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    Is Early Weight-Bearing Appropriate After Surgery for Insertional Achilles Tendinopathy?

    Dr. Kenneth Mroczek comments on a study that shows better initial outcomes, with no long-term negative effects, in a comparison of outcomes with an accelerated versus a conventional postoperative protocol for patients with insertional Achilles tendinopathy.

    Author

    Kenneth J. Mroczek, MD

    Article

    Arunakul M, Pholsawatchi W, Arunakul P, Pitakveerakul A. Controlled vs accelerated rehabilitation protocol following reattachment of Achilles tendon for insertional Achilles tendinopathy. Foot Ankle Int. 2021 Sep;42(9):1121-1129. doi: 10.1177/10711007211003871. Epub 2021 May 24.

    Summary

    In a prospective comparative study, Arunakul et al evaluated outcomes of a conventional versus an accelerated postoperative protocol in 2 groups of patients with insertional Achilles tendinopathy who were undergoing open Achilles tendon debridement, Haglund’s resection, and reattachment of the Achilles.

    RELATED: Insertional Achilles Tendinitis & Midsubtance Tendinosis

    The conventional postoperative protocol was applied to a group of 18 patients, and it included:

    • Short slab splint in gravity equinus and non-weight-bearing for the first 2 postoperative weeks
    • 25% partial weight-bearing with a 2.4-cm heel lift in the CAM boot for weeks 2 to 4
    • 50% partial weight-bearing with a 1.6-cm heel lift in the CAM boot for weeks 4 to 6
    • 75% partial weight-bearing with a 0.8-cm heel lift in the CAM boot for weeks 6 to 8
    • Full weight-bearing and a CAM boot without a heel lift for weeks 8 to 10
    • CAM boot removed; patients transitioned into their usual shoes after week 10

    The accelerated weight-bearing postoperative protocol was applied to a group of 31 patients, and it included:

    • Short slab splint in gravity equinus and non-weight-bearing for the first 2 postoperative weeks
    • Full weight-bearing and a CAM boot with a 2.4-cm heel lift for weeks 2 to 3
    • Full weight-bearing and a CAM boot with a 1.6-cm heel lift for weeks 3 to 4
    • Full weight-bearing and a CAM boot with a 0.8-cm heel left for weeks 4 to 5
    • Full weight-bearing and a CAM boot with no heel lift for weeks 5 to 6
    • CAM boot removed; patients transitioned into their usual shoes after week 6

    The mean ages were similar in both groups, 53 years for the conventional protocol group and 57 years for the accelerated protocol group, and all other characteristics were similar. Outcome measures included visual analog scale (VAS), Foot and Ankle Ability Measure (FAAM), and Short Form Health Survey (SF-36), all of which were measured at 3, 6, and 12 months postoperatively. The single heel test was performed at 6 months postoperatively.

    In the accelerated protocol group, statistically significant improvement was observed at the 3-month mark for all 3 outcome measures. However, at the 6-month and 1-year mark, there were no statistical differences between groups.

    Patients in both groups were able to perform a single leg raise at the 6-month mark. Neither group experienced postoperative complications.

    RELATED: Achilles Tendon Rupture

    Clinical Relevance

    The study by Arunakul et al suggests that early weight-bearing will not have deleterious effects on the final outcome of surgery for insertional Achilles tendinopathy.

    Previous studies have shown that Achilles tendon elongation most commonly occurs in the first 3 months postoperatively with prolonged immobilization versus early immobilization. Proposed theories for less elongation with early immobilization include increased blood flow during plantar flexion exercise and fluid shifting within the paratenon, which could lower the concentration of inflammatory markers that may slow healing. These studies, however, were in midsubstance Achilles repair, which were performed to determine if bone-to-tendon healing would be different than tendon-to-tendon healing.

    It is quite clear that patients would prefer a shorter period of non- and limited weight-bearing following surgery for insertional Achilles tendinopathy. Patients in the accelerated group not only were progressed to full weight-bearing quicker, but they also returned to wearing shoes at 6 weeks compared with 10 weeks in the conventional group. An important finding is that no wound complications were observed in the accelerated group, despite early full weight-bearing.

    A strength of this study is that all procedures were performed by the same surgeon. However, the small sample size and the fact that the accelerated group (April 2015 to October 2107) was studied after the conventional group (January 2013 to March 2015) are limitations.

    As the study authors noted, additional research is needed to confirm the findings of this small study.

    Author Information

    Kenneth J. Mroczek, MD, is an Assistant Professor of Orthopedic Surgery and Assistant Chief of the Division of Foot and Ankle Surgery, Department of Orthopedic Surgery, at NYU Langone Health, New York, New York.

    Disclosures: Dr. Mroczek has no disclosures relevant to this article.