Orthop J Sports Med.
2017;5(8):2325967117723347.
29. Carvalho FA, Kamper SJ. Effects of early rehabilitation following oper-
ative repair of Achilles tendon rupture (PEDro synthesis). Br J Sports
Med. 2016;50(13):829-830.
30. Ceccarelli F, Berti L, Giuriati L, Romagnoli M, Giannini S. Percutane-
ous and minimally invasive techniques of Achilles tendon repair. Clin
Orthop Relat Res. 2007;458:188-193.
31. Cetti R, Christensen S-E, Ejsted R, Jensen NM, Jorgensen U. Oper-
ative versus nonoperative treatment of Achilles tendon rupture: a pro-
spective randomized study and review of the literature. Am J Sports
Med. 1993;21:791-799.
32. Cetti R, Henriksen LO, Jacobsen KS. A new treatment of ruptured
Achilles tendons: a prospective randomized study. Clin Orthop Relat
Res. 1994;308:155-165.
33. Chandrakant V, Lozano-Calderon S, McWilliam J. Immediate weight
bearing after modified percutaneous Achilles tendon repair. Foot
Ankle Int. 2012;33(12):1093-1097.
34. Chen H, Ji X, Zhang Q, Liang X, Tang P. Channel-assisted minimally
invasive repair of acute Achilles tendon rupture. J Orthop Surg Res.
2015;10:167.
35. Chiu C-H, Yeh W-L, Tsai M-C, Chang S-S, Hsu K-Y, Chan Y-S.
Endoscopy-assisted percutaneous repair of acute Achilles tendon
tears. Foot Ankle Int. 2013;34(123):1168-1176.
36. Chmielnicki M, Prokop A. Zwipp percutaneous suture of the Achilles
tendon with the Dresden instruments. Z Orthop Unfall. 2016;154:
303-305.
37. Collins R, Sudlow A, Loizou C, Loveday DT, Smith G. Closing the gap
on Achilles tendon rupture: a cadaveric study quantifying the tendon
apposition achieved with commonly used immobilisation practices.
Foot Ankle Surg. 2018;24(2):124-127.
38. Costa ML, MacMillan K, Halliday D, et al. Randomised controlled trials
of immediate weight-bearing mobilisation for rupture of the tendo
Achillis. J Bone Joint Surg Br. 2006;88(1):69-77.
39. Costa ML, Shepstone L, Darrah C, Marshall T, Donell ST. Immediate
full-weight-bearing mobilisation for repaired Achilles tendon ruptures:
a pilot study. Injury. 2003;34:874-876.
40. Cretnik A, Kosanovic M, Smrkolj V. Percutaneous versus open repair
of the ruptured Achilles tendon: a comparative study. Am J Sports
Med. 2005;33(9):1369-1379.
41. ˇ
Cretnik A, Kosanovic
´M, Smrkolj V. Percutaneous suturing of the
ruptured Achilles tendon under local anesthesia. J Foot Ankle Surg.
2004;43(2):72-81.
42. De Carli A, Lanzetti RM, Ciompi A, et al. Can platelet-rich plasma have
a role in Achilles tendon surgical repair? Knee Surg Sports Traumatol
Arthrosc. 2016;24(7):2231-2237.
43. De la Fuente C, Pen
˜a y Lillo R, Carren
˜o G, Marambio H. Prospective
randomized clinical trial of aggressive rehabilitation after acute Achil-
les tendon ruptures repaired with Dresden technique. Foot (Edinb).
2016;26:15-22.
44. De la Fuente CI, Lillo RPY, Campillo RR, et al. Medial gastrocnemius
myotendinous junction displacement and plantar-flexion strength in
patients treated with immediate rehabilitation after Achilles tendon
repair. J Athl Train. 2016;51(12):1013-1021.
45. Delgado-Brambila H, Cristiani- DG, Tinajero- EC, Burgos-El´
ıas V.
Reparaci ´
on de ruptura del tend ´
on calc ´
aneo y rehabilitaci ´
on
temprana. Acta Ortop ´
edica Mex. 2012;26(2):50-89.
46. Ding W, Yan W, Zhu Y, Liu Z. Treatment of acute and closed Achilles
tendon ruptures by minimally invasive tenocutaneous suturing. Ulus
Travma Acil Cerrahi Derg. 2012;18(5):405-410.
47. Ding WG, Zhu YP, Yan WH. Treatment of acute and closed Achilles
tendon ruptures by minimally invasive tenocutaneous suturing. J Foot
Ankle Surg. 2013;52(2):143-146.
48. Dolphin P, Bainbridge K, Mackenney P, Dixon J. Functional dynamic
bracing and functional rehabilitation for Achilles tendon ruptures: a case
series. Physiotherapy Practice and Research. 2016;37(2):119-125.
49. Domeij-Arverud E, Labruto F, Latifi A, Nilsson G, Edman G, Acker-
mann PW. Intermittent pneumatic compression reduces the risk of
deep vein thrombosis during postoperative lower limb immobilisation:
a prospective randomised trial of acute ruptures of the Achilles ten-
don. Bone Joint J. 2015;97(5):675-680.
50. Don R, Ranavolo A, Cacchio A, et al. Relationship between recovery
of calf-muscle biomechanical properties and gait pattern following
surgery for Achilles tendon rupture. Clin Biomech (Bristol, Avon).
2007;22:211-220.
51. Doral MN. What is the effect of the early weight-bearing mobilisation
without using any support after endoscopy-assisted Achilles tendon
repair? Knee Surg Sports Traumatol Arthrosc. 2013;21:1378-1384.
52. Dos Santos Gomes CT. Ruptura do tenda
˜o de Aquiles: tratamento
cir ´
urgico, mobilizac¸a
˜o e carga precoces. Rev Bras Ortop. 1998;
33(12):951-958.
53. Ebinesan AD, Sarai BS, Walley GD, Maffulli N. Conservative, open or
percutaneous repair for acute rupture of the Achilles tendon. Disabil
Rehabil. 2008;30:1721-1725.
54. Ecker TM, Bremer AK, Krause FG, Mu
¨ller T, Weber M. Prospective
use of a standardized nonoperative early weightbearing protocol for
Achilles tendon rupture: 17 years of experience. Am J Sports Med.
2016;44(4):1004-1010.
55. El-Akkawi AI, Joanroy R, Barfod KW, Kallemose T, Kristensen SS,
Viberg B. Effect of early versus late weightbearing in conservatively
treated acute Achilles tendon rupture: a meta-analysis. J Foot Ankle
Surg. 2018;57(2):346-352.
56. Ellison P, Molloy A, Mason LW. Early protected weightbearing for acute
ruptures of the Achilles tendon: do commonly used orthoses produce
the required equinus? J Foot Ankle Surg. 2017;56(5):960-963.
57. Fern ´
andez-Fair ´
en M, Gimeno C. Augmented repair of Achilles tendon
ruptures. Am J Sports Med. 1997;25(2):177-181.
58. Fitzgibbons RE, Hefferon J, Hill J. Percutaneous Achilles tendon
repair. Am J Sports Med. 1993;21(5):724-727.
59. Freedman B, Gordon J, Bhatt P, et al. Nonsurgical treatment and early
return to activity leads to improved Achilles tendon fatigue mechanics
and functional outcomes during early healing in an animal model. J
Orthop Res. 2016;34(12):2172-2180.
60. Gaiani L, Bertelli R, Palmonari M. Dynamic percutaneous repair of the
ruptured tendo Achillis. Eur J Orthop Surg Traumatol. 2012;22:
709-712.
61. Ganestam A, Kallemose T, Troelsen A, Barfod KW. Increasing inci-
dence of acute Achilles tendon rupture and a noticeable decline in
surgical treatment from 1994 to 2013: a nationwide registry study of
The Orthopaedic Journal of Sports Medicine Early Rehabilitation for Achilles Rupture 9
33,160 patients. Knee Surg Sports Traumatol Arthrosc. 2016;24(12):
3730-3737.
62. Garrido IM, Deval JC, Bosch MN, Mediavilla DH, Garcia VP, Gonz ´
alez
MS. Treatment of acute Achilles tendon ruptures with Achillon device:
clinical outcomes and kinetic gait analysis. Foot Ankle Surg. 2010;
16(4):189-194.
63. Geremia JM, Bobbert MF, Casa Nova M, et al. The structural and
mechanical properties of the Achilles tendon 2 years after surgical
repair. Clin Biomech (Bristol, Avon). 2015;30(5):485-492.
64. Gigante A, Moschini A, Verdenelli A, Del Torto M, Ulisse S, De Palma
L. Open versus percutaneous repair in the treatment of acute Achilles
tendon rupture: a randomized prospective study. Knee Surg Sports
Traumatol Arthrosc. 2008;16:204-209.
65. Gorschewsky O, Pitzl M, Pu
¨tz A, Klakow A, Neumann W. Percutane-
ous repair of acute Achilles tendon rupture. Foot Ankle Int. 2004;25(4):
219-224.
66. Gorschewsky O, Vogel U, Schweizer A, van Laar B. Percutaneous
tenodesis of the Achilles tendon: a new surgical method for the treat-
ment of acute Achilles tendon rupture through percutaneous tenod-
esis. Injury. 1999;30:315-321.
67. Groetelaers RPTGC, Janssen L, van der Velden J, et al. Functional
treatment or cast immobilization after minimally invasive repair of an
acute Achilles tendon rupture: prospective, randomized trial. Foot
Ankle Int. 2014;35(8):771-778.
68. Gwynne-Jones DP, Sims M, Handcock D. Epidemiology and out-
comes of acute Achilles tendon rupture with operative or nonopera-
tive treatment using an identical functional bracing protocol. Foot
Ankle Int. 2011;32:337-343.
69. Hansen M, Christensen M, Budolfsen T, et al. Achilles tendon total
rupture score at 3 months can predict patients’ ability to return to
sport 1 year after injury. Knee Surg Sports Traumatol Arthrosc.
2016;24(4):1365-1371.
70. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG.
Research electronic data capture (REDCap)—a metadata-driven
methodology and workflow process for providing translational
research informatics support. J Biomed Inform. 2009;42(2):377-381.
71. Heikkinen J, Lantto I, Flinkkila T, et al. Soleus atrophy is common after
the nonsurgical treatment of acute Achilles tendon ruptures. Am J
Sports Med. 2017;45(6):1395-1404.
72. Heikkinen J, Lantto L, Flinkkila T, et al. Augmented compared with
nonaugmented surgical repair after total Achilles rupture: results of a
prospective randomized trial with thirteen or more years of follow-up.
J Bone Joint Surg. 2016;98:85-92.
73. Henr´ıquez H, Mun
˜oz R, Carcuro G, Bast´ıas C. Is percutaneous repair
better than open repair in acute Achilles tendon rupture? Clin Orthop
Relat Res. 2012;470:998-1003.
74. Holm C, Kjaer M, Eliasson P. Achilles tendon rupture—treatment and
complications: a systematic review. Scand J Med Sci Sports. 2015;
25(1):e1-e10.
75. Holmenschlager F, Schubert S, Winckler S. Achilles tendon rupture:
early dynamic mobilisation after surgery. Zentralbl Chir. 2002;127:
519-522.
76. Horter M, Horter M, Wetterkamp D, Rieger H. Offene rekonstruktion
der Achillessehnenruptur—wann und wie? Chir Prax. 2007;67:
611-620.
77. Hrnack SA, Crates JM, Barber FA. Primary Achilles tendon repair with
mini-dorsolateral incision technique and accelerated rehabilitation.
Foot Ankle Int. 2012;33:848-851.
78. Huang J, Wang C, Ma X, Wang X, Zhang C, Chen L. Rehabilitation
regimen after surgical treatment of acute Achilles tendon ruptures: a
systematic review with meta-analysis. Am J Sports Med. 2015;43(4):
1008-1016.
79. Huffer D, Hing W, Newton R, Clair M. Strength training for plantar
fasciitis and the intrinsic foot musculature: a systematic review. Phys
Ther Sport. 2017;24(2016):44-52.
80. Hu
¨fner T, Wohifarth K, Fink M, Thermann H, Rollnik JD. EMG moni-
toring during functional non-surgical therapy of Achilles tendon rup-
ture. Foot Ankle Int. 2002;23(7):614-618.
81. Hu
¨fner TM, Brandes DB, Thermann H, Richter M, Knobloch K, Kret-
tek C. Long-term results after functional nonoperative treatment of
Achilles tendon rupture. Foot Ankle Int. 2006;27:167-171.
82. Hutchison AM, Topliss C, Beard D, Evans RM, Williams P. The treat-
ment of a rupture of the Achilles tendon using a dedicated manage-
ment programme. Bone Joint J. 2015;97(4):510-515.
83. Jackson G, Sinclair VF, McLaughlin C, Barrie J. Outcomes of func-
tional weight-bearing rehabilitation of Achilles tendon ruptures.
Orthopedics. 2013;36(8):e1053-e1059.
84. Jacob KM, Paterson R. Surgical repair followed by functional reha-
bilitation for acute and chronic Achilles tendon injuries: excellent
functional results, patient satisfaction and no reruptures. ANZ J
Surg. 2007;77(4):287-291.
85. Jallageas R, Bordes J, Daviet J-C, Mabit C, Coste C. Evaluation of
surgical treatment for ruptured Achilles tendon in 31 athletes. Orthop
Traumatol Surg Res. 2013;99(5):577-584.
86. Jielile J, Sabirhazi G, Chen J, et al. Novel surgical technique and
early kinesiotherapy for acute Achilles tendon rupture. Foot Ankle
Int. 2012;33:1119-1127.
87. Kangas J, Pajala A, Ohtonen P, Leppilahti J. Achilles tendon elon-
gation after rupture repair: a randomized comparison of 2 postoper-
ative regimens. Am J Sports Med. 2007;35:59-64.
88. Kangas J, Pajala A, Siira P, Ha
¨ma
¨la
¨inen M, Leppilahti J. Early func-
tional treatment versus early immobilization in tension of the muscu-
lotendinous unit after Achilles rupture repair: a prospective,
randomized, clinical study. J Trauma. 2003;54(6):1171-1180.
89. Kaniki N, Willits K, Mohtadi NGH, Fung V, Bryant D. A retrospective
comparative study with historical control to determine the effec-
tiveness of platelet-rich plasma as part of nonoperative treatment
of acute Achilles tendon rupture. Arthroscopy. 2014;30(9):
1139-1145.
90. Karaaslan F, Mermerkaya MU, Cirakli A, Karaoglu S, Duygulu F.
Surgical versus conservative treatment following acute rupture of
the Achilles tendon: is there a pedobarographic difference? Ther Clin
Risk Manag. 2016;12:1311-1315.
91. Karabinas PK, Benetos IS, Lampropoulou-Adamidou K, Romoudis
P, Mavrogenis AF, Vlamis J. Percutaneous versus open repair of
acute Achilles tendon ruptures. Eur J Orthop Surg Traumatol.
2014;24:607-613.
92. Kauranen K, Kangas J, Leppilahti J. Recovering motor performance
of the foot after Achilles rupture repair: a randomized clinical study
about early functional treatment vs. early immobilization of Achilles
tendon in tension. Foot Ankle Int. 2002;23(7):600-605.
93. Kearney RS, Achten J, Parsons NR, Costa ML. The comprehensive
cohort model in a pilot trial in orthopaedic trauma. BMC Med Res
Methodol. 2011;11(1):39.
94. Keller A, Ortiz C, Wagner E, Wagner P, Mococain P. Mini-open tenor-
rhaphy of acute Achilles tendon ruptures: medium-term follow-up of
100 cases. Am J Sports Med. 2014;42(3):731-736.
95. Kerkhoffs GM, Struijs PA, Raaymakers EL, Marti RK. Functional
treatment after surgical repair of acute Achilles tendon rupture: wrap
vs walking cast. Arch Orthop Trauma Surg. 2002;122:102-105.
96. Kim U, Choi YS, Jang GC, Choi YR. Early rehabilitation after open
repair for patients with a rupture of the Achilles tendon. Injury. 2017;
48(7):1710-1713.
97. Knobe M, Gradl G, Klos K, et al. Is percutaneous suturing superior to
open fibrin gluing in acute Achilles tendon rupture? Int Orthop. 2015;
39(3):535-542.
98. Korakakis V, Whiteley R, Tzavara A, Malliaropoulos N. The effective-
ness of extracorporeal shockwave therapy in common lower limb
conditions: a systematic review including quantification of patient-
rated pain reduction. Br J Sports Med. 2018;52(6):387-407.
99. Korkmaz M, Erkoc MF, Yolcu S, Balbaloglu O, O
¨ztemur Z, Karaaslan
F. Weight bearing the same day versus non-weight bearing for 4
weeks in Achilles tendon rupture. J Orthop Sci. 2015;20(3):513-516.
100. Kuskucu M, Mahirogullari M, Solakoglu C, et al. Treatment of rupture
of the Achilles tendon with fibrin sealant. Foot Ankle Int. 2005;26(10):
826-831.
10 Zellers et al The Orthopaedic Journal of Sports Medicine
101. Lacoste S, Cherrier B, F ´
eron JM. Intra-operative ultrasonography in
the percutaneous tenorraphy of acute Achilles tendon ruptures. Eur
J Orthop Surg Traumatol. 2012;22(7):585-591.
102. Lansdaal JR, Goslings JC, Reichart M, et al. The results of 163
Achilles tendon ruptures treated by a minimally invasive surgical
technique and functional aftertreatment. Injury. 2007;38:839-844.
103. Lantto I, Heikkinen J, Flinkkila T, et al. A prospective randomized trial
comparing surgical and nonsurgical treatments of acute Achilles
tendon ruptures. Am J Sports Med. 2016;44(9):2406-2414.
104. Lantto I, Heikkinen J, Flinkkila T, et al. Early functional treatment
versus cast immobilization in tension after Achilles rupture repair:
results of a prospective randomized trial with 10 or more years of
follow-up. Am J Sports Med. 2015;43(9):2302-2309.
105. Lantto I, Heikkinen J, Flinkkila T, Ohtonen P, Leppilahti J. Epidemi-
ology of Achilles tendon ruptures: increasing incidence over a 33-
year period. Scand J Med Sci Sports. 2015;25(1):e133-e138.
106. Lapidus LJ, Rosfors S, Ponzer S, et al. Prolonged thromboprophy-
laxis with dalteparin after surgical treatment of Achilles tendon rup-
ture: a randomized, placebo-controlled study. J Orthop Trauma.
2007;21(1):52-57.
107. Lee DK. A preliminary study on the effects of acellular tissue graft
augmentation in acute Achilles tendon ruptures. J Foot Ankle Surg.
2008;47(1):8-12.
108. Leppilahti J, Lahde S, Forsman K, Kangas J, Kauranen K, Orava S.
Relationship between calf muscle size and strength after Achilles
rupture repair. Foot Ankle Int. 2000;21(4):330-335.
109. Li C-G, Li B, Yang Y-F. Management of acute Achilles tendon rup-
ture with tendon-bundle technique. JIntMedRes. 2017;45(1):
310-319.
110. Lill H, Moor C, Fecht E, Kalbe P, Echtermeyer V.
Achillessehnenruptur—operative oder konservativ funktionelle
Behandlung? Akt Traumatol. 1996;26:95-100.
111. Lim CS, Lees D, Gwynne-Jones DP. Functional outcome of acute
Achilles tendon rupture with and without operative treatment using
identical functional bracing protocol. Foot Ankle Int. 2018;38(12):
1331-1336.
112. Lonzaric
´D, Kru ˇ
sˇ
cic
´A, Dinevski D, Povalej Br ˇ
zan P, Jesen ˇ
sek Pape ˇ
z
B. Primary surgical repair of acute Achilles tendon rupture: compar-
ative results of three surgical techniques. Wien Klin Wochenschr.
2017;129(5-6):176-185.
113. Lorkowski J, Brongel L, Hładki W, et al. Evaluation of long term
therapy outcomes for Achilles tendon ruptures. Pol Przegl Chir.
2007;79(6):745-756.
114. MacDermid JC, Silbernagel KG. Outcome evaluation in tendinopa-
thy: foundations of assessment and a summary of selected mea-
sures. J Orthop Sports Phys Ther. 2015;45(11):950-964.
115. Maffulli G, Del Buono A, Richards P, Oliva F, Maffulli N. Conserva-
tive, minimally invasive and open surgical repair for management of
acute ruptures of the Achilles tendon: a clinical and functional retro-
spective study. Muscles Ligaments Tendons J. 2017;7(1):46-52.
116. Maffulli N, Longo UG, Ronga M, Khanna A, Denaro V. Favorable
outcome of percutaneous repair of Achilles tendon ruptures in the
elderly. Clin Orthop Relat Res. 2010;468:1039-1046.
117. Maffulli N, Tallon C, Wong J, Lim KP, Bleakney R. Early weightbear-
ing and ankle mobilization after open repair of acute midsubstance
tears of the Achilles tendon. Am J Sports Med. 2003;31(5):692-700.
118. Maffulli N, Tallon C, Wong J, Peng Lim K, Bleakney R. No adverse
effect of early weight bearing following open repair of acute tears of
the Achilles tendon. J Sports Med Phys Fitness. 2003;43(3):367-379.
119. Maffulli N, Thorpe AP, Smith EW. Magnetic resonance imaging after
operative repair of Achilles tendon rupture. Scand J Med Sci Sports.
2001;11:156-162.
120. Majewski M, Schaeren S, Kohlhaas U, Ochsner PE. Postoperative
rehabilitation after percutaneous Achilles tendon repair: early func-
tional therapy versus cast immobilization. Disabil Rehabil. 2008;
30(20-22):1726-1732.
121. Mandelbaum BR, Myerson MS, Forster R. Achilles tendon ruptures:
a new method of repair, early range of motion, and functional reha-
bilitation. Am J Sports Med. 1995;23(4):392-395.
122. Marti R, Werken van derSchutte P, Bast T. Operative repair of rup-
tured Achilles tendon and functional after-treatment—I: acute rup-
ture. Neth J Surg. 1983;35(2):61-64.
123. Martinelli B. Percutaneous repair of the Achilles tendon in athletes.
Bull Hosp Jt Dis. 2000;59(3):149-152.
124. Mauch M, Ulrich M, Kaelin X, Segesser B, Paul J. Biomechanical
evaluation of rehabilitation after surgical repair of Achilles tendon
ruptures. Sportverletz Sportschaden. 2017;31:222-230.
125. Mavrodontidis A, Lykissas M, Koulouvaris P, Pafilas D, Kontogeor-
gakos V, Zalavras C. Percutaneous repair of acute Achilles tendon
rupture: a functional evaluation study with a minimum 10-year
follow-up. Acta Orthop Traumatol Turc. 2015;49(6):661-667.
126. Mayer A, Frasson VB, Ott R, Fortuna RO, Vaz MA. Desequil´ıbrios
musculares entre flexores dorsais e plantares do tornozelo ap ´
os
tratamento conservador e acelerado da ruptura do tenda
˜o calc ˆ
aneo.
Muscle imbalance between ankle dorsiflexors and plantarflexors
after conservative and accelerated treatment. Fisioter e Pesqui.
2010;17(2):108-113.
127. McComis GP, Nawoczenski DA, DeHaven K. Functional bracing for
rupture of the Achilles tendon: clinical results and analysis of ground-
reaction forces and temporal data. J Bone Joint Surg. 1997;79(12):
1799-1808.
128. McCormack R, Bovard J. Early functional rehabilitation or cast
immobilisation for the postoperative management of acute Achilles
tendon rupture? A systematic review and meta-analysis of rando-
mised controlled trials. Br J Sports Med. 2015;49(20):1329-1335.
129. McNair P, Nordez A, Olds M, Young SW, Cornu C. Biomechanical
properties of the plantar flexor muscle-tendon complex 6 months
post-rupture of the Achilles tendon. JOrthopRes. 2013;31(9):
1469-1474.
130. Metz R, van der Heijden GJMG, Verleisdonk E-JMM, Tamminga R,
van der Werken C. Recovery of calf muscle strength following Achil-
les tendon rupture treatment: a comparison between minimally inva-
sive surgery and conservative treatment. Foot Ankle Spec. 2009;
2(5):219-226.
131. Mezzarobba S, Bortolato S, Giacomazzi A, Fancellu G, Marcovich R,
Valentini R. Percutaneo us repair of Achilles tendon ruptures with
Tenolig: quantitative analysis of postural control and gait pattern.
Foot (Edinb). 2012;22(4):303-309.
132. Miller D, Waterston S, Reaper J, Barrass V, Maffulli N. Conservative
management, percutaneous or open repair of acute Achilles tendon
rupture: a retrospective study. Scott Med J. 2005;50(4):160-165.
133. Miyamoto W, Imade S, Innami K, Kawano H, Takao M. Acute Achil-
les tendon rupture treated by double side-locking loop suture tech-
nique with early rehabilitation. Foot Ankle Int. 2017;38(2):167-173.
134. Moberg A, Nordgren B, Solveborn S. Surgically repaired Achilles
tendon ruptures with postoperative mobile ankle cast: a 12-month
follow-up study with an isokinetic and a dynamic muscle function
test. Scand J Med Sci Sports. 1992;2(4):231-233.
135. Mo
¨ller M, Ka
¨lebo P, Tidebrant G, Movin T, Karlsson J. The ultraso-
nographic appearance of the ruptured Achilles tendon during heal-
ing: a longitudinal evaluation of surgical and nonsurgical treatment,
with comparisons to MRI appearance. Knee Surg Sports Traumatol
Arthrosc. 2002;10:49-56.
136. Mo
¨ller M, Lind K, Movin T, Karlsson J. Calf muscle function after
Achilles tendon rupture: a prospective, randomised study compar-
ing surgical and non-surgical treatment. Scand J Med Sci Sports.
2002;12(1):9-16.
137. Moller M, Movin T, Granhed H, Lind K, Faxen E, Karlsson J. Acute
rupture of tendon Achillis: a prospective randomised study of com-
parison between surgical and non-surgical treatment. J Bone Joint
Surg Br. 2001;83(6):843-848.
138. Mortensen HM, Skov O, Jensen PE. Early motion of the ankle after
operative treatment of a rupture of the Achilles tendon: a prospec-
tive, randomized clinical and radiographic study. J Bone Joint Surg.
1999;81(7):983-990.
139. Mortensen N, Saether J, Steinke M, Staehr H, Mikkelsen S. Sepa-
ration of tendon ends after Achilles tendon repair: a prospective,
randomized, multicenter study. Orthopedics. 1992;15(8):899-903.
The Orthopaedic Journal of Sports Medicine Early Rehabilitation for Achilles Rupture 11
140. Motta P, Errichiello C, Pontini I. Achilles tendon rupture: a new tech-
nique for easy surgical repair and immediate movement of the ankle
and foot. Am J Sports Med. 1997;25(2):172-176.
141. Mukundan C, El Husseiny M, Rayan F, Salim J, Budgen A. “Mini-
open” repair of acute tendo Achilles ruptures—the solution? Foot
Ankle Surg. 2010;16(3):122-125.
142. Mullaney MJ, McHugh MP, Tyler TF, Nicholas SJ, Lee SJ. Weakness
in end-range plantar flexion after Achilles tendon repair. Am J Sports
Med. 2006;34:1120-1125.
143. Neumayer F, Mouhsine E, Arlettaz Y, Gremion G, Wettstein M, Cre-
voisier X. A new conservative-dynamic treatment for the acute rup-
tured Achilles tendon. Arch Orthop Trauma Surg. 2010;130(3):
363-368.
144. Nilsson-Helander K, Silbernagel KG, Thome ´
e R, et al. Acute Achilles
tendon rupture: a randomized, controlled study comparing surgical
and nonsurgical treatments using validated outcome measures. Am
J Sports Med. 2010;38(11):2186-2193.
145. O’Connor SR, Tully MA, Ryan B, Bradley JM, Baxter GD, McDo-
nough SM. Failure of a numerical quality assessment scale to iden-
tify potential risk of bias in a systematic review: a comparison study.
BMC Res Notes. 2015;8:224.
146. Ocguder DA, Dogan M, Bektaser SB, Akgun E, Tolunay T, Ugurlu M.
Comparison of the open primary repair with augmentation and with-
out augmentation in acute Achilles tendon rupture. Turkish J Med
Sci. 2011;41(4):639-646.
147. Olsson N, Karlsson J, Eriksson BI, Brorsson A, Lundberg M, Silber-
nagel KG. Ability to perform a single heel-rise is significantly related
to patient-reported outcome after Achilles tendon rupture. Scand J
Med Sci Sports. 2014;24:152-158.
148. Olsson N, Nilsson-Helander K, Karlsson J, et al. Major functional
deficits persist 2 years after acute Achilles tendon rupture. Knee
Surg Sports Traumatol Arthrosc. 2011;19:1385-1393.
149. Olsson N, Petzold M, Brorsson A, Karlsson J, Eriksson BI, Gra
¨vare
Silbernagel K. Predictors of clinical outcome after acute Achilles
tendon ruptures. Am J Sports Med. 2014;42(6):1448-1455.
150. Olsson N, Silbernagel KG, Eriksson BI, et al. Stable surgical repair
with accelerated rehabilitation versus nonsurgical treatment for
acute Achilles tendon ruptures: a randomized controlled study. Am
J Sports Med. 2013;41(12):2867-2876.
151. Ozer H, Selek HY, Harput G, Oznur A, Baltaci G. Achilles tendon
open repair augmented with distal turndown tendon flap and poste-
rior crural fasciotomy. J Foot Ankle Surg. 2016;55(6):1180-1184.
152. Ozkan H, Ege T, Koca K, Can N, Yurttas Y, Tunay S. Pedobaro-
graphic measurements after repair of Achilles tendon by minimal
invasive surgery. Acta Orthop Belg. 2016;82:271-274.
153. Ozkaya U, Parmaksizoglu AS, Kabukcuoglu Y, Sokucu S, Basilgan
S. Open minimally invasive Achilles tendon repair with early rehabil-
itation: functional results of 25 consecutive patients. Injury. 2009;
40(6):669-672.
154. Peng W-C, Chang Y-P, Chao Y-H, et al. Morphomechanical altera-
tions in the medial gastrocnemius muscle in patients with a repaired
Achilles tendon: associations with outcome measures. Clin Biomech
(Bristol, Avon). 2017;43:50-57.
155. Persson A, Wredmark T. The treatment of total ruptures of the Achil-
les tendon by plaster immobilisation. Int Orthop. 1979;3(2):149-152.
156. Petersen OF, Nielsen MB, Jensen KH, Solgaard S. Randomiseret
sammenligning af genanvendelig stovle og letvaegtsgips til behand-
ling af forstegangs akillesseneruptur. Ugeskr Laeger. 2002;164:
3852-3855.
157. Porter DA, Barnes AF, Rund AM, Kaz AJ, Tyndall JA, Millis AA. Acute
Achilles tendon repair: strength outcomes after an acute bout of
exercise in recreational athletes. Foot Ankle Int. 2014;35(2):123-130.
158. Porter MD, Shadbolt B. Randomized controlled trial of accelerated
rehabilitation versus standard protocol following surgical repair of
ruptured Achilles tendon. ANZ J Surg. 2015;85(5):373-377.
159. Quagliarella L, Sasanelli N, Notarnicola A, Belgiovine G, Moretti L.
Comparative functional analysis of two different Achilles tendon sur-
gical repairs. Foot Ankle Int. 2010;31(4):306-315.
160. Raikin SM, Garras DN, Krapchev PV. Achilles tendon injuries in a
United States population. Foot Ankle Int. 2013;34(4):475-480.
161. Reilmann H, Forster E, Weinberg A, Bruggemann F, Peukert J. Con-
servative functional therapy of closed rupture of the Achilles tendon:
treatment approach and analysis of results. Unfallchirurg. 1996;99:
576-580.
162. Renninger CH, Kuhn K, Fellars T, Youngblood S, Bellamy J. Opera-
tive and nonoperative management of Achilles tendon ruptures in
active duty military population. Foot Ankle Int. 2016;37(3):269-273.
163. Richardson LC, Reitman R, Wilson M. Achilles tendon ruptures:
functional outcome of surgical repair with a “pull-out” wire. Foot
Ankle Int. 2003;24(5):439-443.
164. Richter J, Josten DA, Clasbrummel B, Muhr G. Sportfahigkeit nach
konservativ-funktioneller versus operativer Behandlung von akuten
Achillessehnenrupturen. Zentralbl Chir. 1994;119:538-544.
165. Richter J, Pommer A, Hahn M, David A, Muhr G. Moglichkeiten und
grenzen der funktionell konservativen therapie akuter Achillesseh-
nenrupturen. Chirurg. 1997;68:517-524.
166. Roberts CP, Palmer S, Vince A, Deliss LJ. Dynamised cast manage-
ment of Achilles tendon ruptures. Injury. 2001;32(5):423-426.
167. Rozis M, Benetos I, Karampinas P, Polyzois V, Vlamis J, Pneumati-
cos S. Outcome of percutaneous fixation of acute Achilles tendon
ruptures. Foot Ankle Int. 2018;39(6):689-693.
168. Saleh M, Marshall PD, Senior R, MacFarlane A. The Sheffield splint
for controlled early mobilisation after rupture of the calcaneal ten-
don: a prospective, randomised comparison with plaster treatment.
J Bone Joint Surg Br. 1992;74(2):206-209.
169. Sandberg OH, Danmark I, Eliasson P, Aspenberg P. Influence of a
lower leg brace on traction force in healthy and ruptured Achilles
tendons. Muscles Ligaments Tendons J. 2015;5(2):63-67.
170. Saper D, Lybrand K, Creevy W, Li X. Using a posterior compartment
fasciotomy and paratenon closure in acute Achilles tendon repair.
Orthopedics. 2016;39(4):e790-e793.
171. Saw Y, Baltzopoulos V, Lim A, Rostron PKM. Early mobilization
Achilles tendon after operative repair of ruptured Achilles tendon.
Injury. 1993;24(7):479-484.
172. Saxena A, Ewen B, Maffulli N. Rehabilitation of the operated Achilles
tendon: parameters for predicting return to activity. J Foot Ankle
Surg. 2011;50(1):37-40.
173. Scha
¨fer D, Regazzoni P, Hintermann B. Fru
¨hfunktionelle behandlung
der operativ versorgten Achillessehnenruptur. Unfallchirurg. 2002;
105(8):699-702.
174. Schepull T, Aspenberg P. Early controlled tension improves the
material properties of healing human Achilles tendons after ruptures:
a randomized trial. Am J Sports Med. 2013;41:2550-2557.
175. Schepull T, Kvist J, Andersson C, Aspenberg P. Mechanical prop-
erties during healing of Achilles tendon ruptures to predict final out-
come: a pilot Roentgen stereophotogrammetric analysis in 10
patients. BMC Musculoskelet Disord. 2007;8:116.
176. Scott A, Docking S, Vicenzino B, et al. Sports and exercise-related
tendinopathies: a review of selected topical issues by participants of
the second International Scientific Tendinopathy Symposium (ISTS)
Vancouver 2012. Br J Sports Med. 2013;47:536-544.
177. Sheth U, Wasserstein D, Jenkinson R, Moineddin R, Kreder H, Jaglal
S. Practice patterns in the care of acute Achilles tendon ruptures.
Bone Joint J. 2017;99(12):1629-1636.
178. ShethU,WassersteinD,JenkinsonR,MoineddinR,KrederH,
Jaglal SB. The epidemiology and trends in management of acute
Achilles tendon ruptures in Ontario, Canada. Bone Joint J. 2017;
99(1):78-86.
179. Solveborn S, Moberg A. Immediate free ankle motion after surgical
repair of acute Achilles tendon ruptures. Am J Sports Med. 1994;
22(5):607-610.
180. Sorrenti S. Achilles tendon rupture: effect of early mobilization in
rehabilitation after surgical repair. Foot Ankle Int. 2006;27(6):
407-410.
181. Speck M, Klaue K. Early full weightbearing and functional treatment
after surgical repair of acute Achilles tendon rupture. Am J Sports
Med. 1998;26(6):789-793.
12 Zellers et al The Orthopaedic Journal of Sports Medicine
182. Steele GJ, Harter RA, Ting AJ. Comparison of functional ability fol-
lowing percutaneous and open surgical repairs of acutely ruptured
Achilles tendons. J Sport Rehabil. 1993;2:115-127.
183. Strauss E, Ishak C, Jazrawi L, Sherman O, Rosen J. Operative treat-
ment of acute Achilles tendon ruptures: an institutional review of
clinical outcomes. Injury. 2007;38(7):832-838.
184. Suchak A, Bostick G, Beaupre L, Durand D, Jomha N. The influence
of early weight-bearing compared with non-weight-bearing after
surgical repair of the Achilles tendon. J Bone Joint Surg. 2008;
90(9):1876-1883.
185. Swennergren Hansen M, Weisskirchner Barfod K, Tange Kristensen
M. Development and reliability of the Achilles tendon length measure
and comparison with the Achilles tendon resting angle on patients
with an Achilles tendon rupture. Foot Ankle Surg. 2017;23(4):
275-280.
186. Tarnit¸a
˘DN, Tarnit¸a
˘D, Grecu DC, Calafeteanu DM, Ca
˘pita
˘nescu B.
New technical procedure involving Achilles tendon rupture treatment
through transcutaneous suture. Rom J Morphol Embryol. 2016;
57(1):211-214.
187. Tezeren G, Kuru I. Augmentation vs nonaugmentation techniques for
open repairs of Achilles tendon ruptures with early functional treat-
ment: a prospective randomized study. J Sports Sci Med. 2006;5(4):
607-614.
188. Thermann H, Zwipp H. Achillessehnenruptur. Orthopade. 1989;18:
321-335.
189. Thermann H, Zwipp H, Tscherne H. Functional treatment concept of
acute rupture of the Achilles tendon: 2 years results of a prospective
randomized study. Unfallchirurg. 1995;98(1):21-32.
190. Troop RL, Losse GM, Lane JG, Robertson DB, Hastings PS, Howard
ME. Early motion after repair of Achilles tendon ruptures. Foot Ankle
Int. 1995;16(11):705-709.
191. Twaddle BC, Poon P. Early motion for Achilles tendon ruptures: is
surgery important? A randomized, prospective study. Am J Sports
Med. 2007;35:2033-2038.
192. Vadal ´
a A, De Carli A, Vulpiani M, et al. Clinical, functional and radio-
logical results of Achilles tenorraphy surgically treated with mini-
open technique. J Sports Med Phys Fitness. 2012;52:616-621.
193. Valkering KP, Aufwerber S, Ranuccio F, Lunini E, Edman G, Acker-
mann PW. Functional weight-bearing mobilization after Achilles
tendon rupture enhances early healing response: a single-blinded
randomized controlled trial. Knee Surg Sports Traumatol Arthrosc.
2017;25(6):1807-1816.
194. Vavra-Had ˇ
ziahmetovic N, Had ˇ
ziahmetovic Z, Smajlovic F. Physical
therapy in conservative (functional) treatment of acute Achilles ten-
don rupture. Med Arh. 2000;54(2):121-122.
195. Walz M, Cramer J, Mollenhoff G, Muhr G. Ultrasonographic moni-
toring of conservative-functional treatment of rupture of the Achilles
tendon. Orthopade. 1993;22(5):317-322.
196. Weber M, Niemann M, Lanz R, Mu
¨ller T. Nonoperative treatment of
acute rupture of the Achilles tendon: results of a new protocol and
comparison with operative treatment. Am J Sports Med. 2003;31(5):
685-691.
197. Westin O, Nilsson Helander K, Gra
¨vare Silbernagel K, Mo
¨ller M,
Ka
¨lebo P, Karlsson J. Acute ultrasonography investigation to predict
reruptures and outcomes in patients with an Achilles tendon rupture.
Orthop J Sports Med. 2016;4(10):2325967116667920.
198. Williamson PR, Altman DG, Bagley H, et al. The COMET Handbook:
version 1.0. Trials. 2017;18(suppl 3):280.
199. Willits K, Amendola A, Bryant D, et al. Operative versus nonoperative
treatment of acute Achilles tendon ruptures: a multicenter random-
ized trial using accelerated functional rehabilitation. J Bone Joint
Surg. 2010;92(17):2767-2775.
200. Willy RW, Brorsson A, Powell HC, Willson JD, Tranberg R, Gra
¨vare
Silbernagel K. Elevated knee joint kinetics and reduced ankle kinet-
ics are present during jogging and hopping after Achilles tendon
ruptures. Am J Sports Med. 2017;45(5):1124-1133.
201. Wredmark T, Carlstedt CA. Tendon elongation and muscle function
after repair of Achilles tendon rupture. Scand J Med Sci Sports.
1992;2(3):139-142.
202. Yotsumoto T, Miyamoto W, Uchio Y. Novel approach to repair of
acute Achilles tendon rupture: early recovery without postoperative
fixation or orthosis. Am J Sports Med. 2010;38:287-292.
203. Zayni R, Coursier R, Zakaria M, et al. Activity level recovery after
acute Achilles tendon rupture surgically repaired: a series of 29
patients with a mean follow-up of 46 months. Muscles Ligaments
Tendons J. 2017;7(1):69-77.
204. Zell RA, Santoro VM. Augmented repair of acute Achilles tendon
ruptures. Foot Ankle Int. 2000;21(6):469-474.
APPENDIX
TABLE A1
Search String
Ovid Technologies
Database: Embase <1974 to 2017 Week 14>
Search Strategy:
—————————————————————————————————————————————
1 achilles tendon rupture/
2 (calcaneus or calcanea* or achillis or achillean or achilles).mp.
3 (rupture* or injur* or tear or tears or lesion*).mp.
4 2 and 3
51or4
6 exp rehabilitation/
7 rehabilitation.fs.
8 (rehabilitation or mobilization or mobilisation or ambulation or exercise* or immobilization
or immobilisation).mp.
9 mobilization/
10 exp immobilization/
11 or/6-10
12 5 and 11
(continued)
The Orthopaedic Journal of Sports Medicine Early Rehabilitation for Achilles Rupture 13
Table A1 (continued)
Database: Ovid MEDLINE(R) Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid
MEDLINE(R) <1946 to Present>
Search Strategy:
—————————————————————————————————————————————
1 Achilles Tendon/
2 exp Rupture/
3 (calcaneus or calcanea* or achillis or achillean or achilles).mp.
4 (rupture* or injur* or tear or tears or lesion*).mp.
51or3
62or4
7 5 and 6
8 exp Rehabilitation/
9 rehabilitation.fs.
10 (rehabilitation or mobilization or mobilisation or ambulation or exercise* or
immobilization or immobilisation).mp.
11 exp Immobilization/
12 or/8-11
13 7 and 12
Database: Pedro
Search Strategy:
—————————————————————————————————————————————
1 Achilles tendon rupture
Database: CINAHL
Search Strategy:
—————————————————————————————————————————————
1 (MH “Achilles Tendon Rupture”)
2 calcaneus or calcanea* or achillis or achillean or achilles
3 rupture* or injur* or tear or tears or lesion*
4 #2 and #3
5#1or#4
6 (MH “Rehabilitationþ”)
7 rehabilitation or mobilization or mobilization or ambulation or exercise* or immobilization
or immobilization
8 (MH “Immobilization”)
9#6or#7or#8
10 #5 and #9
Database: Cochrane
Search Strategy:
—————————————————————————————————————————————
1 MeSH descriptor: [Achilles Tendon] explode all trees
2 (calcaneus or calcanea* or achillis or achillean or achilles): ti, ab
3 MeSH descriptor: [Rupture] explode all trees
4 (rupture* or injur* or tear or tears or lesion*): ti, ab
5#1or#2
6#3or#4
7#5or#6
8 MeSH descriptor: [Rehabilitation] explode all trees
9 rehabilitation or mobilization or mobilisation or ambulation or exercise* or immobilization
or immobilization
10 #8 or #9
11 #7 and #10
14 Zellers et al The Orthopaedic Journal of Sports Medicine
TABLE A2
Summary of Interventions in All Included Studies
a
First Author (Year)
Secondary
Study?
No. of
Patients Weightbearing ROM Strength
Isometric
Exercise
Cardiovascular
Exercise
General
Strength Balance Other
Quality
Score
Nonsurgical Management
Aujla
12
(2018) No 236 * * 22
Aujla
11
(2016) No 88 * * 21
Barfod
14
(2014) Yes 60 * * 24
Dolphin
48
(2016) No 25 * * 20
Ecker
54
(2016) No 171 * * * * * 16
Hu
¨fner
81
(2006) No 125 * * * * * 15
Hu
¨fner
80
(2002) No 21 * * * * * * 8
Kaniki
89
(2014) No 145 * * * * * * 20
Korkmaz
99
(2015) No 47 * 21
McComis
127
(1997) No 30 * * * * 20
McNair
129
(2013) No 38 * 14
Neumayer
143
(2010) No 57 * * * * 16
Persson
155
(1979) No 20 * 16
Petersen
156
(2002)
b
No 50 * 19
Reilmann
161
(1996)
c
No 132 * * * * 14
Roberts
166
(2001) No 49 * * 14
Saleh
168
(1992) No 40 * * * * 17
Swennergren
185
(2017) No 28 * * 19
Vavra-
Hadziahmetovic
194
(2000)
No 19 * * * * * * 9
Walz
195
(1993)
c
No 22 * * 15
Surgical Management
Agres
1
(2018) No 14 * * * * * 17
Aisaiding
2
(2018) No 52 * * * * * 21
Aktas
3
(2007) No 30 * * 19
Al-Mouazzen
4
(2015) No 30 * * * 15
Alviti
5
(2017) No 20 * * * 20
Aoki
8
(1998) No 22 * * * 17
Aspenberg
9
(2015) No 16 * * 13
Assal
10
(2002) No 87 * * * * 18
Baumfeld
16
(2019) No 38 * 16
Bevoni
17
(2014) No 66 * * * * * 20
Bhattacharyya
18
(2009) Yes 59 * *12
Buchgraber
25
(1997) No 48 * * * * * 16
Calder
26
(2005) No 46 * 13
Carmont
27
(2015) No 26 * * * 18
Carmont
28
(2017) No 70 * * 21
Ceccarelli
30
(2007) No 24 * * * * 19
Cetti
32
(1994) No 60 * * * 19
Chandrakant
33
(2012) No 52 * * * * * 19
Chen
34
(2015) No 82 * * 22
Chiu
35
(2013) No 19 * 14
Chmielnicki
36
(2016)
c
No 212 * 15
Costa
39
(2003) No 28 * *18
ˇ
Cretnik
41
(2004) Yes 237 * * * 20
De Carli
42
(2016) No 30 * * 20
De la Fuente
43
(2016) No 39 * * * 23
De la Fuente
44
(2016) No 26 * * * * 18
Delgado-Brambila
45
(2012)
d
No 35 * * 13
Ding
46
(2012) Yes 88 * 16
Don
50
(2007) No 49 * * 15
Doral
51
(2013) No 32 * * * * 17
Dos Santos Gomes
52
(1998)
e
No 13 * * * * 10
Fern´
andez-Fair´
en
57
(1997)
No 29 * * * * * 13
Fitzgibbons
58
(1993) No 14 * 16
Gaiani
60
(2012) No 80 * * 11
(continued)
The Orthopaedic Journal of Sports Medicine Early Rehabilitation for Achilles Rupture 15
Table A2 (continued)
First Author (Year)
Secondary
Study?
No. of
Patients Weightbearing ROM Strength
Isometric
Exercise
Cardiovascular
Exercise
General
Strength Balance Other
Quality
Score
Garrido
62
(2010) No 18 * * 16
Geremia
63
(2015) No 18 * * * * * 18
Gigante
64
(2008) No 40 * * 16
Gorschewsky
65
(2004) No 66 * * * * 14
Gorschewsky
66
(1999) No 20 * * * 15
Groetelaers
67
(2014) No 60 * * 21
Heikkinen
72
(2016) No 55 * * 25
Henr´
ıquez
73
(2012) No 32 * * * 14
Holmenschlager
75
(2002)
c
No 45 * * 14
Horter
76
(2007)
c
No 102 * * 9
Hrnack
77
(2012) No 15 * * 15
Jacob
84
(2007) No 36 * * 12
Jallageas
85
(2013) No 31 * * * 20
Jielile
86
(2012) No 107 * * * * * * 18
Kangas
88
(2003) Yes 50 * * * 22
Karabinas
91
(2014) No 34 * 17
Kauranen
92
(2002) No 30 * * * 18
Keller
94
(2014) No 100 * 21
Kerkhoffs
95
(2002) No 39 * 16
Kim
96
(2017) No 56 * * * 17
Kuskucu
100
(2005) No 32 * * 15
Lacoste
101
(2012) No 33 * * 19
Lansdaal
102
(2007) No 163 * * 15
Lapidus
106
(2007) No 105 * 24
Lee
107
(2008) No 11 * 16
Leppilahti
108
(2000) No 85 * 16
Li
109
(2017) No 24 * * 18
Lonzaric
´
112
(2017) No 262 * * 21
Maffulli
116
(2010) No 35 * * * * 17
Maffulli
117
(2003) Yes 53 * * * 21
Maffulli
119
(2001) No 16 * 20
Majewski
120
(2008) No 28 * * 17
Mandelbaum
121
(1995) No 29 * * * * 14
Marti
122
(1983) No 64 * 4
Martinelli
123
(2000) No 30 * 7
Mauch
124
(2017)
c
No 42 * * * 17
Mavrodontidis
125
(2015) No 11 * 17
Mayer
126
(2010)
e
No 24 * * * 17
Mezzarobba
131
(2012) No 40 * * 12
Miyamoto
133
(2017) No 44 * * * 17
Moberg
134
(1992) No 17 * 14
Mortensen
139
(1992) No 57 * 18
Mortensen
138
(1999) No 71 * * 20
Motta
140
(1997) No 71 * * 14
Mukundan
141
(2010) No 21 * 17
Mullaney
142
(2006) No 20 * * 17
Ocguder
146
(2011) No 41 * * * 17
Ozer
151
(2016) No 23 * * * 19
Ozkan
152
(2016) No 15 * * 19
Ozkaya
153
(2009) No 25 * * * * * 19
Peng
154
(2017) No 15 * * * * * 18
Porter
157
(2014) No 40 * * * * * 17
Porter
158
(2015) No 51 * * * 21
Quagliarella
159
(2010) No 51 * 18
Richardson
163
(2003) No 30 * * * * 15
Rozis
167
(2018) No 82 * * * * 19
Sandberg
169
(2015) No 31 * * 14
Saper
170
(2016) No 82 * * 11
Saw
171
(1993) No 19 * * 14
Saxena
172
(2011) No 27 * * * 15
Scha
¨fer
173
(2002)
c
No 40 * 18
(continued)
16 Zellers et al The Orthopaedic Journal of Sports Medicine
Table A2 (continued)
First Author (Year)
Secondary
Study?
No. of
Patients Weightbearing ROM Strength
Isometric
Exercise
Cardiovascular
Exercise
General
Strength Balance Other
Quality
Score
Schepull
174
(2013) No 35 * * * 20
Schepull
175
(2007) No 10 * 20
Solveborn
179
(1994) No 17 * * 15
Sorrenti
180
(2006) No 64 * * * * 13
Speck
181
(1998) No 20 * * 16
Steele
182
(1993) No 20 * 21
Strauss
183
(2007) No 52 * * 19
Suchak
184
(2008) Yes 110 * * * 24
Tarnit¸a
˘
186
(2016) No 15 * * 9
Tezeren
187
(2006) No 24 * * * * * 19
Troop
190
(1995) No 13 * * 17
Vadal´
a
192
(2012) No 80 * 19
Valkering
193
(2017) No 56 * * 23
Wredmark
201
(1992) No 34 * 17
Yotsumoto
202
(2010) No 20 * * * 18
Zayni
203
(2017) No 29 * * 21
Zell
204
(2000) No 25 * * * 10
Both Nonsurgical and Surgical Management
Cetti
31
(1993) No 156 * 21
Costa
38
(2006) No 96 * 21
Ebinesan
53
(2008) No 63 * * * * 16
Gwynne-Jones
68
(2011) No 363 * * * * 19
Hutchison
82
(2015) No 273 * * * 17
Jackson
83
(2013) No 80 * * 20
Karaaslan
90
(2016) No 16 * 17
Kearney
93
(2011) No 49 * * 19
Lantto
103
(2016) Yes 60 * * 22
Lill
110
(1996)
c
No 57 * * * * * 11
Lim
111
(2018) No 132 * * * * 19
Lorkowski
113
(2007) No 94 *13
Maffulli
115
(2017) No 26 * * * * 18
Miller
132
(2005) No 111 * 18
Moller
137
(2001) Yes 112 * * 21
Nilsson-Helander
144
(2010)
Yes 97 * * 22
Olsson
150
(2013) Yes 100 * * * * * * * 22
Renninger
162
(2016) No 57 * * * * * 20
Richter
164
(1994)
c
No 32 * 14
Richter
165
(1997)
c
No 55 * * * * * 17
Thermann
189
(1995)
c
Yes 50 * * * * * 17
Twaddle
191
(2007) No 50 * * 22
Weber
196
(2003) No 47 * * * * * * 19
Willits
199
(2010) No 144 * * * * * * 22
Knobe
97
(2015) No 64 * * 21
a
The quality score was determined using the modified Downs & Black
79,98,145
checklist, in which 26 or above indicates excellent, 20-25
good, 15-19 fair, and 14 or less poor quality. ROM, range of motion.
b
In Danish.
c
In German.
d
In Spanish.
e
In Portuguese.
The Orthopaedic Journal of Sports Medicine Early Rehabilitation for Achilles Rupture 17
TABLE A3
Summary of Outcomes in All Included Studies
First Author (Year)
Outcome Type
Time of Outcome
Assessment, mo
Functional
Outcome
Other
Complications
Rerupture
Rate PROs
Return to
Work/
Sport
Tendon
Properties
Survey-
Based
Functional
Outcome
Other General
Outcome
(Description) 3 4-6 7-12 >1-5 >5
Nonsurgical Management
Aujla
12
(2018) * * * *
Aujla
11
(2016) * * * *
Barfod
14
(2014) * * * * Quality of life * *
Dolphin
48
(2016) * * * *
Ecker
54
(2016) * * * * * * * Pain, satisfaction,
meteosensitivity
*
Hu
¨fner
81
(2006) * * * * * * Pain *
Hu
¨fner
80
(2002) * **
Kaniki
89
(2014) * * * * * *
Korkmaz
99
(2015) * * * * * * *
McComis
127
(1997) * * * * Cost of treatment * *
McNair
129
(2013) * * *
Neumayer
143
(2010) * * * * * Satisfaction * * *
Persson
155
(1979) * * * * * Satisfaction *
Petersen
156
(2002)
b
*** **
Reilmann
161
(1996)
c
* * * * * Meteosensitivity,
pain, shoewear
problems
*
Roberts
166
(2001) * * * * *
Saleh
168
(1992) * * * * Satisfaction * * *
Swennergren
185
(2017)
* Achilles tendon
resting angle
**
Vavra-
Hadziahmetovic
194
(2000)
* * * * * Thompson,
Simmond and
Matles signs;
pain
*
Walz
195
(1993) * * * * * *
Surgical Management
Agres
1
(2018) * * *
Aisaiding
2
(2018) * * * * * * * * *
Aktas
3
(2007) * * * * * * Pain *
Al-Mouazzen
4
(2015) * * * * Satisfaction * * *
Alviti
5
(2017) *
Aoki
8
(1998) * * * Time from
surgery to
weightbearing/
heel rising
**
Aspenberg
9
(2015) * * *
Assal
10
(2002) * * * * * *
Baumfeld
16
(2019) * * * * * Satisfaction *
Bevoni
17
(2014) * * * * * * *
Bhattacharyya
18
(2009)
* * Pain/stiffness,
readmission to
hospital, length
of hospital stay,
pain medication
** *
Buchgraber
25
(1997) * * * * *
Calder
26
(2005) * * * * * * * *
Carmont
27
(2015) * * * * Achilles tendon
resting angle
** *
Carmont
28
(2017) * * * Achilles tendon
resting angle,
calf squeeze test
** *
Ceccarelli
30
(2007) * * * * *
Cetti
32
(1994) * * * * * Satisfaction * * *
Chandrakant
33
(2012) * * * Time to plateau in
improvement
*
(continued)
18 Zellers et al The Orthopaedic Journal of Sports Medicine
Table A3 (continued)
First Author (Year)
Outcome Type
Time of Outcome
Assessment, mo
Functional
Outcome
Other
Complications
Rerupture
Rate PROs
Return to
Work/
Sport
Tendon
Properties
Survey-
Based
Functional
Outcome
Other General
Outcome
(Description) 3 4-6 7-12 >1-5 >5
Chen
34
(2015) * * * * Operative time,
scar length
**
Chiu
35
(2013) * * * * * * *
Chmielnicki
36
(2016)
c
** *
Costa
39
(2003) * * * * * * *
ˇ
Cretnik
41
(2004) * * * * * * Holz score,
satisfaction
*
De Carli
42
(2016) * * * * * * Pain * * *
De la Fuente
43
(2016) * * * * Pain, pain
medication
*
De la Fuente
44
(2016) * * * * * *
Delgado-Brambila
45
(2012)
d
* * Number of physical
therapy visits
*
Ding
46
(2012) * * * * Scar length *
Don
50
(2007) * * * * * *
Doral
51
(2013) * * * *
Dos Santos Gomes
52
(1998)
e
* * * Pain, edema in
Achilles tendon
area
*
Fern´
andez-Fair´
en
57
(1997)
* * * * * Stiffness *
Fitzgibbons
58
(1993) * * * * *
Gaiani
60
(2012) * * * * Satisfaction
Garrido
62
(2010) * * * * * * Satisfaction *
Geremia
63
(2015) * * *
Gigante
64
(2008) * * * * * Operative time * *
Gorschewsky
65
(2004) * * * * Satisfaction *
Gorschewsky
66
(1999) * * * * Length of
hospitalization,
operative time,
time to full
weightbearing,
wound healing,
satisfaction
*
Groetelaers
67
(2014) * * * * * Satisfaction,
Achilles tendon
repair score
** *
Heikkinen
72
(2016) * * * * * * * * *
Henr´
ıquez
73
(2012) * * * * Cosmesis, length of
scar
*
Holmenschlager
75
(2002)
c
******* *
Horter
76
(2007)
c
** *
Hrnack
77
(2012) * * * *
Jacob
84
(2007) * * * * Pain, satisfaction *
Jallageas
85
(2013) * * * * * * Number of physical
therapy
sessions, pain
*
Jielile
86
(2012) * * * * * * * * *
Kangas
88
(2003) * * * * * * * * *
Karabinas
91
(2014) * * * * * * Satisfaction,
wound healing,
Thompson test
*
Kauranen
92
(2002) * * Satisfaction * *
Keller
94
(2014) * * * * * * Satisfaction *
Kerkhoffs
95
(2002) * * * * Length of hospital
stay, satisfaction
*
(continued)
The Orthopaedic Journal of Sports Medicine Early Rehabilitation for Achilles Rupture 19
Table A3 (continued)
First Author (Year)
Outcome Type
Time of Outcome
Assessment, mo
Functional
Outcome
Other
Complications
Rerupture
Rate PROs
Return to
Work/
Sport
Tendon
Properties
Survey-
Based
Functional
Outcome
Other General
Outcome
(Description) 3 4-6 7-12 >1-5 >5
Kim
96
(2017) * * * * Time until able to
do single heel-
raise
*
Kuskucu
100
(2005) * * * * * * * *
Lacoste
101
(2012) * * * * Socioeconomic and
global
satisfaction
**
Lansdaal
102
(2007) * * * * Operative time *
Lapidus
106
(2007) * * *
Lee
107
(2008) * * * * * * Pain * * * *
Leppilahti
108
(2000) * * *
Li
109
(2017) * * * * * * Satisfaction, pain * *
Lonzaric
´
112
(2017) * * * * Number of physical
therapy/clinic
sessions,
duration of
immobilization,
duration of
crutch use
**
Maffulli
116
(2010) * * * * * Time to full
weightbearing
*
Maffulli
117
(2003) * * * * * * Number of clinic/
physical therapy
sessions, Boyden
scale,
satisfaction,
footwear
restrictions,
time to full
weightbearing
*
Maffulli
119
(2001) * * * * Boyden scale *
Majewski
120
(2008) * * * Hannover score,
satisfaction
*
Mandelbaum
121
(1995)
*** * ***
Marti
122
(1983) * * * * *
Martinelli
123
(2000) * * * * *
Mauch
124
(2017)
c
* *
Mavrodontidis
125
(2015)
* * * * * * Pain, satisfaction *
Mayer
126
(2010)
e
* *
Mezzarobba
131
(2012) * * *
Miyamoto
133
(2017) * * * * * * Time until able to
perform heel-
rises
** *
Moberg
134
(1992) * *
Mortensen
139
(1992) * * * * * * Satisfaction * *
Mortensen
138
(1999) * * * * * * Whether they had
physical
therapy, pain,
satisfaction
**
Motta
140
(1997) * * * * * Length of hospital
stay
***
Mukundan
141
(2010) * * * * *
Mullaney
142
(2006) * *
Ocguder
146
(2011) * * * * * * Operative time,
pain
*
Ozer
151
(2016) * * * * *
(continued)
20 Zellers et al The Orthopaedic Journal of Sports Medicine
Table A3 (continued)
First Author (Year)
Outcome Type
Time of Outcome
Assessment, mo
Functional
Outcome
Other
Complications
Rerupture
Rate PROs
Return to
Work/
Sport
Tendon
Properties
Survey-
Based
Functional
Outcome
Other General
Outcome
(Description) 3 4-6 7-12 >1-5 >5
Ozkan
152
(2016) * * * *
Ozkaya
153
(2009) * * * * * *
Peng
154
(2017) * * * *
Porter
157
(2014) * * *
Porter
158
(2015) * * * * *
Quagliarella
159
(2010) * Hannover score *
Richardson
163
(2003) * * * * * * Footwear
restrictions,
satisfaction,
pain
*
Rozis
167
(2018) * * * * * * *
Sandberg
169
(2015) * * * *
Saper
170
(2016) * * *
Saw
171
(1993) * * * * *
Saxena
172
(2011) *
Scha
¨fer
173
(2002)
c
* * * * * * Length of time
using crutches,
special shoe and
night splint
**
Schepull
174
(2013) * * * * * * *
Schepull
175
(2007) * * * * * * Pain * * *
Solveborn
179
(1994) * * * * * * Satisfaction * *
Sorrenti
180
(2006) * * * Time to activities of
daily living
*
Speck
181
(1998) * * * * * * Achilles tendon
evaluation score
(created by the
authors), pain,
satisfaction
** *
Steele
182
(1993) * * * *
Strauss
183
(2007) * * * * * Pain, satisfaction,
footwear
restrictions,
Boyden scale
*
Suchak
184
(2008) * * * * Number of steps * * *
Tarnit¸a
˘
186
(2016) * * Aesthetics of
surgical site
*
Tezeren
187
(2006) * * * * * Operative time,
duration of
hospital stay,
scar adhesions,
footwear
problems,
satisfaction,
pain
*
Troop
190
(1995) * * * * * Satisfaction *
Vadal´
a
192
(2012) * * * * * * Hannover score *
Valkering
193
(2017) * * * * * * *
Wredmark
201
(1992) * * * * * *
Yotsumoto
202
(2010) * * * * * * Time to walk
without pain or
fear, time to
normal walk,
double- and
single-legged
heel-rises
**
Zayni
203
(2017) * * * * * * Satisfaction *
Zell
204
(2000) * * * * * *
(continued)
The Orthopaedic Journal of Sports Medicine Early Rehabilitation for Achilles Rupture 21
Table A3 (continued)
First Author (Year)
Outcome Type
Time of Outcome
Assessment, mo
Functional
Outcome
Other
Complications
Rerupture
Rate PROs
Return to
Work/
Sport
Tendon
Properties
Survey-
Based
Functional
Outcome
Other General
Outcome
(Description) 3 4-6 7-12 >1-5 >5
Both Nonsurgical and Surgical Management
Cetti
31
(1993) * * * * Length of hospital
stay, pain
**
Costa
38
(2006) * * * * Time to activities
(sport, walking,
stair climbing,
work)
** *
Ebinesan
53
(2008) * * Operative time,
length of
hospital stay,
cost
*
Gwynne-Jones
68
(2011)
* * Operative time
Hutchison
82
(2015) * * * Achilles tendon
repair score, cost
**
Jackson
83
(2013) * * * *
Karaaslan
90
(2016) * * * * * Satisfaction *
Kearney
93
(2011) * Completion rates * * *
Lantto
103
(2016) * * * * * * * * *
Lill
110
(1996)
c
* * * * * * Length of hospital
stay
*
Lim
111
(2018) * * *
Lorkowski
113
(2007) * * * * * Pain *
Maffulli
115
(2017) * * * * * * Satisfaction *
Miller
132
(2005) * * * * Pain, satisfaction *
Moller
137
(2001) * * * * * * Pain, satisfaction * * * *
Nilsson-Helander
144
(2010)
**** **
Olsson
150
(2013) * * * * * * *
Renninger
162
(2016) * * * *
Richter
164
(1994)
c
**** *
Richter
165
(1997)
c
* * * * * Pain *
Thermann
189
(1995)
c
* * * * * * Author-developed
score, pain,
satisfaction
** * *
Twaddle
191
(2007) * * * Squeeze test * * *
Weber
196
(2003) * * * * * * Length of hospital
stay, pain, time
to
discontinuation
of crutch use,
satisfaction
**
Willits
199
(2010) * * * * * *
Knobe
97
(2015) * * * * * * * Satisfaction, pain *
a
PROs, patient-reported outcomes.
b
In Danish.
c
In German.
d
In Spanish.
e
In Portuguese.
22 Zellers et al The Orthopaedic Journal of Sports Medicine
... However, these results are likely biased given the lack of standardized RTP measures or definitions. Although RTP is the major goal for athletic patients, only 20% of the studies reported RTP outcomes (13). The length of time to use a protective device, the criteria for allowing progression in exercises, and when to start sport-specific rehabilitation are often based on the preference of the treating doctor and physical therapist rather than being evidence-based. ...
... All 3 groups showed tendon elongation at 6 months, concluding that the initial 8 weeks protocol did not alter the outcome, and full healing can take 12 months. Tendon elongation is an important factor for both short-and long-term recovery (9,13,(37)(38)(39)(40) The concern of tendon elongation is real and can induce long-term deficits (41). ...
Article
Surgical repair of acute mid-substance Achilles tendon ruptures is performed in active patients, but the postoperative rehabilitation program is often based on the experience of the surgeon or therapist, rather than on evidence-based protocols. The aim of the study is to establish an evidence-based protocol for rehabilitation. This study is a consensus statement. The “GAIT” study group (German, American and Italian Tendon), an informal collection of 4 experienced foot and ankle surgeons, met to address the question of what items they felt were important relative to rehabilitate a surgically repaired Achilles tendon acute rupture. Thirty-three statements were formulated. A value of 100% agreement by all the members was set to produce a proposed consensus statement. A value of 80% consensus was set to produce “strong recommendation”. A systematic review of the literature was also performed. The GAIT group reach 100% agreement on the average postoperative nonweightbearing for 2.3 weeks, the foot in plantarflexion for the first 4 weeks, avoiding ROM exercises beyond neutral, and both stretching and eccentric exercise, not started before 12 weeks. Concentric bilateral heel raises should be performed after 6 weeks, and the average return to initiate sports, was 24.4 weeks. The use of a 1/8th-1/4th inch heel cushions in daily shoes after 8 weeks, the use of an anti-gravity treadmill for rehabilitation, and the return to sports based on heel raise repetitions is strongly recommended. Given lack of established verified protocols, the recommendations by our experienced panel should be considered. These proposed consensus statements could be used as a basis for larger controlled trials, and develop best practices.
... Personalized postoperative templates of rehabilitation increase the repair strength of the AT [45]. The reference sources report methodological discrepancies in the applied physiotherapy protocols for patients after the surgical suturing of the AT [46][47][48]. Physiotherapeutic procedures conducted up to 4 months after surgical suturing of the AT have already been described [49,50]. The applied postoperative protocol in this research included the types and number of exercises, series, and rest breaks [19]. ...
... reported that, during the last stages of postoperative physiotherapy, attention should be focused on strengthening the medial head of the gastrocnemius muscle of the operated leg to improve jumping quality [52]. Bruman et al. [47]. Carmont et al. (2020) suggested that the application of weightbearing does not influence the heel-rise height index but increases the AT resting phase one year after injury [53]. ...
Article
Full-text available
The objective of this study was to assess the effectiveness of, and the correlation between, an average of 42 supervised physiotherapy (SVPh) visits for the vertical ground reaction forces component (vGRF) using ankle hops during two- and one-legged vertical hops (TLH and OLH, respectively), six months after the surgical suturing of the Achilles tendon using the open method (SSATOM) via Keesler’s technique. Hypothesis: Six months of supervised physiotherapy with a higher number of visits (SPHNVs) was positively correlated with higher vGRF values during TLH and OLH. Group I comprised male patients (n = 23) after SSATOM (SVPh x = 42 visits), and Group II comprised males (n = 23) without Achilles tendon injuries. In the study groups, vGRF was measured during TLH and OLH in the landing phase using two force plates. The vGRF was normalized to the body mass. The limb symmetry index (LSI) of vGRF values was calculated. The ranges of motion of the foot and circumferences of the ankle joint and shin were measured. Then, 10 m unassisted walking, the Thompson test, and pain were assessed. A parametric test for dependent and independent samples, ANOVA and Tukey’s test for between-group comparisons, and linear Pearson’s correlation coefficient calculations were performed. Group I revealed significantly lower vGRF values during TLH and OLH for the operated limb and LSI values compared with the right and left legs in Group II (p ≤ 0.001). A larger number of visits correlates with higher vGRF values for the operated limb during TLH (r = 0.503; p = 0.014) and OLH (r = 0.505; p = 0.014). An average of 42 SVPh visits in 6 months was insufficient to obtain similar values of relative vGRF and their LSI during TLH and OLH, but the hypothesis was confirmed that SPHNVs correlate with higher relative vGRF values during TLH and OLH in the landing phase.
... is aforementioned loss of both muscle mass and strength has prompted researchers to focus on early mobilization following repair of the ruptured tendon with immediate full weight bearing [75,82,83] in an attempt to minimize atrophy. However, these efforts have not been proven to effectively counteract the loss of muscle mass and function. ...
Article
Full-text available
Persistent muscle weakness, tendon elongation, and incomplete return to preinjury level are frequent sequelae after acute Achilles tendon rupture, and evidence-based knowledge of how to best rehabilitate the injury is largely absent in the literature. The objective of this review is to illuminate and discuss to what extent an Achilles tendon rupture affects muscle, tendon, and function when assessed with the Achilles tendon total rupture score (ATRS), muscle strength, muscle cross-sectional area, tendon length, and the heel-rise test. The patient-reported outcome measures (PROM) data in the literature suggest that the recovery takes longer than 6 months (ATRS, 70 out of 100), that one-year postinjury, the ATRS only reaches 82, and that this does not appear to noticeably improve thereafter. Loss of muscle mass, strength, and function can in some cases be permanent. Over the first 6 months postinjury, the tendon undergoes elongation, which appears to be negatively correlated to heel-rise function. More recently, there has been some interest in how muscle length and excursion is related to the reduced function. The available literature indicates that further research is highly warranted and that efforts to restore normal tendon length may improve the likelihood of returning to preinjury level after an Achilles tendon rupture.
... Regardless of operative or non-operative treatment the rehabilitative phase of TA rupture has seen a shift towards early weight bearing and graduated physiotherapy. There is extensive research showing it is safe, has a low complication rate and achieves a superior functional outcome to conventional immobilisation [7,[10][11][12][13].There is however a lack of consensus on what exactly these functional rehabilitation programmes should consist of given that most trials to are heterogenous in their outcome measurements [14]. ...
Article
Full-text available
Introduction and importance The weekend warrior has long been prey to musculoskeletal injuries as a result of intermittent, high intensity activity. The Achilles tendon is known to be particularly vulnerable in this population cohort but during the COVID-19 lockdowns in Ireland and all over the world there has been a certain level of detraining and deconditioning among all age groups and populations. Throughout the worldwide restrictions, viral internet challenges and dances have encapsulated the spirit of a global community with the ‘Jerusalema’ dance being no exception. The rise of this particular viral sensation was at the detriment of the Achilles tendons of three middle aged gentlemen on who we base our case series. Presentation of cases Over the space of ten days three cases of Achilles tendon rupture repair presented to the emergency department in Midlands Regional Hospital Tullamore (MRHT) with the mechanism of tendon rupture being through the ‘Jerusalema’ dance. These patients were surgically managed in line with local institution practice and postoperative outcomes were good with no complications noted. Follow up is ongoing. Clinical discussion This retrospective case series is based on the impact of the ‘Jerusalema Dance’ on presentations of Achilles tendon rupture to the Emergency Department in a single regional hospital from January to March 2021. We used these cases in conjunction with a review of current literature to highlight the benefit of an integrated Achilles Tendon rehabilitation programme in this at-risk patient cohort. Conclusion This paper highlights the dangers inherent when well intentioned, but physically deconditioned individuals endeavour to perform a physical exercise which is deceptively demanding. Going forward, viral challenges such as the ‘Jerusalema’ may contribute to new and interesting mechanisms of injuries in our ‘weekend warrior’ cohort. In addition to this, given the global deconditioning seen due to the COVID 19 pandemic and subsequent lockdowns we may see a higher rate of Achilles tendon injuries in the near future across a multitude of patient cohorts. Level one evidence suggests that conservative treatment is just as effective as surgical treatments in the majority of patients with an Achilles tendon rupture, as long as a protocol of rehabilitation with early weightbearing is performed. Our accelerated rehabilitation programme in MRHT is in line with others however internal audit and new literature in the future may enable us to refine it further.
... We decided not to evaluate surgery versus non-surgical management of ATR, a subject that has been long debated and remains still controversial [6][7][8]. Recent findings tend to show better outcomes in terms of strength and patient-reported functional outcomes with early functional rehabilitation including weight-bearing and active exercises [44]. We included both surgically and non-surgically treated patients. ...
Article
Objectives Acute Achilles tendon rupture (ATR) is a disabling sport-related injury. Its management involves conservative treatment with early weight-bearing or surgical treatment. Platelet-rich plasma (PRP) has raised interest as an adjuvant for treatment, given its properties on tendon repair and its anti-inflammatory effect. We aimed to assess clinical impact of PRP use in surgical or non-surgical treatment of acute ATR: range of motion, muscle strength, function, return to sport and adverse events. Method A systematic literature research was performed using PubMed, ScienceDirect, and Google Scholar databases to collect studies reporting clinical outcomes after acute ATR treated with PRP. Results Eight studies were eligible and included 543 acute ATR. Four were randomized comparative studies. A total of 128 patients were treated surgically and 415 were treated conservatively, 271 received PRP injection. Five studies described the type of PRP used, which was variable. Only one study including 12 patients found significant outcomes in favor of the PRP group, with a 4-week earlier recovery of a normal range of motion and a 7-week earlier return to running. No difference in clinical or morphological evaluations, strength measurement, and functional outcomes was found in other studies both at short and long-term. PRP did not seem to modify the frequency of adverse events. Conclusions Data are not clearly in favour of a significant effect of the PRP use for treatment of ATR. There might be a slight effect on evolution during the first months. Its interest should be assessed in future studies with strong methodology.
... A matter of discussion remains the correct postoperative recovery technique for acute Achilles tendon rupture (Zhao et al., 2017). It's indeed crucial that patients recover during the first year after injury, as 1-year results predict whether long-term disabilities will remain or not (Zellers et al., 2019). Traditionally, a prolonged period of operational management has been accompanied by non-weight bearing (nWb) to prevent the dreaded complication of tendon re-rupture with rigid cast ankle immobilization (Lightsey et al., 2019). ...
Article
Purpose The primary aim was to determine independent patient, injury and management-related factors associated with symptomatic venous thromboembolism (VTE) following acute Achilles tendon rupture (ATR). The secondary aim was to suggest a clinical VTE risk assessment tool for patients with acute ATR. Methods From 2010-2018, 984 consecutive adults (median age 47yrs, 73% [n=714/984] male) sustaining an acute ATR were retrospectively identified. Ninety-five percent (n=939/984) were managed non-operatively in a below-knee cast (52%, n=507/984) or walking boot (44%, n=432/984), with 5% (n=45/984) undergoing primary operative repair (<6wks post-injury). VTE was diagnosed using local medical records and national imaging archives, reviewed at a mean 5yrs (range 1-10) post-injury. Multivariate logistic regression was performed to determine independent factors associated with VTE. Results The incidence of VTE within 90 days of ATR was 3.6% (n=35/984; deep vein thrombosis 2.1% [n=21/984], pulmonary embolism 1.9% [n=19/984]), and the median time to VTE was 24 days (interquartile range 15-44). Age ≥50yrs (adjusted OR [aOR] 2.3, p=0.027), personal history of VTE/thrombophilia (aOR 6.1, p=0.009) and family history of VTE (aOR 20.9, p<0.001) were independently associated with VTE following ATR. These non-modifiable risk factors were incorporated into a VTE risk assessment tool. Only 23% of patients developing VTE (n=8/35) had a relevant personal or family history, but incorporating age ≥50yrs into the VTE risk assessment tool (alongside personal and family history) identified 69% of patients with VTE (n=24/35). Non weight-bearing for ≥2wks after ATR was also independently associated with VTE (aOR 3.2, p=0.026). Conclusions Age ≥50 years, personal history of VTE/thrombophilia and a positive family history were independently associated with VTE following ATR. Incorporating age into our suggested VTE risk assessment tool enhanced its sensitivity in identifying at-risk patients. Early weight-bearing in an appropriate orthosis may be beneficial to all patients in VTE risk reduction.
Article
Full-text available
Introduction One of the treatment options in chronic damage or unsuccessful suturing of the Achilles tendon is a surgical treatment consisting of its reconstruction using the tendon of semitendinosus and gracilis muscle. The multitude of types of reconstruction causes discrepancies in rehabilitation protocols. All of them aim to return to full functional fitness as the ultimate goal. Aim This study aims to present the proprietary rehabilitation protocol after Achilles tendon reconstruction using the tendon of semitendinosus and gracilis muscle. Material and methods The presented rehabilitation program lasts about 12 months and is divided into six stages. Stage I consists of standing up and anticoagulant exercises, and isometric exercise. Stage II, lasting up to 2 weeks after the procedure, consists of the patient’s independent work in the home environment. Stage III, lasting up to 4 weeks, involves learning to walk and putting weight on the limb in a cam Walker. In the third stage, after the postoperative wounds have healed, exercises in water conditions are started. Stage IV, lasting from 4 weeks after the operation, involves loading the limb with support, increasing the range of dorsiflexion motion, and progressive muscle strengthening. Stage V, which lasts up to 8–12 months after surgery, eliminates functional deficits and prepares the patient for a functional biomechanical assessment. Stage VI is the stage of work on the compensation of deficits resulting from the analysis of the results of the functional biomechanical assessment necessary to return to the full sports activity. Results The rehabilitation time, in accordance with the assumptions of the above protocol, is 8–12 months. After this time, the patient should proceed to a functional biomechanical assessment. Discussion and conclusions The rehabilitation protocol presented by our team describes in detail the stages of post-operative rehabilitation after Achilles tendon reconstruction with a hamstring graft. It provides the conditions necessary for the patient to meet before starting the next phase and returning to sport. Our requirements are consistent with the assumptions available in the scientific base. Keywords: Achilles tendon reconstruction, return to sport, rehabilitation program.
Article
Achilles tendinopathy is a debilitating condition affecting the entire spectrum of society and a condition that increases the risk of tendon rupture. Effective therapies remain elusive, as anti‐inflammatory drugs and surgical interventions show poor long-term outcomes. Eccentric loading of the Achilles muscle-tendon unit is an effective physical therapy for treatment of symptomatic human tendinopathy. Here, we introduce a novel mouse model of hind-limb muscle loading designed to achieve a tissue-targeted therapeutic exercise. This model includes the application of tissue (muscle and tendon) loading "doses," coupled with ankle dorsiflexion and plantarflexion, inspired by human clinical protocols. Under computer control, the foot was rotated through the entire ankle joint range of motion, while the plantar flexors simultaneously contracted to simulate body mass loading, consistent with human therapeutic exercises. This approach achieved two key components of the heel drop and raise movement: ankle range of motion coupled with body mass loading. Model development entailed the tuning of parameters such as footplate speed, number of repetitions, number of sets of repetitions, treatment frequency, treatment duration, and treatment timing. Initial model development was carried out on uninjured mice to define a protocol that was well tolerated and non-deleterious to tendon biomechanical function. When applied to a murine Achilles tendinopathy model, muscle loading led to a significant improvement in biomechanical outcome measures, with a decrease in cross-sectional area and an increase in material properties, compared to untreated animals. Our model facilitates the future investigation of mechanisms whereby rehabilitative muscle loading promotes healing of Achilles tendon injuries.
Article
Full-text available
Background Rupture of the Achilles tendon (AT) is frequent in young recreational athletes. Conservative management, open surgery and percutaneous/minimally invasive approaches are all advocated, and conflicting data are available. This study compared functional and anthropometric outcomes of patients who underwent open or percutaneous repair. Methods A retrospective comparative study, in which 38 patients underwent open and percutaneous techniques to manage AT ruptures. For functional assessment, the calf circumference of both injured and uninjured legs was evaluated. Isokinetic testing included total plantar flexion work, peak plantar flexion torque, total dorsiflexion work peak and dorsiflexion torque. The Achilles Tendon Rupture Score (ATRS) and the American Orthopedic Foot and Ankle Score (AOFAS) were evaluated at a final minimum follow-up of 12 months. Results No major complications were observed. The average time to return to sport was 9 months. AOFAS and ATRS values did not differ statistically between groups. Isokinetic variables and circumference were similar in the operated and non-operated limb in both groups, and did not differ either when comparing open and percutaneous repair. Conclusions Open and percutaneous repair of a torn Achilles tendon produced similar functional outcomes.
Article
The goal of treatment after Achilles tendon rupture (ATR) is to restore appropriate tension to the tendon, so that normal baseline strength and functional soft-tissue length can be achieved. The assessment of plantarflexion strength has shown widespread variability. The purpose of this study is to document variations in strength assessment after the treatment of ATR in the literature. A comprehensive literature review was performed. In total, 2758 articles were found on Achilles tendon rupture and Achilles tendon strength measurement. The full text of articles including strength as a functional outcome measurement in the abstract were assessed. All objective strength measurements performed were reviewed and recorded for comparison. One-hundred articles were included in our study. In 78 articles, a dynamometer was used to measure strength, whereas in 22 articles, an endurance test (n=14) or formal gait assessment (n=8) was applied. When a dynamometer was used, there was wide variability in the various methods used including the incorporation of both isokinetic (n = 65) and isometric (n = 29) exercises utilizing varying degrees of knee flexion and patient testing position. Furthermore, the number of measurements at certain angular velocities varied. This study illustrates that no general consensus exists regarding an optimal method for measuring strength after ATR. The variability creates difficulty and challenges medical professionals’ ability to formulate consistent conclusions when determining functional performance outcomes. A more uniform way of measuring strength after ATR may allow for better comparisons between studies in the literature, potentially leading to a better understanding of strength. Levels of Evidence: Therapeutic, Level II
Article
Background: Conservative treatment of an acute Achilles rupture remains a viable and acceptable option as does surgical fixation, with open and percutaneous repair consisting the main operative techniques. The purpose of this study was to compare the outcomes and complication rates of open versus percutaneous surgical procedures. Methods: From 2009 to 2016, 131 patients were admitted to our department with clinically and radiologically confirmed acute Achilles tendon ruptures. Of those, 82 patients met our inclusion criteria and were randomized into 2 groups, group A (open repair) and group B (percutaneous suturing). Suture equipment was the same for both groups. All patients followed the same rehabilitation protocol. Functional evaluation was made using American Orthopaedic Ankle & Foot Society (AOFAS) hindfoot and Achilles tendon Total Rupture Score (ATRS) questionnaires at the 12-month follow-up. Ankle range of motion (ROM), return-to-work time, and complication rates were additionally measured. Results: Both techniques had similar results regarding complication rates and return-to-work time. The major complication in group A was superficial infection (7%) and skin necrosis (3%), whereas 3 patients in group B developed paresthesias due to sural nerve entrapment. Patients in group B had better AOFAS hindfoot (96/100) and ATRS (95/100) scores, but the difference was not significant. ROM was similar in both groups at the 12-month follow-up. Conclusion: Percutaneous suturing seems to be a safe and effective technique that offers good functional outcomes and low complication rates in patients with acute Achilles tendon ruptures who elect to have surgery. Level of evidence: Level II, prospective case series.
Article
Background Muscles and tendons are subjected to a high level of stress in everyday life and sports. This often leads to injuries and is associated with training failure and reduced performance as well as with high costs for treatment and rehabilitation. Fast and successful treatment is therefore very important, both from an athletic and economic point of view. This study aims to demonstrate the relevance of biomechanical procedures for the objective monitoring of rehabilitation. At the same time, the results are to be used to establish progress and evaluation criteria for an efficient and controlled rehabilitation. Patients and methods In a retrospective study, a total of 42 patients were evaluated biomechanically after surgical repair of a complete Achilles tendon rupture 18 (18 W) and 26 weeks (26 W) postoperatively. Ground reaction forces in barefoot walking on a treadmill as well as isokinetic maximum strength for the plantar flexors and dorsal extensors were assessed. Results The push-off force on the injured side increased from 0.88 (18 W) to 0.95 (26 W). The percentage of heel contact time on the injured side was 59 % at 18 W and 55 % at 26 W. Plantar flexion torque increased from 70 Nm (18 W) to 90 Nm (26 W) on average on the injured side. The percentage of the plantar flexion deficit (injured/non-injured side) decreased from 34 % to 21 % on the two postoperative measuring dates. Conclusions The described biomechanical methods allow for a quantitative assessment and an objective control of the rehabilitation process. The results can also be used for the definition of evaluation and progression criteria in order to assess the progress of a patient's therapy and to guide the rehabilitation process in a controlled manner. © Georg Thieme Verlag KG Stuttgart · New York.
Article
Aims: To determine whether the findings from a landmark Canadian trial assessing the optimal management of acute rupture of the Achilles tendon influenced the practice patterns of orthopaedic surgeons in Ontario, Canada. Materials and methods: Health administrative databases were used to identify Ontario residents ≥ 18 years of age with an Achilles tendon rupture from April 2002 to March 2014. The rate of surgical repair (per 100 cases) was calculated for each calendar quarter. A time-series analysis was used to determine whether changes in the rate were chronologically related to the dissemination of results from a landmark trial published in February 2009. Non-linear spline regression was then used independently to identify critical time-points of change in the surgical repair rate to confirm the findings. Results: A total of 29 531 patients sustained an Achilles tendon rupture during the study period. Consistently, around 21 out of every 100 cases underwent surgical repair up to the first quarter of 2010. However, by the first quarter of 2014, only 6.5 cases per 100 had surgery. A statistically significant decrease in the rate of surgical repair was observed within one year of the presentation of landmark trial results in 2009 (p < 0.001). July 2009 was independently identified as a critical time at which the surgical repair rate began to significantly decline (p < 0.001). The dissemination of trial results was associated with a significant drop in the rate of surgical repair at non-teaching hospitals (p = 0.001). Conclusion: The current study demonstrates that large, well-designed randomised trials, have the potential to encourage significant changes in the practice patterns of orthopaedic surgeons. Cite this article: Bone Joint J 2017;99-B:1629-36.
Article
Objective: Acute closed spontaneous Achilles tendon rupture often occurs in elderly individuals and is usually accompanied with many complications. Conventional surgical approaches to remove the tendon lesions and enthesophytes are highly traumatic and cause complications. In this study, a previously established minimally invasive surgical approach was modified and combined with a Kazakh exercise therapy to reduce trauma, improve wound healing, and promote tendon regeneration in the management of acute closed spontaneous Achilles tendon rupture. Methods: Fifty-two patients with acute closed spontaneous Achilles tendon rupture were randomly classified into 2 groups. Group A included 23 patients that were treated with the novel approach. Group B included 29 patients that were treated with a continuous medial oblique surgical approach. Follow-up examinations were performed at post-operative weeks 12 and 24, and year 2. Outcomes were assessed by Achilles tendon rupture score (ATRS), a heel-rise endurance test, and ultrasonographic and multislice spiral computerized tomography. Results: Mean ATRS in Group A was 68.6 and 86.0 at post-operative week 12 and 24, respectively, significantly higher than that in Group B (55.9 and 72.0, respectively). Recovery of patients in Group A was significantly better compared to Group B (p<0.01), allowing them to participate in early rehabilitating kinesiotherapy. Patients in Group A rarely experienced complications after surgery, such as infection and Achilles tendon exposure, while in Group B, the wound healing was slower, the inside flaps were prone to necrosis and infection, and Achilles tendon exposure occurred in 10% of patients. Conclusions: The novel minimally invasive surgery is more advantageous in the treatment of acute closed spontaneous Achilles tendon rupture over previous approaches by promoting wound healing and tendon regeneration.