CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
Number 445, pp. 216–221
© 2006 Lippincott Williams & Wilkins
Postoperative Rehabilitation Protocols for Achilles
Tendon Ruptures
A Meta-analysis
Amar A. Suchak, MD; Carol Spooner, MSc; David C. Reid, FRCS(C); and
Nadr M. Jomha, FRCS(C)
cises.2 Small prospective human clinical trials13,17,18 used
early functional protocols involving weightbearing as
early as the first postoperative day, with early ROM and
splinting in a walking boot or modified orthosis instead of
a cast. These studies had good patient satisfaction reported
with a low rate of reruptures and infections. Experimental
rat research also showed that weightbearing when compared with immobilization after Achilles tendon rupture
repair results in a stronger tendon with a greater force
required for a rerupture to occur.5,15,16 Therefore, there is
preliminary evidence to support the introduction of an
early functional protocol for postoperative Achilles tendon
rupture repair.
Unfortunately, the majority of the published clinical
trials that document advantages of an early functional protocol do not have control groups for comparison, making
it difficult to determine if this is better than the current
accepted standard treatment. In addition, small numbers of
patients enrolled in these studies provide insufficient assurance that there are no increased risks associated with
early functional protocols. Therefore, it is difficult to
implement an early functional protocol as the standard of
care for the general population of patients with acute surgically treated Achilles tendon rupture.
We determined from prospective, randomized (or quasirandomized) controlled trials whether an early functional
protocol compared with cast immobilization for surgical
repair of an acute Achilles tendon rupture improved subjective patient satisfaction without an increase in rerupture
rate. Secondary outcomes compared among the two protocols included infection rate, ROM, calf strength, and
minor surgical complications.
The optimal postoperative rehabilitation protocol after surgical repair of an Achilles tendon rupture is unknown. Although a 6-week cast immobilization is common, many early
functional rehabilitation protocols have been implemented.
The purpose of this study was to conduct a meta-analysis to
determine if an early functional protocol for surgical repair
of an acute Achilles tendon rupture improves subjective patient satisfaction without an increase in rerupture rates. Secondary outcomes of interest from an early functional protocol include infections, range of motion, strength, and minor
complications. An extensive literature search for randomized
or quasirandomized studies identified six trials involving 315
patients. Early functional treatment protocols, when compared with postoperative immobilization, led to more excellent rated subjective responses and no difference in rerupture rate. Our conclusions are based on six trials with small
sample sizes, and larger randomized trials are required to
confirm these results.
Level of Evidence: Therapeutic Study, Level II (Systematic
review of Level II studies or Level I studies with inconsistent
results). See the Guidelines for Authors for a complete description of levels of evidence.
The optimal postoperative rehabilitation protocol after surgical repair of an Achilles tendon rupture is evolving from
the classic routine using rigid immobilization in a belowknee nonweightbearing cast for 6 weeks with subsequent
ankle range of motion (ROM) and strengthening exerReceived: January 14, 2005
Revised: May 26, 2005; October 17, 2005
Accepted: December 1, 2005
From the Department of Surgery, University of Alberta, Edmonton, Alberta,
Canada.
Each author certifies that he or she has no commercial associations (eg,
consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the
submitted article.
Correspondence to: Dr. Nadr Jomha, #1002, 8215-112th Street, College
Plaza, Edmonton, Alberta, Canada T6G 2C8. Phone: 780-434-3668; Fax:
780-434-4859; E-mail: nadr@interbaun.com.
DOI: 10.1097/01.blo.0000203458.05135.74
MATERIALS AND METHODS
A systematic literature review for randomized controlled trials
that compared early functional protocols with immobilization
regimens for Achilles tendon ruptures was performed specifically identifying studies that documented patient satisfaction and
rerupture rates. Articles were included if they met the following
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criteria: (1) prospective randomized or quasirandomized controlled trials; (2) trials enrolling adults (ⱖ 18 years of age) diagnosed with an acute rupture of the Achilles tendon; (3) trials
that compared a control group assigned to a standard immobilization and delayed weightbearing regimen with a treatment
group assigned to an early functional protocol for postoperative
management of a surgically repaired acute Achilles tendon rupture; and (4) subjective patient satisfaction, reruptures, infections, minor surgical complications, and functional measures (eg,
plantar flexion function strength).
A librarian experienced in systematic review searching assisted with the following search strategy: Achilles tendon AND
(rupture* or torn or tear*) AND (rehab* OR repair* OR operati*
OR postoperati* OR sutur* OR surg* OR mobili* OR immobili*
OR wrap* OR brace* OR weightbear* OR weight bear* OR
walking cast*) (* indicates truncation). The Ovid Medline database January 1966 to July 2004, Cumulative Index to Nursing
& Allied Health Literature (CINAHL) 1982 to July 2004,
EMBASE 1988 to 2004 Week 28, The Physiotherapy Evidence
Database (online PEDro), Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and
the Database of Abstracts of Reviews of Effects were searched.
In addition, a Web of Science cited reference search was done
based on the citations selected for inclusion. The search results
were reviewed by two independent reviewers (AS, NJ) using a
priori inclusion and exclusion criteria. The article quality was
assessed by evaluating components of the study design including
randomization, blinding, population, intervention, and outcomes.
Interreviewer qualitative statistical analysis for these components was not done. Differences were resolved by discussion.
Eighty-four titles and abstracts potentially relevant to the review were retrieved (20 from Medline, 17 from EMBASE, 27
from CINAHL, 20 from the Cochrane Database of Systematic
Reviews and the Cochrane Central Register of Controlled Trials
Cochrane, and none from PEDro). After limiting for prospective,
controlled, human trials and overlap from the search engines,
only eight eligible trials remained. Two studies were eliminated
based on outcome criteria: one was focused on neuromotor function (as opposed to objective and subjective clinical outcomes)
and did not include postoperative complication data,8 and the
other did not follow a standard immobilization regimen and
failed to provide adequate objective results such as plantar flex-
Fig 1. A comparison of the excellent
satisfaction patient response for both
rehabilitation regimes is shown. More
patients reported excellent satisfaction
with an early functional routine. Maffulli
a10; Maffulli b11
Meta-analysis of Tendon Rupture Protocols
217
ion strength or ROM.9 Therefore, six trials2,3,7,10–12 met all the
inclusion criteria.
Although each study had slight differences in their methodology or outcomes, the I2 statistic (for evaluation of the extent of
variability in results among the studies)6 for subjective patient
satisfaction and rerupture rate (the two primary outcomes) was
zero, which is suggestive of low heterogeneity, allowing for
study comparison. Four studies2,3,7,12 used a randomized selection process, with the other two assigning therapy according to
the day of the week.10,11 In four studies,2,3,10,11 it was reported
that the individuals assessing the patients postoperatively were
blinded to the treatment group. All studies had patients lost to
followup. All trials used open surgical techniques, but varied
with the commencement of weightbearing in the active early
functional groups from 1 day to 6.5 weeks postoperatively. Corresponding authors were contacted, if possible,3,10–12 for additional specifics on data or methodology information that were
not provided in the original paper.
The studies recorded subjective patient data, reruptures, ankle
ROM, ankle strength, and postoperative complications for each
group, but not all studies measured identical outcomes. Different
scoring scales were used to record patient satisfaction for each
postoperative rehabilitation routine. To compare these different
subjective scales, patient satisfaction data from each study were
reclassified into excellent, adequate, or poor satisfaction groups
(Fig 1). In all studies, rerupture and infection rates were reported.
Four studies2,3,7,12 investigated ROM. Five studies2,3,10–12 examined gastrocnemius strength and calf circumference.
Data were extracted and entered into Review Manager 4.2.2,
a software program designed specifically for systematic reviews
by the Cochrane Collaboration (Oxford, UK) and available online at http://www.cochrane.org/index0.htm. All calculations
were made using a random effects model, as this model provides
a more conservative summary estimate of treatment effect.14 For
dichotomous data, the odds ratio (OR) with 95% confidence intervals (95% CI) were calculated for individual trials, and similar outcomes were combined to calculate a pooled estimate of effect,
statistical significance, heterogeneity, and total events per group.
Continuous data were combined using a weighted mean difference with 95% CI for individual and pooled estimates. Heterogeneity was tested using the Breslow-Day method and the I2 statistic.4 A p value < 0.05 was used to determine statistical significance.
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Suchak et al
TABLE 1.
Comparison of Study Characteristics
Commencement of Partial Weightbearing
Study
Number of
Subjects
Mortensen et al12 1999
Maffulli et al10 2003
71
53
Costa et al3 2003
Cetti et al2 1994
Kangas et al7 2003
Maffulli et al11 2003
28
60
50
53
Randomization Method
Computer-generated randomization
Dependent on day of presentation
Computer-generated random numbers in
sequentially numbered opaque envelopes
Method not stated
Randomly mixed sealed envelopes
Dependent on day of presentation
RESULTS
The six prospective controlled trials included 315 patients,
156 in the immobilization group and 159 in the early function group. The mean age of the patients was 40 ± 15
years. Of the 315 patients, 84% were men and 90% ruptured their Achilles tendon during a sporting event. The
time until surgery varied in the immobilization group from
0 to 112 hours and in the early functional group from 0 to
508 hours. Commencement of partial weightbearing also
varied among the studies (Table 1).
Early functional treatment protocols led to more (p <
0.0001) excellent subjective responses when compared
with postoperative immobilization (88% versus 62%, respectively) (Fig 1).
The rerupture rate in the early functional treatment
group was not different to that in the immobilized group
(2.5% versus 3.8% respectively) (Fig 2). Ten reruptures
occurred in 315 patients.
No differences in superficial and deep infections occurred in the early functional treatment group (four infections) and immobilized group (six infections) during their
postoperative rehabilitation (Fig 3). The average incisional
infection rate was 2.6% in the early functional treatment
group and 3.9% in the immobilized group.
Fig 2. The rerupture rates in the early
functional rehabilitation groups were
compared rates in the immobilized
groups. The odds ratio trends toward
more reruptures occurring during an
immobilized routine. Maffulli a10; Maffulli b11
Immobilized Group
(Day)
Early Motion Group
(Day)
42
28
1
1
42
42
21
28
1
1
21
1
Other complications, including scar adhesions and transient sural nerve deficits, occurred less frequently (p ⳱
0.01) (Fig 4) in the early functional treatment group
(5.8%) than in the immobilized group (13.5%).
Only one study2 found fewer (p ⳱ 0.02) patients with
calf atrophy with an average of 0.7 cm larger (p ⳱ 0.02)
calf circumference and better (p ⳱ 0.0006) plantar flexion
strength in the early functional treatment group compared
with the immobilized group. All other studies3,7,10–12
showed no difference between their groups. Only one
study2 found a difference (p < 0.00001) in the degree of
ROM in the early functional treatment group, with these
patients having a 25º greater range after 6 weeks.
DISCUSSION
We report the first meta-analysis of randomized studies
comparing an early functional protocol with the traditional
postoperative protocols in acute Achilles tendon rupture
repair. A meta-analysis was used because the current literature lacks appropriately conducted, large prospective,
randomized clinical trials to determine if an early functional rehabilitation protocol improves patient satisfaction
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April 2006
Meta-analysis of Tendon Rupture Protocols
219
Fig 3. The infection rates for each rehabilitation regimen were compared. There were no differences between the two groups.
Maffulli a10; Maffulli b11
without an increase in rerupture rate. In addition, secondary outcomes, such as infection rates, gastrocnemius
strength, and ROM were evaluated to determine other adverse effects of implementing an early functional protocol.
This meta-analysis has certain limitations. There are
only six studies available for comparison and not all of
these studies were strictly randomized, although all were
prospective. Two studies were included that had treatment
groups determined by the day or the week the patient
presented for treatment. These were included because
trauma is a relatively random event and we could not
identify a biasing factor leading patients to present on
specific days or weeks. Each study used different rehabilitation routines. When classifying an early functional rehabilitation protocol, early ROM and type of weightbearing
allowed early during the postoperative period were considered of prime importance. If either of these two factors
Fig 4. A comparison of other postoperative complications occurring in each
rehabilitation regimen is shown. The
odds ratio revealed more complications
occurred when an immobilized routine
was used. Maffulli a10; Maffulli b11
was initiated in the immediate postoperative period, this
was considered early functional rehabilitation when compared with traditional treatment. Finally, contacting all authors via phone or E-mail to discuss study specifics was
largely unsuccessful.
The subjective outcomes reported by patients after an
early functional protocol were significantly better than
outcomes of patients after a traditional rehabilitation protocol. In one study,2 two patients in the mobile cast group
had previously ruptured the same Achilles tendon but were
treated with a traditional rigid cast rehabilitation after their
first injury. Both patients preferred the early functional
protocol with a mobile cast because of “no edema of the
leg in the cast period, the ability to weight bear and walk
during the cast period, the ability to move the foot in a
secure way immediately after the operation, and easier and
faster ability to obtain normal gait after removal of the
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Suchak et al
cast.”2 This meta-analysis strongly suggests that an early
functional protocol can improve patient satisfaction after
surgical repair of an acute Achilles tendon rupture.
The rerupture rate after an early functional protocol is
the same as after an immobilization protocol. Unfortunately, the details of the mechanisms of rerupture were not
provided in all of the studies. A low postsurgical rerupture
rate is in agreement with a review of Achilles tendon
rupture management that compared (1) operative management with functional bracing, (2) nonoperative management with functional bracing, and (3) nonoperative management with immobilization.19 That study did not directly compare various aggressive rehabilitation protocols.
The rerupture rates for these three groups were 1.4%,
1.5%, and 10.7%, respectively.19 These results provide
confidence that an early functional rehabilitation protocol
will not cause undue damage to the healing tendon.
The early functional protocol group experienced fewer
minor surgical complications, including infection rate,
than the immobilized group. This is in agreement with a
previous study, which compared open repair with early
functional protocols with open repair with immobilization
and nonoperative management of Achilles tendon ruptures, and concluded “overall, the best outcome with regard to complication rates was found in those patients
managed with open repair and early mobilization.”19 Postoperative infections after operative treatment for Achilles
tendon ruptures have been reported with a range of
4–20%.1 This is substantially greater than the pooled infection incidence reported in either group of the six studies
in this meta-analysis. One explanation may be an improvement of surgical techniques in recent years, resulting in
fewer complications as documented in this meta-analysis.
The ankle ROM in both groups was comparable at 1
year. The increased ROM at 6 weeks in the mobile cast
group2 is likely related to early timing of the measurement.
Unfortunately, insufficient data for differences in ROM at
1 year postoperatively were provided in this study.
Inconsistencies in data reporting among the six studies
did not allow for a direct or statistical comparison of time
to return to work and return to sport. In one study,11 it was
reported that patients in the early functional group used
less healthcare resources because of less physiotherapy
and fewer cast changes. Also, this group of patients returned to work earlier than the immobilized group. Intuitively, an earlier weightbearing routine would allow a
patient to return to a light duties routine at work and increased use of upper extremities for carrying purposes.
The time to return to work and return to sport are important socioeconomic and psychosocial factors in evaluating
new rehabilitation routines and are important to consider
when designing studies to investigate new treatment regimens.
An early functional rehabilitation protocol for Achilles
tendon ruptures improves patient satisfaction with reduction in minor complications and no increase in rerupture
rate or infection rate. Larger powered, prospective randomized studies are required to investigate the individual
component of early weightbearing and early ROM to determine their effects on the outcome of Achilles tendon
rupture repair and lead to dynamic rehabilitation protocols
to improve patient satisfaction and clinical outcome.
Acknowledgments
We thank Mrs. J. Buckingham for help with the literature search,
and Mrs. L. Beaupre for protocol support.
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