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This section features a recent systematic review that is indexed on PEDro, the Physiotherapy Evidence Database (http://www.pedro.org.au). PEDro is a free, web-based database of evidence relevant to physiotherapy.
▸ Huang J, Weng C, Ma X, et al. Rehabilitation regimen after surgical treatment of acute achilles tendon ruptures. Am J Sports Med 2015;43:1008–16.
Although the Achilles tendon (AT) is the largest and strongest tendon in the body, it is often ruptured. Following operative repair, the treated lower leg is typically immobilised in a cast. In order to reduce the risk of complications arising from immobilisation, such as scar adhesions, delayed wound healing and ankle stiffness, some studies have investigated whether early rehabilitation is an optimal approach to treatment. In practice this involves ankle range of motion exercises begun within a week or two of surgery. However, the role of early weightbearing through injured limb is still unclear.
This systematic review aimed to investigate the effectiveness of early functional rehabilitation following surgical repair of an AT rupture. Early weightbearing combined with early ankle motion exercises; and early ankle motion exercises alone, were compared to complete immobilisation.
Searches and inclusion criteria
The search identified randomised controlled trials (RCTs), quasi-randomised studies or prospective comparative studies indexed on MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials databases since 1990. Two authors conducted screening for inclusion and data extraction independently and discussed discrepancies to reach consensus. The review included RCTs and comparative studies that recruited adults who had received open operative repair within 7 days of an AT rupture. Studies that were retrospective, or included patients with re-ruptures or delayed (>3 weeks) presentation were excluded.
The control condition was immobilisation without exercises or weightbearing for longer than 4 weeks following surgery. The two early rehabilitation regimens compared to control were:
Weightbearing and range of motion exercises within 2 weeks of surgery;
Range of motion exercises within 2 weeks of surgery without weightbearing.
Main outcome measures
The primary outcome measurements for the review were not prespecified by the authors. Rather, all outcomes described in the source studies were reported. Important patient-centred outcomes included; time to return to sports, and to work, return to normal range of motion, heel-raise ability, rates of re-rupture, major complications and minor complications.
The analyses compared complete immobilisation with; early weightbearing and ankle motion exercise, and with ankle motion exercise (without weightbearing). Heterogeneity was assessed using I² test. Fixed-effects models were used when I² was less than 50% and random-effects models when above. Pooled effects were estimated using ORs for dichotomous data and weighted mean differences for continuous data, with 95% CIs.
The review included nine studies published between 1994 and 2007 with a total of 402 patients. In the first comparison, there were six studies that administered a combined early weightbearing and early ankle motion exercises programme, and in the second, three used active or passive early ankle motion exercises only, ie, without weightbearing. Most of the outcomes were significantly better for patients who underwent early weightbearing and ankle motion exercises than for those who underwent cast immobilisation. These included shorter time to the return to normal activities such as sports (p<0.0001), greater heel-raise ability (p=0.05) and achievement of normal ankle range of motion (p=0.03). Patients who underwent early ankle motion exercises without early weightbearing did not have significantly different ankle joint range of motion or strength compared to those who were immobilised. The two early intervention regimens and control had similar rates of re-rupture and major complications, but there were lower rates of minor complications in the early rehabilitation groups.
The lack of comparison between different early functional protocols in the RCTs means that there is little evidence to guide the choice of one particular regimen or another. The study quality and levels of evidence were mentioned in methods, but not used to interpret the data, hence it is not known whether the findings are biased due to poor study quality. For instance, of the nine included studies, only one was blinded and four were strictly randomised, further, there were very few patients included in many of the analyses. Critically, all conclusions are based on the p values for between group differences, rather than the size of the effects. This means that it is unclear whether the differences between groups are large enough to be clinically meaningful. Finally, the primary outcomes and follow-up times were not clearly defined prior to conducting the study.
Patients reported better outcomes on a range of measures when they received early range of motion exercises and weightbearing, as opposed to rigid immobilisation following operative repair of their AT rupture. The same benefits are not apparent from range of motion exercises alone, that is, beneficial early rehabilitation programmes require a weightbearing component. Unfortunately, there are few details regarding the specific make up of early rehabilitation programmes and the size of the effects are unclear.
Early rehabilitation does not appear to increase the rate of re-rupture or other major complications but this finding should be regarded cautiously until studies with greater statistical power have been conducted. For this reason early weightbearing and range of motion interventions should be administered carefully and progressed slowly, particularly in the very early stages after surgery.
Contributors FAC and SJK interpreted the systematic review, wrote and reviewed drafts. Both authors approved the final version.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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