Calf Muscle Performance Deficits Remain 7 Years After an Achilles Tendon Rupture

Brorsson, Annelie; Silbernagel, Karin Grävare; Olsson, Nicklas; Helander, Katarina Nilsson

doi:10.1177/0363546517737055

Cited by 65 publications

(71 citation statements)

References 36 publications

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“…The extent of muscle-tendon impairment identified in the HRET in the injured limb, irrespective of treatment group, highlights the degree of ongoing musculotendinous unit compromise 6 months after tendon rupture. Although musculotendinous impairment has been found in other ATR cohorts, 35 the extent of asymmetry between injured and uninjured legs in this trial was substantial. Optimising recovery of neuromuscular function during rehabilitation is therefore a recommended area of future investigation.…”

Section: Further Researchcontrasting

confidence: 53%

“…29,34 Although different surgical techniques and non-surgical approaches can be used, evidence shows similar outcomes. 35 These approaches are not known to alter the existing biological regenerative pathway of the tendon, so the lengthy rehabilitation, reduced function and re-rupture risk (3-5%) all remain. 36 Functional impairments identified by calf atrophy, heel-raise power compared with the opposite side, poor walking pattern (gait) and lower levels of physical activity are reported as outcomes of these management strategies.…”

Section: Management Of Achilles Tendon Rupturementioning

confidence: 99%

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Platelet-rich plasma injection for adults with acute Achilles tendon rupture: the PATH-2 RCT

et al. 2019

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Background Achilles tendon rupture (ATR) has a long healing period, which is challenging for patients and clinicians. Platelet-rich plasma (PRP) is an autologous concentration of platelets thought to improve tendon function recovery. Although preliminary research has indicated positive effects, there is, as yet, no evidence of clinical efficacy from adequately powered robust clinical trials. Objectives The objectives were to determine the clinical efficacy of PRP in patients with acute ATR using an objective mechanical muscle–tendon function measure and patient-reported outcome measures (PROMs), and to determine which PRP components contribute to its mechanism. Design This was a multicentre, parallel-group, participant- and outcome assessor-blinded randomised controlled trial (RCT) comparing PRP with placebo. Two embedded substudies investigated the PRP’s quality and composition and its effects on healing tendon tissues. Setting This trial was set in trauma and orthopaedic surgery departments in 19 NHS hospitals in England and Wales. Participants Adults with acute ATR presenting within 12 days of injury to be treated non-surgically were eligible. Patients with platelet dysfunction or leg functional deficiency were excluded. Interventions Participants were randomised 1 : 1 to the PRP injection group or the placebo group (dry needle in the rupture gap) by central computer-based randomisation using minimisation, stratified by centre and age. Main outcome measures The primary outcome measure was the Limb Symmetry Index (LSI) of work during the heel-rise endurance test at 24 weeks. Secondary outcomes measures, collected at 4, 7, 13 and 24 weeks, were repetitions, maximum heel-rise height, Achilles tendon Total Rupture Score (ATRS), quality of life (as measured using the Short Form questionnaire-12 items version 2), pain and participant goal attainment. Needle biopsies of the affected tendon zone were taken under ultrasound guidance at 6 weeks from 16 participants from one centre. Whole blood was analysed for cell count. PRP was analysed for cell count, platelet activation and growth factor concentration. The primary analysis was intention to treat. Results A total of 230 participants were randomised: 114 to the PRP group (103 treated) and 116 to the placebo group (all treated). One participant withdrew after randomisation but before the intervention. At 24 weeks, 201 out of 230 participants (87.4%) completed the primary outcome and 216 out of 230 participants (93.9%) completed the PROMs. The treatment groups had similar participant characteristics. At 24 weeks, there was no difference in work LSI (mean difference –3.872; 95% confidence interval –10.454 to 2.710; p = 0.231), ATRS, pain or goal attainment between PRP- and placebo-injected participants. There were no differences between the groups in any PROM at any time point or in complication rates, including re-rupture and deep-vein thrombosis. There was no correlation between work LSI and platelet activation in PRP, or erythrocyte, leucocyte or platelet counts in whole blood or PRP. Biopsies showed similar cellularity and vascularity between groups. Conclusions This trial design and standardised PRP preparation gives the first robust RCT evidence about PRP’s role in managing ATR, which suggests that PRP offers no patient benefit. Equally robust evidence to investigate PRP application in tendon and soft tissue injuries is required. The 24-month follow-up will be completed in April 2020. Trial registration Current Controlled Trials ISRCTN54992179. Funding This project was funded by the Efficacy and Mechanism Evaluation programme, a Medical Research Council and National Institute for Health Research (NIHR) partnership. The trial was supported by the NIHR Biomedical Research Centre, Oxford, and the NIHR Fellowship programme.

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Section: Further Researchcontrasting

confidence: 53%

Section: Management Of Achilles Tendon Rupturementioning

confidence: 99%

Platelet-rich plasma injection for adults with acute Achilles tendon rupture: the PATH-2 RCT

et al. 2019

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“…35 Surgical repair also may provide improved long-term plantarflexion power compared to non-surgical treatment of Achilles tendon ruptures. 2 However, the link between surgical repair and improved patient function is tenuous, 4 and tendon elongation appears to be a stronger predictor of patient function. 8,38 Surgically shortening tendon length in a small animal model stimulates muscle remodeling that results in larger, longer, and more powerful skeletal muscle.…”

Section: Discussionmentioning

confidence: 99%

Plantarflexor fiber length and tendon slack length are the strongest determinates of simulated single-leg heel raise function

Baxter

Farber

Hast

2018

Preprint

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Achilles tendon ruptures lead to reduced ankle function and often limits recreational activity. Single-leg heel raises are often used clinically to characterize patient function. However, it is unclear how the structure of the Achilles tendon and plantarflexor muscles affects single-leg heel raise function. Therefore, the purpose of this study was to develop a musculoskeletal model in order to simulate the effects of muscle-tendon unit (MTU) parameters on peak plantarflexion during this clinically-relevant task. The ankle joint was plantarflexed by two MTUs that represented the soleus and gastrocnemius muscles. The optimal fiber length, maximal muscle force, muscle pennation, tendon stiffness, and resting ankle anglea surrogate measure of tendon slack length were iteratively adjusted to test the combined effects of each of these MTU parameters. Singleleg heel raises were simulated by maximally exciting the two plantarflexor MTUs for each model configuration (N = 161,051 simulations). Optimal muscle fiber and tendon slack lengths had the greatest effect on peak plantarflexion during simulated single-leg heel raises. Simulations that were unable to produce at least 30 degrees of plantarflexion had muscle fibers that were shorter than healthy muscle and longer tendon slack lengths. These findings highlight the importance of preserving muscle fascicle and tendon length following Achilles tendon injuries.

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“…Deficits in plantarflexion function of the affected limb play a large role in preventing return to preinjury levels of activity (26) and have been shown to persist as far out as 14-years following injury (5,11). Clinically, these deficits present as decreased resting ankle angle (37), reduced calf-raise function (6,30), and 10-20% reductions in plantarflexion strength (11,21,27).…”

Section: Introductionmentioning

confidence: 99%

Gastrocnemius fascicles are shorter and more pennate throughout the first month following acute Achilles tendon rupture

Hullfish

O’Connor

Baxter

2018

Preprint

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1The purpose of this study was to characterize the short-term effects of Achilles tendon 2 ruptures on medial gastrocnemius. We hypothesized that the fascicles of the medial 3 gastrocnemius muscle of the injured Achilles tendon would be shorter and more pennate 4 immediately following the injury and would persist throughout 4 weeks post-injury. B-mode 5 longitudinal ultrasound images of the medial gastrocnemius were acquired in 10 adults who 6 suffered acute Achilles tendon ruptures and were treated non-operatively. Ultrasound images 7 were acquired during the initial clinical visit following injury as well as two and four weeks 8 following this initial clinical visit. Resting muscle structure was characterized by measuring 9 fascicle length, pennation angle, muscle thickness, and muscle echo intensity in both the injured 1 0 and contralateral (control) limbs. Fascicle length was 15% shorter (P < 0.001) and pennation 1 1 angle was 21% greater (P < 0.001) in the injured muscle compared to the uninjured (control) 1 2 muscle at the presentation of injury (week 0). These differences in fascicle length and pennation 1 3 angle persisted throughout the 4 weeks after the injury (P < 0.008). Muscle thickness changes 1 4were not detected at any of the post-injury visits (difference < 4%, P > 0.04). Echo intensity of 1 5 the injured limb was 8% lower at the presentation of the injury and 11% lower (P = 0.008) than 1 6 the contralateral muscle at 2 weeks following injury (P < 0.001) but returned to within 1% by 4 1 7 weeks (P = 0.393). Our results suggest that Achilles tendon ruptures elicit rapid changes in the

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Calf Muscle Performance Deficits Remain 7 Years After an Achilles Tendon Rupture

Abstract: Continued deficits in calf muscle endurance and strength remained 7 years after ATR. No continued improvement in calf muscle performance occurred after the 2-year follow-up except for heel-rise height.

Cited by 65 publications

References 36 publications

Platelet-rich plasma injection for adults with acute Achilles tendon rupture: the PATH-2 RCT

Platelet-rich plasma injection for adults with acute Achilles tendon rupture: the PATH-2 RCT

Plantarflexor fiber length and tendon slack length are the strongest determinates of simulated single-leg heel raise function

Gastrocnemius fascicles are shorter and more pennate throughout the first month following acute Achilles tendon rupture

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