© 2012 John Wiley & Sons A/S.
Scand J Med Sci Sports 2014: 24: 152–158
doi: 10.1111/j.1600-0838.2012.01497.x
Published by John Wiley & Sons Ltd
Ability to perform a single heel-rise is significantly related to
patient-reported outcome after Achilles tendon rupture
N. Olsson1, J. Karlsson1, B. I. Eriksson1, A. Brorsson1, M. Lundberg1, K. G. Silbernagel2
1
Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Sahlgrenska
University Hospital, Mölndal, Sweden, 2Department of Physical Therapy, University of the Sciences, Philadelphia, Pennsylvania, USA
Corresponding author: Nicklas Olsson, MD, Orthocenter IFK-Kliniken, Arvid Wallgrens Backe 4a, SE-413 46 Göteborg, Sweden. Tel:
+46 31 818250, Fax: +46 31 818251, E-mail: nicklas.olsson@gu.se
Accepted for publication 24 May 2012
This study evaluated the short-term recovery of function
after an acute Achilles tendon rupture, measured by a
single-legged heel-rise test, with main emphasis on the
relation to the patient-reported outcomes and fear of
physical activity and movement (kinesiophobia). Eightyone patients treated surgically or non-surgically with
early active rehabilitation after Achilles tendon rupture
were included in the study. Patient’s ability to perform a
single-legged heel-rise, physical activity level, patientreported symptoms, general health, and kinesiophobia
was evaluated 12 weeks after the injury. The heel-rise test
showed that 40 out of 81 (49%) patients were unable to
perform a single heel-rise 12 weeks after the injury. We
found that patients who were able to perform a heel-rise
were significantly younger, more often of male gender,
reported a lesser degree of symptoms, and also had a
higher degree of physical activity at 12 weeks. There was
also a significant negative correlation between kinesiophobia and all the patient-reported outcomes and the
physical activity level. The heel-rise ability appears to be
an important early achievement and reflects the general
level of healing, which influences patient-reported
outcome and physical activity. Future treatment protocols focusing on regaining strength early after the injury
therefore seem to be of great importance. Kinesiophobia
needs to be addressed early during the rehabilitation
process.
Acute Achilles tendon rupture is a common injury with a
reported annual incidence of 6–18/100 000 per year
(Leppilahti et al., 1996; Maffulli et al., 1999). The
typical patient is a middle-aged male active in recreational sports (Leppilahti et al., 1996). In the past years,
randomized clinical trials to evaluate if either surgical or
non-surgical treatments, with or without early mobilization, are superior have been published (Costa et al.,
2006; Twaddle & Poon, 2007; Suchak et al., 2008;
Nilsson-Helander et al., 2010; Willits et al., 2010;
Keating & Will, 2011). In summary, early active rehabilitation and weight-bearing are associated with better
outcome after Achilles tendon rupture treatment (Costa
et al., 2006; Suchak et al., 2006, 2008; Nilsson-Helander
et al., 2010; Willits et al., 2010). The main outcomes in
these studies have mostly been the evaluation of complications such as re-ruptures, 6–24 months after the injury
(Moller et al., 2001; Twaddle & Poon, 2007; NilssonHelander et al., 2010; Willits et al., 2010).
A 2-year follow-up study showed that Achilles tendon
ruptures caused long-term functional deficits (Olsson
et al., 2011). However, there is very little known about
the initial short-term results. To minimize long-term
deficits, it is important to understand when the window
of opportunity exists to prevent functional deficits from
occurring and becoming permanent. Based on the
current literature, examining tendon healing in animals,
the mechanical loading during the early stages of healing
appears to be beneficial (Kjaer, 2004; Aspenberg, 2007;
Eliasson et al., 2012). However, fear of physical activity
and movement (kinesiophobia) is also a known complicating factor for poor rehabilitation outcome in other
conditions (Kvist et al., 2005; Lundberg et al., 2009).
Despite allowing early weight-bearing, in patients with
an Achilles tendon rupture, the actual loading may be
limited due to fear. Therefore, if these patients fear
loading, return of function may be negatively impacted.
To deepen the understanding of how the Achilles tendon
recovers after injury in humans, it therefore appears
important to also evaluate the short-term return of function and patient-reported symptoms and compare the
degree of kinesiophobia. This knowledge might help
implement a more optimal design in treatment protocols
to address the early recovery of function and not just to
prevent complications such as re-rupture, scarring, and
infections. Costa et al. (2006) and Suchak et al. (2008)
evaluated general health in patients with an Achilles
tendon rupture 3 months after the injury. A few studies
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Achilles tendon rupture, short-term result
have reported the return of function at 3 months (Kangas
et al., 2003; Twaddle & Poon, 2007; Keating & Will,
2011), but as far as we know, no study has evaluated
function in connection to how it may affect the patients’
general health and quality of life.
The purpose of this study was therefore to evaluate the
recovery of function at 12 weeks after the injury and to
study how function relates to the patient-reported outcomes, with regard to the lower limb function, as well as
general health and quality of life. The secondary purpose
was to evaluate the degree of patients’ fear of movement
and how this fear relates to function and patient-reported
symptoms.
We hypothesized that patients who are able to perform
a single-legged heel-rise at 12 weeks would report less
symptoms, report higher level of physical activity, and
less impact on function of daily activity and sports and
improved quality of life compared with patients that
were unable. Furthermore, we hypothesized that the
degree of kinesiophobia would correlate with patientreported symptoms, quality of life, and function.
Materials and methods
The study is part of a randomized controlled trial (RCT) conducted
at the Department of Orthopedics Sahlgrenska University Hospital, Gothenburg, Sweden. Patients, 18–65 years of age, were
included if they had an acute mid-substance rupture presented
within 4 days. The subjects were randomized to either surgical or
non-surgical treatment. The results of the RCT will be presented
separately. In this short-term follow-up, we have included the first
81 patients, from the larger randomized study. One patient was lost
to follow-up at the 12-week evaluation.
Between April 2009 and September 2010, a total of 81 (69
males and 12 females) patients had been followed up for 12 weeks.
The mean [standard deviation (SD)] age was 40 (10), the mean
(SD) weight was 84 (12) kg, and the mean (SD) height was 179 (8)
cm.
All subjects gave written informed consent to participate in the
study. Ethical approval was obtained from the Regional Ethical
Review Board in Gothenburg, Sweden.
Treatment procedure
Surgical group
Forty patients were treated surgically with open repair using identical suture technique. The tendon was repaired end-to-end with
core suturing using two semi-absorbable sutures (No. 2 Orthocord™; Depuy Mitek, Norwood, Massachusetts, USA) in a modified Kessler technique (Kessler, 1973). A running circumferential
suture was used with absorbable sutures (No. 0 Polysorb™; Tyco,
Norwalk, Connecticut, USA) using a modified Silvferskiold technique (Silfverskiold & May, 1994) to reinforce the core sutures.
The patients were post-operatively immobilized in a pneumatic
walker brace (Aircast XP Diabetic Walker; DJO, Vista, California,
USA) including heel pads. No cast was used. Patients were
allowed full weight-bearing immediately post-operatively. During
the first 2 weeks, no other specific rehabilitation recommendation
was prescribed besides the weight-bearing. The following 4
weeks, active rehabilitation following a standardized protocol
including training without brace under the supervision of a physical therapist was performed. In this group, the brace was used for
a total time of 6 weeks.
Non-surgical group
Forty-one patients were included in the non-surgical group. Treatment started immediately after the randomization using the same
brace as in the surgical group. Full weight-bearing was allowed
from the start. This treatment group started the active rehabilitation, supervised by a physical therapist, when the brace was
removed at 8 weeks.
Evaluation
All the patients were evaluated at mean (SD) 12 (0.9) weeks by the
same physical therapist at our testing laboratory. The evaluating
physical therapist was not involved in the treatment of the patients.
Patient-reported outcome and physical activity
Questionnaires were used to evaluate patient-reported outcome
and were answered prior to the functional testing. All the scores
used have in previous studies been shown to be reliable and valid
(Grimby, 1986; EuroQol, 1990; Roos et al., 2001; Lundberg et al.,
2004; Nilsson-Helander et al., 2007). The Physical Activity Scale
(PAS) questionnaire (Grimby, 1986) was used to evaluate the
activity level and a score of 1 equals to no physical activity,
whereas a score of 6 equals to heavy physical exercise several
times per week. The Achilles Tendon Total Rupture Score (ATRS)
(Nilsson-Helander et al., 2007) was used to evaluate injury specific patient-reported outcome. The ATRS ranges from 0 to 100; a
lower score indicates more symptoms and greater limitations of
physical activity. Three subscales of the Foot and Ankle Outcome
Score (FAOS) (Roos et al., 2001) were used to get a foot and ankle
perspective: function in daily living (ADL), function in sport and
recreation (Sport&Rec), and foot- and ankle-related quality of life
(QoL). All the subscales of FAOS ranged from 0 to 100 and a score
of 0 indicates extreme foot- and ankle-related symptoms, whereas
100 indicates no symptoms. For measuring the general healthrelated quality of life, EQ-5D (EuroQol Group) was used
(EuroQol, 1990; Brooks, 1996). An EQ-5D score of 0 is considered to be the worst imaginable health state and a score of 1.00 is
considered the best imaginable health state. One should notice that
the quality-of-life scores FAOS QoL and EQ-5D differ from each
other in terms of different perspective, such as quality of life from
a foot and ankle perspective (FAOS) or a total health state (EQ5D). Fear of physical activity and movement was measured with
the Tampa Scale for Kinesiophobia Swedish Version (TSK-SV)
(Lundberg et al., 2004). TSK varies between 17 and 68. A high
TSK value indicates a high degree of kinesiophobia. Kinesiophobia is defined when the value is more than 37.
At the time of inclusion (baseline), PAS and EQ-5D were measured. During the follow-up at 12 weeks, all the scores above were
measured (PAS, ATRS, FAOS, EQ-5D, and TSK-SV).
Functional evaluation
The single heel-rise test is a part of a more extensive functional
evaluation, but the ability to perform a single-legged heel-rise is
the only functional outcome measurement reported in this study.
This test is simple to perform in the clinic and we believe it to be
suitable in this early stage of rehabilitation. In several other
Achilles tendon studies (Moller et al., 2002, 2005; Weber et al.,
2003; Bostick et al., 2010; Silbernagel et al., 2010), single-legged
heel-rise is a commonly used test. Prior to testing, the patients
153
Olsson et al.
warmed up for 5 min on a stationary bicycle and then performed
3 sets of 10 two-legged heel-rises. Standardized instructions were
used prior to testing. The participants were standing on a flat box
with the ankle in neutral position and asked to perform a single
heel-rise. The patients were classified as being able to perform a
one-legged heel-rise if they were able to lift the heel at least 2 cm
once while keeping the knee straight. MuscleLab® (Ergotest
Technology, Oslo, Norway) measurement system was used for
the evaluations as previously described in the literature (Silbernagel et al., 2010). A linear encoder was used. A spring-loaded
string is connected to a sensor inside the liner encoder unit. When
the string is pulled, the sensor outputs a series of digital pulses
that is proportional to the distance traveled. The resolution is
approximately one pulse every 0.07 mm. The spring-loaded
string of the linear encoder was attached to the heel of the subject’s shoe.
Table 1. Demographics and results from the 12-week evaluation
Variable
12 weeks
Number of patients
Age (years)
81
40.0 (9.6)
40 (20; 63)
69 (85%)
12 (15%)
2.9 (1.0)
3 (1; 6)
38.8 (17.3)
37 (6; 86)
77.8 (15.5)
81 (13; 100)
31.1 (19.1)
30 (0; 80)
42.6 (17.2)
44 (0; 75)
0.75 (0.16)
0.73 (0.19; 1.00)
35.9 (7.5)
35 (18; 60)
41/40
51%/49%
Male (n)
Female (n)
PAS
ATRS
FAOS – ADL
FAOS – Sport&Rec
FAOS – QoL
EQ-5D
Statistical analysis
Descriptive data are reported as mean, median, SD, and range
(minimum-maximum) in the tables and in the text as mean
and SD. The Mann-Whitney U-test was used for continuous
variables to compare different groups. The level of significance
was set at P < 0.05. For comparison between groups, the chisquare test was used for dichotomous variables and Fischer’s
exact test when the sample size was small. The correlations were
analyzed with Spearman’s rank correlation. All data were analyzed using SPSS statistics (version 18.0, SPSS inc., Chicago,
Illinois, USA).
Results
Comparison between the initial treatment groups
At the 12-week evaluation, there was no statistical difference (P = 0.269) between surgical and non-surgical
group according to heel-rise ability. The number of
patients with the ability to perform a single heel-rise was
23 out of 40 (58%) in the surgical treated group and 18
out of 41 (44%) in the non-surgical group. There were no
statistical differences (P-values: 0.18–0.88) between the
two treatment groups in terms of demographics and
other parameters at baseline (PAS and EQ-5D) or at the
12-week evaluation [PAS, ATRS, FAOS (ADL,
Sport&Rec, and QoL), EQ-5D, and TSK-SV]. Therefore, we present the results for the whole group regardless of treatment.
Patient-reported outcome at 12 weeks
At the 12-week evaluation, the patient-reported questionnaires show that the patients have symptoms affecting function and quality of life (Table 1).
According to the reported physical activity level, there
was a significant (P < 0.001) reduction of physical activity 12 weeks after the injury, 2.9(1.0) compared with
baseline 4.1(1.1).
There was also a significant reduction (P < 0.001) of
EQ-5D from the baseline value of 0.97(0.08) to
0.75(0.16) 12 weeks after the injury.
154
TSK
Heel-raise ability (yes/no)
For categorical variables, data are reported as n and (%). For continuous
variables mean (standard deviation)/median (minimum–maximum).
Patient-reported outcomes scores (normal range): PAS [Physical Activity
Scale (1–6)], ATRS [Achilles Tendon Total Rupture Score (0–100)], FAOS
[Foot and Ankle Outcome Score (0–100)], and the subscales: ADL (function in daily living), Sport&Rec (function in sport and recreation) and QoL
(foot- and ankle-related quality of life), EQ-5D [EuroQol Group, general
health-related quality of life (0–1.00)], and TSK-SV [Tampa Scale for Kinesiophobia Swedish Version (17–68)].
Function at 12 weeks
The heel-rise test showed that 40 out of 81 (49%)
patients were unable to perform a single heel-rise 12
weeks after the injury (Table 1).
Recovery of function in relation to age, gender,
and symptoms
Ability to perform a heel-rise at 12 weeks related to age,
gender, and symptoms are shown in Table 2. We found
that patients who were able to perform a heel-rise were
significantly younger, more often of male gender and
had a higher score in ATRS and all subscales of FAOS,
and had a higher degree of physical activity at 12 weeks.
There was no significant difference (P = 0.270) between
the degree of kinesiophobia between patients who were
able to perform a heel-rise and those who could not.
Correlation between degree of kinesiophobia and
patient-reported outcome
At the 12-week evaluation, we found a highly significant
negative correlation between the TSK-SV score and
ATRS, FAOS – ADL, FAOS – Sport&Rec, and FAOS –
Achilles tendon rupture, short-term result
Table 2. Comparison between patients who were able to perform a heelrise and those who were not
Variable
Heel-rise YES
Heel-rise NO
Number of patients
Age (years)
41 (51%)
36.8 (8.3)
37.0 (20; 58)
39
2
3.2 (1.0)
3 (2; 6)
44.7 (17.4)
43 (9; 86)
82.3 (12.5)
85 (53; 97)
36.3 (19.0)
40 (5; 80)
49.2 (16.3)
50 (19; 75)
0.78 (0.15)
0.73 (0.29; 1.00)
35.0 (6.9)
36 (18; 52)
40 (49%)
43.2 (9.9)
43 (27; 63)
30
10
2.7 (1.1)
3 (1; 6)
32.8 (15.3)
31 (6; 73)
73.2 (17.0)
74 (13; 100)
25.8 (17.7)
25 (0; 65)
35.7 (15.7)
31 (0; 69)
0.72 (0.17)
0.73 (0.19; 1.00)
36.9 (8.0)
34 (20; 60)
Male
Female
PAS
ATRS
FAOS – ADL
FAOS – Sport&Rec
FAOS – QoL
EQ-5D
TSK
P-value
0.005
0.013
0.022
0.002
0.008
0.017
0.001
0.094
0.270
For categorical variables, data are reported as n and (%). For continuous
variables mean (standard deviation)/median (minimum–maximum). For
comparison between groups, the Fischer’s exact test was used for
dichotomous variables. The Mann-Whitney U-test was used for continuous variables.
ADL, function in daily living; ATRS, Achilles Tendon Total Rupture
Score; EQ-5D, EuroQol Group, general health-related quality of life; FAOS,
Foot and Ankle Outcome Score; PAS, Physical Activity Scale; QOL, foot
and ankle-related quality of life; Sport&Rec, function in sport and
recreation; TSK-SV, Tampa Scale for Kinesiophobia Swedish Version.
Table 3. Evaluation of relationship between level of kinesiophobia (TSKSV) and patient-reported outcome at 12 weeks
Variable
Correlations coefficient*
P-value (two-tailed)
PAS
ATRS
FAOS – ADL
FAOS – Sport&Rec
FAOS – QoL
EQ-5D
-0.275
-0.371
-0.376
-0.346
-0.321
-0.239
0.013
0.001
0.001
0.002
0.003
0.032
*Spearman’s rank correlation was used.
ADL, function in daily living; ATRS, Achilles Tendon Total Rupture Score;
EQ-5D, EuroQol Group, general health-related quality of life; FAOS, Foot
and Ankle Outcome Score; PAS, Physical Activity Scale; QoL, foot- and
ankle-related quality of life; Sport&Rec, function in sport and recreation;
TSK-SV, Tampa Scale for Kinesiophobia Swedish Version.
QoL. A negative correlation was also found between
TSK-SV and PAS and EQ-5D, respectively, at 12 weeks
(Table 3).
Discussion
The most important finding in our study was that at 12
weeks, approximately only half of the patients had
achieved the ability to perform a single-legged heel-rise.
The patients who were able to perform a heel-rise were
significantly younger, more often of male gender, had
less patient-reported symptoms, and had a higher degree
of physical activity. The degree of kinesiophobia measured with TSK-SV was also negatively correlated with
symptoms and measures of general health. Thus, our
hypotheses were confirmed. The ability to perform a
heel-rise appears to be an important milestone in
patients’ recovery following an Achilles tendon rupture.
To be able to test the hypothesis of the present study,
we collected data from a cohort, which was a part of a
larger study, where we collected data at the time of
rupture and at 12 weeks. At the time of this study, the
patients had undergone 4 or 10 weeks (depending of the
treatment group) of supervised rehabilitation focused on
regaining calf muscle strength and function. In comparison with other studies, this can be considered as an early
start of the rehabilitation exercises. Despite the early
start of the exercises, supervised by physical therapists,
only half of the patients were able to perform the singlelegged heel-rise and there was no difference between the
two treatment groups. It could be questioned if the treatments and outcomes in the present study are comparable
to other studies. In order to put our results into perspective of the literature, we have only found one publication
presenting short-term data on one-legged heel-rise after
acute Achilles tendon rupture. Uchiyama et al. (2007)
showed at 12 weeks that after modified surgical technique, approximately half of the patients were able to
perform a single-legged heel-rise. They also reported the
timing for achieving this critical test to a mean of 12
weeks (range: 7–25 weeks).
The injury- and joint-specific questionnaires all indicate that the patients have major symptoms relating to
their foot and ankle, along with limitations in activities
of daily living, physical activity, and quality of life.
Because the degree of patient-reported symptoms were
significantly different between the group who could
perform a heel-rise and those who could not, deficit in
calf muscle strength appears to have a profound impact
on the patient’s recovery. The results regarding patientreported outcome could also be very useful both to clinicians and patients in providing information about
realistic short-term expectations with regard to recovery
and symptoms.
Not only did this patient group have deficits in lower
leg function and patient-reported symptoms, but their
general health also appeared to be negatively affected.
As a comparison to our results, a general population
study by Burstrom et al. (2001) had a mean EQ-5D of
0.86 (SD 0.009) in a corresponding age group. Our baseline value for these patients was higher. This might
reflect that patients with an Achilles tendon rupture are
more active and healthier compared with the general
population. In the present study, there was a significant
decrease in EQ-5D from baseline to 12 weeks. Costa
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Olsson et al.
et al. (2006) reported an EQ-5D value of 0.69–0.73 at 10
and 14 weeks after acute Achilles tendon rupture
depending on the type of treatment. This corresponds
well to the value reported in the present study 12 weeks
after the injury and indicates that also general health is
negatively affected at this time point. In the general
population study, Burstrom et al. reported a similar
EQ-5D value (0.74) in the age group of 80–88 years
(Burstrom et al., 2001).
Twelve weeks after an Achilles tendon rupture, there
is a significant decrease in terms of physical activity,
which is expected of course. Earlier studies have shown
that even 2 years after the injury, approximately only half
of the patients have reached their previous physical
activity level (Moller et al., 2001). This patient group, in
general, is very active and often describes a desire to
return to the same activity level, but several studies have
shown that this might not be the case, mainly due to
deficits in lower leg function or fear of re-injury (Moller
et al., 2001). At the present time, we do not know if the
early recovery of heel-rise can predict the return to
physical activity, but this would be of interest to investigate in future studies.
Most studies and clinical guidelines recommend
return to running and non-contact sports between weeks
16 and 20 (van Sterkenburg et al. 2008; Maffulli et al.,
2011). In general, most of the guidelines are time-based
and do not include any specific criteria with regard to
return of strength or lower leg function. Costa et al.
(2006) reported a median time of 12.5–18 weeks
(depending of treatment) to return to normal walking.
The Achilles Tendon Study Group has given guidelines
for sport resumption in their book Achilles Tendon
Rupture – Current Concepts (van Sterkenburg et al.
2008). They divided the recovery into four levels of
increasing activity: walking, running, return to noncontact sport, and return to contact sport. Each phase
must be fully accomplished prior to entering the next
one. The first level ends when the patient is able to walk
normally again. To achieve that, the difference in
strength is said to be less than 25% compared with the
uninjured side in repeated single heel-rises and also toe
walking should be possible. The proposed time for this
level is 12 weeks, but 8 weeks for operative treatment
with a functional brace. We conclude similar to the
Achilles Tendon Study Group that a functional perspective rather than a time perspective is of major importance
when rehabilitation is advanced. On the other hand, our
data do not support that the majority of patients could go
into the Achilles Tendon Study Group’s next level of
rehabilitation, including resumed running, after 12
weeks. This simple test of heel-rise ability appears to be
an important milestone in the early rehabilitation
process; however, its importance in relation to achieving
a normal gait pattern needs to be further investigated.
As indicated by the results of the present study, we
suggest that the heel-rise test could have an important
156
clinical application and give realistic expectations for
both the patient and the physical therapist/doctor with
regard to expected return of various activities such as
running and sports. However, if early return of a singlelegged heel-rise capacity is predictive of achieving a full
recovery needs to be further investigated. Future treatment protocols focusing on treatment modalities allowing early weight-bearing and early strength training
appears warranted based on this and other studies (Costa
et al., 2006; Suchak et al., 2006, 2008; Willits et al.,
2010). Identifying signs of kinesiophobia during the
early stage of rehabilitation might also be of great importance in order to achieve compliance with early weightbearing and early exercise protocols.
In the present study, it was shown that males had
significant better functional outcome, based on the single
heel-rise test, than females. Difference in gender has also
been reported by Saxena et al. (2011) when they looked
at parameters for predicting return to activity after Achilles tendon surgery. It has previously been suggested that
there are gender differences in tendon healing (Magnusson et al., 2007; Miller et al., 2007; Westh et al., 2008).
However, as Achilles tendon ruptures occur mostly in
males, and in this study, only 15% of the included
patients were females, it is difficult to draw any conclusions regarding possible differences in tendon healing.
The results in the present study indicate that kinesiophobia is a factor that correlates negatively with the
physical activity level, the degree of symptoms, and
general health in patients 12 weeks following an Achilles
tendon rupture (Table 3). This suggests that during the
rehabilitation process this might need to be addressed
separately by the treating physician and/or the physical
therapist or rehabilitation specialist in order to achieve
optimal outcome. The instructions to the patients in this
study were that full weight-bearing was allowed and
promoted from the start. It could be that patients with a
higher degree of fear of movement actually do not
weight-bear (less compliance) and load the tendon to the
same degree as patients with less fear (high compliance).
Histological studies have shown better collagen formation after mechanical loading (Jarvinen et al., 1997;
Kannus et al., 1997; Rantanen et al., 1999; Kjaer et al.,
2005). Clinical studies have also shown improved results
of early functional treatment after an Achilles tendon
rupture (Kangas et al., 2003; Maffulli et al., 2003; Costa
et al., 2006; Nilsson-Helander et al., 2010; Willits et al.,
2010). However, further studies are needed to evaluate if
the degree of weight-bearing and loading of the tendon is
affected by kinesiophobia.
Perspectives
Half of the patients were able to perform a singlelegged heel-rise at 12 weeks after an Achilles tendon
rupture. The ability to perform a single heel-rise at this
time is significantly related to physical activity and
Achilles tendon rupture, short-term result
patient-reported outcome. Male gender and younger age
seem to be of importance to obtain a satisfactory functional outcome at 12 weeks after an Achilles tendon
rupture. Future treatment protocols should focus on
regaining strength in the calf muscle early in the rehabilitation process and we believe that the single-legged
heel-rise test is critical in the recovery after an Achilles
tendon rupture. In a functional perspective, this test
might be an important tool to monitor the progress of the
rehabilitation. The present study also demonstrated that
kinesiophobia correlates with physical activity, patientreported symptoms, and general health. Fear of physical
activity and movement needs to be addressed especially
during the early stages of the rehabilitation process.
Key words: Achilles Tendon Total Rupture Score
(ATRS), Foot and Ankle Outcome Score (FAOS), EQ-5D,
kinesiophobia, calf muscle strength.
Conflict of interest
The authors declare that they have no conflict of
interest.
Acknowledgements
This study was supported by the Swedish National Centre for
Research in Sports (CIF).
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