[ research report ]

Geoff P. Bostick, PT1 Nadr M. Jomha, MD, PhD2 Amar A. Suchak, MD3 Lauren A. Beaupr, PT, PhD4

Factors Associated With Calf Muscle

Endurance Recovery 1 Year After
Achilles Tendon Rupture Repair
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A
chilles tendon ruptures (ATR) are commonly surgically was surgical3,15 or conservative.12 For ex-
repaired in young active adults.7 When evaluating the efficacy ample, long-term follow-up of ATRs indi-
cate that calf muscle endurance recovers
of surgically repaired ATRs, outcomes such as rerupture rate,11
on average from 52% to 88% compared
patient satisfaction,10,14 return to sport,1,14 range of motion,1
Copyright 2010 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

to the noninjured side. 3,12 In spite of a

and plantar flexion strength1,6 suggest that surgical repair of the lack of clarity regarding the implications
Achilles tendon provides a good outcome for patients 6 months and 1 of persistent deficits in calf muscle endur-
year postsurgery. However, other important objective outcomes, such ance after ATR, research has suggested
an association between poor calf muscle
as endurance and gait analysis, which may be delays in full recovery for the in- endurance and Achilles tendinopathy in a
evaluate the functional performance of jured extremity in comparison to the non- nonsurgical population.9,18 While it is dif-
the calf muscle group, indicate that there injured extremity, whether the treatment ficult to say whether muscle dysfunction
is a cause or an effect of tendinopathy, it
Journal of Orthopaedic & Sports Physical Therapy

t STUDY DESIGN: Cohort study.
t OBJECTIVES: To describe calf muscle endur-
ance recovery and to explore factors predictive of
poor calf muscle endurance recovery 1 year after
surgical repair of an Achilles tendon rupture (ATR).
t BACKGROUND: ATR is a common sports-
related injury and is often managed with open
surgical repair. After ATR repair most patients
return to usual activities 6 months after surgery.
However, calf endurance impairment can persist
up to 6 years, possibly impacting performance of
daily activities and sport.
t METHODS: A secondary analysis of a
73-patient cohort from a randomized controlled
trial assessing the effects of early weight bearing
after surgical repair of an ATR was performed.
Calf muscle endurance recovery was measured
by single-heel raises using a customized counting
device at 6 months and 1 year postoperatively.
Descriptive statistics were used to outline recovery
of calf muscle endurance. Physical and patient-
reported outcomes were examined for their
association with calf-muscle endurance recovery.
Multiple linear regression analysis was performed
to explore variables associated with recovery of
calf endurance 1 year postoperatively.
t RESULTS: Mean recovery of calf muscle endur-
ance was 76% at 1 year. Multivariate regression
analysis showed an association of being female,
reporting no resting pain at 3 months, and physical
functioning and calf endurance at 6 months, with
better recovery of calf endurance at 1 year.
t CONCLUSIONS: Calf muscle endurance at 1
year remained impaired in a considerable portion
of the sample. Pain, gender, and physical function-
ing are likely important factors in determining
recovery of calf muscle endurance.
t LEVEL OF EVIDENCE: Prognosis, level 2b.
J Orthop Sports Phys Ther 2010;40(6):345-351.
doi:10.2519/jospt.2010.3204
t KEY WORDS: ankle, gender, plantar flexors,
prognosis
is thought to play a role in the etiology
of tendinopathy.9 Additionally, a recently
published ATR-specific outcome mea-
sure highlights the importance of calf
endurance in evaluating ATR recovery.16
Thus, while the consequences of delayed
recovery of calf muscle function are not
clear, it appears to be an important fac-
tor to consider in the rehabilitation and
evaluation of ATRs.
Calf muscle endurance can be mea-
sured as the maximum number of heel
raises that can be performed in a full
weight-bearing position. This measure
of calf muscle endurance has been
shown to be reliable (intraclass corre-
lation coefficient [ICC] = 0.78-0.84 13)
and valid, insofar as heel raises have
been correlated with isokinetic mea-
surements and Achilles tendon symp-

1
PhD candidate, Department of Physical Therapy, University of Alberta, Edmonton, AB, Canada. 2Orthopaedic Surgeon, Director of Research, Department of Surgery, University
of Alberta, Edmonton, AB, Canada. 3Orthopaedic Surgery Resident, Department of Surgery, University of Alberta, Edmonton, AB, Canada. 4Assistant Professor, Departments
of Physical Therapy and Surgery, University of Alberta, Edmonton, AB, Canada. This study was approved by the University of Alberta Health Research Ethics Board. Address
correspondence to Geoff P. Bostick, 3-48 Corbett Hall, University of Alberta, Edmonton, AB, Canada, T6G 2G4. E-mail: bostick@ualberta.ca

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 [ research report ]
toms. 13,19 This endurance measure
requires differentiation from strength Comparison of the 6-Month Outcome
measures, which are typically per- TABLE 1 Variables Between Groups From the
formed in nonweight-bearing posi- Original Randomized Controlled Trial
tions (eg, dynamometry). 14,20 Thus, calf
Variables WBAT (n = 44) NWB (n = 47) P Value
muscle endurance, as measured by heel
Physical assessment measures*
raises, more closely mimics the daily
Calf endurance (heel raises) 42 36 49 32 .31
function of the calf muscles, making it a
Isometric plantar flexion strength 87 15 87 20 .89
useful clinical measure. 19 Moreover, re-
Isometric dorsiflexion strength 97 18 99 15 .44
search has shown differential recovery
Dorsiflexion ROM 103 23 108 27 .31
of strength and endurance after ATR
Plantar flexion ROM 91 16 93 17 .52
repair,20 further emphasizing the im-
Calf circumference 97 3 97 4 .83
portance of examining endurance, not
Patient-reported measures
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just strength, when evaluating recovery

Physical functioning 83 21 86 12 .43
of calf muscle function. Despite the im-
Achilles pain at rest 8 (18) 9 (20) .12
portance of calf endurance as outlined
Achilles pain with walking 23 (53) 22 (46) .58
above, the factors associated with delays
Returned to sport 37 (83) 43 (92) .20
in its recovery are not well defined.
Returned to work 42 (96) 46 (98) .62
Given the deficits observed in calf
Copyright 2010 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

Abbreviations: NWB, nonweight-bearing group; ROM, range of motion; WBAT, earlyweight-bear-

muscle endurance after surgical repair of
ing-as-tolerated group.
ATRs and the clinical importance of opti- * Values are mean SD percent relative to noninjured side.
mal calf muscle function, it would be use-
For the categorical variables, the frequencies, with proportions in parentheses, are given. For physical
functioning, the mean SD is given. Physical functioning is measured on a 100-point scale, with
ful for physical therapists and surgeons
higher values indicating higher levels of physical functioning.
to understand the factors associated with
delayed recovery of calf muscle endur-
ance. Therefore, the primary objective of Setting and Participants and treatment. Decisions to return to
this analysis is to explore possible factors Individuals between 17 and 65 years of work and sport were made in consulta-
associated with delayed recovery of calf age, who presented to 1 of 2 major trau- tion with the treating surgeon. After the
Journal of Orthopaedic & Sports Physical Therapy

muscle endurance 1 year following surgi- ma tertiary-care centers in Edmonton,
cal repair of an acutely ruptured Achilles Canada between October 2003 and May
tendon. 2006 with an acute complete ATR, were
candidates for study inclusion. All pa-
METHODS tients had open surgical repair by 1 of 14
participating orthopaedic surgeons with-
Study Design in 14 days after the injury. All patients
baseline assessment, the patients were
reassessed at 6 weeks, 3 months, and
6 months postsurgery. In addition, the
trial follow-up was extended to include
a 1-year reassessment, based on clinical
observations of the evaluating physical
therapists who noted that calf-muscle

W
e performed a secondary
analysis of data from a ran-
domized controlled trial that
evaluated the effects of weight bearing
compared to non-weight bearing in the
early postsurgical period, 1 year after sur-
gical repair of an acute ATR. The details
of this original randomized controlled
trial (design, study population, and re-
sults) are described elsewhere.20 In the
original study, the intervention and
control groups were similar in all mea-
sures at the 6-month postsurgical period
(TABLE 1). Therefore, in the current analy-
sis, the intervention and control groups
were combined into a single cohort for
the 1-year analysis.
provided informed consent according to
the standards of the health research eth-
ics board at the University of Alberta and
the rights of the research participants
were protected. With the exception of
commencement of weight bearing, the
postsurgical regimen, including rehabili-
tation, was standardized.20 The standard-
ized rehabilitation regimen after the early
postsurgical period (6 weeks) consisted
of active ankle range of motion (ROM),
gentle resisted ankle strengthening with
a resistance band, walking as tolerated,
and at 3 months postsurgery patients
began a progressive heel raise exercise
protocol. Participants were free to con-
sult physical therapists for assessment
endurance performance was substantial-
ly impaired at the 6-month assessment in
study participants.
Outcomes and Measurement
Primary Outcome The primary out-
come of this analysis was calf endurance
evaluated at 1 year postsurgery. Calf en-
durance was measured by single-limb
heel raises using a customized counting
device similar to those constructed in
previous studies,12,14 and that has been
shown to be reliable13 and valid.12,19 This
device was equipped with an adjustable
laser beam used to determine the height
of the heel raise to be performed. A suc-
cessful heel raise was determined by the

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 breaking of the laser beam by the affect-
ed heel. When the laser beam was bro-
ken, the assessor was alerted. The level
of the laser beam was determined by the
height attained with a single-limb heel
raise on the noninjured side. Patients
performed unilateral heel raises until
they were no longer able to attain the
height required to break the laser beam.
Calf endurance was reported as the pro-
portion of successful heel raises on the
injured side compared to the noninjured
side to allow a reference comparison of
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the percentage of deficit and/or recovery
of the affected side.
Independent Variables The independent
variables evaluated as possible predictors
for the primary outcome included de-
mographic variables (age, self-reported
Copyright 2010 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
body-mass index, and gender), initial
treatment (early weight bearing or de-
layed weight bearing), surgical variables
such as time to surgery, physical mea-
sures (plantar flexion and dorsiflexion
ROM and nonweight-bearing isometric
strength, calf circumference measured at
6 weeks, 3 months, and 6 months, and
calf endurance measured, as described
Journal of Orthopaedic & Sports Physical Therapy
previously, at 6 months), patient-report-
ed measures (physical functioning, pain,
and preinjury level of work and sport),
and complications.
The patients were assessed by expe-
rienced physiotherapists who measured
ankle ROM with a goniometer accord-
ing to published standards.2 Isometric
plantar flexion and dorsiflexion strength
were assessed with use of a handheld dy-
namometer in the supine position. Calf
circumference was assessed with a mea-
suring tape placed 10 cm distal to the
patellar apex of the fully extended knee.
Physical measures were reported as a per-
centage relative to the noninjured side.
As there was no disease-specific scale
to assess outcomes following ATR at the
time of study commencement, patient-
reported outcomes included the physical
function domain of the RAND-36, pain
at rest and with activity, and activity lev-
el. The RAND-36 is a validated health-
related quality-of-life tool that has been
journal of orthopaedic & sports physical therapy | volume 40 | number 6 | june 2010 |
03 Bistick.indd 347
Assessed for eligibility (n = 160)
Allocated to WBAT at baseline (n = 55)
Received allocated treatment (n = 55)
Lost to follow-up at 1 year (n = 16)
Intervention groups combined
(n = 73)
FIGURE. Flow chart depicting the participant flow through the study. Abbreviations: NWB, nonweight-bearing
group; WBAT, earlyweight-bearing-as-tolerated group.
used for multiple patient groups.4,21 It
contains identical items to the more fa-
miliar SF-36.4 The RAND-36 was chosen
over the SF-36 because of its availability
in the public domain without cost. Physi-
cal functioning is reported on a 100-point
scale, with higher scores indicating high-
er levels of physical functioning. Achilles
tendon pain at rest and with walking was
measured on a 4-point scale (none, mild,
moderate, and severe). Activity level was
similarly measured on a 4-point scale
(sedentary, light, moderate, and heavy).
In addition, complications recorded in
the patients chart were grouped into mi-
nor (eg, superficial infection, paresthesia)
or major (eg, rerupture, deep vein throm-
bosis) complications.
Finally, although no group differenc-
es in the original randomized controlled
trial were found at the 6-month assess-
ment, the effect of treatment allocation
(early weight bearing versus delayed
weight bearing) on the primary outcome
was also examined.
Sample Size One hundred ten patients
were recruited, based on the power analy-
sis for the original randomized controlled
trial.20 For this secondary analysis, 73 pa-
tients with complete follow-up data were
available (FIGURE).
Excluded (n = 50)
Not meeting inclusion criteria (n = 24)
Refused to participate (n = 14)
Other reasons (n = 12)
Allocated to NWB at baseline (n = 55)
Received allocated treatment (n = 55)
Lost to follow-up at 1 year (n = 21)
Analysis Descriptive statistics, such as
means and standard deviations, were
used to describe continuous variables
and frequencies and proportions for cat-
egorical variables. Recovery of calf mus-
cle endurance at 1 year postsurgery and
the pattern of recovery from 6 months to
1 year were described as a proportion to
the noninjured side. The recovery pattern
of calf-endurance recovery was also ex-
plored descriptively and through statisti-
cal analysis.
To examine the association between
the potential independent variables above
and calf muscle endurance at 1 year, mul-
tiple linear regressions were performed
using the forward stepwise procedure to
develop the model and the backward step-
wise procedure to test the stability of the
model. To determine which variables were
eligible to be included in the multivariate
model, each variable was examined in-
dependently for its association with the
primary outcome in a preliminary uni-
variate analysis. As this was a hypothesis-
generating analysis, several variables were
selected for initial evaluation. However,
variables were only considered eligible for
inclusion in the multivariate model if they
were significant at a level of = .05, with a
correlation coefficient of at least 0.25, rep-
347
5/14/10 5:14:32 PM
 [ research report
resenting the lower limit of a meaningful
association between variables.17 The strict
criteria were used to limit the number
of eligible variables for the multivariate
model due to the small sample size. Vari-
ables measured on a 4-point scale were
collapsed into dichotomies due to the
limited number of variables permitted in
the model and the binary distribution of
responses in many of these ordinal vari-
ables. For example, pain in the Achilles
tendon was collapsed into either pres-
ent or absent. In addition, age and gen-
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der were also included in the regression
model as they were considered clinically
important variables. Based on the 73 pa-
tients who had complete 1-year physical
assessment data, up to 7 variables could be
included in the multiple linear regression
Copyright 2010 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
model.8 The dependent variable (primary
outcome of interest) was the percentage
of calf endurance recovery (relative to the
noninjured side) at 1 year postsurgery.
Statistical significance was set at = .05.
Missing data were handled via listwise
deletion. Data were analyzed using SPSS
Version 16 (SPSS Inc, Chicago, IL).
Journal of Orthopaedic & Sports Physical Therapy
RESULTS
Participants
O
f the 110 patients who partici-
pated in the original 6-month trial,
73 (66%) completed the 1-year
physical examination follow-up. An ad-
ditional 11 patients completed the survey
portion of the 1-year follow-up examina-
tion by phone. Patients who completed the
1-year follow-up were similar to those who
missed the 1-year follow-up, with the ex-
ception of a nonsignificant but potentially
meaningful difference in the percentage
of recovered calf endurance at 6 months
postsurgery, which was 43% relative to the
noninjured side in those with complete
data versus 57% in those with missing
data at the 1-year follow-up (P = .29).
One-Year Calf Endurance Recovery
The mean percentage (SD) of complet-
ed heel raises relative to the noninjured
side at 1 year postsurgery was 76%
348 | june 2010 | volume 40 | number 6 | journal of orthopaedic & sports physical therapy
03 Bistick.indd 348
]
TABLE 2 Descriptive Data for the 1-Year Cohort
Variables 1-Year Cohort
Demographics
Age (y) 40 9
Gender, males (%) 61 (82%)
Body mass index (kg/m2) 28 6
Work reported as heavy (%) 24.1
Activity reported as heavy (%) 30.1
Physical assessment measures*
Calf endurance (heel raises) 76 29
Isometric plantar flexion strength 94 12
Isometric dorsiflexion strength 100 14
Dorsiflexion ROM 105 23
Plantar flexion ROM 95 11
Calf circumference 97 3
Patient-reported measures
Physical functioning (RAND-36) 92 15
Achilles pain at rest 23 (28)
Achilles pain with walking 34 (41)
Returned to sport 71 (84)
Returned to work 84 (100)
Abbreviations: ROM, range of motion.
* Values are mean SD percent relative to noninjured side.
The mean SD for physical functioning is given. Physical functioning is measured on a 100-point
scale, with higher values indicating higher levels of physical functioning. The frequencies with propor-
tions in parentheses are given for the categorical variables.
29% (minimum, 0%; maximum, 138%). ance at 6 months, physical functioning at
The mean number of heel raises (SD) 6 months, and resting pain in the Achil-
performed on the injured side was 26.4 les tendon at 3 months (TABLE 3). Age and
11.7 (minimum, 0; maximum, 60) and gender were retained in the multivariate
35.1 11.9 (minimum, 14; maximum, 76) model, as they were considered clinically
on the noninjured side. Other descriptive important variables.
data of the cohort at the 1 year postsurgi-
cal period are found in TABLE 2. Multivariate Analysis
Our data suggest that there may be a The final regression model demonstrat-
different recovery pattern between males ing the associations between calf endur-
and females from the 6-month to the ance recovery at 1 year postsurgery and
1-year postsurgical evaluation period. The the included independent variables (gen-
average change in the proportion (SD) der, 6-month calf endurance and physical
of single-limb heel raises relative to the functioning, and resting Achilles tendon
noninjured side between 6 months and pain at 3 months) can be found in TABLE
1 year postsurgery was 50.7% 37.2% 3. Age was retained in the final model as a
in females and only 29.6% 37.5% in clinically important variable, despite sta-
males (P = .07). tistical nonsignificance. At 1 year, males
recovered approximately 27% less of
Univariate Analysis their calf endurance relative to females.
Of the 32 variables tested, the following Compared to those without pain in the
3 met the a priori selection criteria set Achilles tendon at rest at the 3-month
for the multivariate analysis: calf endur- follow-up, those with ongoing 3-month
5/14/10 5:14:33 PM

Multivariate Linear Regression Model
TABLE 3
Predicting 1-year Calf Endurance (n = 63)

Univariate Association With Calf Endurance at 1 Year Multivariate Association With Calf Endurance at 1 Year*
Correlation Coefficient (95% CI) P Value Coefficient (95% CI) P Value
Gender (males) 0.11 (0.33, 0.12) .37 27.19 (46.82, 9.07) .01
Calf endurance (6 mo) 0.30 (0.08, 0.50) .01 0.20 (0.02, 0.40) .04
Physical functioning (6 mo) 0.33 (0.10, 0.53) .01 0.64 (0.25, 1.11) .01
Achilles pain at rest (3 mo) 0.25 (0.01, 0.46) .04 15.00 (28.92, 0.58) .04
Age 0.19 (0.40, 0.04) .11 0.37 (1.03, 0.29) .26
Abbreviation: CI, confidence interval.
* Adjusted R2 = 0.28
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rest pain recovered approximately 15%
less calf endurance 1 year postsurgery.
Finally, lower levels of calf endurance and
physical functioning at 6 months postsur-
gery were associated with lower levels of
Copyright 2010 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
between poor calf muscle endurance
and Achilles tendinopathy in a nonsur-
gical population.18 Therefore, examining
calf endurance is an important outcome
in the provision of a comprehensive re-
males and females was also seen. As
our study was exploratory in nature, we
cannot state with certainty whether the
apparent difference in recovery pattern
between genders is real or a consequence

1-year calf endurance recovery. habilitation program aimed not only at of measurement error. This finding is,
recovery after ATR repair but optimiz- however, worthy of further exploration in
DISCUSSION ing performance and preventing pos- future studies with larger cohorts. A pos-
sible future problems such as Achilles sible explanation for the apparent differ-

T
his study describes calf muscle
endurance recovery 1 year after sur-
gical repair of an acute ATR and
explores possible factors associated with
delay in recovery of endurance. Consis-
Journal of Orthopaedic & Sports Physical Therapy
tendinopathy. Assuming that recovery
of calf muscle endurance is important in
preventing tendinopathy and improving
performance in sport and recreation, the
rehabilitation period may need to be ex-
ence in calf endurance recovery pattern is
the extra weight that males place on the
recovering tendon, which may increase
stretching of the tendon and cause a sub-
optimal length-tendon relationship in the

tent with previous research,3,12,14,15 a sub-
stantial deficit in calf muscle endurance
1 year postsurgery was demonstrated
in this study. The deficit measured in
the current study (24%) falls within the
range of 12% and 48% reported in other
studies.3,12 One possible explanation for
the incomplete recovery of calf endur-
ance is increased tendon length, causing
a suboptimal length-tendon relationship
in the muscle-tendon unit. Previous re-
search has shown that better clinical
outcome is achieved when less tendon
elongation occurs.5 In our study, tendon
elongation was measured by ankle dor-
siflexion ROM. This was not associated
with poor recovery of calf endurance,
although our measure of tendon elonga-
tion may not have been sensitive enough
to detect subtle differences.
While the specific effects of poor calf
muscle endurance after ATR on recov-
ery or subsequent injury are not clear,
research has suggested an association
tended to reflect this delay in calf muscle
endurance recovery.
Males, those with Achilles tendon
pain at rest at 3 months, or those with
lower physical functioning and calf en-
durance at 6 months appear to have de-
layed recovery of calf endurance at 1 year.
The finding that pain in the Achilles ten-
don at 3 months postsurgery influences
recovery of calf muscle endurance is an
important and practical finding for cli-
nicians and patients, as it is a potential
early marker of poor prognosis. The re-
habilitation or extent of follow-up may be
modified at an earlier stage in an attempt
to attenuate delays in calf muscle endur-
ance recovery. Moreover, resting pain
in the Achilles tendon is possibly a fac-
tor that can be managed by clinicians in
the early postsurgical recovery period to
positively impact recovery of calf muscle
endurance.
A potentially important difference in
the recovery of calf endurance between
muscle-tendon unit. Previous research
has shown that better clinical outcome is
achieved when less tendon elongation oc-
curs.5 However, similar to prior research,6
body-mass index in our study was not as-
sociated with tendon lengthening, sug-
gesting that extra weight on the healing
tendon did not lead to tendon elongation.
As previously stated, it is possible that
our measure of tendon elongation may
not have been sensitive enough to detect
subtle differences.
The primary limitation of this study
was the relatively high attrition rate at
the 1-year physical follow-up assess-
ment. Increasing the follow-up time from
6 months to 1 year midway into the data
collection is one possible explanation for
the lower 1-year follow-up (78% of par-
ticipants with missing 1-year data were
enrolled prior to increasing the follow-
up to 1 year). As those without complete
1-year data had better calf muscle endur-
ance at 6 months than those subjects who

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 [ research report
returned at 1 year (although not statisti-
cally significant), it is possible that the
patients completing the 1-year follow-up
do not represent all postsurgical patients,
but instead may represent those experi-
encing more prolonged recovery. Another
consequence of attrition in this trial was
a reduction in the sample size, thus in
study power. Therefore, the number of
factors we could consider as potential
predictors of recovery were limited. The
limited sample size available in this study
precludes stating conclusively which fac-
Downloaded from www.jospt.org at on February 25, 2017. For personal use only. No other uses without permission.
tors are associated with recovery of calf
muscle endurance.
Additional limitations include the
possibility that some variables that we
did not measure might have had a sub-
stantial influence in the recovery of calf
Copyright 2010 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
muscle endurance. For example, compli-
ance to the prescribed exercise protocol
after the early postsurgical period was not
measured, as this was not the component
of the protocol under investigation in the
original randomized controlled trial.19
Also, at the time of the study inception,
there was no access to a recently validat-
ed outcome measure specific to ATRs16 or
Journal of Orthopaedic & Sports Physical Therapy
a newly proposed more sensitive measure
of calf endurance.19 In addition, some of
the data available for analysis were mea-
sured at an ordinal level, potentially dilut-
ing stronger relationships. Future studies
intending to examine similar relation-
ships should use ratio level measures if
possible. Finally, this study was planned
as a hypothesis-generating evaluation
subsequent to the originally conceived
randomized trial. Care must therefore
be taken in interpreting our findings, as
they represent preliminary investigations
in this area and require confirmation in
future studies examining recovery after
surgical repair of acute ATRs.
CONCLUSIONS
T
o our knowledge, this is the
first study to examine factors that
may be associated with calf muscle
endurance recovery 1 year after open sur-
gical repair of acute ATRs. Poor pain man-
350 | june 2010 | volume 40 | number 6 | journal of orthopaedic & sports physical therapy
03 Bistick.indd 350
]
agement in early rehabilitation may be an
important early sign of delayed recovery
of calf muscle endurance. In addition,
physical functioning and calf endurance
at 6 months may also be associated with
lower calf endurance performance at 1
year. Attention to these symptoms and
signs is recommended when assessing
postsurgical follow-up with the intent of
potentially limiting delays in calf muscle
endurance recovery. Finally, males may
follow a different pattern of recovery than
females and may have lower return of calf
endurance at 1 year postsurgery. Future
investigations focused on optimizing the
postsurgical management of patients
with Achilles tendon repair should also
consider these clinical factors. t
KEY POINTS
FINDINGS: Substantial calf muscle endur-
ance impairments persist 1 year after
surgical repair of acute Achilles tendon
ruptures. Males, those with Achilles ten-
don pain at rest at 3 months, or lower
physical functioning and calf endurance
at 6 months had delayed recovery of calf
endurance at 1 year.
IMPLICATION: The presence of resting pain
in the Achilles tendon area at 3 months
may be an early indicator of delayed re-
covery of calf endurance 1 year after sur-
gery. Persistent pain at 3 months should
be addressed to facilitate adherence to
the postsurgical rehabilitation program.
CAUTION: This study is exploratory in
nature and requires confirmation in fur-
ther prospective evaluations.
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2. Clarkson HM. Joint Motion and Function Assess-
ment: A Research-Based Practical Guide. Phila-
delphia, PA: Lippincott Williams and Wilkins;
2005.
3. Don R, Ranavolo A, Cacchio A, et al. Relation-
ship between recovery of calf-muscle biome-
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