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Weakness in End-Range Plantar Flexion After Achilles Tendon Repair

From the Nicholas Institute of Sports Medicine & Athletic Trauma, Lenox Hill Hospital, New York, New York

^* Address correspondence to Michael J. Mullaney, MPT, Nicholas Institute of Sports Medicine & Athletic Trauma, Lenox Hill Hospital, 130 East 77th Street, New York, NY 10021 (e-mail: mike{at}nismat.org).

Background: Separation of tendon ends after Achilles tendon repair may affect the tendon repair process and lead to postoperative end-range plantarflexion weakness.

Hypothesis: Patients will have disproportionate end-range plantarflexion weakness after Achilles tendon repair.

Study Design: Descriptive laboratory study.

Methods: Four-strand core suture repairs of Achilles tendon were performed on 1 female and 19 male patients. Postoperatively, patients were nonweightbearing with the ankle immobilized for 4 weeks. Plantarflexion torque, dorsiflexion range of motion, passive joint stiffness, toe walking, and standing single-legged heel rise (on an incline, decline, and level surface) were assessed after surgery (mean, 1.8 years postoperative; range, 6 months-9 years). Maximum isometric plantarflexion torque was measured at 20° and 10° of dorsiflexion, neutral, and 10° and 20° of plantar flexion. Percentage strength deficit (relative to noninvolved leg) was computed at each angle. Passive dorsiflexion range of motion was measured goniometrically. Passive joint stiffness was computed from increase in passive torque between 10° and 20° of dorsiflexion, before isometric contractions.

Results: Significant plantarflexion weakness was evident on the involved side at 20° and 10° of plantar flexion (34% and 20% deficits, respectively; P <.001), with no torque deficits evident at other angles (6% at neutral, 3% at 10° of dorsiflexion, 0% at 20° of dorsiflexion). Dorsiflexion range of motion was not different between involved and noninvolved sides (P = .7). Passive joint stiffness was 34% lower on the involved side (P <.01). All patients could perform an incline heel rise; 14 patients could not perform a decline heel rise (P <.01).

Conclusion: Disproportionate weakness in end-range plantar flexion, decreased passive stiffness in dorsiflexion, and inability to perform a decline heel rise are evident after Achilles tendon repair. Possible causes include anatomical lengthening, increased tendon compliance, and insufficient rehabilitation after Achilles tendon repair.

Clinical Relevance: Impairments will have functional implications for activities (eg, descending stairs and landing from a jump). Weakness in end-range plantar flexion may be an unrecognized problem after Achilles tendon repair.

Key Words: heel rise • isometric • elongation • length tension

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