Achilles tendon repair: Difference between revisions

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== Description<br> ==
== Description  ==
 
The [[achilles tendon]] connects the calf muscles to the calcaneus (heel bone) and is one of the important tendons in the human body. The main action of the achilles tendon is foot plantar flexion. Common pathologies include: [[tendinopathy]], tear or [[Achilles Rupture|rupture]].  Examples of mechanisms of injury for rupture includes: falling from a height, forceful plantar flexion of the ankle (as in jumping with an extended knee), or using the foot to break a fall if you stumble<ref name=":0" />.  Achilles tendon rupture is either managed conservatively with a cast or surgically with an '''achilles tendon repair'''.  
[[Image:Achilles tendon rupture.jpg|thumb|right|Achilles tendon rupture]]The [[achilles tendon]] connects the calf muscles to the calcaneus (heel bone) and is one of the important tendons in the human body. The main action of the achilles tendon is foot plantar flexion. Common pathologies include: [[tendinopathy]], tear or [[Achilles Rupture|rupture]].  Examples of mechanisms of injury for rupture includes: falling from a height, forceful plantar flexion of the ankle (as in jumping with an extended knee), or using the foot to break a fall if you stumble<ref name=":0" />.  


{{#ev:youtube|Kr84-NEoYiE}}  
{{#ev:youtube|Kr84-NEoYiE}}  


== Conservative vs Surgical intervention:  ==
== Conservative vs surgical intervention:  ==


There is much disagreement in the literature about treatment for ATR with the two options comprising of a conservative or surgical approach.Some literature suggests that nonoperative treatment is not the gold standard for Achilles tendon repair  anymore ,Meta-analyses of studies have shown that the re-rupture rates are higher in cases of non-operative management: 13% for conservative management compared with 4% for surgically repaired Achilles tendons, so the surgical option a good option because it offers advantages over nonsurgical treatment in terms of clinical outcomes and recurrence [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4436906/#B31]    
There is much disagreement in the literature about treatment for achilles tendon rupture with the two options comprising of a conservative or surgical approach. Studies have shown that the re-rupture rates are higher in cases of non-operative management: 13% compared with 4% for surgically repaired achilles tendons<ref>Gulati V, Jaggard M, Al-Nammari SS, Uzoigwe C, Gulati P, Ismail N, Gibbons C, Gupte C. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4436906 Management of achilles tendon injury: a current concepts systematic review.] World journal of orthopedics. 2015 May 18;6(4):380.</ref>    


== Clinical Presentation and Assessment  ==
== Clinical Presentation and Assessment  ==


In 2010, the American Academy of Orthopaedic Surgeons published clinical guidelines regarding ATR.<ref name=":0">Chiodo CP, Glazebrook M, Bluman EM, Cohen BE, Femino JE, Giza E, et al. American Academy of Orthopaedic Surgeons clinical practice guideline on treatment of Achilles tendon rupture. J Bone Joint Surg Am 2010;92(14):2466–8.</ref><span style="line-height: 1.5em;">&nbsp;They describe following a detailed history, a physical examination should include two or more of the following tests;</span>
In 2010, the American Academy of Orthopaedic Surgeons published clinical guidelines regarding ATR.<ref name=":0">Chiodo CP, Glazebrook M, Bluman EM, Cohen BE, Femino JE, Giza E, et al. [http://www.aaos.org/research/guidelines/atrguideline.pdf American Academy of Orthopaedic Surgeons clinical practice guideline on treatment of Achilles tendon rupture.] J Bone Joint Surg Am 2010;92(14):2466–8.</ref><span style="line-height: 1.5em;">&nbsp;They suggest that, following a detailed history, a physical examination should include two or more of the following tests;</span>


*Clinical Thompson test (Simmonds squeeze test) -&nbsp;The test is performed with the patient in prone. The tester gently squeezes the calf around the gastroc muscle bellies. The test is considered positive if there is little or no movement of the ankle into plantar flexion. The Sensitivity of this test is .96<ref name="cleland">Cleland J. Orthopaedic Clinical Examination: An Evidence Based Approach for Physical Therapists. Carlstadt, NJ: Icon Learning Systems:2005.</ref>  
*[[Thompson Test|Thompson test]] -&nbsp;the test is performed with the patient in prone, the tester gently squeezes the calf around the gastroctronemius muscle bellies, the test is considered positive if there is little or no movement of the ankle into plantar flexion. The Sensitivity of this test is 0.96<ref name="cleland">Cleland J. Orthopaedic Clinical Examination: An Evidence Based Approach for Physical Therapists. Carlstadt, NJ: Icon Learning Systems:2005.</ref>  
*Decreased ankle plantar flexion strength  
*Heel raise - decreased ankle plantar flexion strength.
*presence of a palpable gap (defect, loss of contour)
*Palpation - positive result is indicated by the presence of a palpable gap.
*Increased passive ankle dorsiflexion
*Passive dorsiflexion - a positive is indicated by increased passive ankle dorsiflexion.
*Additional general clinical observations include: report of sharp onset of pain or the sound of a “gunshot” at the time of injury, and an inability to stand in plantar flexion.  
*Additional general clinical observations include - report of sharp onset of pain or the sound of a “gunshot” at the time of injury, and an inability to stand in plantar flexion.  


== Pre-op  ==
== Pre-op  ==


Prior to surgery general edema reduction should be used (Rest, Ice, Compression, Elevation). The surgery will ideally occur within one week of the rupture.  
Prior to surgery general oedema reduction should be used ([[RICE|Rest, Ice, Compression, Elevation]]). The surgery will ideally occur within one week of the rupture.  


== Surgery Description  ==
== Surgery Description  ==
 
[[File:Achilles_tendon_rupture_2.jpg|thumb]]
[[Image:Achilles tendon rupture 2.jpg]]  
 
Many techniques exist for this surgery, including transverse, medial and longitudinal incisions. The ankle is placed in neutral position and the severed ends of the tendon are sutured together. The surgeon will then take the ankle through complete range of motion to look at the integrity of the repair. A cast is often applied, with the surgical technique determining how long the cast stays on.<ref name="Dutton" /> Many surgeons are now focusing on early weight bearing and passive motion to improve tendon healing. A new minimally-invasive technique involves utilization of the peroneus brevis via two para-midline incisions. The technique reportedly preserves skin integrity over the site most prone to breakdown in a vertical incision, open reconstruction.<ref>Carmont MR, Maffulli N. Less invasive Achilles tendon reconstruction. BMC Musc Dis. 2007:8(100).</ref> Another study recommended percutaneous repair in the recreational athlete and in patients concerned with cosmesis, and open repair for all high-caliber athletes who cannot afford any chance of rerupture."<ref>Bradley JP, Tibone JE. Percutaneous and open surgical repairs of Achilles tendon ruptures: A comparative study. AJSM. 1990;18:188-195.</ref>  
Many techniques exist for this surgery, including transverse, medial and longitudinal incisions. The ankle is placed in neutral position and the severed ends of the tendon are sutured together. The surgeon will then take the ankle through complete range of motion to look at the integrity of the repair. A cast is often applied, with the surgical technique determining how long the cast stays on.<ref name="Dutton" /> Many surgeons are now focusing on early weight bearing and passive motion to improve tendon healing. A new minimally-invasive technique involves utilization of the peroneus brevis via two para-midline incisions. The technique reportedly preserves skin integrity over the site most prone to breakdown in a vertical incision, open reconstruction.<ref>Carmont MR, Maffulli N. Less invasive Achilles tendon reconstruction. BMC Musc Dis. 2007:8(100).</ref> Another study recommended percutaneous repair in the recreational athlete and in patients concerned with cosmesis, and open repair for all high-caliber athletes who cannot afford any chance of rerupture."<ref>Bradley JP, Tibone JE. Percutaneous and open surgical repairs of Achilles tendon ruptures: A comparative study. AJSM. 1990;18:188-195.</ref>  


{{#ev:youtube|0DNeeGuHKGU|300}}
{{#ev:youtube|0DNeeGuHKGU|300}}


== Post-op<ref name="Dutton">Dutton M. Orthopaedic Examination, Evaluation, and Intervention. New York, NY:McGraw-Hill:2004.</ref>  ==
== Post-op<ref name="Dutton">Dutton M. Orthopaedic Examination, Evaluation, and Intervention. New York, NY:McGraw-Hill:2004.</ref>  ==
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Phase I typically lasts three weeks.  
Phase I typically lasts three weeks.  


Goals of this phase are as follows:<br>
Goals of this phase are as follows:  


*-Control edema and protect the repair site  
*Control oedema and protect the repair site  
*-Minimize scar adhesion and detrimental effects of immobilization
*Minimise scar adhesion and detrimental effects of immobilisation
*-Progress to full weight bearing as tolerated/ indicated  
*Progress to full weight bearing as tolerated/ indicated  
*-Pain 5/10 or less, strength 4/5 all LE muscles except plantar flexors
*Pain 5/10 or less, strength 4/5 all LE muscles except plantar flexors


Phase I interventions include:<br>
Phase I interventions include:  


*-Modalities for pain and edema
*Modalities for pain and oedema
*-Stretching of large LE muscle groups, gastrocnemius/soleus added at week 3  
*Stretching of large LE muscle groups, gastrocnemius/soleus added at week 3  
*-AROM POD#2: plantar and dorsiflexion 3x5; 3 times daily; add inversion and  
*AROM POD#2: plantar and dorsiflexion 3x5; 3 times daily; add inversion and eversion at week 2  
*eversion at week 2  
*Foot/ankle isometrics at week 2; band exercises week 3  
*-Foot/ankle isometrics at week 2; band exercises week 3  
*Proprioceptive training for lower extremities; Gait training  
*-Proprioceptive training for lower extremities; Gait training  
*Upper extremity cardiovascular exercise  
*-Upper extremity cardiovascular exercise  
*Joint mobilisation and soft tissue work, as indicated
*-Joint mobilization and soft tissue work, as indicated


==== '''Phase II'''  ====
==== '''Phase II'''  ====
Line 65: Line 61:
Phase II typically lasts from post op week 4-6.  
Phase II typically lasts from post op week 4-6.  


Goals for this phase are as follows:<br>
Goals for this phase are as follows:  


*-Normalized gait pattern  
*Normalized gait pattern  
*-full ankle ROM  
*Full ankle ROM  
*-5/5 LE strength  
*5/5 LE strength  
*-Return to full ADL ability  
*Return to full ADL ability  
*-Pain reported to be &lt;2/10  
*Pain reported to be &lt;2/10  
*-Proprioceptive reactions equal to non-surgical side
*Proprioceptive reactions equal to non-surgical side


Phase II interventions include:<br>
Phase II interventions include:  


*-Ankle flexibility at various knee angles  
*Ankle flexibility at various knee angles  
*-Progressive closed kinetic chain LE strengthening  
*Progressive closed kinetic chain LE strengthening  
*-Cardiovascular progression  
*Cardiovascular progression  
*-Proprioceptive training on variety of surfaces  
*Proprioceptive training on variety of surfaces  
*-Manual resisted exercises and joint mobilization, as indicated
*Manual resisted exercises and joint mobilization, as indicated


==== '''Phase III'''  ====
==== '''Phase III'''  ====
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Phase III typically lasts from post op week 6-15.  
Phase III typically lasts from post op week 6-15.  


Goals for this phase are as follows:<br>
Goals for this phase are as follows:  


*-Initiate running program  
*Initiate running program  
*-Improve balance and coordination  
*Improve balance and coordination  
*-Increase velocity of activity  
*Increase velocity of activity  
*-Return to sport
*Return to sport


Phase III interventions include:<br> -Progressive ankle and LE strengthening<br> -Agility exercises<br> -Double heel raise/lower progressing to single leg heel raise at various speeds<br>
Phase III interventions include:
* Progressive ankle and LE strengthening
* Agility exercises
* Double heel raise/lower progressing to single leg heel raise at various speeds


== Evidence Based Treatment Protocol  ==
== Evidence Based Treatment Protocol  ==
<div>A recent systematic review by Brumann and colleagues (2014)<ref name="brumann">Brumann, M., Baumbach, S. F., Mutschler, W., &amp; Polzer, H. Accelerated rehabilitation following Achilles tendon repair after acute rupture-Development of an evidence-based treatment protocol.&amp;nbsp;Injury. 2014</ref> identified the most up-to-date rehabilitation protocol for an Achilles tendon repair. They summarised their findings with the following guidelines;<br></div>  
<div>A recent systematic review by Brumann and colleagues (2014)<ref name="brumann">Brumann, M., Baumbach, S. F., Mutschler, W., &amp; Polzer, H. Accelerated rehabilitation following Achilles tendon repair after acute rupture-Development of an evidence-based treatment protocol.&amp;nbsp;Injury. 2014</ref> identified the most up-to-date rehabilitation protocol for an achilles tendon repair. They summarised their findings with the following guidelines;</div>  
==== Week 0 - 2  ====
==== Week 0 - 2  ====
 
* Nil ankle RoM  
Nil ankle RoM  
* Orthosis fixed at 30° of PF  
 
* Progress to full weight bearing (FWB)  
Orthosis fixed at 30° of PF  
 
Progress to full weight bearing (FWB)  


==== Week 3 - 6  ====
==== Week 3 - 6  ====
 
* FWB  
FWB  
* Active ankle RoM 0-30°  
 
* Orthosis limited to plantargrade&nbsp;(0° DF) to 30° PF  
Active ankle RoM 0-30°  
 
Orthosis limited to plantargrade&nbsp;(0° DF) to 30° PF<br>


==== Week 7+  ====
==== Week 7+  ====
 
* Full RoM  
Full RoM  
* Nil orthosis  
 
Nil orthosis  
<div></div>
 
== Key Evidence  ==
 
[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1725061/pdf/v039p00857.pdf/?tool=pmcentrez Calder J, Saxby T. Early, active rehabilitation following mini-open repair of Achilles tendon rupture: a prospective study. Br J Sports Med. 2005;39(11):857-859.]
 
Krueger-Franke M, Siebert CH, Scherzer S. Surgical treatment of ruptures of the Achilles tendon: a review of long-term results. Br J Sports Med. 1995;29(2):121-125.
 
[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464596/pdf/1471-2474-9-100.pdf/?tool=pmcentrez Maffulli N, Longo UG, Gougolias N, Denaro V. Ipsilateral free semitendinosus tendon graft transfer for reconstruction of chronic tears of the Achilles tendon. BMC Musculskelet Disord. 2008;9(100). ]
 
[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2194676/pdf/1471-2474-8-108.pdf/?tool=pmcentrez Metz R, Kerkhoffs G, Verleisdonk EJ, van der Heijden G. Acute Achilles tendon rupture: minimally invasive surgery versus non operative treatment, with immediate full weight bearing. Design of a randomized controlled trial. BMC Musculoskelet Disord. 2007;8(108).]
 
[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684209/pdf/12178_2008_Article_9025.pdf/?tool=pmcentrez Metzl JA, Ahmad CS, Levine WN. The ruptured Achilles tendon: operative and non-operative treatment options. Curr Rev Musculoskelet Med. 2008;1(2):161-164. ]<br>[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2504975/pdf/jcca00004-0023.pdf/?tool=pmcentrez Ramelli FD. Diagnosis, management and post-surgical rehabilitation of an Achilles tendon rupture: a case report. J Can Chiropr Assoc. 2003;47(4):261-268.]
 
[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2576038/?tool=pmcentrez Shin D, Finni T, Ahn S, Hodgson JA, Lee HD, Edgerton R, Sinha S. Effect of chronic unloading and rehabilitation on human Achilles tendon properties: a velocity-encoded phase-contrast MRI study. J Appl Physiol. 2008;105(4):1179-1186.] 


== Resources  ==
== Resources  ==


[http://www.aaos.org/research/guidelines/atrguideline.pdf AAOS Guidlines] for diagnosis and treatment of Acute Achilles Tendon Rupture.
[http://www.aaos.org/research/guidelines/atrguideline.pdf AAOS Guidlines] for diagnosis and treatment of Acute Achilles Tendon Rupture.
Vivek Gulati, Matthew Jaggard, Shafic Said Al-Nammari, Chika Uzoigwe, Pooja Gulati, Nizar Ismail, Charles Gibbons, and Chinmay Gupte. Management of achilles tendon injury: A current concepts systematic review ''World J Orthop''. 2015 May 18; 6(4): 380–386<br>
== References :  ==
== References :  ==
<references />
<references />

Revision as of 12:15, 13 November 2017

Original Editor - Matt Anderson.

Top Contributors - Admin, Ben Kasehagen, Rachael Lowe, Darine Mohieldeen, Kim Jackson, Aminat Abolade, Matt Anderson, Johnathan Fahrner, WikiSysop, 127.0.0.1, Tony Lowe, George Prudden, Tobias Meerts and Kai A. Sigel  

Description[edit | edit source]

The achilles tendon connects the calf muscles to the calcaneus (heel bone) and is one of the important tendons in the human body. The main action of the achilles tendon is foot plantar flexion. Common pathologies include: tendinopathy, tear or rupture. Examples of mechanisms of injury for rupture includes: falling from a height, forceful plantar flexion of the ankle (as in jumping with an extended knee), or using the foot to break a fall if you stumble[1]. Achilles tendon rupture is either managed conservatively with a cast or surgically with an achilles tendon repair.

Conservative vs surgical intervention:[edit | edit source]

There is much disagreement in the literature about treatment for achilles tendon rupture with the two options comprising of a conservative or surgical approach. Studies have shown that the re-rupture rates are higher in cases of non-operative management: 13% compared with 4% for surgically repaired achilles tendons[2]

Clinical Presentation and Assessment[edit | edit source]

In 2010, the American Academy of Orthopaedic Surgeons published clinical guidelines regarding ATR.[1] They suggest that, following a detailed history, a physical examination should include two or more of the following tests;

  • Thompson test - the test is performed with the patient in prone, the tester gently squeezes the calf around the gastroctronemius muscle bellies, the test is considered positive if there is little or no movement of the ankle into plantar flexion. The Sensitivity of this test is 0.96[3]
  • Heel raise - decreased ankle plantar flexion strength.
  • Palpation - positive result is indicated by the presence of a palpable gap.
  • Passive dorsiflexion - a positive is indicated by increased passive ankle dorsiflexion.
  • Additional general clinical observations include - report of sharp onset of pain or the sound of a “gunshot” at the time of injury, and an inability to stand in plantar flexion.

Pre-op[edit | edit source]

Prior to surgery general oedema reduction should be used (Rest, Ice, Compression, Elevation). The surgery will ideally occur within one week of the rupture.

Surgery Description[edit | edit source]

File:Achilles tendon rupture 2.jpg

Many techniques exist for this surgery, including transverse, medial and longitudinal incisions. The ankle is placed in neutral position and the severed ends of the tendon are sutured together. The surgeon will then take the ankle through complete range of motion to look at the integrity of the repair. A cast is often applied, with the surgical technique determining how long the cast stays on.[4] Many surgeons are now focusing on early weight bearing and passive motion to improve tendon healing. A new minimally-invasive technique involves utilization of the peroneus brevis via two para-midline incisions. The technique reportedly preserves skin integrity over the site most prone to breakdown in a vertical incision, open reconstruction.[5] Another study recommended percutaneous repair in the recreational athlete and in patients concerned with cosmesis, and open repair for all high-caliber athletes who cannot afford any chance of rerupture."[6]

Post-op[4][edit | edit source]

Early mobilization following Achilles tendon repair has been reported to be beneficial in terms of postoperative recovery and improved tendon vascularity. Dutton describes three phases of post-surgical rehabilitation following Achilles tendon repair. 

Phase I[edit | edit source]

Phase I typically lasts three weeks.

Goals of this phase are as follows:

  • Control oedema and protect the repair site
  • Minimise scar adhesion and detrimental effects of immobilisation
  • Progress to full weight bearing as tolerated/ indicated
  • Pain 5/10 or less, strength 4/5 all LE muscles except plantar flexors

Phase I interventions include:

  • Modalities for pain and oedema
  • Stretching of large LE muscle groups, gastrocnemius/soleus added at week 3
  • AROM POD#2: plantar and dorsiflexion 3x5; 3 times daily; add inversion and eversion at week 2
  • Foot/ankle isometrics at week 2; band exercises week 3
  • Proprioceptive training for lower extremities; Gait training
  • Upper extremity cardiovascular exercise
  • Joint mobilisation and soft tissue work, as indicated

Phase II[edit | edit source]

Phase II typically lasts from post op week 4-6.

Goals for this phase are as follows:

  • Normalized gait pattern
  • Full ankle ROM
  • 5/5 LE strength
  • Return to full ADL ability
  • Pain reported to be <2/10
  • Proprioceptive reactions equal to non-surgical side

Phase II interventions include:

  • Ankle flexibility at various knee angles
  • Progressive closed kinetic chain LE strengthening
  • Cardiovascular progression
  • Proprioceptive training on variety of surfaces
  • Manual resisted exercises and joint mobilization, as indicated

Phase III[edit | edit source]

Phase III typically lasts from post op week 6-15.

Goals for this phase are as follows:

  • Initiate running program
  • Improve balance and coordination
  • Increase velocity of activity
  • Return to sport

Phase III interventions include:

  • Progressive ankle and LE strengthening
  • Agility exercises
  • Double heel raise/lower progressing to single leg heel raise at various speeds

Evidence Based Treatment Protocol[edit | edit source]

A recent systematic review by Brumann and colleagues (2014)[7] identified the most up-to-date rehabilitation protocol for an achilles tendon repair. They summarised their findings with the following guidelines;

Week 0 - 2[edit | edit source]

  • Nil ankle RoM
  • Orthosis fixed at 30° of PF
  • Progress to full weight bearing (FWB)

Week 3 - 6[edit | edit source]

  • FWB
  • Active ankle RoM 0-30°
  • Orthosis limited to plantargrade (0° DF) to 30° PF

Week 7+[edit | edit source]

  • Full RoM
  • Nil orthosis

Resources[edit | edit source]

AAOS Guidlines for diagnosis and treatment of Acute Achilles Tendon Rupture.

References :[edit | edit source]

  1. ↑ 1.0 1.1 Chiodo CP, Glazebrook M, Bluman EM, Cohen BE, Femino JE, Giza E, et al. American Academy of Orthopaedic Surgeons clinical practice guideline on treatment of Achilles tendon rupture. J Bone Joint Surg Am 2010;92(14):2466–8.
  2. ↑ Gulati V, Jaggard M, Al-Nammari SS, Uzoigwe C, Gulati P, Ismail N, Gibbons C, Gupte C. Management of achilles tendon injury: a current concepts systematic review. World journal of orthopedics. 2015 May 18;6(4):380.
  3. ↑ Cleland J. Orthopaedic Clinical Examination: An Evidence Based Approach for Physical Therapists. Carlstadt, NJ: Icon Learning Systems:2005.
  4. ↑ 4.0 4.1 Dutton M. Orthopaedic Examination, Evaluation, and Intervention. New York, NY:McGraw-Hill:2004.
  5. ↑ Carmont MR, Maffulli N. Less invasive Achilles tendon reconstruction. BMC Musc Dis. 2007:8(100).
  6. ↑ Bradley JP, Tibone JE. Percutaneous and open surgical repairs of Achilles tendon ruptures: A comparative study. AJSM. 1990;18:188-195.
  7. ↑ Brumann, M., Baumbach, S. F., Mutschler, W., & Polzer, H. Accelerated rehabilitation following Achilles tendon repair after acute rupture-Development of an evidence-based treatment protocol.&nbsp;Injury. 2014
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