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Three Part Question

In [patients with complete achilles tendon rupture repaired surgically] is [early mobilisation and weight-bearing better than the traditional immobilising cast treatment] in [speeding time to recovery and improving functional outcome]?

Clinical Scenario

A 27 year old athlete presents with acute rupture of his Achilles tendon, which is treated surgically. What is the best rehabilitation regimen for optimising his recovery and returning him to competitive sport?

Search Strategy

Medline via the OVID interface 1950 to week 4 April 2009:
{[exp achilles tendon or achilles.mp] AND [exp rupture or rupture.mp or tear.mp or torn.mp] AND [mobilisation.mp or moblisation.mp or exp immobilisation or immobilisation.mp or immobilisation.mp or cast.mp]}.

Search Outcome

A total of 233 articles was found. Studies were included if they were randomised controlled trials (RCT) comparing a mobilising regime (either weight bearing or physical exercises) with full cast immobilisation, in postoperative patients. Simple cohort studies and before–after cohort studies were excluded. Two other publications from 2007 and 2003 were excluded as results from the same cohort of patients have already been reported and are included in the table

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Costa et al, 2003, UK	28 Active patients presenting with first-time unilateral acute rupture of the achilles tendon	RCT comparing early weight-bearing with traditional serial cast immobilisation.	Time to return to competitive sport	Two months shorter in the early mobilisation group	Small sample size.
			Peak torque deficit	Less in the early mobilisation group
			Postoperative complications	Not increased in the early mobilisation group
Maffulli et al, 2003, UK	53 Patients presenting with first-time rupture of the Achilles tendon	RCT comparing removable cast, ankle moilisation exercises and weight bearing when comfortable, with immobilsation in cast with weight bearing at 4 weeks	Number of Outpatient Visits	Significantly reduced in early mobilisation group	Randomisation by day of week.
			Time to walking without crutches	Earlier for the mobilisation group
			Patient satisfaction	Higher in the early mobilisation group
			Average thickness of the tendon	No difference between the groups
			Isometric muscle strength	No difference between the groups
Kangas et al, 2003, Finland	50 Patients presenting with first-time rupture of the Achilles Tendon	RCT comparing splint allowing free plantarflexion and immobile cast	Isokinetic calf muscle strength	Better in the early mobilisation group, especially during the early phase of rehabilitation	Use of non-parametric statistics for data analysis.
			Pain, stiffness and postoperative complications	No difference between the groups
Mortensen et al, 1999, Denmark	71 Patients undergoing first-time Achilles tendon repair	RCT comparing cast immobilisation with restricted-ankle-motion cast	Radiological assesssment of tendon separation (treatment failure)	No difference between the groups	Small sample size. Otherwise very well designed.
			Loss of range of motion	More favourable results in the early motion group
			Skin-tendon adhesions	Fewer adhesions in the early motion group
			Complications	No difference between groups
			Patient satisfaction	Higher in the early motion group
			Re-ruptures	None
			Speed of rehabilitation	Reported to be quick, but no second arms for comparison
Cetti et al, 1994, Denmark	60 Active patients undergoing surgical repair of ruptured Achilles tendon.	RCT of mobile versus immobile cast after surgical repair of ruptured Achilles tendon.	Return to sporting activities at pre-injury level	More patients in the early mobilisation group	Well designed and executed study.
			Post-operative complications	Identical for major complications; fewer minor complications in the early mobilisation group
			Recovery of ankle movements	Better in the early mobilisation group
			Sick leave duration	Shorter in the early mobilisation group
			Tendon lengthening	Less in the early mobilisation group
			Arner–Lindholm rating scale	Mostly excellent and occurring earlier in the course of rehabilitation than "normal"

Comment(s)

There is evidence that early ankle motion and weight bearing do not compromise the surgical repair of ruptured Achilles tendon. One meta-analysis concluded that the only statistically significant outcome was improved patient satisfaction.

Editor Comment

RCT, randomised controlled trial.

Clinical Bottom Line

Early weight-bearing and ankle motion is likely to be of considerable benefit following surgical repair of ruptured achilles tendon and should be encouraged.

References

1. Costa ML. Shepstone L. Darrah C. Marshall T. Donell ST. Immediate full-weight-bearing mobilisation for repaired Achilles tendon ruptures: a pilot study. Injury 2003:34(11):874-6.
2. Maffulli N. Tallon C. Wong J. Peng Lim K. Bleakney R. No adverse effect of early weight bearing following open repair of acute tears of the Achilles tendon. J Sports Med Phys Fitness. 2003;43(3):367-79.
3. Kangas J. Pajala A. Siira P. Hamalainen M. Leppilahti J. Early functional treatment versus early immobilization in tension of the musculotendinous unit after Achilles rupture repair: a prospective, randomized, clinical study. J Trauma 2003;54(6):1171-1180.
4. 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(7):983-90.
5. Cetti R. Henriksen LO. Jacobsen KS. A new treatment of ruptured Achilles tendons. A prospective randomized study. Clin Orthop 1994;308:155-65.