Does early mobilisation following achilles tendon repair speed up recovery and improve functional outcome?
Date First Published:
December 12, 2003
Last Updated:
August 11, 2009
Report by:
Dr Ali Jalal, Senior House Officer (West Suffolk Hospital, Bury St Edmunds)
Search checked by:
Dr Reza Nouraei, West Suffolk Hospital, Bury St Edmunds
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:
Search Details:
{[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]}.
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):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Immediate full-weight-bearing mobilisation for repaired Achilles tendon ruptures: a pilot study. Costa ML. Shepstone L. Darrah C. Marshall T. Donell ST. 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 | ||||
| No adverse effect of early weight bearing following open repair of acute tears of the Achilles tendon. Maffulli N. Tallon C. Wong J. Peng Lim K. Bleakney R. 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 | ||||
| Early functional treatment versus early immobilization in tension of the musculotendinous unit after Achilles rupture repair: a prospective, randomized, clinical study. Kangas J. Pajala A. Siira P. Hamalainen M. Leppilahti J. 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 | ||||
| Early motion of the ankle after operative treatment of a rupture of the Achilles tendon. A prospective, randomized clinical and radiographic study. Mortensen HM. Skov O. Jensen PE. 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 | Reported to be quick, but no second arms for comparison | ||||
| Speed of rehabilitation | |||||
| A new treatment of ruptured Achilles tendons. A prospective randomized study. Cetti R. Henriksen LO. Jacobsen KS. 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" |
Author Commentary:
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.
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:
- Costa ML. Shepstone L. Darrah C. Marshall T. Donell ST.. Immediate full-weight-bearing mobilisation for repaired Achilles tendon ruptures: a pilot study.
- 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.
- 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.
- 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.
- Cetti R. Henriksen LO. Jacobsen KS.. A new treatment of ruptured Achilles tendons. A prospective randomized study.