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Hoeffner R, Agergaard AS, Svensson RB, Cullum C, Mikkelsen RK, Konradsen L, Krogsgaard M, Boesen M, Kjaer M, Magnusson SP. Tendon Elongation and Function After Delayed or Standard Loading of Surgically Repaired Achilles Tendon Ruptures: A Randomized Controlled Trial. Am J Sports Med 2024; 52:1022-1031. [PMID: 38353060 DOI: 10.1177/03635465241227178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
BACKGROUND Achilles tendon ruptures often result in long-term functional deficits despite accelerated (standard) rehabilitation. PURPOSE/HYPOTHESIS The purpose of this study was to investigate if delayed loading would influence functional, clinical, and structural outcomes of the muscles and tendon 1 year after a surgical repair. It was hypothesized that delaying the loading would reduce the heel-rise height deficit 1 year after Achilles tendon rupture. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS In total, 48 patients with a surgically repaired Achilles tendon rupture were randomized to 2 groups: the standard group received the currently accepted rehabilitation, and the delayed group received the same rehabilitation except that initial loading was delayed by 6 weeks. The primary outcome was the heel-rise height difference between the injured and uninjured sides at 1 year. The secondary outcomes were (1) tendon length measured with magnetic resonance imaging, (2) muscle fascicle length and pennation angle of the gastrocnemius medialis muscle, (3) Doppler activity measured with ultrasonography, (4) Achilles tendon Total Rupture Score (ATRS), and (5) isometric muscle strength. RESULTS The mean heel-rise height deficits for the standard and delayed groups were -2.2 cm and -2.1 cm, respectively (P = .719). The soleus part of the tendon was already elongated 1 week after surgery in both groups without a between-group difference (side-to-side difference: standard, 16.3 mm; delayed, 17.5 mm; P = .997) and did not change over 52 weeks. The gastrocnemius tendon length was unchanged at 1 week but elongated over time without a between-group difference (side-to-side difference at 52 weeks: standard, 10.5 mm; delayed, 13.0 mm; P = .899). The delayed group had less Doppler activity at 12 weeks (P = .006) and a better ATRS (standard, 60 points; delayed, 72 points; P = .032) at 52 weeks. CONCLUSION Delayed loading was not superior to standard loading in reducing the heel-rise height difference at 1 year. The data indirectly suggested reduced inflammation in the initial months and a better patient-reported outcome at 1 year in the delayed group. The soleus part of the tendon was already markedly elongated (35%) 1 week after surgery, while the length of the gastrocnemius tendon was unchanged at 1 week but was 6% elongated at 1 year. Together, these data indirectly suggest that the delayed group fared better, although this finding needs to be confirmed in future investigations. REGISTRATION NCT04263493 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Rikke Hoeffner
- Institute of Sports Medicine Copenhagen, Department of Orthopaedic Surgery, University Hospital Bispebjerg-Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Physical and Occupational Therapy, University Hospital Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Anne-Sofie Agergaard
- Institute of Sports Medicine Copenhagen, Department of Orthopaedic Surgery, University Hospital Bispebjerg-Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Physical and Occupational Therapy, University Hospital Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Rene B Svensson
- Institute of Sports Medicine Copenhagen, Department of Orthopaedic Surgery, University Hospital Bispebjerg-Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Camilla Cullum
- Department of Physical and Occupational Therapy, University Hospital Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Rasmus Kramer Mikkelsen
- Section for Sports Traumatology, Department of Orthopedic Surgery, University Hospital Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Lars Konradsen
- Section for Sports Traumatology, Department of Orthopedic Surgery, University Hospital Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Michael Krogsgaard
- Section for Sports Traumatology, Department of Orthopedic Surgery, University Hospital Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Mikael Boesen
- Department of Radiology, University Hospital Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Michael Kjaer
- Institute of Sports Medicine Copenhagen, Department of Orthopaedic Surgery, University Hospital Bispebjerg-Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - S Peter Magnusson
- Institute of Sports Medicine Copenhagen, Department of Orthopaedic Surgery, University Hospital Bispebjerg-Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Physical and Occupational Therapy, University Hospital Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
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Khair RM, Stenroth L, Cronin NJ, Ponkilainen V, Reito A, Finni T. Exploration of muscle-tendon biomechanics one year after Achilles tendon rupture and the compensatory role of flexor hallucis longus. J Biomech 2023; 152:111586. [PMID: 37080080 DOI: 10.1016/j.jbiomech.2023.111586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/30/2023] [Accepted: 04/10/2023] [Indexed: 04/22/2023]
Abstract
Achilles tendon (AT) rupture leads to long-term structural and functional impairments. Currently, the predictors of good recovery after rupture are poorly known. Thus, we aimed to explore the interconnections between structural, mechanical, and neuromuscular parameters and their associations with factors that could explain good recovery in patients with non-surgically treated AT rupture. A total of 35 patients with unilateral rupture (6 females) participated in this study. Muscle-tendon structural, mechanical, and neuromuscular parameters were measured 1-year after rupture. Interconnections between the inter-limb differences (Δ) were explored using partial correlations, followed by multivariable linear regression to find associations between the measured factors and the following markers that indicate good recovery: 1) tendon length, 2) tendon non-uniform displacement, and 3) flexor hallucis longus (FHL) normalized EMG amplitude difference between limbs. Δmedial gastrocnemius (MG) (β = -0.12, p = 0.007) and Δlateral gastrocnemius (β = -0.086, p = 0.030) subtendon lengths were associated with MG tendon Δstiffness. MG (β = 11.56, p = 0.003) and soleus (β = 2.18, p = 0.040) Δsubtendon lengths explained 48 % of variance in FHL EMG amplitude. Regression models for tendon length and non-uniform displacement were not significant. Smaller inter-limb differences in Achilles subtendon lengths were associated with smaller differences in the AT stiffness between limbs, and a smaller contribution of FHL muscle to the plantarflexion torque. In the injured limb, the increased contribution of FHL appears to partially counteract a smaller contribution from MG due to the elongated tendon, however the role of FHL should not be emphasized during rehabilitation to allow recovery of the TS muscles.
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Affiliation(s)
- Ra'ad M Khair
- Faculty of Sport and Health Sciences, Neuromuscular Research Center, University of Jyväskylä, Jyväskylä, Finland.
| | - Lauri Stenroth
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland
| | - Neil J Cronin
- Faculty of Sport and Health Sciences, Neuromuscular Research Center, University of Jyväskylä, Jyväskylä, Finland; School of Sport and Exercise, University of Gloucestershire, UK
| | | | - Aleksi Reito
- Central Finland Central Hospital Nova, Jyväskylä, Finland
| | - Taija Finni
- Faculty of Sport and Health Sciences, Neuromuscular Research Center, University of Jyväskylä, Jyväskylä, Finland
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De la Fuente C, Martinez-Valdes E, da Rocha ES, Geremia JM, Vaz MA, Carpes FP. Distal overactivation of gastrocnemius medialis in persistent plantarflexion weakness following Achilles tendon repair. J Biomech 2023; 148:111459. [PMID: 36738627 DOI: 10.1016/j.jbiomech.2023.111459] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 01/09/2023] [Accepted: 01/17/2023] [Indexed: 01/21/2023]
Abstract
Structural alterations of the triceps surae and Achilles tendon (AT) can promote plantarflexion weakness one-year following an AT repair, influencing the activation strategies of the Gastrocnemius Medialis (GM) muscle. However, this is yet to be demonstrated. We aimed to determine whether patients with plantar flexion weakness one-year after AT repair show altered GM spatial activation. In this cross-sectional and case-control study, ten middle-aged men (age 34 ± 7 years old, and 12.9 ± 1.1 months post-surgery) with a high AT total rupture score who attended conventional physiotherapy for six months after surgery, and ten healthy control men (age 28 ± 9 years old), performed maximal and submaximal (40, 60 and 90%) voluntary isometric plantarflexion contractions on a dynamometer. The peak plantar flexor torque was determined by isokinetic dynamometry and the GM neuromuscular activation was measured with a linear surface-electromyography (EMG) array. Overall EMG activation (averaged channels) increased when the muscle contraction levels increased for both groups. EMG spatial analysis in AT repaired group showed an increased activation located distally at 85-99%, 75-97%, and 79-97% of the electrode array length for 40%, 60%, and 90% of the maximal voluntary isometric contractions, respectively. In conclusion, patients with persistent plantar flexion weakness after AT rupture showed higher distal overactivation in GM.
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Ko PY, Hsu CH, Hong CK, Hung MT, Su WR, Jou IM, Wu PT, Su FC. Jigless Knotless Internal Brace Versus Other Minimal Invasive Achilles Tendon Repair Techniques in Biomechanical Testing Simulating the Progressive Rehabilitation Protocol. J Foot Ankle Surg 2022; 62:61-67. [PMID: 35477848 DOI: 10.1053/j.jfas.2022.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/22/2022] [Accepted: 03/26/2022] [Indexed: 02/03/2023]
Abstract
The jigless knotless internal brace surgery (JKIB), an alternative method for minimal invasive surgery (MIS) repair of acute Achilles tendon rupture, has advantages of preventing sural-nerve injury in MIS and superficial wound infection in open surgery, as previous clinical research demonstrates. However, no comparative study on the biomechanical performance between JKIB and other MIS techniques has been reported until now. In this study, 50 fresh porcine Achilles tendons were used to compare the JKIB with open surgery (two-stranded Krachow suture) with other MIS techniques, including Percutaneus Achilles Repair System (PARS), Speedbridge (SB), and Achillon Achilles Tendon Suture System (ACH), using a biomechanical testing with cyclic loading at 1 Hz. This test was used to simulate a progressive rehabilitation protocol where 20 to 100 N was applied in the first 250 cycles, followed by 20 to 190 N in the second 250 cycles, and then 20 to 369 N in the third 250 cycles. The cyclic displacement after 10, 100 and 250 cycles were recorded. The survived cycles were defined as a sudden drop in measured load. In survived cycles, the JKIB group (552.3 ± 72.8) had significantly higher cycles than the open, PARS, and ACH groups (204.3 ± 33.3, 395.9 ± 96.0, and 397.1 ± 80.9, respectively, p < .01) as analyzed by post hoc analysis, but no significant difference as compared with the SB group (641.6 ± 48.7). In cyclic displacement after 250 cyclic loadings, the JKIB group (11.29 ± 1.29) showed no significant difference as compared with PARS, SB, and ACH groups (12.21 ± 1.18, 9.80 ± 0.80, and 11.57 ± 1.10 mm, respectively) and significant less displacement than the open group (14.50 ± 1.85, p < .01). These findings suggest that JKIB could be an option for acute Achilles tendon repair in the MIS fashion due to no larger cyclic elongation compared with other MIS techniques.
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Affiliation(s)
- Po-Yen Ko
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan; Department of Orthopedics, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chieh-Hsiang Hsu
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Kai Hong
- Department of Orthopedics, National Cheng Kung University Hospital, Tainan, Taiwan
| | | | - Wei-Ren Su
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - I-Ming Jou
- Departments of Orthopedic Surgery and Pathology, E-Da Hospital, I-Shou University, Yen-Chao District, Kaohsiung, Taiwan; GEG Orthopedic Clinic, Tainan, Taiwan
| | - Po-Ting Wu
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan; Department of Orthopedics, National Cheng Kung University Hospital, Tainan, Taiwan.
| | - Fong-Chin Su
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan.
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Hoeffner R, Svensson RB, Bjerregaard N, Kjær M, Magnusson SP. Persistent Deficits after an Achilles Tendon Rupture: A Narrative Review. Transl Sports Med 2022; 2022:7445398. [PMID: 38655161 PMCID: PMC11022787 DOI: 10.1155/2022/7445398] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/03/2022] [Accepted: 06/15/2022] [Indexed: 04/26/2024]
Abstract
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.
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Affiliation(s)
- Rikke Hoeffner
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Physical and Occupational Therapy, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Rene B. Svensson
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Nicolai Bjerregaard
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Michael Kjær
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Stig Peter Magnusson
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Physical and Occupational Therapy, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
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Wenning M, Mauch M, Heitner A, Lienhard J, Ritzmann R, Paul J. Neuromechanical activation of triceps surae muscle remains altered at 3.5 years following open surgical repair of acute Achilles tendon rupture. Knee Surg Sports Traumatol Arthrosc 2021; 29:2517-2527. [PMID: 33660053 PMCID: PMC8298360 DOI: 10.1007/s00167-021-06512-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 02/17/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess whether the neuromuscular activation pattern following Achilles tendon rupture and repair may contributes to the observable functional deficits in this severe and increasingly frequent injury. METHODS In this study, the neuromuscular activation using surface EMG of n = 52 patients was assessed during a battery of functional performance tasks to assess potential alterations of muscular activation and recruitment. We analyzed the injured leg vs. the contralateral healthy leg at a mean of 3.5 years following open surgical repair. The testing battery included isokinetic strength testing, bipedal and single-legged heel-rise testing as well as gait analysis. RESULTS During isokinetic testing, we observed a higher activation integral for all triceps surae muscles of the injured side during active dorsiflexion, e.g., eccentric loading on the injured leg, while concentric plantarflexion showed no significant difference. Dynamic heel-rise testing showed a higher activation in concentric and eccentric loading for all posterior muscles on the injured side (not significant); while static heel-rise for 10 sec. revealed a significantly higher activation. Further analysis of frequency of fast Fourier-transformed EMG revealed a significantly higher median frequency in the injured leg. Gait analysis revealed a higher pre-activation of the tibialis anterior before ground contact, while medial and lateral gastrocnemius muscles of the injured leg showed a significantly higher activation during push-off phase. CONCLUSIONS The results of this study provide evidence on the neuromuscular changes 3.5 years following open surgical Achilles tendon repair. These complex neuromuscular changes are manifested to produce the maximum force output whilst protecting the previously injured tendon. The observed alterations may be related to an increased recruitment of type II muscle fibers which could make the muscles prone to fatigue. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Markus Wenning
- Rennbahnklinik, Muttenz, Basel, Switzerland.
- Department of Orthopedic and Trauma Surgery, Faculty of Medicine, University Medical Center Freiburg, Albert-Ludwigs University of Freiburg, Freiburg, Germany.
| | | | | | - Johannes Lienhard
- Department of Sport and Sport Science, Biomechanics and Motor Control, Albert-Ludwigs University of Freiburg, Freiburg, Germany
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