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The relative stress on the Achilles tendon during ambulation in an ankle immobiliser: implications for rehabilitation after Achilles tendon repair
  1. K H Akizuki1,
  2. E J Gartman1,
  3. B Nisonson2,
  4. S Ben-Avi3,
  5. M P McHugh1
  1. 1Nicholas Institute of Sports Medicine and Athletic Trauma, Lenox Hill Hospital, New York, NY, USA
  2. 2Department of Orthopaedics, Lenox Hill Hospital
  3. 3School of Engineering, The Cooper Union for the Advancement of Science and Art, New York, NY, USA
  1. Correspondence to: Dr McHugh, Director of Research, Nicholas Institute of Sports Medicine and Athletic Trauma, Lenox Hill Hospital, 130 East 77th Street, New York, NY 10021, USA mchugh{at}


Background—After Achilles tendon repair, immediate weightbearing and immobilisation closer to neutral plantarflexion are thought to limit atrophy and stiffness, but may place deleterious stress on the repair.

Objectives—To estimate the relative stress on the Achilles tendon during weightbearing with immobilisation in varying degrees of plantarflexion.

Methods—Electromyographic (EMG) activity from the plantarflexors was recorded during walking in 10 subjects (six men, four women) without ankle pathology. Four walking conditions were examined: (a) normal walking; (b) immobilised (cam-walker) in neutral plantarflexion; (c) immobilised with a 0.5 inch heel lift; (d) immobilised with a 1 inch heel lift. EMG activity relative to plantarflexor torque was determined for each subject during isometric contractions at 25%, 50%, 75%, and 100% of maximal voluntary contraction (MVC). EMG activity during walking was calculated as a percentage of MVC based on the EMG-torque relation during graded isometric contractions.

Results—During normal walking, the plantarflexor torque was estimated to be 30 (12)% (mean (SD)) of MVC, compared with 21 (15)% MVC for immobilisation in neutral (p<0.05), 17 (15)% MVC with the addition of a 0.5 inch heel lift (p<0.01), and 12 (12)% MVC with the addition of a 1 inch heel lift (p<0.01). The 1 inch heel lift resulted in less than 10° plantarflexion in all subjects.

Conclusions—When the ankle is immobilised, stress on the Achilles tendon is determined by the degree of plantarflexion and the contractile activity of the plantarflexors. In the immobilised ankle, the addition of a 1 inch heel lift was sufficient to minimise plantarflexor activity during walking.

  • Achilles tendon
  • EMG
  • heel lifts
  • soleus
  • gastrocnemius

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