Effects of early functional mobilization after acute Achilles tendon rupture repair

Background: Patient outcome after Achilles tendon rupture (ATR) varies greatly, and complications such as deep venous thrombosis (DVT) and tendon elongation are common. Although accelerated rehabilitation is considered safe, the optimal content of the rehabilitation protocol is still unknown. Immediate early functional mobilization (EFM) could possibly be a way to reduce the risk of complications and improve outcome.

Aim: The overall aim of this thesis was to investigate whether EFM could reduce the risk of complications and improve outcome in individuals after surgical treatment of acute ATR.

Methods: A total of 149 ATR patients treated with a standardized surgical protocol were postoperatively randomized to either EFM (immediate full weightbearing and ankle motion in an orthosis) or standard treatment (ST, non-weightbearing plaster cast for 2 weeks). The incidence of DVT was examined by means of compression duplex ultrasound at 2 and 6 weeks postoperatively. Self-reported loading, steps and pain were recorded as well as evaluations of plantar pressure measurement, ultrasound imaging of the muscle-tendon morphology, clinical assessments, questionnaires, gait analysis, and functional outcome at different time points over the first postoperative year.

Results: EFM did not increase the risk of re-ruptures and infections compared to ST. EFM versus ST showed no difference in the incidence of DVT at 2 or 6 weeks. Risk factors for exhibiting a DVT postoperatively were older age and BMI >26, as well as low loading (≤50%) the first week after surgery in the EFM group. More experience of pain during activity was associated with lower degree of loading. Suffering from a DVT postoperatively resulted in inferior patient-reported outcome up to a year after ATR repair. Patients in the EFM group reported higher general health and vitality compared to ST at 6 months postoperatively. The two groups exhibited no differences in functional outcome, neither at 6 months nor at one year. EFM resulted in more pronounced tendon elongation at 2 weeks compared to ST. At later time points, no significant differences in elongation were found. However, tendon elongation of more than 3 cm resulted in inferior outcome in the heel-rise test at one year. No significant differences in muscle atrophy between groups were observed, although a trend for increased atrophy was seen in the ST group. The soleus atrophy seemed to be persistent at one year postoperatively. No significant differences in gait patterns between groups were observed at 8 weeks or at 6 months.

Conclusions: EFM after ATR repair does not increase or reduce the risk of DVT, re-rupture and infection in the short term or tendon elongation and muscle atrophy in the long term, but EFM resulted in enhanced general health and vitality in the medium term outcome. Higher loading in the EFM group was associated with a lower risk of DVT. Suffering a DVT results in inferior patient-reported outcome and exhibiting excessive tendon elongation leads to impaired functional outcome at one year.

List of scientific papers

I. Aufwerber S, Heijne A, Edman G, Silbernagel KG, Ackermann PW. Early mobilization does not reduce the risk of deep venous thrombosis after Achilles tendon rupture: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc. 2020;28(1):312-319.
https://doi.org/10.1007/s00167-019-05767-x

II. Aufwerber S, Heijne A, Silbernagel KG, Ackermann PW. High plantar force loading after Achilles tendon rupture repair with early functional mobilization. Am J Sports Med. 2019;47(4):894-900.
https://doi.org/10.1177/0363546518824326

III. Aufwerber S, Edman G, Silbernagel KG, Ackermann PW. Changes in tendon elongation and muscle atrophy over time after Achilles tendon rupture repair – a prospective cohort on the effects of early functional mobilization. Am J Sports Med. 2020;48(13):3296-3305.
https://doi.org/10.1177/0363546520956677

IV. Aufwerber S, Naili JE, Silbernagel KG, Ackermann PW. Effects of early functional mobilization on gait pattern after acute Achilles tendon rupture repair. [Manuscript]

V. Aufwerber S, Heijne A, Edman G, Silbernagel KG, Ackermann PW. Does early functional mobilization affect long-term outcomes after an Achilles tendon rupture? A randomized clinical trial. Orthop J Sports Med. 2020;16;8(3):2325967120906522.
https://doi.org/10.1177/2325967120906522