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Achilles tendon resting angle is able to detect deficits after an Achilles tendon rupture, but it is not a surrogate for direct measurements of tendon elongation, function or symptoms

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  • University of Gothenburg Institute of Clinical Sciences

Abstract and Figures

Purpose The aim of this study was to investigate how the Achilles tendon resting angle (ATRA), an indirect measurement of tendon elongation, correlates with ultrasonography (US) measurements of the Achilles tendon length 6 and 12 months after an acute ATR and relates to other clinical outcome measurements such as heel-rise height, jumping ability and patient-reported outcome measurements (PROMs). Methods Patients were included following acute Achilles tendon rupture (ATR). Achilles tendon length, ATRA, heel-rise height (HRH), drop countermovement jump (Drop CMJ) and PROMs (Achilles tendon total rupture score (ATRS) and physical activity scale (PAS)) were evaluated 6 and 12 months after injury. Achilles tendon length was evaluated using US, while the ATRA was measured with a goniometer. Results Sixty patients (13 women, 47 men), mean (SD) age 43 (9) years, with an acute ATR undergoing either surgical (35%) or non-surgical (65%) treatment were evaluated. A negative correlation ( r = − 0.356, p = 0.010) between relative ATRA and tendon elongation was seen at 12 months after ATR. There were also significant positive correlations at 6 and 12 months between relative ATRA and HRH ( r = 0.330, p = 0.011 and r = 0.379, p = 0.004). There were no correlations between ATRA and ATRS or ATRA and Drop CMJ, at either 6 or 12 months after the injury. Conclusion In combination with other clinical evaluations such as HRH and US, ATRA could be a clinical tool for indirect measurements of tendon elongation. However, ATRA cannot be recommended as a direct surrogate for US for determining Achilles tendon length. Level of evidence III.
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Knee Surgery, Sports Traumatology, Arthroscopy
https://doi.org/10.1007/s00167-022-07142-9
ANKLE
Achilles tendon resting angle isable todetect deficits afteranAchilles
tendon rupture, butit isnotasurrogate fordirect measurements
oftendon elongation, function orsymptoms
ElinLarsson1· KatarinaNilssonHelander1· LottaFalkhedenHenning2,3· MerviHeiskanen1· MichaelR.Carmont2,4·
KarinGrävareSilbernagel5· AnnelieBrorsson2,6
Received: 4 May 2022 / Accepted: 23 August 2022
© The Author(s) 2022
Abstract
Purpose The aim of this study was to investigate how the Achilles tendon resting angle (ATRA), an indirect measurement
of tendon elongation, correlates with ultrasonography (US) measurements of the Achilles tendon length 6 and 12months
after an acute ATR and relates to other clinical outcome measurements such as heel-rise height, jumping ability and patient-
reported outcome measurements (PROMs).
Methods Patients were included following acute Achilles tendon rupture (ATR). Achilles tendon length, ATRA, heel-rise
height (HRH), drop countermovement jump (Drop CMJ) and PROMs (Achilles tendon total rupture score (ATRS) and
physical activity scale (PAS)) were evaluated 6 and 12months after injury. Achilles tendon length was evaluated using US,
while the ATRA was measured with a goniometer.
Results Sixty patients (13 women, 47 men), mean (SD) age 43 (9) years, with an acute ATR undergoing either surgical (35%)
or non-surgical (65%) treatment were evaluated. A negative correlation (r = − 0.356, p = 0.010) between relative ATRA and
tendon elongation was seen at 12months after ATR. There were also significant positive correlations at 6 and 12months
between relative ATRA and HRH (r = 0.330, p = 0.011 and r = 0.379, p = 0.004). There were no correlations between ATRA
and ATRS or ATRA and Drop CMJ, at either 6 or 12months after the injury.
Conclusion In combination with other clinical evaluations such as HRH and US, ATRA could be a clinical tool for indirect
measurements of tendon elongation. However, ATRA cannot be recommended as a direct surrogate for US for determining
Achilles tendon length.
Level of evidence III.
Keywords Achilles tendon rupture· Achilles tendon resting angle· ATRA · Tendon elongation· Tendon length·
Ultrasound· Functional tests
Abbreviations
ATR Achilles tendon rupture
DVT Deep vein thrombosis
MRI Magnetic resonance imaging
US Ultrasonographic
ATRA Achilles tendon resting angle
PROMs Patient-reported outcome measures
HRH Heel-rise height
Drop CMJ Drop countermovement jump
ATRS Achilles tendon total rupture score
* Elin Larsson
elin.ma.larsson@vgregion.se
1 The Department ofOrthopaedics, Sahlgrenska University
Hospital Mölndal, Institute ofClinical Sciences
atSahlgrenska Academy, Gothenburg University,
Göteborgsvägen 31, 43180Mölndal, Sweden
2 Department ofOrthopaedics, Institute ofClinical Sciences
atSahlgrenska Academy, Gothenburg University,
Gothenburg, Sweden
3 Aktiva Rehab Team, Gothenburg, Sweden
4 The Department ofTrauma andOrthopaedic Surgery,
Princess Royal Hospital, Shrewsbury andTelford Hospital
NHS Trust, Shropshire, UK
5 Department ofPhysical Therapy, University ofDelaware,
Newark, DE, USA
6 IFK Kliniken Rehab, Gothenburg, Sweden
Knee Surgery, Sports Traumatology, Arthroscopy
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SU/Mölndal Sahlgrenska University Hospital/Mölndal
IQR Interquartile range
Introduction
The question of how best to treat an acute Achilles ten-
don rupture (ATR), surgically or non-surgically, has been
addressed in numerous studies, but there is still no consen-
sus [13, 16, 17, 19]. The aim of treatment is to optimise the
functional outcome and minimise the complications of the
injury and treatment. Meta-analyses have concluded that the
re-rupture rate is lower when ATR is treated surgically com-
pared with non-surgical treatment [9, 20]. The risk of other
complications, such as wound infection and iatrogenic nerve
injury, is reported to be higher with surgical treatment, while
the incidence of deep vein thrombosis (DVT) is similar in
both treatment regimens [9, 20].
Tendon elongation is a complication after an ATR, lead-
ing to reduced plantar flexion strength and poor outcome
[10]. Regardless of surgical or non-surgical treatment, the
injured tendon elongates during the healing process [10].
Reduced tendon elongation correlates with superior clini-
cal outcome [12]. There are several methods for assessing
tendon length and elongation. Radiography with intra-tendi-
nous markers and magnetic resonance imaging (MRI) have
been used, but these methods are expensive and may not
be accessible for monitoring during recovery [12, 15]. The
ultrasonographic (US) measurement of tendon length has
been validated and found to be a reliable and useful tool, but
requires expertise and suitable ultrasound machines may not
be readily available in clinics [26].
The Achilles tendon resting angle (ATRA) is a simple,
readily available, less expensive means of determining the
resting position of the ankle following ATR, with a low
measurement error [27]. The ATRA is defined as “the angle
between the long axis of the fibula and the line from the
tip of the fibula to the head of the fifth metatarsal” [4]. The
ATRA has been validated for assessing tendon elongation
against US [28]. According to Carmont etal. [3], the abso-
lute ATRA increases following injury, reduces as a result of
surgery and increases again during the first phase of reha-
bilitation by 3 months. In previous studies, the ATRA has
been reported to correlate with patient-reported outcome
measurements (PROMs) at three and 6months after surgi-
cal treatment [3]. In overall terms, the ATRA is a frequently
used evaluation of tendon length in studies focusing on reha-
bilitation after ATR, as it has been considered to be more
accessible at an earlier stage in the clinical practice than US
[35, 7, 8, 28].
Like the ATRA, the heel-rise test is an easily performed
evaluation of ankle plantar flexion function during reha-
bilitation. Studies evaluating recovery at 6 and 12months
often include measurements of both heel-rise endurance
(repetitions or total work performed) and maximum heel-
rise height [13, 21, 25]. The deficit in maximum heel-rise
height (HRH), as compared with the uninjured side, has
been found to correlate to the degree of tendon elongation.
The evaluation of tendon elongation and associated out-
comes needs to be further explored to improve our clinical
tools in order to optimise the rehabilitation and outcome
after an ATR. It is important to find a clinical evaluation
method that is valid and responsive to changes over time and
correlates with tendon elongation (14). The aim of this study
is therefore to determine how the ATRA correlates with the
length of the Achilles tendon measured with US, HRH, drop
countermovement jump (Drop CMJ) and the Achilles tendon
total rupture score (ATRS) 6 and 12months after an acute
ATR.
Materials andmethods
The research protocol was approved by the Swedish Ethical
Review Authority (Dnr 803–15).
All the subjects gave their written consent for enrolment
after having been provided with oral and written information
about the study.
The patients were recruited within 6months following an
acute ATR between 2016 and 2020 by physiotherapists at
five different clinics in Gothenburg, Sweden. The inclusion
criteria for the study were age 18–65years and treatment
commenced within 4 days of injury. The exclusion criteria
included previous injury to the Achilles tendon on either leg,
neurological disease or lack of comprehension of written
and oral Swedish.
The patients were evaluated at 6 and 12months following
rupture and the same experienced physiotherapist performed
all the evaluations.
Achilles tendon resting angle (ATRA)
For measurements of the ATRA, patients were positioned
prone with their knee flexed to 90 degrees and encouraged
to relax their ankle joints. The non-injured leg was exam-
ined first. The patients were encouraged to relax their ankle
joints. The axis of the goniometer (1˚increments) was posi-
tioned at the tip of the fibula. One arm of the goniometer was
aimed towards the head of the fibula and the other arm of
the goniometer was positioned to bisect the head of the fifth
metatarsal (Fig.1). The ATRA has been reliability tested by
Carmont etal. [4] and the reported ICC value of the ATRA
is 0.91–0.92 [4].
The ATRA was reported as either the absolute ATRA of
the injured foot or the relative ATRA referring to differen-
tiation between the resting angle of the injured foot and the
Knee Surgery, Sports Traumatology, Arthroscopy
1 3
non-injured foot respectively. Increased dorsiflexion is con-
sidered to be a negative relative ATRA value and increased
plantar flexion a positive ATRA value compared with the
non-injured side [3].
Ultrasonographic (US) measurement
Achilles tendon length was measured using a US extended
field-of-view feature. The patients lay prone on the examina-
tion table with both feet hanging over the edge of the exami-
nation table. This enabled both feet to be equally relaxed
during measurement. The length of the tendon was measured
between the calcaneal notch, the most proximal attachment
of the Achilles tendon on the calcaneum, and the gastroc-
nemius musculotendinous junction, with extended field-of-
view US (Logiq E or Logiq P9 Ultrasound; GE Healthcare X
AB), using a wideband array linear probe (5.0–13.0MHz).
The B-mode at 10MHz and a depth of 3cm were used to
record the images. This has been found to be a valid and reli-
able method with an ICC value of 0.90 [26]. All the images
were measured by a second experienced physiotherapist.
The mean value of two to three images for each foot and
patient was used for calculations. The tendon elongation was
calculated as the value on the injured limb minus the value
on the healthy limb and expressed in centimetres.
Achilles tendon total rupture score (ATRS)
The evaluation of patient-reported symptoms and function
was assessed using the Achilles tendon total rupture score
(ATRS). The ATRS is a ten-item injury-specific and self-
administered score with a maximum score of 100. The maxi-
mum score implies no limitations and a full recovery. The
ATRS has been found to be a valid and reliable instrument
for measuring the outcome related to symptoms and physical
activity after ATR [18].
Functional evaluations
Functional evaluations were made with a test battery that
included the standing heel-rise work test to evaluate mus-
cular endurance (Joule) and the height of the heel rise (cm)
[23]. The single-leg heel rise, which is used in this study, is
a reliable and valid clinical test for evaluating patients with
ATR [24]. The Muscle Lab® measurement system (Ergot-
est Technology, Oslo, Norway) was used for functional
evaluations.
Before the evaluation, patients performed a 5-min warm-
up on a stationary bike and performed three sets of ten two-
legged heel rises. Standardised shoes (Bagheera Omega)
were worn and the non-injured side was evaluated first.
In the single-leg heel-rise test, the patient stood on one
foot on a box with a 10° incline and a linear encoder was
attached to the shoe on the tested leg. The patients were
instructed to lift as high as possible during the heel rise
and keep their knee straight. The test continued for as long
as patients were able to perform a heel rise of at least 2cm
height and maintain the tempo indicated by a metronome
at a tempo of 30 heel rises a minute. For heel-rise height,
the maximum height was used for calculations. Deficits in
heel-rise height were defined as the difference between the
injured and the non-injured side expressed in cm.
A further functional evaluation was performed using
a Drop CMJ test [23]. This is a one-legged jump from a
20cm high box down to the floor, followed by an immedi-
ate maximum vertical countermovement jump. A light mat,
consisting of infrared light beams placed in front of the box,
determined the height of the jump. Three to five jumps were
performed using each leg and the highest value for both the
injured and healthy limb was used.
Statistical analysis
The sample size was calculated based on the results of the
tendon length of the injured limb at 6 and 12months after
injury [25]. It was estimated that a sample of 57 patients
Fig. 1 The Achilles tendon resting angle (ATRA) measured with a
goniometer
Knee Surgery, Sports Traumatology, Arthroscopy
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was needed to detect a statistically significant difference
(p < 0.05, power 95%) for the elongation of the Achil-
les tendon length between 6 and 12months after injury.
Descriptive data are reported as the mean, standard devia-
tion (SD), median and interquartile range (IQR). A com-
parison between the ATRA, tendon length, HRH and Drop
CMJ between the injured and non-injured limb at 6 and
12months after injury was made using a paired t test. The
primary outcome for this study is the correlation between
tendon elongation, evaluated with US (cm), and the rela-
tive ATRA (°) 6 and 12months after the injury.
The correlations between two continuous variables
(relative ATRA, HRH, Drop CMJ, ATRS) were estimated
using Spearman’s rho correlation coefficient for non-nor-
mally distributed data and Pearson’s correlation for nor-
mally distributed data. The distribution was determined by
a visual inspection of a histogram and by the finding of a
statistically significant p value in the Shapiro–Wilk test.
As an effect size, r2 was calculated. The strength of the
correlation was determined by the correlation coefficient.
A correlation coefficient of > 0.8 was considered very
strong, 0.8–0.6 moderately strong, 0.5–0.3 fair and < 3
poor [6]. The level of significance was set at p < 0.05. All
the data were analysed using IBM SPSS Statistics Ver-
sion 28.
Results
Sixty-six subjects were included in this study. 6 patients
were excluded; 1 patient declined due to fear of COVID-
19, another suffered excessive elongation and was unable to
perform the evaluations, 1 patient was incorrectly included
(older than the upper age limit) and 3 subjects withdrew
from the study after the 6-month evaluation for unknown
reasons. The demographics of the study subjects are pre-
sented in Table1.
There was a significant difference between the injured
side compared with the non-injured side at 6months and
12months regarding the ATRA, tendon length, HRH and
Drop CMJ. The data are presented in Table2.
The correlations between the relative ATRA at 6 and
12months and tendon length, ATRA, HRH, Drop CMJ and
ATRS are presented in Figs.2, 3, 4, 5. A negative correla-
tion (r = − 0.356, p = 0.010) between the relative ATRA and
tendon elongation was seen at 12months but not at 6months
after ATR (Fig.2). There was also a positive correlation at
both 6 and 12months between the relative ATRA and HRH
(r = 0.330, p = 0.011; r = 0.379, p = 0.004) (Fig. 3). There
was no correlation between Drop CMJ and the relative
ATRA or ATRS and the relative ATRA, at 6 or 12months
after the injury (Figs.4 and 5).
Discussion
The most important finding in this study is that, in all out-
come measurements (ATRA, HRH, Drop CMJ and tendon
length), the injured side had significant deficits compared
with the uninjured side at both 6 and 12months. There
was a significant fair negative correlation between the rela-
tive ATRA and tendon elongation at 12months, but not at
6months after an ATR. Furthermore, there were fair posi-
tive correlations between the relative ATRA and deficits in
HRH at 6 and 12months, such as a resting angle in more
dorsiflexion related to a greater deficit in HRH.
The results demonstrate that clinical evaluations includ-
ing HRH, Drop CMJ and tendon length measured by US
provide a better full picture of the functional outcome after
an ATR, but that the ATRA follows a similar trend, indicat-
ing its value to indirect measurements of the presence of
tendon elongation. However, the ATRA could not be recom-
mended as a direct surrogate for US for determining Achilles
tendon length.
A correlation between the ATRA and tendon length was
also reported by Zellers etal. [28], who found a moderate
correlation (r = 0.491, p = 0.001) between the relative ATRA
and tendon elongation evaluated with US 12months after
an ATR. However, Zeller etal. [28] used an inclinometer
compared with the manual measurement by a goniometer
that was used in the present study, so the results may not be
completely comparable. Previously, Carmont etal. [3] found
a correlation with the absolute ATRA and the HRH limb
symmetry index (LSI) at 12months, but this was not found
to be the case at 9 months following injury. These results
are in line with ours. It is worth mentioning that we used
the deficits in heel-rise height and not the LSI values. Nor
did we use the absolute ATRA. In support of our results, Sil-
bernagel etal. [25] found statistically significant differences
Table 1 Patient demographics presented by the mean (SD) and per-
centage (n)
n number of patients
Variable Total
n = 60
Women
n = 13
Men
n = 47
Age, years 43 (9) 42 (8) 44
Height, cm 178 (8) 169 (5) 181 (6)
Weight, kg 82 (13) 68 (5) 86 (11)
BMI 25.7 (3.0) 24.0 (2.0) 26.1 (3.1)
Injured side
Right (n) 53% (32) 54% (7) 53% (25)
Left (n) 47% (28) 46% (6) 47% (22)
Treatment
Surgery 35% (21) 38% (5) 34% (16)
Non-surgery 65% (39) 62% (8) 66% (31)
Knee Surgery, Sports Traumatology, Arthroscopy
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between the injured and uninjured side after an ATR at 6 and
12months after injury (mean (SD) at 6/12months) in both
HRH (− 6.1cm (1.7)/ − 4.1cm (1.8)) and tendon length
measured by US (3.0 (1.2)/2.6cm (1.4)).
Mortensen etal. [15] and Kangas etal. [12] found that the
injured tendon elongates during the healing process during
the first months after an ATR, which is in line with Car-
mont etal.’s [3] finding that the ATRA also increases up
to 3 months after the same injury. However, Eliasson etal.
[11] reported elongation up to 6 months following a rupture.
Tendons have been noted subsequently to shorten a couple
of millimetres, a statistically non-significant amount, up to
12months following injury [12].
There was no significant correlation between Drop CMJ
and the ATRA at either 6 or 12months. This may require
further investigation if it is assumed that a greater relative
ATRA contributes to poorer plantar flexion power. It has
been shown that a vertical jump test may be less applicable
Table 2 Comparison between
the injured and non-injured side
at 6 and 12months presented by
the mean (SD)
a Achilles tendon resting angle
b Heel-rise height
c Drop countermovement jump
Variable 6months 12months
Non-injured side Injured side p value Non-injured side Injured side p value
ATRA
a (°) 47.1 (5.7) 52.9 (6.4) < 0.001 46.6 (6.2) 51.6 (5.6) < 0.001
Tendon length (cm) 21.4 (2.7) 23.4 (3.1) < 0.001 21.5 (2.2) 23.1 (2.9) < 0.001
HRHb (cm) 14.0 (2.4) 10.1 (3.1) < 0.001 13.9 (2.1) 11.6 (2.1) < 0.001
Drop CMJc (cm) 15.6 (4.8) 12.1 (4.6) < 0.001 15.8 (3.8) 13.1 (3.9) < 0.001
Fig. 2 Correlation between tendon elongation (cm) and relative Achilles tendon resting angle (degrees) at 6months and at 12 months after
Achilles tendon rupture. The line represents linear regression model
Fig. 3 Correlation between deficits in heel-rise height (cm) and relative Achilles tendon resting angle (degrees) at 6months and at 12 months
after Achilles tendon rupture. The line represents the linear regression model
Knee Surgery, Sports Traumatology, Arthroscopy
1 3
in the evaluation of lower limb strength and tendon elonga-
tion [14]. Jumping is a complex movement including multi-
ple muscle groups rather than the calf muscles in isolation.
Jumping additionally involves other aspects such as balance
and co-ordination [14]. It has also been shown that, dur-
ing jumping, the decrease in work performed at the ankle
can be compensated for by increased work performed at the
knee and the hip, resulting in no noticeable deficits in jump
heights [29].
In this study, there was no significant correlation between
the ATRA and patient-reported outcome (ATRS) at 6 or
12months after ATR. It is important to highlight the fact
that it is not uncommonly noticed that patients adapt their
everyday life to their limitations [1, 22]. However, Carmont
etal. [3] found a positive association with the ATRA and
ATRS at 3 and 6 months but not at 9 months following
surgery.
All the patients were evaluated by one experienced
physiotherapist with a standardised test battery, which is an
important strength. One limitation of this study is that the
study design did not include a standardised rehabilitation
protocol. Another aspect that could be taken into account
is the non-random inclusion of patients, which could be a
bias, since the patient population might not represent the
common population.
The measurement of the ATRA in patients with an ATR
is widely used among orthopaedic surgeons and physio-
therapists. The great advantages of the ATRA are that only
a goniometer is required and the measurement is easy to
perform. The findings in this study confirm that, together
with other clinical evaluations, the ATRA could be useful
in detecting and evaluating tendon elongation in the clinical
setting.
Conclusion
In combination with other clinical measurements, such as
HRH and US, the ATRA is a useful clinical tool for indirect
measurements of the presence of tendon elongation through-
out recovery. However, the ATRA cannot be regarded as a
direct surrogate for US.
Fig. 4 Correlation between deficits in drop countermovement jump (cm) and relative Achilles tendon resting angle (degrees) at 6months and at
12months after Achilles tendon rupture. The line represents the linear regression model
Fig. 5 Correlation between Achilles tendon total rupture score and relative Achilles tendon resting angle (degrees) at 6months and at 12months
after Achilles tendon rupture. The line represents linear regression model
Knee Surgery, Sports Traumatology, Arthroscopy
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As a result, tendon elongation after an ATR is not pos-
sible to either detect or reject using only one clinical assess-
ment, such as the ATRA.
Authors contributions KGS, AB, LFH, MC and KNH participated in
the design of the study. LFH and AB performed all clinical evaluations
including the ultrasound measurement. EL, MH and AB performed
the data processing and statistical analysis. All of the authors have
contributed to the manuscript.
Funding Open access funding provided by University of Gothen-
burg. Funding was provided by the Local Research and Develop-
ment Board for Gothenburg and Södra Bohuslän, Sweden Dnr:
VGFOUGSB-904421 and Swedish Research Council for Sports Sci-
ence (CIF) nr: P2019-0156.
Declarations
Conflict of interest None of the authors have any conflicts of interest.
Ethical approval The research protocol was approved by the Swedish
Ethical Review Authority (Dnr 803–15).
Open Access This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
included in the article's Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in
the article's Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.
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... Therefore, our aim was to assess whether early symmetry of AT and triceps surae muscle properties at 2 months after rupture were associated with sideto-side symmetry in isometric plantarflexor maximal voluntary contraction (MVC) and AT nonuniformity at 6 and 12 months. We examined whether participant age [3], sex [3], early symmetry of MG muscle and AT architecture [2,[4][5][6][7], ATRA [8,[15][16][17], or AT shear wave velocity (SWV, m × s −1 ) [7] measured at 2 months postinjury would serve as potential predictors of MVC and AT nonuniformity. We hypothesized that younger age and better structural and mechanical symmetry at 2 months would be related to better symmetry of MVC and AT nonuniformity at 6 and 12 months. ...
... Based on the multiple regression models, a 1% improvement in ATRA LSI would result in a 2.5% improvement in MVC LSI at 6 months and a 1.6% improvement at 12 months. These findings align with previous cross-sectional studies reporting a correlation between ATRA and heel-rise performance after ATR [15][16][17]. Furthermore, Carmont and colleagues [8] found an association between greater intraoperative ATRA and 12 month heel-rise performance in operatively treated patients, supporting our findings. The results of this study show that in addition to heel-rise performance, ATRA is also related to the isometric plantarflexor muscle strength deficit tested with ankle in neutral position, suggesting that ATRA is associated with plantarflexor force production capacity under different conditions. ...
... ATRA measured at 2 months was found to be associated with plantarflexor strength deficit within 1 year after rupture, which aligns with previous studies reporting a relationship between ATRA and heel-rise performance [8,[15][16][17]. The findings suggest that ATRA may be a relevant biomarker of the progression of tendon healing and have potential as a clinical tool for identifying patients at risk of prolonged strength deficits. ...
Article
Full-text available
Purpose To investigate early structural and mechanical predictors of plantarflexor muscle strength and the magnitude of Achilles tendon (AT) nonuniform displacement at 6 and 12 months after AT rupture. Methods Thirty‐five participants (28 males and 7 females; mean ± SD age 41.7 ± 11.1 years) were assessed for isometric plantarflexion maximal voluntary contraction (MVC) and AT nonuniformity at 6 and 12 months after rupture. Structural and mechanical AT and plantarflexor muscle properties were measured at 2 months. Limb asymmetry index (LSI) was calculated for all variables. Multiple linear regression was used with the 6 and 12 month MVC LSI and 12 month AT nonuniformity LSI as dependent variables and AT and plantarflexor muscle properties at 2 months as independent variables. The level of pre‐ and post‐injury sports participation was inquired using Tegner score at 2 and 12 months (scale 0–10, 10 = best possible score). Subjective perception of recovery was assessed with Achilles tendon total rupture score (ATRS) at 12 months (scale 0–100, 100=best possible score). Results Achilles tendon resting angle (ATRA) symmetry at 2 months predicted MVC symmetry at 6 and 12 months after rupture (β = 2.530, 95% CI 1.041–4.018, adjusted R² = 0.416, p = 0.002; β = 1.659, 95% CI 0.330–2.988, adjusted R² = 0.418, p = 0.016, respectively). At 12 months, participants had recovered their pre‐injury level of sports participation (Tegner 6 ± 2 points). The median (IQR) ATRS score was 92 (7) points at 12 months. Conclusion Greater asymmetry of ATRA in the early recovery phase may be a predictor of plantarflexor muscle strength deficits up to 1 year after rupture. Trial Registration: This research is a part of “nonoperative treatment of Achilles tendon rupture in Central Finland: a prospective cohort study” that has been registered in ClinicalTrials.gov (NCT03704532)
... Preoperatively, the contralateral Achilles tendon resting angle (ATRA) is assessed and used as a reference for determining the ATRA after tendon repair. ATRA reflects the position of the ankle joint, measured with the patient positioned prone, the knee flexed at 90°, and the ankle joint fully relaxed [14]. The distal portion of the surgical limb, starting from the knee joint, is disinfected and prepared with sterile draping. ...
... In comparison, they found that five patients with midsubstance Achilles tendon ruptures unfortunately experienced tendon elongation. Tendon elongation can significantly impact a patient's plantarflexion power and overall satisfaction [34,35]. All patients in the myotendinous group were able to do a single-leg heel raise and had on average 79% the heel-raise ability (HRHI) compared to their contralateral side. ...
Article
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Background Achilles tendon ruptures are the most common lower extremity tendinous rupture. While there has been extensive research into the management of mid-substance Achilles tendon ruptures, there is a paucity of literature on the management of myotendinous Achilles tendon ruptures. Methods The aim of this systematic review is to compile all available literature on the treatment of myotendinous Achilles tendon tears. A systematic search of Web of Science, Embase, and Medline databases was performed for all studies published from database inception to April 13, 2024. All publications addressing the treatment of myotendinous Achilles ruptures of all levels of evidence were included. The PRISMA Checklist guided the reporting and data abstraction. Descriptive statistics are presented. Results A total of five studies with 70 patients were included for analysis. Sixty-seven patients underwent non-operative management with an average age ranging from 40.8 to 51.0 years. Three patients underwent operative management with ages of 16, 36, and 39. The majority of patients tore their Achilles tendon during sports. For nonoperatively treated patients, one group underwent immobilization for a total of 6 weeks and one study treated patients with functional rehabilitation. All patients were able to perform a single heel-raise, had good reported strength, and returned to work or sport. Nonoperative patients reported statistically significant improvements in subjective outcomes and high rates of satisfaction. Conclusion Both nonoperative and operative management of myotendinous Achilles tendon ruptures demonstrated good outcomes after injury, although there is a limited amount of literature on this topic. Given that nonoperative treatment appears to yield good strength and return to activity, it may be preferred for the majority of patients. Operative management may be indicated in high level athletes. Imaging to determine the exact location of injury, quality of remaining tendon, and gap distance may further aid when considering treatment options. Higher level evidence studies are required to determine the optimal treatment of myotendinous Achilles tendon ruptures. Level of evidence IV; Systematic review of Level IV-V studies.
... Tendon elongation is a common complication of AATR and may occur at the rehabilitation stage regardless of the chosen treatment, leading to an inferior outcome [23]. Achilles tendon elongation affects foot and ankle biomechanics, plantar flexion strength, maximum calf circumference, and muscular volume [9]. ...
... Previous studies have investigated the impact of these structural alterations on subjective PROMs (Patient-Related Outcome Measures) and objective outcomes (gait analysis) [ that the Achilles Tendon Resting Angle (ATRA) can be indirectly used to assess the length of the Achilles tendon. Contrary to Larsson et al. [20], Carmont et al. [5] found a strong correlation between ATRA and ATRS after surgery. In addition, it has been reported that after ATR, differential elongation of the gastrocnemius relative to the soleus may compromise the ability of athletes to return to competition [16]. ...
Article
Full-text available
Purpose The aim of this study was to assess whether variances in Achilles tendon elongation are linked to dissimilarities in the plantar pressure distribution following two different surgical approaches for an Achilles tendon rupture (ATR). Methods All patients who were treated with open or minimally invasive surgical repair (MIS) and were over 2 years post their ATR were eligible for inclusion. A total of 65 patients with an average age of 43 ± 11 years were included in the study. Thirty‐five patients were treated with open repair, and 30 patients were treated with MIS. Clinical outcomes were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) and ATR Score (ATRS). Achilles tendon elongation was measured using axial and sagittal magnetic resonance imaging scans. Plantar pressure measurements for the forefoot, midfoot and hindfoot during gait were divided into percentages based on total pressure, measured in g/cm ² for each area. Results The average AOFAS score was found ‘excellent’ (93 ± 2.8) in the MIS group, while it was found ‘good’ (87.4 ± 5.6) in the open repair group. In addition, the MIS group showed significantly superior ATRS scores (78.8 ± 7.4) compared to the open repair group (56.4 ± 15.4) ( p < 0.001). The average tendon elongation in the MIS group was 11.3 ± 2 mm, while it was 17.3 ± 4.3 mm ( p < 0.001) in the open repair group. While the open repair group showed significantly higher plantar pressure distribution in the initial contact and preswing phases compared to uninjured extremities, there was no significant difference between the uninjured extremities and the MIS group. Conclusion In conclusion, the findings of this study demonstrated that minimally invasive surgery was associated with less tendon elongation, more proximity to the plantar pressure distributions of the uninjured extremity and superior clinical outcomes compared to open surgical repair. Therefore, minimally invasive surgery may be considered a more suitable option for acute Achilles tendon repair to achieve overall better outcomes. Level of Evidence Level III.
... The regeneration process of the rupture site was assessed using MRI. The Achilles Tendon Total Rupture Score (ATRS) [15], Achilles Tendon Resting Angle (ATRA) [12] and Heel Rise Height Scale (HRHS) [25] were modified to evaluate the clinical outcomes at the final follow-up. In this study, the patient was placed in the prone position with knee flexion at 90°, while the angle between the lateral side of the sole and horizontal plane was measured with a digital protractor. ...
Article
Purpose The safety and reliability of endoscopic Achilles tendon rupture repair are still concerning aspects. This study's aim is to evaluate an all‐inside endoscopic semiautomatic running locked stitch (Endo‐SARLS) technique. Methods Forty cases with acute Achilles tendon rupture were treated with the all‐inside Endo‐SARLS technique between 2020 and 2021. Under endoscopic control, the proximal tendon stumps were stitched with the running locked method using a semiautomatic flexible suture passer. The threads of the high‐strength suture were grasped through the paratenon subspace and then fixed into calcaneal insertion with a knotless anchor. Magnetic resonance imaging (MRI), surgical time and complications were assessed. Achilles Tendon Total Rupture Score (ATRS), Achilles Tendon Resting Angle (ATRA) and Heel Rise Height Scale (HRHS) were utilised to evaluate final outcomes. Results The average follow‐up time was 25.4 ± 0.4 (range: 24–32) months. Appropriate tendon regeneration was observed on MRI after 12 months. At the final follow‐up, the median value of ATRS score was 95 (interquartile range: 94, 98). Furthermore, there is no significant difference between the injured and contralateral side in the average ATRA (18.2 ± 1.8 vs. 18.3 ± 1.9°, ns) and median value of HRHS [14.5 (13.3, 15.5) vs. 14.8 (13.5, 15.6) cm, ns]. No infection and nerve injuries were encountered. Thirty‐nine patients reported that they resumed casual sports activity after 6 months. One patient had a slight anchor cut‐out, due to an addition injury, which was removed after 5 months. Conclusions An all‐inside Endo‐SARLS technique showed promising clinical results for acute Achilles tendon ruptures. This procedure reduces the risk of sural nerve injuries while establishing a reliable connection between the tendon stumps. Level of Evidence Level IV.
... Interestingly, a recent study showed that ATRA detected deficits after an Achilles tendon rupture, but was not a surrogate for direct measurements of tendon elongation, [13]. In future, authors should consider using other methods to measure tendon elongation. ...
Article
Full-text available
Purpose: Achilles tendon ruptures (ATR) result in loss of strength and function of the gastrosoleus-Achilles tendon complex, probably because of gradual tendon elongation and calf muscle atrophy, even after surgical repair. Flexor hallucis longus (FHL) augmentation not only reinforces the repair and provides new blood supply to the tendon, but also protects the repair, internally splinting the repaired Achilles tendon, maintaining optimal tension. We prospectively compared the clinical outcomes of patients with acute ATR, managed with either percutaneous repair only or percutaneous repair and FHL augmentation. Methods: Patients with acute ATR undergoing operative management were divided into two groups. Thirty patients underwent percutaneous repair under local anesthesia, and 32 patients underwent percutaneous repair augmented by FHL tendon, harvested through a 3 cm longitudinal posteromedial incision, and transferred to the calcaneus, under epidural anesthesia. All patients were treated by a single surgeon between 2015 and 2019 and were followed prospectively for 24 months. Results: The percutaneous only group was younger than the augmented one (35.4 ± 8.0 vs 40.4 ± 6.6 years, p = 0.01). In the augmented group, 25 patients stayed overnight and only 5 were day cases, whereas in the percutaneous only group 4 patients stayed overnight and 28 of them were day cases (p < 0.001). The duration of the procedure was significantly longer in the augmented group (38.9 ± 5.2 vs 13.2 ± 2.2 min, p < 0.001). At 24 months after repair, the Achilles tendon resting angle (ATRA) was better in the augmented group (-0.5 ± 1.7 vs -4.0 ± 2.7, p < 0.001), as was Achilles tendon rupture score (ATRS) (91.7 ± 2.2 vs 89.9 ± 2.4, p = 0.004). Calf circumference of the injured and the non-injured leg did not differ between the groups, as did the time interval to single toe raise and the time interval to walking in tiptoes. Although plantarflexion strength of the operated leg was significantly weaker than the non-operated leg in both groups, the difference in isometric strength of the operated leg between the groups was not significant at 24 months (435 ± 37.9 vs 436 ± 39.7 N, n.s.). Conclusion: Percutaneous repair and FHL tendon augmentation may have a place in the management of acute Achilles tendon ruptures, reducing tendon elongation and improving functional outcome. Level of evidence: Level II.
Article
Full-text available
Background: Whether surgical repair of an acute Achilles' tendon rupture by an open-repair or minimally invasive approach is associated with better outcomes than nonsurgical treatment is not clear. Methods: We performed a multicenter, randomized, controlled trial that compared nonoperative treatment, open repair, and minimally invasive surgery in adults with acute Achilles' tendon rupture who presented to four trial centers. The primary outcome was the change from baseline in the Achilles' tendon Total Rupture Score (scores range from 0 to 100, with higher scores indicating better health status) at 12 months. Secondary outcomes included the incidence of tendon rerupture. Results: A total of 554 patients underwent randomization, and 526 patients were included in the final analysis. The mean changes in the Achilles' tendon Total Rupture Score were -17.0 points in the nonoperative group, -16.0 points in the open-repair group, and -14.7 points in the minimally invasive surgery group (P = 0.57). Pairwise comparisons provided no evidence of differences between the groups. The changes from baseline in physical performance and patient-reported physical function were similar in the three groups. The number of tendon reruptures was higher in the nonoperative group (6.2%) than in the open-repair or minimally invasive surgery group (0.6% in each). There were 9 nerve injuries in the minimally invasive surgery group (in 5.2% of the patients) as compared with 5 in the open-repair group (in 2.8%) and 1 in the nonoperative group (in 0.6%). Conclusions: In patients with Achilles' tendon rupture, surgery (open repair or minimally invasive surgery) was not associated with better outcomes than nonoperative treatment at 12 months. (Funded by the South-Eastern Norway Regional Health Authority and Akershus University Hospital; ClinicalTrials.gov number, NCT01785264.).
Article
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Objectives To compare re-rupture rate, complication rate, and functional outcome after operative versus nonoperative treatment of Achilles tendon ruptures; to compare re-rupture rate after early and late full weight bearing; to evaluate re-rupture rate after functional rehabilitation with early range of motion; and to compare effect estimates from randomised controlled trials and observational studies. Design Systematic review and meta-analysis. Data sources PubMed/Medline, Embase, CENTRAL, and CINAHL databases were last searched on 25 April 2018 for studies comparing operative versus nonoperative treatment of Achilles tendon ruptures. Study selection criteria Randomised controlled trials and observational studies reporting on comparison of operative versus nonoperative treatment of acute Achilles tendon ruptures. Data extraction Data extraction was performed independently in pairs, by four reviewers, with the use of a predefined data extraction file. Outcomes were pooled using random effects models and presented as risk difference, risk ratio, or mean difference, with 95% confidence interval. Results 29 studies were included—10 randomised controlled trials and 19 observational studies. The 10 trials included 944 (6%) patients, and the 19 observational studies included 14 918 (94%) patients. A significant reduction in re-ruptures was seen after operative treatment (2.3%) compared with nonoperative treatment (3.9%) (risk difference 1.6%; risk ratio 0.43, 95% confidence interval 0.31 to 0.60; P<0.001; I ² =22%). Operative treatment resulted in a significantly higher complication rate than nonoperative treatment (4.9% v 1.6%; risk difference 3.3%; risk ratio 2.76, 1.84 to 4.13; P<0.001; I ² =45%). The main difference in complication rate was attributable to the incidence of infection (2.8%) in the operative group. A similar reduction in re-rupture rate in favour of operative treatment was seen after both early and late full weight bearing. No significant difference in re-rupture rate was seen between operative and nonoperative treatment in studies that used accelerated functional rehabilitation with early range of motion (risk ratio 0.60, 0.26 to 1.37; P=0.23; I ² =0%). No difference in effect estimates was seen between randomised controlled trials and observational studies. Conclusions This meta-analysis shows that operative treatment of Achilles tendon ruptures reduces the risk of re-rupture compared with nonoperative treatment. However, re-rupture rates are low and differences between treatment groups are small (risk difference 1.6%). Operative treatment results in a higher risk of other complications (risk difference 3.3%). The final decision on the management of acute Achilles tendon ruptures should be based on patient specific factors and shared decision making. This review emphasises the potential benefits of adding high quality observational studies in meta-analyses for the evaluation of objective outcome measures after surgical treatment.
Article
Background Knowledge is limited about how Achilles tendon elongation following acute Achilles tendon rupture (ATR) affects the ability to return to work and return to sport. This study aimed to examine if the indirect length measures, the heel-rise height (HRH) and the Achilles tendon resting angle (ATRA), correlated with patient limitations and return to previous activities one year after ATR. Methods The study was performed as a registry study in the Danish Achilles tendon Database (DADB). The analyses investigated if HRH (limb symmetry index (LSI)) and relative ATRA one year after rupture, correlated with return to the same type of work, return to the same type of sport and the Achilles tendon total rupture score (ATRS) at the same time point. Results 477 patients were included in the study. HRH (LSI) showed fair correlation to ATRS (r=0.35, p<0.001), poor correlation to same type of work (r=0.29, p<0.001) and did not statistically significantly correlate with return to the same type of sport. Relative ATRA showed poor correlation to ATRS (r=0.09, p=0.04) and did not correlate statistically significantly with return to same type of work or sport. Conclusions Neither relative ATRA nor HRH (LSI) showed strong correlations to return to work, return sport or ATRS. When comparing the relative ATRA and HRH (LSI), HRH (LSI) seems to be a better outcome in reflecting patient limitations and return to previous activities one year after ATR.
Article
PurposeStudies have shown that elongation of the injured Achilles tendon after acute Achilles tendon rupture (ATR) is negatively associated with clinical outcomes. The difference between operative and non-operative treatment on the length of the Achilles tendon is only sparsely investigated. The aim of the study was to investigate if the operative and non-operative treatment of ATR had different effects on tendon elongation.Methods The study was performed as a registry study in the Danish Achilles tendon database (DADB). The primary outcome of the study was an indirect measure of Achilles tendon length: the Achilles tendon resting angle (ATRA) at 1-year follow-up. The variable of interest was treatment (operative or non-operative).ResultsFrom August 2015 to January 2019, 438 patients (154 operatively treated and 284 non-operatively treated) were registered with full baseline data and had their ATRA correctly registered at 1-year follow-up in DADB. The analysis did not show a clinically relevant nor statistically significant difference in ATRA between operative and non-operatively treated patients at 1-year follow-up (mean difference − 1.2°; 95% CI − 2.5; 0.1; n.s) after adjustment for potential confounders.Conclusion There were neither clinically relevant nor statistically significant differences in terms of the ATRA at 1-year follow-up between the operative and non-operatively treated patients. This finding suggests that operative treatment does not lead to a clinically relevant reduction in tendon elongation compared to non-operative treatment and it should therefore not be used as an argument in the choice of treatment.Level of evidenceLevel III.
Article
PurposeRupture of the Achilles tendon (AT) is a common injury. Strength deficits may persist over the long term, possibly owing to elongation of the tendon or inferior mechanical properties. This study aimed to provide a systematic review of the literature on the prevalence and consequences of tendon elongation in patients after acute AT rupture treatment. It was hypothesized that an elongated tendon would be associated with a worse clinical outcome.Methods The databases for MEDLINE, CENTRAL and Web of Science were searched. Clinical studies related to AT rupture reporting tendon elongation and clinical or functional outcomes, with a minimum follow-up of 6 months, were eligible for inclusion. Only studies testing for statistical correlations (SCs) between AT elongation and other outcomes were eligible, with the exception of biomechanical studies in which statistically significant AT elongation was found to be a generalized finding in the study group. For these studies to be eligible, the study group had to be compared with a healthy control group, or the injured limb compared with the uninjured limb, regarding biomechanical parameters.ResultsTwenty-eight papers were selected for inclusion. Mean AT elongation measured with imaging techniques ranged from 0.15 to 3.1 cm (n = 17). Ten studies investigated SCs with Patient Reported Outcome Measures (PROMs), in which two found SCs with tendon elongation. Five studies reported strength and power evaluations and their correlation with AT elongation, with two having found SCs between decreased strength and tendon elongation. In ten studies reporting data on biomechanical tests, nine found influence of tendon elongation. In this group, four out of five studies found SCs with biomechanical parameters.Conclusion Fair evidence of the influence of tendon elongation in biomechanical parameters was found. In a general population, evidence of a detrimental effect of tendon elongation on PROMs or functional strength at follow-up was not found in this review.Level of evidenceLevel IV.
Article
Achilles tendon rupture leads to long term plantar flexor deficits. The purpose of this study was to describe changes in jumping biomechanics along with triceps surae structure and activation in individuals after Achilles repair. Eleven individuals 1‐3 years following Achilles repair and 10 healthy controls were included. Kinetics and kinematics, analyzed using a constituent lower extremity work approach, and muscle activity using surface electromyography (EMG) were collected during a unilateral hopping task. Triceps surae myotendinous structure was assessed using ultrasound imaging. There were no differences in jump height, absolute limb work, or cost of transport between groups. During takeoff, the knee did more (p < 0.001) and ankle did less concentric work (p < 0.001), and lateral gastrocnemius rate of rise was higher (p = 0.02) on the ruptured side. During landing, the knee did more eccentric work (p = 0.033) and lateral gastrocnemius (p = 0.003) and soleus (p = 0.02) activation amplitude prior to landing was higher on the ruptured side. Individuals after Achilles tendon repair shift work toward the knee and alter muscle recruitment. Differences in lateral gastrocnemius activity may indicate that it is well‐situated to generate power during takeoff and assist in landing with the soleus. The lack of change in muscle activity and decreased cross sectional area of the medial gastrocnemius may suggest that this muscle atrophies and does not accommodate to the hopping task. Clinical Significance: Proximal lower extremity strengthening along with emphasizing medial gastrocnemius and soleus activation during the recovery of patients with Achilles tendon repair may be rehabilitative targets for improved jumping performance. This article is protected by copyright. All rights reserved
Article
Background: Treatment strategies for Achilles tendon rupture vary considerably, and clinical outcome may depend on the magnitude of tendon elongation after surgical repair. The aim of this project was to examine whether tendon elongation, mechanical properties, and functional outcomes during rehabilitation of surgically repaired acute Achilles tendon ruptures were influenced by different rehabilitation regimens during the early postsurgical period. Hypothesis: Restricted early weightbearing that permits only limited motion about the ankle in the early phase of tendon healing limits tendon elongation and improves functional outcome. Study design: Randomized controlled trial; Level of evidence, 1. Methods: 75 consecutive patients with an acute Achilles tendon rupture were included. They underwent surgical repair, and tantalum beads were placed in the distal and proximal parts of the tendon; thereafter, the patients were randomized into 3 groups. The first group was completely restricted from weightbearing until week 7. The second group was completely restricted from weightbearing until week 7 but performed ankle joint mobilization exercises. The first and second groups were allowed full weightbearing after week 8. The third group was allowed partial weightbearing from day 1 and full weightbearing from week 5. All patients received the same instructions in home exercise guidelines starting from week 9. Results: The rehabilitation regimen in the initial 8 weeks did not significantly influence any of the measured outcomes including tendon elongation. Achilles tendon elongation and tendon compliance continued for up to 6 months after surgery, and muscle strength, muscle endurance, and patient-reported functional scores did not reach normal values at 12 months. Conclusion: Differences in rehabilitation loading pattern in the initial 8 weeks after the repair of an Achilles tendon rupture did not measurably alter the outcome. The time to recover full function after an Achilles tendon rupture is at least 12 months. Registration: NCT02422004 ( ClinicalTrials.gov identifier).
Article
Background: Following Achilles tendon rupture, tendon elongation leads to long term deficits in calf function. A surrogate measure of Achilles tendon length, Achilles tendon resting angle (ATRA), has been described but has not been validated against length measured using ultrasound. Therefore, the purpose of this study was to validate the ATRA against ultrasound. Secondarily, this study aimed to identify the relationship of other factors (tendon mechanical properties, heel-rise test performance) to the ATRA. Methods: Individuals following unilateral Achilles tendon rupture were included. ATRA was measured in knee flexed and extended positions. Tendon elongation was measured using extended field of view ultrasound imaging. Continuous shear wave elastography quantified tendon mechanical properties. The relationship between variables was tested using Spearman's ρ. Subgroup analysis was used to compare subjects with less then or greater than 1 year following rupture. A total of 42 participants (with a mean of 18.2 months following rupture [SD = 35.9]) were included. Results: Tendon elongation related with relative ATRA with knee flexed (ρ = .491, P = .001) and knee extended (ρ = 0.501, P = .001) positions. In individuals greater than 1 year following rupture, relative ATRA with the knee flexed related to shear modulus (ρ = .800, P = .01) and total work on the heel-rise test (ρ = -.782, P = .008) relative to the uninjured side. Conclusion: Relative ATRA in both knee flexed and knee extended positions has a moderate relationship to tendon elongation within the first year following rupture. After 1 year, the relative ATRA with knee flexed may be a better indicator of tendon elongation and also related to tendon mechanical properties and heel-rise test performance. Level of evidence: Level III, case-control study.
Article
Acute Achilles tendon ruptures can be treated with surgical and nonsurgical treatment. However, the optimal intervention for acute Achilles tendon rupture remains controversial. The aim of the present study was to compare the clinical outcomes of surgical treatment versus conservative management for acute Achilles tendon rupture. Eight randomized controlled studies involving 762 patients were included in the meta-analysis. In general, re-rupture occurred in 14 of 381 surgically treated patients (3.7%) and 37 of 377 nonsurgically treated patients (9.8%). Pooled results showed that the total re-rupture rate was significantly lower in surgical group than that in the nonsurgical group (risk ratio 0.38, 95% confidence interval 0.21 to 0.68; p =.001). No significant differences were found between the 2 treatment groups in the incidence of deep venous thrombosis, the number who returned to sport, ankle range of motion (dorsiflexion, plantarflexion), Achilles tendon total rupture score, or physical activity scale. Surgical treatment can effectively reduce the re-rupture rate and might be a better choice for the treatment of acute Achilles tendon rupture. Multicenter, double-blind randomized controlled trials with stratification and long-term follow-up are needed to obtain a higher level of evidence and to guide clinical practice, especially in the comparison and selection of different treatments.