RESUMO
Substantial research on complete Achilles tendon ruptures is available, but guidance on partial ruptures is comparatively sparse. Conservative management is considered acceptable in partial tendon ruptures affecting less than 50% of the tendon's width, but supporting experimental evidence is currently lacking. Using a previously validated finite element model of the Achilles tendon, this study aimed to assess whether loading conditions simulating an early functional rehabilitation protocol could elicit progression to a complete rupture in partial ruptures of varying severity. In silico tendon rupture simulations were performed to locate the most likely rupture site for least, moderate, and extreme subtendon twist configurations. These three models were split at the corresponding rupture site and two sets of partial ruptures were created for each, starting from the medial and lateral sides, and ranging from 10% to 50% loss of continuity. Simulations were conducted with material parameters from healthy and tendinopathic tendons. Partial ruptures were considered to progress if the volume of elements showing a maximum principal strain above 10% exceeded 3 mm3. To assess whether the tendinopathic tendons typical geometric characteristics could compensate for the inferior material properties found in tendinopathy, an additional model with increased cross-sectional area in the free tendon region was developed. Progression to complete ruptures occurred even with less than a 50% loss of continuity, regardless of subtendon twisting, and material parameters. The tendinopathic tendon model with increased cross-sectional area showed similar results. These findings suggest the current criteria for surgical treatment of partial ruptures should be reconsidered. Statement of clinical significance: The clinical significance and most appropriate treatment of partial ruptures of the Achilles tendon is unclear. Despite the widespread use of the "50% rule" in treatment decisions of partial tendon ruptures, experimental evidence supporting it is missing. The present study provides new data, from a validated aponeurotic and free Achilles tendon finite element model, showing that partial ruptures may progress to complete ruptures under loading conditions elicited from functional rehabilitation protocols, even for partial ruptures affecting less than 50% of the tendon's width. Under these novel findings, the current criteria for surgical treatment of partial ruptures should be reconsidered.
Assuntos
Tendão do Calcâneo , Análise de Elementos Finitos , Tendão do Calcâneo/lesões , Tendão do Calcâneo/fisiopatologia , Humanos , Ruptura/reabilitação , Traumatismos dos Tendões/reabilitação , Traumatismos dos Tendões/fisiopatologia , Simulação por Computador , Progressão da DoençaRESUMO
AIM: To determine the influence of gap distance and its location on clinical and radiological outcomes in patients with acute rupture of Tendo-Achilles (TA) treated non-operatively with functional rehabilitation. METHODS: Twenty-six patients with acute complete TA rupture underwent ultrasound (US) scanning within a week of their injury. The measurements taken included the distance of the rupture from the enthesis and the gap distance between the tendon edges in varying degrees of ankle and knee positions. All patients were managed non-operatively in functional weight-bearing orthoses. Nineteen patients were then followed up at a mean of 6.1 years (range 5.8-6.5) to assess their clinical and radiological outcomes. The outcomes included ultrasound assessment of tendon healing, Achilles Tendon Rupture Score (ATRS) and modified Leppilahti Score (mLS). RESULTS: In the initial ultrasound, the mean distance of the rupture from the enthesis was 52 mm (range: 40-76). The mean gap distance with the foot plantigrade was 11.4 mm, which reduced to 4.8 mm with the foot in equinus. At final follow up, no re-ruptures had occurred. The mean ATRS and mLS were 86 and 71 respectively. There was a significant correlation between the distance of the rupture from the enthesis with the MLS total score (p = 0.02), mLS Fatigue domain score (p = 0.03), and the ATRS domains of strength (p = 0.04) and fatigue (p = 0.02). There was no significant correlation between the measured gap distance with respect to the mLS, ATRS or individual ATRS domain scores. Also, there was no significant difference in ATRS and mLS outcomes when comparing tendons with respect to healed tissue appearance and fibre orientation on ultrasound. CONCLUSION: The initial gap distance had no relationship with any of the measured clinical outcomes at the final follow up. The distance of the gap from the enthesis, however, may carry a greater prognostic value following non-operative treatment of Achilles tendon injuries.
Assuntos
Tendão do Calcâneo , Traumatismos do Tornozelo , Traumatismos dos Tendões , Humanos , Resultado do Tratamento , Tendão do Calcâneo/lesões , Modalidades de Fisioterapia , Traumatismos dos Tendões/diagnóstico por imagem , Traumatismos dos Tendões/terapia , Braquetes , Ruptura/terapia , Ruptura/reabilitação , Doença AgudaRESUMO
Diagnosis and Therapy of Acute Achilles Tendon Ruptures Abstract. Acute Achilles tendon ruptures are a common pathology and often affect young athletic patients. Diagnosis is mostly clinical and by ultrasound. Conservative and operative treatment algorithms exist. The result of the treatment is mostly influenced by the elongation of the tendon during healing. Operative procedures tend to lead to less elongation but have a complication risk. After-treatment should be functional to reduce complication rate and faster rehabilitation. Treatment results are good in general, but some weakness is often found on the injured side.
Assuntos
Tendão do Calcâneo , Traumatismos dos Tendões , Tendão do Calcâneo/diagnóstico por imagem , Tendão do Calcâneo/patologia , Tendão do Calcâneo/cirurgia , Humanos , Ruptura/diagnóstico , Ruptura/reabilitação , Ruptura/cirurgia , Traumatismos dos Tendões/diagnóstico , Traumatismos dos Tendões/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: Delayed treatment of Achilles tendon ruptures is generally due to either misdiagnosis or patient delay. When the treatment is delayed more than 4 weeks, the rupture is defined as "chronic", and almost always requires more invasive surgery and longer rehabilitation time compared with acute Achilles tendon ruptures. There is insufficient knowledge of patient experiences of sustaining and recovering from a chronic Achilles tendon rupture. METHODS: To evaluate patients' experiences of suffering a chronic Achilles tendon rupture, semi-structured group interviews were conducted 4-6 years after surgical treatment using a semi-structured interview guide. The data were analyzed using qualitative content analysis described by Graneheim and Lundman. RESULTS: The experiences of ten patients (65 ± 14 years, 7 males and 3 females) were summarized into four main categories: (1) "The injury", where the patients described immediate functional impairments, following either traumatic or non-traumatic injury mechanisms that were misinterpreted by themselves or the health-care system; (2) "The diagnosis", where the patients expressed relief in receiving the diagnosis, but also disappointment and/or frustration related to the prior misdiagnosis and delay; (3) "The treatment", where the patients expressed high expectations, consistent satisfaction with the surgical treatment, and addressed the importance of the physical therapist having the right expertise; and (4) "The outcomes", where the patients expressed an overall satisfaction with the long-term outcome and no obvious limitations in physical activity, although some fear of re-injury emerged. CONCLUSIONS: An Achilles tendon rupture can occur during both major and minor trauma and be misinterpreted by both the assessing health-care professional as well as the patient themselves. Surgical treatment and postoperative rehabilitation for chronic Achilles tendon rupture results in overall patient satisfaction in terms of the long-term outcomes. We emphasize the need for increased awareness of the occurrence of Achilles tendon rupture in patients with an atypical patient history.
Assuntos
Tendão do Calcâneo , Traumatismos do Tornozelo , Traumatismos dos Tendões , Tendão do Calcâneo/lesões , Tendão do Calcâneo/cirurgia , Feminino , Frustração , Humanos , Masculino , Avaliação de Resultados da Assistência ao Paciente , Satisfação do Paciente , Ruptura/reabilitação , Ruptura/cirurgia , Traumatismos dos Tendões/diagnóstico , Traumatismos dos Tendões/reabilitação , Traumatismos dos Tendões/cirurgia , Resultado do TratamentoRESUMO
Surgical repair of acute mid-substance Achilles tendon ruptures is performed in active patients, but the postoperative rehabilitation program is often based on the experience of the surgeon or therapist, rather than on evidence-based protocols. The aim of the study is to establish an evidence-based protocol for rehabilitation. This study is a consensus statement. The "GAIT" study group (German, American, and Italian Tendon), an informal collection of 4 experienced foot and ankle surgeons, met to address the question of what items they felt were important relative to rehabilitate a surgically repaired Achilles tendon acute rupture. Thirty-three statements were formulated. A value of 100% agreement by all the members was set to produce a proposed consensus statement. A value of 80% consensus was set to produce "strong recommendation." A systematic review of the literature was also performed. The GAIT group reach 100% agreement on the average postoperative non-weightbearing for 2.3 weeks, the foot in plantarflexion for the first 4 weeks, avoiding ROM exercises beyond neutral, and both stretching and eccentric exercise, not started before 12 weeks. Concentric bilateral heel raises should be performed after 6 weeks, and the average return to initiate sports, was 24.4 weeks. The use of a 1/8th-1/4th inch heel cushions in daily shoes after 8 weeks, the use of an antigravity treadmill for rehabilitation, and the return to sports based on heel raise repetitions is strongly recommended. Given lack of established verified protocols, the recommendations by our experienced panel should be considered. These proposed consensus statements could be used as a basis for larger controlled trials, and develop best practices.
Assuntos
Tendão do Calcâneo , Traumatismos dos Tendões , Tendão do Calcâneo/cirurgia , Humanos , Ruptura/reabilitação , Ruptura/cirurgia , Traumatismos dos Tendões/reabilitação , Traumatismos dos Tendões/cirurgia , Resultado do Tratamento , Suporte de CargaRESUMO
BACKGROUND: Achilles tendon rupture (ATR) is one of the most frequently encountered injuries in Sports Medicine. ATR can be managed surgically or conservatively followed by early functional rehabilitation or cast immobilization. The aim of the present systematic review and meta-analysis was to provide an update about the role of early weightbearing (WB) versus late WB on the clinical outcomes of adults with acute ATR. METHODS: We performed a systematic literature search in Web of Science, Ovid, Medline/PubMed, and CENTRAL. We included randomized controlled trials (RCTs) that compared early WB, defined as weight-bearing within 4 weeks of treatment, to late WB for individuals with acute (<14 days) ATR. We sought to evaluate the following outcomes: re-rupture rate, Achilles Tendon Rupture Score (ATRS), return to pre-injury sport activity, time to return to work, and adverse event rate. The standardized mean difference (SMD) was used to represent continuous outcomes while the risk ratio (RR) was used to represent dichotomous outcomes. RESULTS: A total of 9 RCTs that enrolled 1046 participants were deemed eligible. There was no significant difference between early WB and late WB in terms of re-rupture rate (RR=0.75, 95% CI 0.49 to 1.16), ATRS (SMD=0.06, 95% CI -0.03 to 0.16), return to pre-injury sport activity (RR=1.05, 95% CI 0.86 to 1.28), time to return to work (SMD=0.03, 95% CI -0.20 to 0.26), or adverse event rate (RR=1.87, 95% CI 0.53 to 6.63). CONCLUSION: This meta-analysis shows no difference in the functional outcomes and patient-reported outcomes between early functional rehabilitation and cast immobilization for conservatively treat individuals with acute ATR.
Assuntos
Tendão do Calcâneo , Tendão do Calcâneo/lesões , Adulto , Tratamento Conservador , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Ruptura/reabilitação , Resultado do Tratamento , Suporte de CargaRESUMO
The incidence of Achilles tendon rupture is increasing. Postoperative rehabilitation after repairing acute Achilles tendon rupture is very important because the choice of treatment during the rehabilitation period can influence the results. Moreover, the method of functional rehabilitation varies and is developing steadily. Recent studies recommend a functional rehabilitation protocol, and this approach is accepted widely. This study aimed to introduce our most accelerated functional rehabilitation protocol following surgery for acute Achilles tendon rupture and to review the results retrospectively. From July 2014 to July 2016, 67 patients underwent surgery for acute Achilles tendon rupture by one surgeon. Age, sex, body mass index, injury mechanism, rehabilitation method and progress, time to return to previous physical activity, and complications were evaluated. The mean time to be able to squat fully was 10 ± 4.7 (4-20) weeks. Full squatting was possible in 92.8% (52 patients). The mean time to perform a single-limb heel rise and repetitive single-limb heel rise was 12.6 ± 3.9 (6-24) and 23.3 ± 7.7 (8-40) weeks, respectively. The mean time to return to sports was 20.6 ± 5.2 (12-32) weeks. The major complication rate was 3.5% (one re-rupture and one tendon elongation). The mean pre- and postoperative Achilles Tendon Total Rupture Score was 29.5 ± 3.7 (20-38) and 79.3 ± 18.5 (20-98) points, respectively. The increase was significant (p < .01). In conclusion, immediate full weightbearing and ankle motion exercise after repair of acute Achilles tendon rupture can provide a good rehabilitation option with a low re-rupture rate and satisfactory functional results.
Assuntos
Tendão do Calcâneo , Traumatismos do Tornozelo , Traumatismos dos Tendões , Tendão do Calcâneo/lesões , Doença Aguda , Tornozelo , Humanos , Estudos Retrospectivos , Ruptura/reabilitação , Ruptura/cirurgia , Traumatismos dos Tendões/reabilitação , Resultado do Tratamento , Suporte de CargaRESUMO
The importance of the menisci in providing joint stability and their role in load transmission within the knee are well understood. A growing body of literature has emerged on 2 distinct injury patterns to these crucial anatomic structures, ramp lesions and root tears. Ramp lesions may be characterized as tears at the posterior meniscocapsular junction, while root tears involve bony or soft tissue avulsion of the meniscal insertions at the anterior or posterior intercondylar regions. In this 2-part review, we present an overview of the current available literature on ramp lesions and meniscal root tears, summarizing the unique anatomic considerations, etiology, biomechanics, management decisions, clinical outcomes pertinent to these very distinct injuries.
Assuntos
Lesões do Menisco Tibial , Lesões do Ligamento Cruzado Anterior/complicações , Artroscopia , Fenômenos Biomecânicos , Humanos , Imageamento por Ressonância Magnética , Ilustração Médica , Meniscos Tibiais/anatomia & histologia , Meniscos Tibiais/diagnóstico por imagem , Fatores de Risco , Ruptura/diagnóstico por imagem , Ruptura/etiologia , Ruptura/reabilitação , Ruptura/cirurgia , Lesões do Menisco Tibial/diagnóstico por imagem , Lesões do Menisco Tibial/etiologia , Lesões do Menisco Tibial/reabilitação , Lesões do Menisco Tibial/cirurgiaRESUMO
Injuries to the meniscus, particularly tears, can have significant negative impacts on pain, function, and quality of life. Preservation of the meniscus is favorable, especially in the athletic and active populations. While first line treatment is often nonoperative in nature, recalcitrant, and more complex tears, typically require surgery. Meniscus repair rates have increased significantly during the last 2 decades as surgical techniques and postoperative outcomes have improved. Longer postoperative timeframes are to be expected when compared with menisectomy, however, accelerated programs have demonstrated favorable outcomes. Rehabilitation and return to play guidelines should reflect the intricacies of the tear type and repair procedure. Close communication with the surgeon is a vital component to optimize patient outcomes. Further, the patient's goals and expected level of return to function, or sport, must be taken into account for a rehabilitation program to be fully successful.
Assuntos
Volta ao Esporte , Lesões do Menisco Tibial/reabilitação , Braquetes , Constrição , Terapia por Estimulação Elétrica , Exercício Físico , Humanos , Força Muscular , Tratamentos com Preservação do Órgão , Músculo Quadríceps/fisiologia , Qualidade de Vida , Amplitude de Movimento Articular , Fluxo Sanguíneo Regional , Retorno ao Trabalho , Ruptura/reabilitação , Ruptura/cirurgia , Lesões do Menisco Tibial/cirurgia , Suporte de CargaRESUMO
The optimal postoperative management of Achilles tendon (AT) rupture remains unknown. The past 2 decades have witnessed a trend toward less rigid immobilization, earlier weightbearing, and accelerated functional rehabilitation postoperatively. The objective of this study was to identify all high-quality studies pertaining to rehabilitation after AT repair and characterize the various rehabilitation protocols that have been described. A systematic review of the English-language literature was performed according to PRISMA guidelines. All included studies represented level 1, 2, or 3 evidence and examined postoperative rehabilitation protocols following the repair of an acute AT rupture. A total of 1187 subjects were included. Surgical technique, rehabilitation protocol, and outcome assessment varied widely between studies. Early postoperative weightbearing with less rigid immobilization appears to accelerate short-term functional recovery. An aggressive rehabilitation program may also be advantageous in the short term, but further studies are needed to determine the long-term effects of these accelerated physical therapy and return-to-play protocols.
Assuntos
Tendão do Calcâneo/lesões , Tendão do Calcâneo/cirurgia , Traumatismos dos Tendões/reabilitação , Traumatismos dos Tendões/cirurgia , Terapia Combinada , Humanos , Medidas de Resultados Relatados pelo Paciente , Cuidados Pós-Operatórios , Recuperação de Função Fisiológica , Ruptura/reabilitação , Ruptura/cirurgiaRESUMO
PURPOSE: This study aims to measure the distance between the common site of Achilles tendon rupture and calcaneal insertion through ultrasound and to compare the outcomes between proximal and distal rupture groups. METHODS: We investigated the electronic medical records of 117 patients and preoperative ultrasound describing the rupture site. Among 88 patients, we compared the patient-reported outcome and re-rupture rate of proximal and distal rupture groups. RESULTS: The mean rupture site of the 117 included subjects was 4.5 ± 1.3 cm. The rupture site had a weak negative correlation with body mass index (ρ = -0.230, P = 0.013). Furthermore, 77% of the patients with distal rupture reported good outcome (Achilles Tendon Rupture Score > 80) compared to 56% of the patients with proximal rupture (P = 0.041). CONCLUSION: Patients with proximal rupture had less satisfactory postoperative outcomes than those with distal rupture.
Assuntos
Tendão do Calcâneo/lesões , Tendão do Calcâneo/cirurgia , Ruptura/cirurgia , Traumatismos dos Tendões/cirurgia , Tendão do Calcâneo/patologia , Adolescente , Adulto , Idoso , Calcâneo/cirurgia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Medidas de Resultados Relatados pelo Paciente , Prognóstico , Procedimentos de Cirurgia Plástica/efeitos adversos , Procedimentos de Cirurgia Plástica/métodos , Procedimentos de Cirurgia Plástica/reabilitação , Procedimentos de Cirurgia Plástica/estatística & dados numéricos , Estudos Retrospectivos , Ruptura/diagnóstico , Ruptura/patologia , Ruptura/reabilitação , Traumatismos dos Tendões/diagnóstico , Traumatismos dos Tendões/patologia , Traumatismos dos Tendões/reabilitação , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Despite surgical reconstruction and extensive rehabilitation, persistent quadriceps inhibition, gait asymmetry, and functional impairment remain prevalent in patients after anterior cruciate ligament (ACL) injury. A combination of reports have suggested underlying central nervous system adaptations in those after injury govern long-term neuromuscular impairments. The classic assumption has been to attribute neurophysiologic deficits to components of injury, but other factors across the continuum of care (e.g. surgery, perioperative analgesia, and rehabilitative strategies) have been largely overlooked. OBJECTIVE: This review provides a multidisciplinary perspective to 1) provide a narrative review of studies reporting neuroplasticity following ACL injury in order to inform clinicians of the current state of literature and 2) provide a mechanistic framework of neurophysiologic deficits with potential clinical implications across all phases of injury and recovery (injury, surgery, and rehabilitation) RESULTS: Studies using a variety of neurophysiologic modalities have demonstrated peripheral and central nervous system adaptations in those with prior ACL injury. Longitudinal investigations suggest neurophysiologic changes at spinal-reflexive and corticospinal pathways follow a unique timecourse across injury, surgery, and rehabilitation. CONCLUSION: Clinicians should consider the unique injury, surgery, anesthesia, and rehabilitation on central nervous system adaptations. Therapeutic strategies across the continuum of care may be beneficial to mitigate maladaptive neuroplasticity in those after ACL injury.
Assuntos
Lesões do Ligamento Cruzado Anterior/cirurgia , Reconstrução do Ligamento Cruzado Anterior/efeitos adversos , Reconstrução do Ligamento Cruzado Anterior/reabilitação , Sistema Nervoso Central/fisiologia , Ruptura/reabilitação , Adaptação Fisiológica , Lesões do Ligamento Cruzado Anterior/diagnóstico por imagem , Lesões do Ligamento Cruzado Anterior/reabilitação , Sistema Nervoso Central/fisiopatologia , Potenciais Somatossensoriais Evocados , Marcha , Humanos , Bloqueio Nervoso/métodos , Neuroimagem , Músculo Quadríceps/fisiopatologia , Ruptura/cirurgiaRESUMO
BACKGROUND: The best treatment for acute Achilles tendon ruptures remains controversial. No cohort studies have compared different immobilisation durations after open surgery. This retrospective cohort study aimed to determine the optimal duration of immobilisation after this surgery. METHODS: A total of 266 patients with acute Achilles tendon rupture were divided into 4 groups (A, B, C, and D) according to immobilisation duration of 0, 2, 4, and 6 weeks, respectively. All patients underwent the same suture technique with a similar rehabilitation protocol and were examined clinically at 2, 4, 6, 8, 10, 12, 14, 16, 24, and 48 weeks, with a final follow-up at a mean of 22.3 months postoperatively. The primary outcome was the time of return to light sports activity (LSA). Secondary outcomes included range of motion (ROM) and single-legged heel rise height (SHRH). Data on operation time, complications, visual analogue pain scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, and Achilles tendon Total Rupture score (ATRS) were also collected. Demographic baseline data were analysed using one-way analysis of variance; outcome parameters were analysed using Kruskal-Wallis H test, and complications were analysed using Fisher's exact test. Statistical significance was considered at P ≤ 0.05. RESULTS: VAS scores decreased significantly, reaching 0 in all groups after 12 weeks. The AOFAS and ATRS scores were significantly different between the groups from weeks 2 to 12 (P<0.001) and weeks 2 to 16 (P<0.001), respectively. All the mean scores showed better results in group B than in the other groups. In terms of recovery time of ROM, SHRH, and LSA, groups A and B were significantly faster than groups C and D (P<0.001). There were 13 (13/266, 4.9%) complications: 5 superficial infections, 3 deep venous thrombosis, and 5 trauma-related re-ruptures. On the last follow-up, all complications had recovered. There were no significant differences in complications between the groups. CONCLUSIONS: Immobilisation for 2 weeks after this open surgery is the best choice for early rehabilitation and weight-bearing while minimising pain and other complications.
Assuntos
Tendão do Calcâneo/lesões , Tendão do Calcâneo/cirurgia , Imobilização/métodos , Procedimentos Ortopédicos/métodos , Ruptura/cirurgia , Traumatismos dos Tendões/cirurgia , Tendão do Calcâneo/fisiopatologia , Adulto , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Amplitude de Movimento Articular , Recuperação de Função Fisiológica , Estudos Retrospectivos , Ruptura/fisiopatologia , Ruptura/reabilitação , Traumatismos dos Tendões/fisiopatologia , Traumatismos dos Tendões/reabilitação , Fatores de Tempo , Resultado do Tratamento , Suporte de Carga , Adulto JovemRESUMO
BACKGROUND: Various rehabilitation treatments may be offered following surgery for flexor tendon injuries of the hand. Rehabilitation often includes a combination of an exercise regimen and an orthosis, plus other rehabilitation treatments, usually delivered together. The effectiveness of these interventions remains unclear. OBJECTIVES: To assess the effects (benefits and harms) of different rehabilitation interventions after surgery for flexor tendon injuries of the hand. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials, the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, MEDLINE, Embase, two additional databases and two international trials registries, unrestricted by language. The last date of searches was 11 August 2020. We checked the reference lists of included studies and relevant systematic reviews. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi-RCTs that compared any postoperative rehabilitation intervention with no intervention, control, placebo, or another postoperative rehabilitation intervention in individuals who have had surgery for flexor tendon injuries of the hand. Trials comparing different mobilisation regimens either with another mobilisation regimen or with a control were the main comparisons of interest. Our main outcomes of interest were patient-reported function, active range of motion of the fingers, and number of participants experiencing an adverse event. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials for inclusion, extracted data, assessed risk of bias and assessed the quality of the body of evidence for primary outcomes using the GRADE approach, according to standard Cochrane methodology. MAIN RESULTS: We included 16 RCTs and one quasi-RCT, with a total of 1108 participants, mainly adults. Overall, the participants were aged between 7 and 72 years, and 74% were male. Studies mainly focused on flexor tendon injuries in zone II. The 17 studies were heterogeneous with respect to the types of rehabilitation treatments provided, intensity, duration of treatment and the treatment setting. Each trial tested one of 14 comparisons, eight of which were of different exercise regimens. The other trials examined the timing of return to unrestricted functional activities after surgery (one study); the use of external devices applied to the participant to facilitate mobilisation, such as an exoskeleton (one study) or continuous passive motion device (one study); modalities such as laser therapy (two studies) or ultrasound therapy (one study); and a motor imagery treatment (one study). No trials tested different types of orthoses; different orthosis wearing regimens, including duration; different timings for commencing mobilisation; different types of scar management; or different timings for commencing strengthening. Trials were generally at high risk of bias for one or more domains, including lack of blinding, incomplete outcome data and selective outcome reporting. Data pooling was limited to tendon rupture data in a three trial comparison. We rated the evidence available for all reported outcomes of all comparisons as very low-certainty evidence, which means that we have very little confidence in the estimates of effect. We present the findings from three exercise regimen comparisons, as these are commonly used in clinical current practice. Early active flexion plus controlled passive exercise regimen versus early controlled passive exercise regimen (modified Kleinert protocol) was compared in one trial of 53 participants with mainly zone II flexor tendon repairs. There is very low-certainty evidence of no clinically important difference between the two groups in patient-rated function or active finger range of motion at 6 or 12 months follow-up. There is very low-certainty evidence of little between-group difference in adverse events: there were 15 overall. All three tendon ruptures underwent secondary surgery. An active exercise regimen versus an immobilisation regimen for three weeks was compared in one trial reporting data for 84 participants with zone II flexor tendon repairs. The trial did not report on self-rated function, on range of movement during three to six months or numbers of participants experiencing adverse events. The very low-certainty evidence for poor (under one-quarter that of normal) range of finger movement at one to three years follow-up means we are uncertain of the finding of zero cases in the active group versus seven cases in the immobilisation regimen. The same uncertainty applies to the finding of little difference between the two groups in adverse events (5 tendon ruptures in the active group versus 10 probable scar adhesion in the immobilisation group) indicated for surgery. Place and hold exercise regimen performed within an orthosis versus a controlled passive regimen using rubber band traction was compared in three heterogeneous trials, which reported data for a maximum of 194 participants, with mainly zone II flexor tendon repairs. The trials did not report on range of movement during three to six months, or numbers of participants experiencing adverse events. There was very low-certainty evidence of no difference in self-rated function using the Disability of the Arm, Shoulder and Hand (DASH) functional assessment between the two groups at six months (one trial) or at 12 months (one trial). There is very low-certainty evidence from one trial of greater active finger range of motion at 12 months after place and hold. Secondary surgery data were not available; however, all seven recorded tendon ruptures would have required surgery. All the evidence for the other five exercise comparisons as well as those of the other six comparisons made by the included studies was incomplete and, where available, of very low-certainty. AUTHORS' CONCLUSIONS: There is a lack of evidence from RCTs on most of the rehabilitation interventions used following surgery for flexor tendon injuries of the hand. The limited and very low-certainty evidence for all 14 comparisons examined in the 17 included studies means that we have very little confidence in the estimates of effect for all outcomes for which data were available for these comparisons. The dearth of evidence identified in this review points to the urgent need for sufficiently powered RCTs that examine key questions relating to the rehabilitation of these injuries. A consensus approach identifying these and establishing minimum study conduct and reporting criteria will be valuable. Our suggestions for future research are detailed in the review.
Assuntos
Traumatismos da Mão/reabilitação , Traumatismos dos Tendões/reabilitação , Adolescente , Adulto , Idoso , Viés , Criança , Terapia por Exercício/efeitos adversos , Terapia por Exercício/métodos , Exoesqueleto Energizado , Feminino , Traumatismos da Mão/cirurgia , Humanos , Imobilização , Terapia a Laser , Masculino , Pessoa de Meia-Idade , Contração Muscular/fisiologia , Cuidados Pós-Operatórios/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto/estatística & dados numéricos , Amplitude de Movimento Articular , Ruptura/reabilitação , Ruptura/cirurgia , Traumatismos dos Tendões/cirurgia , Terapia por Ultrassom , Adulto JovemRESUMO
OBJECTIVES: To compare re-rupture rate, functional and quality-of-life outcomes, return to sports and work, complications, and resource use in patients treated non-surgically with different rehabilitation regimens for Achilles tendon rupture. DESIGN: Systematic review and meta-analysis. METHODS: We performed a systematic literature search in PubMed, Embase, Scopus and the Cochrane Library through May 2020 to identify randomized controlled trials (RCTs) that included patients treated non-surgically for Achilles tendon rupture. All analyses were stratified according to rehabilitation protocols. RESULTS: Eight RCTs with a total of 978 patients were included. There was no significant difference about re-rupture rate (P=0.38), return to sports (P=0.85) and work (P=0.33), functional outcome (P=0.34), quality of life (P=0.50), and complication rate (P=0.29) between early weight bearing with functional ankle motion and traditional ankle immobilisation with non-weight bearing. Similarly, no significant difference in re-rupture rate (P=0.88), return to sports (P=0.45) and work (P=0.20), functional outcome (P=0.26), and complication rate (P=0.49) was seen between ankle immobilisation with non-weight bearing and early weight bearing without functional ankle motion. CONCLUSIONS: Traditional ankle immobilisation with non-weight bearing was not found to be superior to early weight bearing with or without functional ankle motion for patients treated non-surgically for Achilles tendon rupture. Clinicians may consider early weight bearing in functional brace as a safe and cost-effective alternative to non-weight bearing with plaster casting.
Assuntos
Tendão do Calcâneo/lesões , Imobilização/métodos , Ruptura/reabilitação , Suporte de Carga , Adulto , Idoso , Articulação do Tornozelo , Braquetes , Feminino , Necessidades e Demandas de Serviços de Saúde , Humanos , Imobilização/instrumentação , Masculino , Pessoa de Meia-Idade , Movimento , Aparelhos Ortopédicos , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Recidiva , Volta ao Esporte/estatística & dados numéricos , Retorno ao Trabalho/estatística & dados numéricos , Ruptura/complicações , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: The choice of the best therapeutic regimen for Acute Achilles Tendon Rupture (AATR) remains controversial. Our study aims to evaluate the efficacy and safety of therapeutic regimens in AATR patients using a network meta-analysis of data from clinical randomized controlled trials. MATERIAL/METHODS: The studies were abstracted from Medline, Embase, Web of Science, Google Scholar and the Cochrane Central Register of Controlled Trials. RCTs meeting the inclusion and exclusion criteria were selected. Statistical analyses were conducted using Stata software, version 14.0 (Stata Corporation, College Station, Texas, USA). RESULTS: 38 randomized controlled trials involving 2480 participants were included. The studies were published between 1981 and 2019. A total of 6 therapeutic regimens -open repair (OR), minimally invasive repair (MIR) and nonoperative treatment (non) combined with traditional standard rehabilitation (TSR) and accelerated functional rehabilitation (AFR) - were included in the literature. The treatments were ranked based on the Surface Under the Cumulative Ranking Curve (SUCRA) probability. In terms of the re-rupture rate, the therapeutic regimens were ranked as follows: OR&AFR, OR&TSR, MIR&AFR, MIR&TSR, nonoperative treatment &AFR and nonoperative treatment &TSR. In terms of the wound-related complication, the therapeutic regimens were ranked as follows: MIR&AFR, nonoperative treatment &AFR, MIR&TSR, nonoperative treatment &TSR, OR&AFR and OR&TSR. In terms of the sural nerve injury, the therapeutic regimens were ranked as follows: non, OR and MIR. In terms of the deep venous thrombosis, the therapeutic regimens were ranked as follows: MIR&AFR, OR&AFR, nonoperative treatment &AFR, OR&TSR, MIR&TSR and nonoperative treatment &TSR. In terms of the returning back to sport, the therapeutic regimens were ranked as follows: MIR&TSR, OR&AFR, OR&TSR, nonoperative treatment &AFR, nonoperative treatment &TSR and MIR&AFR. CONCLUSIONS: MIR can repair the ruptured Achilles tendon and narrow the tendon gap with low risk of complications. AFR is superior to TSR without increasing the risk of rerupture. MIR&AFR is the best therapeutic regime for AATR. More RCTs focused on AATR are needed to further indicate this conclusion.
Assuntos
Tendão do Calcâneo/lesões , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Metanálise em Rede , Procedimentos Ortopédicos/efeitos adversos , Procedimentos Ortopédicos/métodos , Complicações Pós-Operatórias/etiologia , Ruptura/cirurgia , Traumatismos dos Tendões/cirurgia , Doença Aguda , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/reabilitação , Procedimentos Ortopédicos/reabilitação , Complicações Pós-Operatórias/reabilitação , Ensaios Clínicos Controlados Aleatórios como Assunto , Ruptura/reabilitação , Traumatismos dos Tendões/reabilitação , Resultado do Tratamento , Adulto JovemRESUMO
PURPOSE: The purpose of this study was to evaluate concurrent validity of the heel-rise work test performed with use of the heel as a surrogate for the center of body mass. METHODS: The study was a validity study performed on a prospective cohort of consecutive patients. Forty-five patients were included in the study. The heel-rise work test estimates the total work performed by repeated heel-rises until fatigue. In this study, the heel-rise work was assessed by the linear encoder and a motion capture system simultaneously for validation. The linear encoder was attached to the patient's heel and reflective marker was attached to the pelvis and heel. Student's paired t-test, linear regression analysis and Bland Altman plots were used to estimate the measurement error of the linear encoder. RESULTS: The heel-rise work test overestimated the total work with 21.0% on the injured leg and 24.7% on the non-injured leg. Student's paired t-test showed no difference in measurement error between the limbs (n.s.). The linear regression analysis showed no difference in limb symmetry index between the two methods of heel-rise work estimation (a (slope) = 1.00, R = 0.94, p < 0.0001). CONCLUSION: The heel-rise work test performed using the heel as a surrogate for center of body mass overestimates the total work with 21.0-24.7% compared to a gold standard but was able to precisely detect the relative difference between the limbs. The heel marker can be considered a valid measurement device for assessing relative differences between the limbs. CLINICAL RELEVANCE: Clinical testing of injuries to the lower body using the heel-rise work test is valid when using the relative difference between the limbs. LEVEL OF EVIDENCE: I.
Assuntos
Tendão do Calcâneo/lesões , Tendão do Calcâneo/cirurgia , Teste de Esforço/métodos , Ruptura/reabilitação , Ruptura/cirurgia , Tendão do Calcâneo/fisiopatologia , Adulto , Feminino , Calcanhar , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Recuperação de Função Fisiológica , Reprodutibilidade dos Testes , Ruptura/fisiopatologia , Resultado do TratamentoRESUMO
Acute hamstring injuries are often caused by the heel hook technique. This technique is unique to climbing and causes injury to muscular and inert tissues of the posterior thigh. The heel hook is used by climbers during strenuous ascent on overhanging walls and when crossing difficult terrain. The technique reduces the amount of upper body strength required during strenuous climbing because the climber's center of mass is retained within the base of support. The heel hook is stressful collectively for the hamstring muscle group and musculotendinous junction. Depending on injury severity, both conservative and surgical methods exist for the management of hamstring injuries. Contemporary approaches to rehabilitation primarily advocate the use of eccentric muscle strengthening strategies because of high rates of elongation stress associated with sprinting and team sports. However, there is reason to doubt whether this alone is sufficient to rehabilitate the climbing athlete in light of the high degree of concentric muscle strength required in the heel hook maneuver. This review examines the contemporary rehabilitation and strength and conditioning literature in relation to the management of acute hamstring musculotendinous injuries for the climbing athlete. The review provides a comprehensive approach for the rehabilitation and athletic preparation of the climbing athlete from the initial injury to full return to sports participation.
Assuntos
Traumatismos em Atletas/reabilitação , Músculos Isquiossurais/lesões , Ruptura/reabilitação , Fenômenos Biomecânicos , Humanos , Traumatismos da Perna , Músculo Esquelético/lesões , Músculo Esquelético/patologia , Fatores de Risco , EsportesRESUMO
After an Achilles tendon (AT) injury, the decision to return to full weightbearing for the practice of sports or strenuous activities is based on clinical features only. In this study, tendon stiffness and foot plantar pressure, as objective quantitative measures that could potentially inform clinical decision making, were repeatedly measured in 15 patients until 3 months after the AT rupture by using shear wave elastography (SWE) and wearable insoles, respectively. Meanwhile, patient reported outcomes assessing the impact on physical activity were evaluated using the Achilles Tendon Total Rupture Score (ATRS). At week-2 post-injury, stiffness of the injured tendon varied from 6.00 ± 1.62 m/s (mean ± SD) close to the rupture to 8.91 ± 2.29 m/s when measured more distally. While near complete recovery was observed in distal and middle regions at week-8, the shear wave velocity in the proximal region recovered to only 65% of the contralateral value at week-12. In a parallel pre-clinical study, the tendon stiffness measured in vivo by SWE in a rat model was found to be strongly correlated with ex vivo values of the Young's modulus, which attests to the adequacy of SWE for these measures. The insole derived assessment of the plantar pressure distribution during walking showed slight sub-optimal function of the affected foot at week-12, while the ATRS score recovered to a level of 59 ± 16. Significant correlations found between tendon stiffness, insole variables and distinct ATRS activities, suggest clinical relevance of tendon stiffness and foot plantar pressure measurements. These results illustrate how an alteration of the AT structure can impact daily activities of affected patients and show how digital biomarkers can track recovery in function over time.
Assuntos
Técnicas de Imagem por Elasticidade/métodos , Marcha/fisiologia , Medidas de Resultados Relatados pelo Paciente , Recuperação de Função Fisiológica , Ruptura/reabilitação , Traumatismos dos Tendões/fisiopatologia , Traumatismos dos Tendões/reabilitação , Tendão do Calcâneo/lesões , Tendão do Calcâneo/fisiopatologia , Animais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ratos , Ratos Sprague-Dawley , Ruptura/fisiopatologia , Resultado do Tratamento , Caminhada , Suporte de CargaRESUMO
OBJECTIVES: To (1) describe which resistance exercises are used in the first 8 weeks of treatment for acute Achilles tendon rupture and (2) assess the completeness of reporting of the exercise descriptions. DESIGN: Scoping review. LITERATURE SEARCH: We searched the MEDLINE, Embase, CINAHL, Cochrane Library, and Physiotherapy Evidence Database (PEDro) databases. STUDY SELECTION CRITERIA: Randomized controlled trials, cohort studies, and case series (10 or more participants) that reported using resistance exercise in the immobilization period in the first 8 weeks of treatment for acute Achilles tendon rupture were included. DATA SYNTHESIS: Completeness of exercise description was assessed with the Consensus on Exercise Reporting Template (CERT) and the Toigo and Boutellier exercise descriptor framework. RESULTS: Thirty-eight studies were included. Fifty-one resistance exercises were extracted and categorized as isometric exercises (n = 20), heel raises (n = 6), strengthening with external resistance (n = 13), or unspecified (n = 12). A median of 8 (interquartile range, 6-10) of a possible 19 CERT items was reported. The amount of items described of the 13 Toigo and and Boutellier exercise descriptors ranged from 0 to 11. CONCLUSION: A variety of resistance exercises targeted at the ankle plantar flexors were used as part of early functional rehabilitation after Achilles tendon rupture. However, most studies provided inadequate description of resistance exercise interventions. J Orthop Sports Phys Ther 2020;50(12):681-691. Epub 23 Oct 2020. doi:10.2519/jospt.2020.9463.