Comparable Recovery and Compensatory Strategies in Heel-Rise Performance After a Surgically Repaired Acute Achilles Tendon Rupture 

SLR - March 2023 - Paul Marinos, DPM 

Title: Comparable Recovery and Compensatory Strategies in Heel-Rise Performance After a Surgically Repaired Acute Achilles Tendon Rupture 

Reference: Aufwerber S, Silbernagel KG, Ackermann PW, Naili JE. Comparable Recovery and Compensatory Strategies in Heel-Rise Performance After a Surgically Repaired Acute Achilles Tendon Rupture: An In Vivo Kinematic Analysis Comparing Early Functional Mobilization and Standard Treatment. Am J Sports Med. 2022 Dec;50(14) 

Level of Evidence: Level 2- cohort study  

Reviewed By: Paul Marinos, DPM 

Residency Program: Kaiser San Francisco Bay Area Residency Program   

Podiatric Relevance: Acute Achilles tendon ruptures are injuries that can lead to severe functional limitations. There is still no consensus in the literature regarding surgical vs non-surgical treatment but it is known that the end goal is restoring the Achilles tendon length-tension relationship to allow for appropriate recovery and return to daily activities. A common complication after an acute Achilles tendon rupture is strength deficit to the injured limb and decrease in the end-range ankle plantarflexion which is hypothesized to be due to tendon overlengthening during the healing process and/or calf atrophy. This paper’s goal was to evaluate differences in recovery for patients treated with early functional mobilization (EFM) or standard treatment (ST) after a surgically treated Achilles tendon rupture.    

Methods: This was a prospective cohort study of 47 patients included in a prospective randomized control trial who had sustained an acute Achilles tendon rupture and were treated with open surgical repair within 1 week of the injury. They were randomized 2:1 postoperatively to the EFM or ST groups. The EFM group received a dynamic orthosis which was set to 15° to 30° of plantarflexion during the first 2 weeks after surgery. They were able to be weightbearing as tolerated for the first 2 weeks followed by 4 weeks of full weightbearing. The ST group was treated with immobilization in a below the knee plaster cast and were instructed to be non-weightbearing for the first 2 weeks followed by full weightbearing in an ankle stable orthosis which initially had 3 heel wedges that were gradually removed over the next 4 weeks. These patients were then seen at 8 weeks and 6 months post operatively and 3D motion analysis of heel rise performance was conducted and compared between the two cohorts. At 6 months, the tendon length and muscle volume were assessed with ultrasound imaging, calf muscle function with the heel-rise test, and patient reported outcomes with the Achilles tendon Total Rupture Score.  

Results: At 8 weeks and 6 months there were no significant differences between the two groups in heel-rise performance. Both groups exhibited a significant decreased peak ankle plantarflexion angle and increased knee flexion angle on the injured side compared to the contralateral side during bilateral heel raises. They also demonstrated that greater medial gastrocnemius muscle atrophy and higher body weight were predictors of a decreased maximum peak ankle plantarflexion angle on the injured limb at 6 months.    

Conclusions: Contrary to what was expected, EFM after an acute Achilles tendon repair did not lead to superior recovery of calf muscle function compared to ST. As this paper demonstrates, decreased ankle plantarflexion leads to a more proximal compensatory mechanism and an increase in knee flexion to help raise the heel during gait. Overall, it was very interesting to see that there was no significant difference between the two groups even though patient compliance with the rehabilitation protocol was never documented and could be pivotal to the results of this study. Also, the post-operative protocols did not differ much apart from the initial 2 weeks, so future studies studying a more prolonged immobilization period compared to early rehabilitation would be beneficial to evaluate and study the difference between these two protocols.