Skip to main content
PMC home page
British Journal of Sports Medicine logoLink to British Journal of Sports Medicine
. 2001 Oct;35(5):329–333. doi: 10.1136/bjsm.35.5.329

The relative stress on the Achilles tendon during ambulation in an ankle immobiliser: implications for rehabilitation after Achilles tendon repair

K Akizuki 1, E Gartman 1, B Nisonson 1, S Ben-Avi 1, M McHugh 1
PMCID: PMC1724396  PMID: 11579067

Abstract

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.

Key Words: Achilles tendon; EMG; heel lifts; soleus; gastrocnemius

Full Text

The Full Text of this article is available as a PDF (139.9 KB).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Aoki M., Ogiwara N., Ohta T., Nabeta Y. Early active motion and weightbearing after cross-stitch achilles tendon repair. Am J Sports Med. 1998 Nov-Dec;26(6):794–800. doi: 10.1177/03635465980260061001. [DOI] [PubMed] [Google Scholar]
  2. Benum P., Berg V., Fretheim O. J. The strain on sutured Achilles tendons in walking cast. An EMG analysis. Eur Surg Res. 1984;16 (Suppl 2):14–21. doi: 10.1159/000128616. [DOI] [PubMed] [Google Scholar]
  3. Booth F. W. Effect of limb immobilization on skeletal muscle. J Appl Physiol Respir Environ Exerc Physiol. 1982 May;52(5):1113–1118. doi: 10.1152/jappl.1982.52.5.1113. [DOI] [PubMed] [Google Scholar]
  4. Booth F. W. Physiologic and biochemical effects of immobilization on muscle. Clin Orthop Relat Res. 1987 Jun;(219):15–20. [PubMed] [Google Scholar]
  5. Bradley J. P., Tibone J. E. Percutaneous and open surgical repairs of Achilles tendon ruptures. A comparative study. Am J Sports Med. 1990 Mar-Apr;18(2):188–195. doi: 10.1177/036354659001800213. [DOI] [PubMed] [Google Scholar]
  6. Carter T. R., Fowler P. J., Blokker C. Functional postoperative treatment of Achilles tendon repair. Am J Sports Med. 1992 Jul-Aug;20(4):459–462. doi: 10.1177/036354659202000417. [DOI] [PubMed] [Google Scholar]
  7. Cetti R. Ruptured Achilles tendon--preliminary results of a new treatment. Br J Sports Med. 1988 Mar;22(1):6–8. doi: 10.1136/bjsm.22.1.6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Crosby C. A., Wehbé M. A. Early motion protocols in hand and wrist rehabilitation. Hand Clin. 1996 Feb;12(1):31–41. [PubMed] [Google Scholar]
  9. Enwemeka C. S., Spielholz N. I., Nelson A. J. The effect of early functional activities on experimentally tenotomized Achilles tendons in rats. Am J Phys Med Rehabil. 1988 Dec;67(6):264–269. [PubMed] [Google Scholar]
  10. Finni T., Komi P. V., Lukkariniemi J. Achilles tendon loading during walking: application of a novel optic fiber technique. Eur J Appl Physiol Occup Physiol. 1998 Feb;77(3):289–291. doi: 10.1007/s004210050335. [DOI] [PubMed] [Google Scholar]
  11. Gelberman R. H., Manske P. R., Vande Berg J. S., Lesker P. A., Akeson W. H. Flexor tendon repair in vitro: a comparative histologic study of the rabbit, chicken, dog, and monkey. J Orthop Res. 1984;2(1):39–48. doi: 10.1002/jor.1100020107. [DOI] [PubMed] [Google Scholar]
  12. Gelberman R. H., Menon J., Gonsalves M., Akeson W. H. The effects of mobilization on the vascularization of healing flexor tendons in dogs. Clin Orthop Relat Res. 1980 Nov-Dec;(153):283–289. [PubMed] [Google Scholar]
  13. Gelberman R. H., Vande Berg J. S., Lundborg G. N., Akeson W. H. Flexor tendon healing and restoration of the gliding surface. An ultrastructural study in dogs. J Bone Joint Surg Am. 1983 Jan;65(1):70–80. [PubMed] [Google Scholar]
  14. Gelberman R. H., Woo S. L., Lothringer K., Akeson W. H., Amiel D. Effects of early intermittent passive mobilization on healing canine flexor tendons. J Hand Surg Am. 1982 Mar;7(2):170–175. doi: 10.1016/s0363-5023(82)80083-x. [DOI] [PubMed] [Google Scholar]
  15. Inglis A. E., Scott W. N., Sculco T. P., Patterson A. H. Ruptures of the tendo achillis. An objective assessment of surgical and non-surgical treatment. J Bone Joint Surg Am. 1976 Oct;58(7):990–993. [PubMed] [Google Scholar]
  16. Komi P. V., Fukashiro S., Järvinen M. Biomechanical loading of Achilles tendon during normal locomotion. Clin Sports Med. 1992 Jul;11(3):521–531. [PubMed] [Google Scholar]
  17. Komi P. V., Salonen M., Järvinen M., Kokko O. In vivo registration of Achilles tendon forces in man. I. Methodological development. Int J Sports Med. 1987 Mar;8 (Suppl 1):3–8. doi: 10.1055/s-2008-1025697. [DOI] [PubMed] [Google Scholar]
  18. Mandelbaum B. R., Myerson M. S., Forster R. Achilles tendon ruptures. A new method of repair, early range of motion, and functional rehabilitation. Am J Sports Med. 1995 Jul-Aug;23(4):392–395. doi: 10.1177/036354659502300403. [DOI] [PubMed] [Google Scholar]
  19. Mortensen H. M., Skov O., Jensen P. E. Early motion of the ankle after operative treatment of a rupture of the Achilles tendon. A prospective, randomized clinical and radiographic study. J Bone Joint Surg Am. 1999 Jul;81(7):983–990. doi: 10.2106/00004623-199907000-00011. [DOI] [PubMed] [Google Scholar]
  20. Mortensen N. H., Saether J. Achilles tendon repair: a new method of Achilles tendon repair tested on cadaverous materials. J Trauma. 1991 Mar;31(3):381–384. [PubMed] [Google Scholar]
  21. Nistor L. Surgical and non-surgical treatment of Achilles Tendon rupture. A prospective randomized study. J Bone Joint Surg Am. 1981 Mar;63(3):394–399. [PubMed] [Google Scholar]
  22. PEACOCK E. E., Jr BIOLOGICAL PRINCIPLES IN THE HEALING OF LONG TENDONS. Surg Clin North Am. 1965 Apr;45:461–476. doi: 10.1016/s0039-6109(16)37543-0. [DOI] [PubMed] [Google Scholar]
  23. Rothman R. H., Slogoff S. The effect of immobilization on the vascular bed of tendon. Surg Gynecol Obstet. 1967 May;124(5):1064–1066. [PubMed] [Google Scholar]
  24. Saw Y., Baltzopoulos V., Lim A., Rostron P. K., Bolton-Maggs B. G., Calver R. F. Early mobilization after operative repair of ruptured Achilles tendon. Injury. 1993 Aug;24(7):479–484. doi: 10.1016/0020-1383(93)90155-y. [DOI] [PubMed] [Google Scholar]
  25. Shields C. L., Jr, Kerlan R. K., Jobe F. W., Carter V. S., Lombardo S. J. The Cybex II evaluation of surgically repaired Achilles tendon ruptures. Am J Sports Med. 1978 Nov-Dec;6(6):369–372. doi: 10.1177/036354657800600610. [DOI] [PubMed] [Google Scholar]
  26. Soma C. A., Mandelbaum B. R. Repair of acute Achilles tendon ruptures. Orthop Clin North Am. 1995 Apr;26(2):239–247. [PubMed] [Google Scholar]
  27. Speck M., Klaue K. Early full weightbearing and functional treatment after surgical repair of acute achilles tendon rupture. Am J Sports Med. 1998 Nov-Dec;26(6):789–793. doi: 10.1177/03635465980260060901. [DOI] [PubMed] [Google Scholar]
  28. Sölveborn S. A., Moberg A. Immediate free ankle motion after surgical repair of acute Achilles tendon ruptures. Am J Sports Med. 1994 Sep-Oct;22(5):607–610. doi: 10.1177/036354659402200507. [DOI] [PubMed] [Google Scholar]
  29. Troop R. L., Losse G. M., Lane J. G., Robertson D. B., Hastings P. S., Howard M. E. Early motion after repair of Achilles tendon ruptures. Foot Ankle Int. 1995 Nov;16(11):705–709. doi: 10.1177/107110079501601106. [DOI] [PubMed] [Google Scholar]
  30. Watson T. W., Jurist K. A., Yang K. H., Shen K. L. The strength of Achilles tendon repair: an in vitro study of the biomechanical behavior in human cadaver tendons. Foot Ankle Int. 1995 Apr;16(4):191–195. doi: 10.1177/107110079501600404. [DOI] [PubMed] [Google Scholar]
  31. Wills C. A., Washburn S., Caiozzo V., Prietto C. A. Achilles tendon rupture. A review of the literature comparing surgical versus nonsurgical treatment. Clin Orthop Relat Res. 1986 Jun;(207):156–163. [PubMed] [Google Scholar]

Articles from British Journal of Sports Medicine are provided here courtesy of BMJ Publishing Group

RESOURCES