In previous literature [11], on average, the complete Achilles tendon injury is associated with a prolonged rehabilitation period (not less than 6 months) and a 10 to 30% sometimes permanent strength deficit.
Our early functional rehabilitation protocol is in line with the previous literature, including a variety of different exercise-based intervention. Concerning anearly recovery of full weight bearing, the clinical results are controversial [12]: in a systematic review, Mc Cormack et al. [13] concluded that early function rehabilitation, includes weight bearing initiated within first two weeks, is associated with higher patient satisfaction level, minimizing patients disability. Ankle range of motion was the most commonly included intervention [14] followed by progressive isometric strengthening of sural triceps. Many authors [14, 15] suggest that fast rehabilitation programs after open achilles tenorraphy allows to accelerate and facilitate the physiological repair process of the tendon suture, bringing a faster recovery of daily life activities and a return to pre-injury sports performance. Moreover, Maffulli et al. [16] reported that better satisfaction rate is due to shorter recovery time and less negative influence on daily life correlated with prolonged use of cast and immobilization.
In their study, Twaddle and Poon [17] suggest that the lower risk of recurrence and the apparently better outcome of surgical treatment compared to the conservative one can be attributed to the reduced immobilization that characterizes open surgery compared to the conservative method. They demonstrated that early mobilization affects both clinical outcome and relapse rates, as does surgery.
Kangas et al. [18] analysed fifty patients with acute Achilles tendon rupture which were randomized postoperatively to receive either early movement of the ankle between neutral and plantar flexion in a brace for 6 weeks of immobilization in tension using a below-knee cast with the ankle in a neutral position for 6 weeks. Tendon elongation occurred in both groups but was somewhat less in the early motion group (median 2 mm in the early motion group vs median 5 mm in the cast group a mean of 60 weeks postoperatively, P = 0.054). The elongation curves first rose and then slowly fell in both groups. The patients who had less elongation achieved a better clinical outcome (P = 0.042, P = 0.017). The authors concluded that Achilles tendon elongation was somewhat less in the early motion group and correlated with the clinical outcome scores and recommend early functional postoperative treatment after Achilles rupture repair.
This generalized increased in volume, mostly on medial third of tendon, is due to surgical scar. Also we noticed that the proximal width, at the medial and distal regions, was increased in patients who underwent accelerated rehabilitation program compared to the ones treated with the standard one. The depth at the medial third, is the value who suffered more variation between the healthy tendon and the operated one, increase less with the accelerated rehabilitation program compared to the standard one.
Regarding the distal depth, in contrast to what observed on the healthy side, it increased in tendons treated with accelerated rehabilitation program but it is not statistically relevant.
The proximal, middle and distal third width in the case of patients treated with the accelerated protocol is higher than that of patients treated with the standard. Again, the fact that there is no statistically significant difference is due to the sample size. If the tendon is larger, it may mean that giving an accelerated mobilization stimulates more collagen deposition, this could be a protective factor against recurrence even if subjected to greater loads. The same reasoning can be performed on the proximal and distal depth values increased more with the accelerated method. On the other hand, the depth value in the middle third seems to contrast with the theory of greater collagen deposition as it appears to have increased less with the accelerated protocol compared to the standard one.
Although the results are not always uncontroversial between standard and accelerated protocols, in both cases the patients regain high levels of functional recovery. This evidence is due to the use of reliable surgical suture technique and development of suture material, combined with a rehabilitation program can be effective in reducing elongation of tendon and prevent re-rupture. At the time of data collect the patients had resumed work, the activities of daily life and completed the program for the return to sports. Regardless of the rehabilitation protocol it has been observed that the people who performed the postoperative physiotherapy more rigorously are also those who, as a rule, have the best outcome.
However accelerated protocol seems to provide positive aspects: first off all, according to Huang et al. [19] faster mobility of the ankle joint produced a better restoration of articular range of motion, with an improvement of local edema and to prevent stiffness and calf atrophy [20]. Moreover in previous literature [21] early weight bearing and faster recovery of ankle range of motion is linked to a reduction of some complications, as scarring adhesions, abnormal sensation and a fewer risk of deep vein thrombosis. The patient has to remove the brace several times during the day, so it is important recognize patient’s compliance. The walker is easy to manage by the patient, the level of constriction of the brace can be regulated by straps and it makes him autonomous in removing wedges. The disadvantages of the accelerated protocol compared to the standard lie mainly in the fact that the patient has to bear the cost of purchasing the walker brace, as it is not provided by the NHS. Elective cases suitable for accelerated program rehabilitation are reliable patients who can join the rehabilitation program, especially to restore mobilization and muscles function. Young and sportive patient are theoretically ideal case, but it is important to underline that the compliance of the patient is mandatory to avoid suture dehiscence.
Regarding clinical and functional outcomes, Ryu et al. [22] reported a case series of 112 patients treated with early rehabilitation for acute tear of Achilles tendons. All patients included in this study were fully satisfied, with an AOFAS score at 1 year follow up of 95.7. In a previous study, Kim [23] et al. compared functional results between a patients treated with an early rehabilitation protocol and patients treated with immobilization in cast. In this study the AOFAS score was slightly higher in the earlier group (93 compared to 89 of the cast group) with a statistically significant difference (p < 0.05). This result is comparable with the outcome reported in our series (92.2), although the difference is not statistically significant; this date is probably due to a low sample size of our study.
We agree with Porter and Shadbott [11] who demonstrated that an immediate mobilization after surgical Achilles tendon repair reduces tendon lengthening and time to return to sports, but it leads to similar Achilles tendon total rupture score relative to the standard rehabilitation. However, early functional rehabilitation has lacked a standardized definition, intervention and outcomes measures are highly variable [14].
After a surgical repair normally there is a lengthening of the tendon caused by separation of the tendon ends and by an elongation proximally and distally to the rupture site. The first matter can be reduced by a meticulous suture technique with appropriate suture wires; the second matter can be avoided, or reduced, by early mobilizations as evidenced by Kangas et al [15]. The authors showed in a randomized controlled trial that tendon elongation occurred both in early mobilization patients group both in immobilization patients group, but less in the early motion group and so this group of patient achieved a better clinical outcome. These evidences seem to favor adoption of this faster rehabilitation protocol especially in suitable and compliant patients. Benefits can be observed not only in terms of functional results but also in terms of tendon elasticity. Pathological processes at the level of the Achilles tendon, as for many other tissues, modify its physical characteristics of elasticity, viscoelasticity and mechanics. These modifications in turn influence the performance of the tendon causing the clinical symptoms. These alterations can be assessed through histological and biomechanical investigations which, however, as invasive, are not suitable for a clinical context such as post-surgery follow-up. So, ES has demonstrated to be a quick, relatively inexpensive, safe examination and therefore can be performed over time as many times as necessary without subjecting the patient to radiation. Furthermore, no special instruments are required but it is performed with a special ultrasound as it is equipped with additional software and hardware to determine the elasticity of the tissues, this factor brings both an economic and practical advantage for the radiologist who will not have to acquire additional skills. However, ultrasound is a method influenced by operator and it requires many hours of experience to be performed and interpreted in the most correct way.
The limits of the study are the limited sample size and the lack of randomization and double blindness. These last two points could have influenced the homogeneity of the patients assigned to the two clinical-rehabilitative treatments (standard protocol vs accelerated protocol) or have introduced potential prejudices in favor of one treatment rather than the other.