Identify surgical and nonsurgical treatment options and the risks and ben- efits between .... of tendon injury in older athletes.10. In patients with .... Failure of the foot to plantarflex with calf squeeze is a positive Thompson test (C). Figure 2:
Jul 24, 2014 - Achilles tendon ruptures to determine which meta-analyses provide the highest level of evidence for treatment recommendations. Study Design: ...... review. Clin J Sport Med. 1997;7:207-211. 11. Longo UG, Petrillo S, Maffulli N, Denaro
Purpose. To survey the practice of orthopaedic consultants in the Greater London area for treating. Achilles tendon ruptures. Methods. 221 orthopaedic consultants working in. 28 hospitals within the Greater London area were identified. A questionnair
Sep 29, 2016 - 1 Faculty of Engineering, Computing and Mathematics, University of Western Australia, Crawley, Western. Australia, Australia, 2 School of Engineering and ..... Adaptive Remodeling of Achilles Tendon. PLOS Computational Biology | DOI:10
In an early version, Thetis anointed Achilles with ambrosia (Figure 1), a drink of the gods that reinforced their immortality. Then she put him in a fire so that all his mortal parts would burn away, leaving only his immortal anointed parts. However,
as rheumatoid arthritis or psoriatic arthritis, with inflammatory bursitis and pannus formation should be considered.3 Conventional radiography promptly reveals avulsive fractures, calcification, or ossification of the tendon and adjacent soft tissue
Mar 20, 2014 - Purpose: To report trends in nonoperative and operative treatment of Achilles tendon tears in the United States from 2005 to 2011 in patients registered with a ... in recreational athletes.9 Achilles tendon ruptures have clas- sically
Department of Orthopaedics and. Traumatology, Caritas Medical Centre,. Shamshuipo, Kowloon, Hong Kong. SK Chan, FHKCOS, FHKAM (Orthopaedic Surgery). SCY Chung, MB, BS, MRCS (Ed). YF Ho, FHKCOS, FHKAM (Orthopaedic Surgery). Correspondence to: Dr SK Ch
shuttle running during a simulated cricket batting innings. J Strength Cond .... cricketers (16). Previous research has demonstrated that at least. 2â3 plyometric sessions per week over at least 6 weeks are required to improve strength and power (2
Barfod KW, Bencke J, Lauridsen HB, Ban I, Ebskov L, Troelsen. A. Non-operative ...... 4.6.2 Return to sport. Most acute Achilles tendon ruptures are acquired through sport- ing activities. The return to sports, and preferably a level of sport- ing ac
ruptures represent a subset of athletic foot and ankle injuries that have ... Achilles tendon ruptures often occur during eccentric loading of the foot. Athletes who participate in sports requiring explosive acceleration, sudden changes in direction
SPORTS HEALTH vol. 5 â¢ no. 5. Rupture of the Achilles tendon (AT) is a devastating injury for athletes. Surgical repair is often required for athletes, with recovery periods ... musculotendinous unit predisposes athletes to the rupture of the AT.3,
PPT between groups or over time. The physical ... Abbreviations: ATL, Achilles tendon lengthening; PPT, physical performance test; TCC, total contact casting. ..... rate of ulcer recurrence at the 8-month and 2-year follow-up compared with a. TCC tre
Surviving in an environment that actively impedes your progress can leave you vulnerable during an escape; couple this with the need to conserve limited oxygen reserves and the magnitude of the challenges faced by many cetaceans when threatened becom
Jan 8, 2012 - incidence between 6 and 18% (Rees et al., 2006; Mazzone and McCue, 2002; Shepsis et al.,. 2002). The risk of the .... In several sports, especially in those where its expected the run and/or the jumps, the injuries ... criteria were ado
Sep 17, 2014 - Kristoffer Weisskirchner Barfod, PhD, MD, Jesper Bencke, MSc, PhD, Hanne Bloch Lauridsen, MSc, Ilija Ban, MD,. Lars Ebskov ... immediate weight-bearing with non-weight-bearing in a nonoperative dynamic treatment protocol for Achilles t
The Achilles tendon (AT) is one of the most ruptured and surgically treated tendons in the human body (JÃ³zsa et al., 1989). It is often injured in sports, especially in activities involving strenuous stretching of the tendon such as jumping or runni
Jan 8, 2012 - Gene Variants that Predispose to Achilles Tendon Injuries: An Update on Recent Advances. Stuart M. Raleigh1 and Malcolm Collins2. 1School of Health, Division of Health and Life Sciences,. University of Northampton, Northampton. 2MRC/UCT
Mar 30, 2017 - Inclusion criteria for filtering results were: research papers with original data, English lan- guage ... Based on our knowledge of biological functions of the Achilles tendon and ACL, we generated a list of 90 ..... Besides evaluating
pISSN 1738-3757 eISSN 2288-8551. J Korean Foot Ankle Soc 2016;20(1):39-42 http://dx.doi.org/10.14193/jkfas.2016.20.1.39 a smoker and had .... 61 Felcher AH, Mularski RA, Mosen DM, Kimes TM, DeLoughery. TG, Laxson SE. Incidence and risk factors for ve
The Achilles tendon, named after the legendary warrior and hero of Homer's Iliad, is the strongest and thickest tendon in the human body. Despite this fact .... after calf flexibility improves because it can perpetuate calf inflexibility. Finally, cr
same as above (SAA). â¢ Stretching and Eccentric heel drops: SAA. * Exercise performed 2 times/week in office, 3 times/week at home. WEEK 3. â¢ 2 sessions .... identified as tender or dysfunctional during the initial as- sessment and subsequent tre
A dramatic example is the aging of present aircrafts due to repeating loading in a corrosive environment . The interaction between multiple defects and the existence of several characteristic scales present a considerable challenge to the modeling
Oct 17, 2013 - Users may download and/or print one copy of any article(s) in LSE Research Online to facilitate their ... cian and surgeon, who equipped him with a steel truss. He was sent a brayer ...... ouvert tous les jours au fond de la cour de Ro
■ sports medicine update S P OT L I G H T O N
Management of Acute Achilles Tendon Ruptures STEVEN J. LAWRENCE, MD; GREGORY F. GRAU, MD Regardless of treatment modality—operative or nonoperative— the goals of Achilles tendon rupture management include restoration of normal function of the muscle-tendon complex with normal plantar flexor power and endurance.
xplosive athletic motions such as leaping and sprinting are dependent on an intact gastrocsoleus-tendon complex. The optimal treatment to restore these athletic abilities following an Achilles tendon rupture remains controversial. Operative management appears to be the preferred treatment, especially in young, high-performance athletes. In the past, treatment was primarily limited to open surgical repair or plaster immobilization. More contemporary means include limited exposure repairs and functional bracing. Both are designed to minimize the shortcomings of traditional
From the Section of Orthopedic Foot and Ankle Surgery, Division of Orthopedic Surgery, University of Kentucky, Lexington, Ky. Reprint requests: Steven J. Lawrence, MD, Division of Orthopedic Surgery, University of Kentucky, Kentucky Clinic, 740 S Limestone, Ste K401, Lexington, KY 40536.
JUNE 2004 | Volume 27 • Number 6
management—wound breakdown, rerupture, and loss of plantar flexor power. Furthermore, rehabilitation protocols have advanced the benefits of early motion and weight bearing to minimize muscle atrophy and tendocutaneous scarring. Regardless of treatment form, goals include the restoration of normal function of the muscle-tendon complex. This requires recovery of preinjury muscle strength, power, and endurance, as well as a painless, healed tendon with adequate excursion. Restoration of the musculotendinous unit can be achieved by indirect healing via tendon immobilization or by more direct means with varying forms of surgical repair. Prolonged immobilization of any torn tendon results in predictable sequela—muscle atrophy, joint stiffness, adhesion formation, and generalized deconditioning. These are detrimental to performance in any competitive athlete.
Surgical repair has been touted as providing a precise, secure, end-to-end repair with a low rerupture rate. However, wound breakdown and infection are common complications that portend an unsatisfactory outcome. Although a minimal exposure or percutaneous technique may produce fewer wound problems, a weaker and less accurate repair with an increased risk of rerupture or iatrogenic nerve injury may result.
LITERATURE REVIEW The comparison of clinical series detailing operative and nonoperative management is difficult when confounding variables such as surgical technique, patient selection, rehabilitation protocols, and outcome scoring are present. Wong et al1 retrospectively analyzed the results of ⬎125 well-documented reports comprising the treatment of ⬎5000 patients. They confirmed a
strong bias toward surgical treatment for these injuries. The reported incidence of complications appeared to be trending downward—with a 13% overall complication rate. Nonoperative treatment was associated with a five-fold increase in rerupture rates, whereas operative intervention was associated with a 30-fold increase of wound complications. The complication rate was highest in a subset of patients undergoing percutaneous repair with early mobilization. This group had a complication rate ⬎30%. Functional Bracing The use of custom or overthe-counter functional walking braces has recently gained popularity (Figure 1). In general, such management must be instituted within several days of the injury. Again, differences in treatment protocols, such as time to initiation of weight bearing, position of ankle
■ sports medicine update
a 1.5-inch heel for an additional 4 weeks. Running and jumping were prohibited for 6 months. The rerupture rate was 6%. The results of isokinetic testing were comparable to open repairs. Ninety-five percent of patients were completely satisfied with their treatment; average American Orthopaedic Foot and Ankle Society score
lization), restores normal length-tension relations, and decreases incidence of wound breakdown and infection. With limited surgical exposure, iatrogenic injury to the sural nerve may occur due to its intimate association with the Achilles tendon (Figure 2). Several studies have documented the outcomes following
immobilization, and length of immobilization, make direct comparisons difficult. The use of a functional brace was first popularized by Carter et al2 in 1992. McComis et al3 reported the results of 15 athletes treated with a protocol of immobilization in a customized polypropylene orthosis with early motion but limited weight bearing for 8 weeks. Good to excellent results were reported in 80% of the series. Although an increase of an average 2.6° of dorsiflexion was noted, no significant differences were reported in functional testing compared to ageand gender-matched controls. The authors estimated the cost of nonoperative treatment to be
approximately 25% of the operative cost. Interestingly, professional and collegiate scholarship athletes were excluded from this study. The effect of immediate weight bearing has also been studied. Josey et al4 reported excellent outcomes in 39 patients with 40 Achilles tendon ruptures treated with immediate full weight-bearing casts. Follow-up averaged 55 months. Treatment consisted of casting in maximum equinus with a heel lift for 4 weeks with the use of crutches with weight bearing as tolerated. Subsequently, gravity equinus casting was undertaken for an additional 4 weeks; this was followed by use of a shoe with
2 was 95. Although numerous recreational athletes were included in this series, no elite athletes were treated. Limited Exposure/ Percutaneous Repairs Over the past decade, minimal incision and percutaneous techniques to repair the Achilles tendon have been devised to decrease skin healing problems. The first description was reported by Ma and Griffith.5 This limited but multiple incision technique produces a repair with adequate strength (to permit early mobi-
percutaneous tendon repair. In a prospective, randomized study comparing percutaneous and open repair techniques, Lim et al6 reported outcomes in 66 patients. In their postoperative regime, all patients were immobilized in plaster for a mean of 12.4 weeks. In the 33 patients undergoing percutaneous procedures, an equal or superior outcome was documented. Specifically, 12 complications occurred in the open group and 5 in the percutaneous group. Twenty individuals who described themselves as either athletes or sportsmen were
■ sports medicine update
included in this series; however, none were considered high-performance athletes. Lim et al6 also highlighted an 11% incidence of preoperative sural nerve hypersensitivity, implying a concomitant neuropraxic injury may accompany Achilles tendon ruptures. They concluded that the percutaneous repair was a simple procedure performed under local anesthesia with a low complication rate, equivalent functional outcome, and superior cosmesis. Hockenbury and Johns7 compared the strength of a percutaneous tendon repair using no. 1 nonabsorbable suture to an open repair using a Bunnelltype suture in 10 cadaveric specimens. Each repair was stressed to failure—the open repair construct was twice as strong as the percutaneous. Furthermore, sural nerve entrapment occurred in 3 of 5 specimens undergoing a percutaneous repair. A 1-cm diastases of the tendon edges resulted following “repair” in 1 specimen with this surgical approach. A comparative study of open versus percutaneous repairs involving 27 athletes was reported by Bradley and Tibone.8 Unfortunately, the study was longitudinal and comparative. The open procedures were performed with a direct repair using Bunnell sutures reinforced with a gastrocsoleus fascial graft. Both groups were managed with 4 weeks of nonweight-bearing casts, followed by use of a walking cast for an additional 4
weeks. All patients were satisfied with their outcomes. Objective isokinetic testing of each group’s plantar flexion strength, power, and endurance revealed no statistically significant differences. Cosmesis of the percutaneous repair was noted to be significantly better than in open repairs. Two reruptures were reported; both were percutaneous repairs. The authors recommend treating recreational athletes with the percutaneous technique, but prefer an open repair in professional athletes.
until 4 weeks postoperatively. All patients were immobilized in equinus with an anterior slab of plaster for the first 4 weeks post-injury. The early mobilization group demonstrated a shorter rehabilitation period, shorter use of crutches, and were more satisfied.10 Neither rehabilitation form resulted in less atrophy or a stronger calf. In general, aggressive mobilization of the muscle and tendon appeared to be appropriate and beneficial with little risk of anastomosis failure.
DISCUSSION Rehabilitation Protocols In a prospective, randomized study, Mortensen et al9 compared early motion versus static casting following traditional open repairs in 71 patients. Weight bearing was permitted at 4 and 6 weeks for the functionally braced and casted patients, respectively. They concluded that early mobilization was safe, resulted in a more normal range of motion, with fewer surgical adhesions and acceleration to return to work and sports. However, at 16 months, no significant difference in calf circumference or strength was detected. Recently, Maffulli et al10 reported a comparative, longitudinal study that compared two forms of rehabilitation following the open repair of 53 Achilles tendon ruptures. The results of immediate weight bearing were compared to the outcome of patients in whom weight bearing was delayed
Currently, multiple viable management options are available for the treatment of an Achilles tendon disruption. Conservative treatment appears to be gaining in popularity. All treatment is designed to provide a milieu for tendon healing with full restoration of plantar flexion power and endurance. Literature review does not support an overwhelming superior treatment modality; therefore, the management of an acute Achilles rupture should be individually tailored. Although operative and nonoperative means appear to produce comparable outcomes, each has distinct advantages and disadvantages. In the elite athlete, an open procedure with aggressive mobilization may be the most appropriate means to optimize return to preinjury activity. Parameters such as time at presentation, age, medical fitness, and occupational demands can help direct treatment decisions.
REFERENCES 1. Wong J, Barrass V, Maffulli N. Quantitative review of operative and nonoperative management of Achilles tendon ruptures. Am J Sports Med. 2002; 30:565-575. 2. Carter TR, Fowler PJ, Blokker C. Functional postoperative treatment of Achilles tendon repair. Am J Sports Med. 1992; 20:459-462. 3. McComis GP, Nawoczenski DA, DeHaven KE. Functional bracing for rupture of the Achilles tendon. Clinical results and analysis of ground-reaction forces and temporal data. J Bone Joint Surg Am. 1997; 79:17991808. 4. Josey RA, Marymont JV, Varner KE, Borom A, O’Connor D, Oates JC. Immediate, full weightbearing cast treatment of acute Achilles tendon ruptures: a long-term follow-up study. Foot Ankle Int. 2003; 24:775-779. 5. Ma GW, Griffith TG. Percutaneous repair of acute closed ruptured Achilles tendon: a new technique. Clin Orthop. 1977; 128:247-255. 6. Lim J, Dalal R, Waseem M. Percutaneous vs. open repair of the ruptured Achilles tendon–A prospective randomized controlled study. Foot Ankle Int. 2001; 22:559-565. 7. Hockenbury RT, Johns JC. A biomechanical in vitro comparison of open versus percutaneous repair of tendon Achilles. Foot Ankle. 1990; 11:67-72. 8. Bradley JP, Tibone JE. Percutaneous and open surgical repairs of Achilles tendon ruptures. A comparative study. Am J Sports Med. 1990; 18:188-195. 9. Mortensen HM, Skov O, Jensen PE. Early motion of the ankle after operative treatment of a rupture of the Achilles tendon. A prospective, randomized clinical and radiographic study. J Bone Joint Surg Am. 1999; 81:983990. 10. Maffulli N, Tallon C, Wong J, Lim KP, Bleakney R. Early weightbearing and ankle mobilization after open repair of acute midsubstance tears of the Achilles tendon. Am J Sports Med. 2003; 31:692-700.
Section Editor: Darren L. Johnson, MD JUNE 2004 | Volume 27 • Number 6