SLR - January 2018 - Garret L. Strand

Heel-Rise Height Deficit 1 Year After Achilles Tendon Rupture Relates to Changes in Ankle Biomechanics Six Years After Injury

Reference: Brorsson A, Willy R, Tranberg R, Grävare Silbernagel K. Heel-Rise Height Deficit 1 Year After Achilles Tendon Rupture Relates to Changes in Ankle Biomechanics 6 Years After Injury. American Journal of Sports Medicine. November 2017;45(13):3060–3068.

Scientific Literature Review

Reviewed By: Garret L. Strand, DPM
Residency Program: Wheaton Franciscan Healthcare, St. Joseph Hospital, Milwaukee, WI

Podiatric Relevance: Achilles tendon ruptures are frequent injuries especially among the athletic population. After these injuries, nearly 20 percent of patients will be unable to perform at their preinjury activity level due to complications. One well documented complication is tendon elongation resulting in decreased calf muscle strength, altered gait biomechanics and ankle function. These complications alter the patient’s physical ability, especially short-term, but what still remains unknown is how these alterations correlate long term. This study explores two groups with known heel rise heights at one-year follow-up and explores the differences in ankle biomechanics, calf muscle recover, tendon length and patient-reported outcomes at an average of six years after injury.

Methods: A level III cohort study of 173 patients was utilized from two prior randomized controlled trials comparing surgical versus nonsurgical treatment for Achilles tendon ruptures. These patients were then randomly assigned into two groups. Sixty-five patients had less than 15 percent side-to-side difference in heel rise height, and 45 patients had greater than 30 percent side-to-side difference in heel rise height at one year. Patient-reported outcomes were reported using Achilles Tendon Total Rupture Score (ATRS), Physical Activity Scale (PAS) and Foot and Ankle Outcome Score (FAOS). Additional physical measurements included ultrasonography Achilles tendon length, single-leg standing heel rise and biomechanical measurements during walking, jogging and jumping activities.

Results: No differences were found between the < 15 percent group and the > 30 percent group in patient-reported outcomes, including the ATRS, PAS and FAOS. No statistically significant differences were found between the groups in ankle kinematics (plantarflexion, dorsiflexion, eversion and abduction) during walking, jogging or hopping at six-year follow-up. Significant differences were found between eccentric and concentric plantarflexion power, peak Achilles tendon force and Achilles impulse with the > 30 percent group being the lesser of the two. Significant differences were found between the < 15 percent group and the > 30 percent group in heel-rise height, heel-rise work and tendon length. The results also found that tendon length six years after the rupture correlated negatively with heel-rise height.

Conclusions: Patients with > 30 percent of side-to-side difference in heel rise height at one-year follow-up had significantly larger deficits in ankle kinetics, including joint power and Achilles tendon loads during walking, jogging and jumping. The > 30 percent group also averaged lower heel rise heights and increased tendon length. Average lengthening of the Achilles tendon was 6 percent in the < 15 percent group and 14 percent in the > 30 percent group at the six-year follow-up. This finding showed the strongest correlation for the patient’s ability to regain normal ankle biomechanics long term, especially during higher demand activities like jumping. Therefore, minimizing tendon elongation and regaining heel rise height seem to be of great importance for recovery of ankle biomechanics for high-demanding activities and athletes.  

Educational Opportunities