Skip to main content

Advertisement

SpringerLink
Log in

Achilles tendon cross-sectional area at 12 weeks post-rupture relates to 1-year heel-rise height

  • ANKLE
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Achilles tendon rupture leads to long-term plantar flexor deficits, but some patients recover functional performance better than others. Early indicators of tendon healing could be helpful in establishing patient prognosis and making individualized decisions regarding rehabilitation progression. The purpose of this study was to investigate relationships between early tendon morphology and mechanical properties to long-term heel-rise and jumping function in individuals after Achilles tendon rupture.

Methods

Individuals after Achilles tendon rupture were assessed at 4, 8, 12, 24, and 52 weeks post-injury. Tendon cross-sectional area, length, and mechanical properties were measured using ultrasound. Heel-rise and jump tests were performed at 24 and 52 weeks. Correlation and regression analysis were used to identify relationships between tendon structural variables in the first 12 weeks to functional outcomes at 52 weeks, and determine whether the addition of tendon structural characteristics at 24 weeks strengthened relationships between functional performance at 24 and 52 weeks. Functional outcomes of individuals with < 3 cm of elongation were compared to those with > 3 cm of elongation using a Mann–Whitney U test.

Results

Twenty-two participants [mean (SD) age = 40 (11) years, 17 male] were included. Tendon cross-sectional area at 12 weeks was the strongest predictor of heel-rise height (R2 = 0.280, p = 0.014) and work symmetry (R2 = 0.316, p = 0.008) at 52 weeks. Jumping performance at 52 weeks was not significantly related to any of the tendon structural measures in the first 12 weeks. Performance of all functional tasks at 24 weeks was positively related to performance on the same task at 52 weeks (r = 0.456–0.708, p < 0.05). The addition of tendon cross-sectional area improved the model for height LSI (R2 = 0.519, p = 0.001). Tendon elongation > 3 cm significantly reduced jumping symmetry (p < 0.05).

Conclusion

Tendon cross-sectional area and excessive elongation related to plantar flexor performance on functional testing after Achilles tendon rupture. Once an individual is able to perform function-based testing, tendon structural measures may inform long-term prognosis. Ultrasound-based measures of tendon structure early in recovery seem to relate to later performance on functional testing. Clinically, assessing tendon structure has the potential to be used as a biomarker of tendon healing early in recovery and better predict patients at risk of negative functional outcome.

Level of evidence

II.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Aujla R, Patel S, Jones A, Bhatia M (2018) Predictors of functional outcome in non-operatively managed Achilles tendon ruptures. Foot Ankle Surg 24:336–341

    PubMed  Google Scholar 

  2. Baxter JR, Hullfish TJ, Chao W (2018) Functional deficits may be explained by plantarflexor remodeling following Achilles tendon rupture repair: preliminary findings. J Biomech 79:238–242

    PubMed  Google Scholar 

  3. Brorsson A, Olsson N, Nilsson-Helander K, Karlsson J, Eriksson BI, Silbernagel KG (2015) Recovery of calf muscle endurance 3 months after an Achilles tendon rupture. Scand J Med Sci Sports 26:844–853

    PubMed  Google Scholar 

  4. Brorsson A, Silbernagel KG, Olsson N, Helander KN (2017) Calf muscle performance deficits remain 7 years after an Achilles tendon rupture. Am J Sports Med 46:470–477

    PubMed  Google Scholar 

  5. Brorsson A, Willy RW, Tranberg R, Grävare Silbernagel K (2017) Heel-rise height deficit 1 year after Achilles tendon rupture relates to changes in ankle biomechanics 6 years after injury. Am J Sports Med 45:3060–3068

    PubMed  Google Scholar 

  6. Byrne C, Keene DJ, Lamb SE, Willett K (2017) Intrarater reliability and agreement of linear encoder derived heel-rise endurance test outcome measures in healthy adults. J Electromyogr Kinesiol 36:34–39

    PubMed  Google Scholar 

  7. Carmont MR, Zellers JA, Brorsson A, Olsson N, Nilsson-Helander K, Karlsson J, Silbernagel KG (2017) Functional outcomes of achilles tendon minimally invasive repair using 4- and 6-strand nonabsorbable suture: a cohort comparison study. Orthop J Sport Med 5(8):2325967117723347

    Google Scholar 

  8. Corrigan P, Zellers JA, Balascio P, Silbernagel KG, Cortes DH (2019) Quantification of mechanical properties in healthy achilles tendon using continuous shear wave elastography: a reliability and validation study. Ultrasound Med Biol 45(7):1574–1585

    PubMed  Google Scholar 

  9. Cortes DH, Suydam SM, Silbernagel KG, Buchanan TS, Elliott DM (2015) Continuous shear wave elastography: a new method to measure viscoelastic properties of tendons in vivo. Ultrasound Med Biol 41:1518–1529

    PubMed  PubMed Central  Google Scholar 

  10. Freedman B, Gordon J, Bhatt P, Pardes A, Thomas S, Sarver J, Riggin C, Tucker J, Williams A, Zanes R, Hast M, Farber D, Silbernagel K, Soslowsky L (2016) Nonsurgical treatment and early return to activity leads to improved Achilles tendon fatigue mechanics and functional outcomes during early healing in an animal model. J Orthop Res 34:2172–2180

    CAS  PubMed  PubMed Central  Google Scholar 

  11. Ganestam A, Kallemose T, Troelsen A, Barfod KW (2016) Increasing incidence of acute Achilles tendon rupture and a noticeable decline in surgical treatment from 1994 to 2013. A nationwide registry study of 33,160 patients. Knee Surg Sports Traumatol Arthrosc 24:3730–3737

    PubMed  Google Scholar 

  12. Gravare Silbernagel K, Brorsson A, Olsson N, Eriksson BI, Karlsson J, Nilsson-Helander K, Silbernagel KG, Brorsson A, Olsson N, Eriksson BI, Karlsson J, Nilsson-Helander K (2015) Sex differences in outcome after an acute Achilles tendon rupture. Orthop J Sport Med 3(6):2325967115586768

    Google Scholar 

  13. Hansen M, Christensen M, Budolfsen T, Ostergaard T, Kallemose T, Troelsen A, Barfod K (2016) Achilles tendon total rupture score at 3 months can predict patients’ ability to return to sport 1 year after injury. Knee Surg Sports Traumatol Arthrosc 24:1365–1371

    PubMed  Google Scholar 

  14. Hansen W, Shim VB, Obst S, Lloyd DG, Newsham-West R, Barrett RS (2017) Achilles tendon stress is more sensitive to subject-specific geometry than subject-specific material properties: a finite element analysis. J Biomech 56:26–31

    PubMed  Google Scholar 

  15. Hébert-Losier K, Wessman C, Alricsson M, Svantesson U (2017) Updated reliability and normative values for the standing heel-rise test in healthy adults. Physiotherapy 103:446–452

    PubMed  Google Scholar 

  16. Heikkinen J, Lantto I, Piilonen J, Flinkkil T, Ohtonen P, Siira P, Laine V, Niinim J, Pajala A, Leppilahti J (2017) Tendon length, calf muscle atrophy, and strength deficit after acute Achilles tendon rupture. J Bone Joint Surg 99:1509–1515

    PubMed  Google Scholar 

  17. Heikkinen J, Lantto L, Flinkkila T, Ohtonen P, Pajala A, Siira P, Leppilahti J (2016) Augmented compared with non-augmented surgical repair after total Achilles rupture: results of a prospective randomized trial with 13 or more years of follow-up. J Bone Joint Surg 98:85–92

    PubMed  Google Scholar 

  18. Kangas J, Pajala A, Ohtonen P, Leppilahti J (2007) Achilles tendon elongation after rupture repair: a randomized comparison of two postoperative regimens. Am J Sports Med 35:59–64

    PubMed  Google Scholar 

  19. Lantto I, Heikkinen J, Flinkkila T, Ohtonen P, Kangas J, Siira P, Leppilahti J (2015) Early functional treatment versus cast immobilization in tension after Achilles rupture repair: results of a prospective randomized trial with 10 or more years of follow-up. Am J Sports Med 43:2302–2309

    PubMed  Google Scholar 

  20. Lantto I, Heikkinen J, Flinkkila T, Ohtonen P, Leppilahti J (2015) Epidemiology of Achilles tendon ruptures: increasing incidence over a 33-year period. Scand J Med Sci Sport 25:e133–e138

    CAS  Google Scholar 

  21. Lawrence JE, Nasr P, Fountain DM, Berman L, Robinson AHN (2017) Functional outcomes of conservatively managed acute ruptures of the Achilles tendon. Bone Joint J 99:87–93

    PubMed  Google Scholar 

  22. Möller M, Kälebo P, Tidebrant G, Movin T, Karlsson J (2002) The ultrasonographic appearance of the ruptured Achilles tendon during healing: a longitudinal evaluation of surgical and nonsurgical treatment, with comparisons to MRI appearance. Knee Surg Sports Traumatol Arthrosc 10:49–56

    PubMed  Google Scholar 

  23. Mortensen N, Saether J, Steinke M, Staehr H, Mikkelsen S (1992) Separation of tendon ends after Achilles tendon repair: a prospective, randomized, multicenter study. Orthopedics 15:899–903

    CAS  PubMed  Google Scholar 

  24. Nilsson-Helander K, Thomeé R, Silbernagel KG, Thomeé P, Faxén E, Eriksson BI, Karlsson J (2007) The Achilles tendon total rupture score (ATRS): development and validation. Am J Sports Med 35:421–426

    PubMed  Google Scholar 

  25. Oda H, Sano K, Kunimasa Y, Komi PV, Ishikawa M (2017) Neuromechanical modulation of the Achilles tendon during bilateral hopping in patients with unilateral Achilles tendon rupture, over 1 year after surgical repair. Sport Med 47:1221–1230

    Google Scholar 

  26. Olsson N, Karlsson J, Eriksson BI, Brorsson A, Lundberg M, Silbernagel KG (2014) Ability to perform a single heel-rise is significantly related to patient-reported outcome after Achilles tendon rupture. Scand J Med Sci Sport 24:152–158

    CAS  Google Scholar 

  27. Olsson N, Petzold M, Brorsson A, Karlsson J, Eriksson BI, Grävare Silbernagel K (2014) Predictors of clinical outcome after acute Achilles tendon ruptures. Am J Sports Med 42:1448–1455

    PubMed  Google Scholar 

  28. Olsson N, Silbernagel KG, Eriksson BI, Sansone M, Brorsson A, Nilsson-Helander K, Karlsson J (2013) Stable surgical repair with accelerated rehabilitation versus nonsurgical treatment for acute Achilles tendon ruptures: a randomized controlled study. Am J Sports Med 41:2867–2876

    PubMed  Google Scholar 

  29. Peng W-C, Chang Y-P, Chao Y-H, Fu S, Rolf C, Shih TT, Su S-C, Wang H-K (2017) Morphomechanical alterations in the medial gastrocnemius muscle in patients with a repaired Achilles tendon: associations with outcome measures. Clin Biomech 43:50–57

    Google Scholar 

  30. Powell HC, Silbernagel KG, Brorsson A, Tranberg R, Willy RW (2018) Individuals post-Achilles tendon rupture exhibit asymmetrical knee and ankle kinetics and loading rates during a drop countermovement jump. J Orthop Sport Phys Ther 48:34–43

    Google Scholar 

  31. Raikin SM, Garras DN, Krapchev PV (2013) Achilles tendon injuries in a United States population. Foot Ankle Int 34:475–480

    PubMed  Google Scholar 

  32. Rosso C, Vavken P, Polzer C, Buckland DM, Studler U, Weisskopf L, Lottenbach M, Müller AM, Valderrabano V (2013) Long-term outcomes of muscle volume and Achilles tendon length after Achilles tendon ruptures. Knee Surg Sports Traumatol Arthrosc 21:1369–1377

    PubMed  Google Scholar 

  33. Ryan ED, Rosenberg JG, Scharville MJ, Sobolewski EJ, Thompson BJ, King GE (2013) Test–retest reliability and the minimal detectable change for Achilles tendon length: a panoramic ultrasound assessment. Ultrasound Med Biol 39:2488–2491

    PubMed  Google Scholar 

  34. Schepull T, Aspenberg P (2013) Early controlled tension improves the material properties of healing human achilles tendons after ruptures: a randomized trial. Am J Sports Med 41:2550–2557

    PubMed  Google Scholar 

  35. Schepull T, Kvist J, Aspenberg P (2012) Early E-modulus of healing Achilles tendons correlates with late function: similar results with or without surgery. Scand J Med Sci Sport 22:18–23

    CAS  Google Scholar 

  36. Sheth U, Wasserstein D, Jenkinson R, Moineddin R, Kreder H, Jaglal SB (2017) The epidemiology and trends in management of acute Achilles tendon ruptures in Ontario, Canada. Bone Joint J 99:78–86

    PubMed  Google Scholar 

  37. Silbernagel KG, Nilsson-Helander K, Thomeé R, Eriksson BI, Karlsson J (2010) A new measurement of heel-rise endurance with the ability to detect functional deficits in patients with Achilles tendon rupture. Knee Surg Sports Traumatol Arthrosc 18:258–264

    PubMed  Google Scholar 

  38. Silbernagel KG, Shelley K, Powell S, Varrecchia S (2016) Extended field of view ultrasound imaging to evaluate Achilles tendon length and thickness: a reliability and validity study. Muscles Ligaments Tendons J 6:104–110

    PubMed  PubMed Central  Google Scholar 

  39. Silbernagel KG, Steele R, Manal K (2012) Deficits in heel-rise height and Achilles tendon elongation occur in patients recovering from an Achilles tendon rupture. Am J Sports Med 40:1564–1571

    PubMed  Google Scholar 

  40. Silbernagel KGK, Gustavsson A, Thomeé R, Karlsson J, Thomee R, Karlsson J (2006) Evaluation of lower leg function in patients with Achilles tendinopathy. Knee Surg Sports Traumatol Arthrosc 14:1207–1217

    PubMed  Google Scholar 

  41. Soroceanu A, Sidhwa F, Aarabi S, Kaufman A, Glazebrook M (2012) Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials. J Bone Joint Surg 94:2136–2143

    PubMed  Google Scholar 

  42. Suydam SM, Soulas EM, Elliott DM, Silbernagel KG, Buchanan TS, Cortes DH (2015) Viscoelastic properties of healthy Achilles tendon are independent of isometric plantar flexion strength and cross-sectional area. J Orthop Res 33:926–931

    PubMed  PubMed Central  Google Scholar 

  43. Westin O, Nilsson Helander K, Grävare Silbernagel K, Möller M, Kälebo P, Karlsson J (2016) Acute ultrasonography investigation to predict reruptures and outcomes in patients with an Achilles tendon rupture. Orthop J Sport Med 4:1–7

    Google Scholar 

  44. Willy RW, Brorsson A, Powell HC, Willson JD, Tranberg R, Grävare Silbernagel K (2017) Elevated knee joint kinetics and reduced ankle kinetics are present during jogging and hopping after Achilles tendon ruptures. Am J Sports Med 45:1124–1133

    PubMed  Google Scholar 

  45. Zellers JA, Cortes DH, Corrigan P, Pontiggia L, Silbernagel KG (2017) Side-to-side difference in Achilles tendon geometry and mechanical properties following Achilles tendon rupture. Muscles Ligaments Tendons J 7:541–547

    PubMed  Google Scholar 

  46. Zellers JA, Cortes DH, Pohlig RT, Silbernagel KG (2018) Tendon morphology and mechanical properties assessed by ultrasound show change early in recovery and potential prognostic ability for 6 month outcomes. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-018-5277-8

    Article  PubMed  Google Scholar 

  47. Zhang L, Wan W, Wang Y, Jiao Z, Zhang L, Luo Y, Tang P (2016) Evaluation of elastic stiffness in healing Achilles tendon after surgical repair of a tendon rupture using in vivo ultrasound shear wave elastography. Med Sci Monit 22:1186–1191

    PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

This study was funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health under Award Number R21AR067390 and the National Institutes of Health under Award number P30-GM103333 and T32 HD007434. This study was also funded by the Foundation for Physical Therapy and the University of Delaware Research Foundation. The study sponsors did not play a role in the study design, collection, analysis, interpretation of data, or the writing/submission of this manuscript for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Funding

Funding for this study was provided by the National Institutes of Health, Foundation for Physical Therapy, and University of Delaware Research Foundation with additional details disclosed in the ackowledgements.

Author information

Authors and Affiliations

  1. Program in Physical Therapy, Washington University School of Medicine in St. Louis, St. Louis, MO, USA

    Jennifer A. Zellers

  2. College of Health Sciences biostatistics Core Facility, University of Delaware, Newark, DE, USA

    Ryan T. Pohlig

  3. Department of Mechanical and Nuclear Engineering, Penn State University, State College, PA, USA

    Daniel H. Cortes

  4. Department of Physical Therapy, University of Delaware, 540 South College Ave, Newark, DE, 19713, USA

    Karin Grävare Silbernagel

Authors
  1. Jennifer A. Zellers
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ryan T. Pohlig
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Daniel H. Cortes
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Karin Grävare Silbernagel
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Karin Grävare Silbernagel.

Ethics declarations

Conflict of interest

The authors have no additional conflict of interest.

Ethical approval

Ethical approval was obtained from the University of Delaware Institutional Review Board (784188-1).

Informed consent

All participants provided written informed consent prior to participation.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Zellers, J.A., Pohlig, R.T., Cortes, D.H. et al. Achilles tendon cross-sectional area at 12 weeks post-rupture relates to 1-year heel-rise height. Knee Surg Sports Traumatol Arthrosc 28, 245–252 (2020). https://doi.org/10.1007/s00167-019-05608-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-019-05608-x

Keywords

Search

Navigation