Less Is About the Same for Rehab After Achilles Repair

What’s the Claim

This is a complicated biomechanical study but the main clinical message is simple: If you prefer to keep patients off of your acute Achilles tendon repairs (with a cast or splint and nonweightbearing crutches for two weeks or so), they’re not losing anything substantial in terms of the mechanics of the leg or ankle, heel rise performance at 6 months, or self-reported outcomes scores compared to allowing early ROM in a functional orthosis and WBAT. If early mobilization has benefits, they were too subtle to be discerned by a pretty sophisticated biomechanical setup in this randomized trial of nearly 50 patients that also used a valid patient-reported outcomes scale.

How’s It Stack Up?

The pendulum has swung in the minds of many toward more-aggressive mobilization after repair of acute Achilles tendon ruptures. It’s an interesting trend. The apparent benefits in many of the randomized trials on this topic appear pretty small (with effect sizes that may not be large enough for the typical patient to notice, despite sexy p values), problems with wound healing are front-of-mind among the complications we worry about after these procedures, and although tendon lengthening has been documented both in patients treated with aggressive rehab as well as nonweightbearing protocols, one naturally wonders what may happen if we ask too much of these repairs too soon. For these reasons, the findings in this study provide something of a counterweight on that tipping scale for those who feel that it may have tipped too far, too fast. This study also provides biomechanical affirmation of something that most of us know (and most studies have shown), which is that the big differences are not between patients treated with different rehabilitation approaches but rather between the injured and uninjured leg, a finding that appears to persist essentially forever.

What’s Our Take?

We note that with only 18 patients in the control group (the randomization ratio was 2:1), this study could have missed a small or perhaps even a modest difference in patient-reported outcomes favoring the early-mobilization group. Even so, CORRelations’ Foot & Ankle advisor shares that this study came from a center that has been enthusiastic about early functional rehabilitation, and the main finding of no difference is “a boon to those who, like myself, would rather wait for the wound to heal before starting motion.” No shade on those who are more aggressive in this regard — and there are some more clinically focused RCTs that show benefits to using that approach — but it appears you don’t have to be.

Source

Aufwerber S, Silbernagel KG, Ackermann PW, Naili JE. Comparable Recovery and Compensatory Strategies in Heel-Rise Performance After a Surgically Repaired Acute Achilles Tendon Rupture: An In Vivo Kinematic Analysis Comparing Early Functional Mobilization and Standard Treatment. Am J Sports Med. 2022;50:3856-3865.