Functional Rehabilitation Protocol Research Articles

A Comparative Analysis of Outcomes using PROMIS after Operative vs Non-operative Treatment of Achilles Rupture

Introduction/Purpose: Achilles tendon rupture is a common injury in the adult population. The role of operative and non- operative management remains controversial with the development of functional rehabilitation programs. The purpose of this study is to evaluate and compare the patient-reported outcomes using Patient-Reported Outcomes Measurement Information System (PROMIS) after operative and non-operative treatment of acute Achilles rupture. PROMIS is a valid, reliable, and effective tool to evaluate patient outcomes after treatment for Achilles ruptures. Our hypothesis is that there is no significant difference in PROMIS scores between patients undergoing operative compared to non-operative treatment of Achilles rupture. Methods: Under an IRB-approved protocol, Achilles rupture was identified using ICD 9 and ICD10 codes of 727.67 and S86.0. Patients who underwent Achilles tendon primary repair were identified using CPT code 27650 (Repair, primary open or percutaneous, ruptured Achilles tendon). Revision Achilles repair and chronic Achilles ruptures were excluded. All patients treated non-operative underwent a strict functional rehabilitation protocol. We included patients treated between 1/1/2015 and 11/30/2022. PROMIS physical function (PF), pain interference (PI), and depression scores were routinely collected prospectively during the initial office visit and follow-up appointments. A distribution-based method used to determine the minimal clinically important difference (MCID), which was 1/2 standard deviation of each PROMIS domain. A medical records review was performed to collect patient demographic data. Statistical analysis was used to compare preoperative and postoperative scores and significance was indicated when P< 0.05. Results: 216 patients with Achilles tendon ruptured were included (115 Nonoperative versus 101 Operative). Patients treated non-operatively were older than those treated surgically (mean age: 45.1 vs 35.6; p< 0.001). The operative group had a lower BMI compared to non-operative group (27.8 vs. 29.5; p=0.004). There is no statistical difference in the Achilles tendon re-rupture rate between both groups (operative: 2% vs. 4.3%; p=0.344). Both groups are effective in improving PROMIS PF, PI, and depression scores (p < 0.001). The mean PROMIS PF change (pre- to post-treatment) is significantly greater in the operative, compared to the non-operative group (13.2 vs. 9.5; p=0.042). Both treatments had similar mean PROMIS PI change, mean PROMIS depression change, and rates of meeting MCID for all 3 PROMIS domains at 6 months. Conclusion: In patients with Achilles tendon rupture, operative management may lead to statistically significant higher improvements in physical function compared to non-operative management. However, non-operative management was associated with similar overall rates of re-rupture, PROMIS PI and depression outcomes, and chances of meeting MCID as those who underwent operative intervention. Nonoperative management of Achilles tendon rupture, similar to operative treatment, is a successful treatment option and leads to significant improvement in physical function, pain interference, and depression PROMIS scores.

Progression of partial to complete ruptures of the Achilles tendon during rehabilitation: Astudy using a finite element model.

Substantial research on complete Achilles tendon ruptures is available, but guidance on partial ruptures is comparatively sparse. Conservative management is considered acceptable in partial tendon ruptures affecting less than 50% of the tendon's width, but supporting experimental evidence is currently lacking. Using a previously validated finite element model of the Achilles tendon, this study aimed to assess whether loading conditions simulating an early functional rehabilitation protocol could elicit progression to a complete rupture in partial ruptures of varying severity. In silico tendon rupture simulations were performed to locate the most likely rupture site for least, moderate, and extreme subtendon twist configurations. These three models were split at the corresponding rupture site and two sets of partial ruptures were created for each, starting from the medial and lateral sides, and ranging from 10% to 50% loss of continuity. Simulations were conducted with material parameters from healthy and tendinopathic tendons. Partial ruptures were considered to progress if the volume of elements showing a maximum principal strain above 10% exceeded 3 mm3 . To assess whether the tendinopathic tendons typical geometric characteristics could compensate for the inferior material properties found in tendinopathy, an additional model with increased cross-sectional area in the free tendon region was developed. Progression to complete ruptures occurred even with less than a 50% loss of continuity, regardless of subtendon twisting, and material parameters. The tendinopathic tendon model with increased cross-sectional area showed similar results. These findings suggest the current criteria for surgical treatment of partial ruptures should be reconsidered. Statement of clinical significance: The clinical significance and most appropriate treatment of partial ruptures of the Achilles tendon is unclear. Despite the widespread use of the "50% rule" in treatment decisions of partial tendon ruptures, experimental evidence supporting it is missing. The present study provides new data, from a validated aponeurotic and free Achilles tendon finite element model, showing that partial ruptures may progress to complete ruptures under loading conditions elicited from functional rehabilitation protocols, even for partial ruptures affecting less than 50% of the tendon's width. Under these novel findings, the current criteria for surgical treatment of partial ruptures should be reconsidered.

An Early Functional Unsupervised Rehabilitation Protocol Allows Safe Return to Function After Achilles Tendon Repair.

Acute Achilles tendon tears in young active individuals are often treated surgically with prolonged rehabilitation, with the leg initially immobilized in plantar flexion in serial non-weight bearing casts and gradually progressing to full weight bearing. This study aimed to evaluate the safety of an early functional unsupervised rehabilitation protocol. The medical records of 25 patients treated with open repair were available for follow-up. In 10 patients, an early functional unsupervised rehabilitation protocol was used with a removable cast, active range of motion exercises of the ankle from the first postoperative day, and full weight bearing in a walking boot with the foot plantigrade after the second week. Another 15 patients who followed the classic rehabilitation protocol were used as controls. The patients were evaluated with the Victorian Institute of Sports Assessment-Achilles (VISA-A) and an ultrasound examination-based score. A Wilcoxon test was used to compare the scores between the groups. The mean VISA-A score was 90.1 (SD = 9.87) for the early functional rehabilitation protocol group, while it was 83.8 (SD = 17.06, p = 0.624) for the control group. The mean ultrasound score was 7.75 (SD = 1.71)for the early functional rehabilitation protocol group, while it was 7.60 (SD = 3.05, p = 0.414) for the control group. There were no intra- or early postoperative complications in the groups, and all patients were satisfied with the results of their operation. An early unsupervised functional rehabilitation protocol after open Achilles repair may allow for safe early mobilization and minimize the need for physiotherapy. The small number of participants is a limitation of this study, and further evaluation with more patients is necessary to document the efficacy.

Acute Achilles tendon rupture: modern management

Achilles tendon rupture is a common injury and its incidence is increasing. There is a large body of literature on the subject and much of it debates the influence of management on re-rupture rates. Operative treatment was thought to be superior in reducing the risk of re-rupture. However, it must be balanced against the risks, in particularly wound infection and breakdown, and sural nerve injury. Minimally invasive surgery aimed to reduce wound complications but has frequently been associated with a higher risk of sural nerve damage and irritation. The introduction of functional rehabilitation, which includes early weight bearing and range of motion within an orthosis, has been pivotal in improving outcomes particularly in non-operatively managed patients. More recent evidence suggests that re-rupture rates are now similar between operatively and non-operatively managed patients when incorporating a functional rehabilitation protocol. The publication of the Achilles Tendon Rupture Score, which has been validated specifically for this injury, has been helpful in providing a more detailed picture of post-injury symptoms and function. The studies which have included this as an outcome measure have also shown comparable results between operatively and non-operatively treated patients.

Traditional Open Repair and Reconstruction of Achilles Tendon Rupture

Despite the development of minimally invasive techniques and more effective nonoperative functional rehabilitation protocols, traditional open approaches remain viable options for both acute and chronic Achilles tendon rupture repair and reconstruction. Here, techniques for open Achilles tendon repair and reconstruction are discussed, along with outcomes, possible complications, and brief comparisons to other management options.Level of Evidence:Level V.

THE EFFICIENCY OF PHYSIOTHERAPY IN THE TREATMENT OF LUMBAR DISCOPATHY IN ELDERLY PATIENTS

Lumbar pain is one of the most common pathologies encountered among the population. With advancing age, the predisposition to this type of pain increases, which can lead to a decrease in the quality of life. The present study was carried out on a group of 10 patients aged between 70 and 83 years, clinically diagnosed with lumbar discopathy. The recovery program consisted of specific physical therapy exercises associated with massage and medium frequency currents. The obtained results highlight the fact that the pain level decreased significantly following the functional rehabilitation protocol, and the mobility of the lumbar spine improved. The conclusions of the study emphasize the importance of physiotherapy programs in association with massage and medium frequency currents, in terms of improving the symptoms specific to lumbar discopathy in the elderly patient.

117 Achilles Tendon Rupture Clinic, a Successful and Reproducible Model

Abstract Background In the view of busy Emergency departments and general fracture clinics, a delay in the assessment, diagnosis and treatment of Achilles tendon injuries can lead to poor outcomes. A dedicated Achilles tendon rupture clinic can provide efficient care and avoid such complications. Aim To assess the efficiency of the dedicated Achilles tendon rupture clinic (model) in avoiding delay in the assessment and management of Achilles tendon injuries. Method Analysis of retrospectively collected data of the patients who have been reviewed in the Achilles clinic. All patients had Ultrasound scan (USS) by trained Orthopaedic surgeons to assess the size of the gap. Non operative treatment followed an approved functional rehabilitation protocol in the department. Data for analysis included : demographic data, Time interval between injury and assessment in the Achilles clinic ,size of the gap (USS) and ATRS (The Achilles tendon Total Rupture Score ). Results 45 patients have been reviewed in the Achilles tendon rupture clinic over nine months, the mean age was 52.05 the mean time interval between referral and assessment in the Achilles clinic was 6.1 days (SD 3.59 ), The mean size of the tear was 10.65 mm (SD 5.95). The mean ATSR score at three months follow up was 70.29 ( SD 15.3). Conclusions The model of dedicated Achilles tendon rupture clinic including on-site USS can help deliver a safe and more efficient arm of the trauma service to patients and avoid delay in management that might affect the patients functional outcome and require complex surgical procedures.

Outcomes of a functional rehabilitation protocol in chronic critical disease by COVID-19: A case report

The 2019 novel coronavirus (SARS-CoV-2) is the virus that causes COVID-19. It can cause severe illness, with significant increase in morbidity and mortality rates, requiring the need for hospitalization and mechanical ventilation. This study aims to describe a functional rehabilitation protocol applied to a patient with COVID-19 after 21 days of mechanical ventilation (MV). We report a case of a 56-year-old female patient diagnosed with COVID-19 who presented severe hypoxemic respiratory failure, chronic critical disease, intensive care unit acquired weakness, difficult and prolonged weaning, organ dysfunction, and needed tracheotomy. The patient responded satisfactorily to a late functional rehabilitation protocol showing the importance of well-designed and individualized protocols to achieve maximum functional recovery.

Multidisciplinary rehabilitation in intensive care for COVID-19: randomised controlled trial.

The coronavirus disease 2019 (COVID-19) has led to an increasing number of patients in the intensive care units (ICU). The size of this post-ICU cohort will be unprecedented, with many patients vulnerable to post-intensive care syndrome. We analysed the respiratory and functional effects of a multidisciplinary rehabilitation program on functional performance, in patients hospitalized in ICU due to COVID-19.We conducted a randomized controlled clinical trial. Ninety-six patients, who fulfilled the eligible criteria, were randomized into control or intervention group. The control group received standard of care in the ICU, and the intervention group received a functional and respiratory rehabilitation protocol, that included medical, nursing, physiotherapy, and occupational therapy interventions.At discharge, the intervention group showed significantly better muscular strength and respiratory capacity, and significantly less days of hospitalization (12.90±5.8 versus 15.60±6.7 days, p=0.037). At the 4- and 12-week follow-up we applied our main outcome measure – 6-minute walking test. The intervention group had significantly better results than the control group on the 6-minute walking test at the 4-week follow-up (604±67 versus 571±57 m, p=0.018) and at the 12-week follow-up (639±53 37 versus 611±67, p=0.025).These results support the role of a multidisciplinary rehabilitation program in COVID-19 patients hospitalized in ICU and adds evidence that the implementation of rehabilitation programs in ICU could result in beneficial outcomes for the critical ill patients.

Rehabilitation following operative treatment of acute Achilles tendon ruptures: a systematic review and meta-analysis.

The aim of this systematic review and meta-analysis was to compare re-rupture rates, complication rates, functional outcomes, as well as return to work (RTW)/sport (RTS) among different rehabilitation protocols following operative treatment of acute Achilles tendon ruptures. Systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Five databases were searched for randomized controlled trials (RCTs) comparing at least two rehabilitation protocols following surgical repair of acute Achilles tendon ruptures. Rehabilitation protocols were classified as a variation of either non-weightbearing (NWB) or weightbearing (WB) and immobilization (IM) or mobilization (M). The data collection consisted of re-ruptures, complications, and RTW/RTS. Out of 2760 studies screened, 20 RCTs with 1007 patients were eligible. Fourteen studies included a group consisting of WB + M (Group 1), 11 of WB + IM (Group 2), 3 of NWB + M (Group 3), and 13 of NWB + IM (Group 4). Outcome parameters available for a meta-analysis were re-ruptures, complications, RTW, and RTS. Re-ruptures overall occurred in 2.7%, with prevalences ranging between 0.04 and 0.08. Major complications occurred in 2.6%, with prevalences ranging between 0.02 and 0.03. Minor complications occurred in 11.8% with prevalances ranging between 0.04 to 0.17. Comparing the odds-ratios between the four different groups revealed no significant differences with overall favourable results for group 1 (WB+M). Early functional rehabilitation protocols with early ankle M and WB following surgical repair of acute Achilles tendon ruptures are safe and they apparently allow for a quicker RTW and RTS and seem to lead to favourable results.

Fast Functional Rehabilitation Protocol versus Plaster Cast Immobilization Protocol after Achilles Tendon Tenorrhaphy: Is It Different? Clinical, Ultrasonographic, and Elastographic Comparison.

Background: the incidence of Achilles tendon (AT) rupture is rising; however, there is no clear consensus regarding the optimal treatment. The aim of this retrospective study was to compare instrumental and patient-reported outcome scores after fast functional rehabilitation (group A) versus plaster cast immobilization (group B) programs in patients who underwent AT tenorrhaphy. Methods: 33 patients, with similar clinical and demographic features, underwent open AT tenorrhaphy between January and July 2018. Of these, 15 patients were treated with fast functional rehabilitation program (group A), and 18 patients were treated with plaster cast immobilization protocol (group B). Sural triceps hypotrophy and functional scores (American Orthopaedic Foot and Ankle Society (AOFAS) Ankle–Hindfoot Score, and Achilles tendon Total Rupture Score (ATRS)) were recorded at a 12-month follow-up. Ultrasonography (US) and elastosonography (ES) were used to compare the characteristics of the tendons after surgery. Results: At 12 months, no significant differences in any of the patient-reported outcomes or the instrumental measurement tests were seen between the two groups. Conclusions: fast functional rehabilitation after AT surgical repair is safe, effective, and may be the first choice of treatment, especially in young, collaborative, and active patients.

Functional Rehabilitation and Return to Play After Arthroscopic Surgical Stabilization for Anterior Shoulder Instability.

There exists limited objective functional return-to-play criteria after surgical stabilization for anterior shoulder instability in the competitive athlete. The proposed functional rehabilitation program and psychological evaluation after arthroscopic Bankart repair will help athletes return to sport with a decreased redislocation rate on return. Case series. Level 4. Participants were contact or overhead athletes at the high school or collegiate level. Each underwent arthroscopic Bankart repair after a single dislocation event, with less than 10% glenoid bone loss. Western Ontario Shoulder Instability Index (WOSI) scores, Single Assessment Numeric Evaluation (SANE) scores, and American Shoulder and Elbow Surgeons (ASES) scores were evaluated pre- and postoperatively. Athletes were only allowed to return to competition after completing the proposed functional and psychological rehabilitation protocol. A total of 62 participants were enrolled (52 male, 10 female; average age, 18.7 years (range 16-24 years); mean Instability Severity Index Score, 5.63 ± 0.55). All returned to sport for 1 full season and completed a minimum of 2 years of follow-up. The average time to pass functional testing was 6.2 ± 0.7 months, psychological testing was 5.2 ± 0.5 months, and return to sport was 6.5 ± 0.7 months. SANE scores improved from 44.3 to 90.0, ASES from 45.5 to 89.3, and WOSI from 1578.0 to 178.9 (all P < 0.001). Redislocation rate was 6.5% (4 of 62). The proposed functional rehabilitation and psychological assessment protocol is safe and effective in returning athletes to sport after arthroscopic surgical intervention for anterior shoulder instability. This demonstrated a low redislocation rate after 2-year follow-up. Most return-to-play protocols after arthroscopic Bankart repair are centered on recovery time alone, with limited focus on functional rehabilitation, psychological assessment, and return-to-play testing parameters. To our knowledge, this is the first study to propose a dedicated rehabilitation program incorporating functional testing, psychological readiness, and return-to-play criteria for competitive athletes recovering from arthroscopic shoulder stabilization.

Immediate Weightbearing and Ankle Motion Exercise After Acute Achilles Tendon Rupture Repair

The incidence of Achilles tendon rupture is increasing. Postoperative rehabilitation after repairing acute Achilles tendon rupture is very important because the choice of treatment during the rehabilitation period can influence the results. Moreover, the method of functional rehabilitation varies and is developing steadily. Recent studies recommend a functional rehabilitation protocol, and this approach is accepted widely. This study aimed to introduce our most accelerated functional rehabilitation protocol following surgery for acute Achilles tendon rupture and to review the results retrospectively. From July 2014 to July 2016, 67 patients underwent surgery for acute Achilles tendon rupture by one surgeon. Age, sex, body mass index, injury mechanism, rehabilitation method and progress, time to return to previous physical activity, and complications were evaluated. The mean time to be able to squat fully was 10 ± 4.7 (4-20) weeks. Full squatting was possible in 92.8% (52 patients). The mean time to perform a single-limb heel rise and repetitive single-limb heel rise was 12.6 ± 3.9 (6-24) and 23.3 ± 7.7 (8-40) weeks, respectively. The mean time to return to sports was 20.6 ± 5.2 (12-32) weeks. The major complication rate was 3.5% (one re-rupture and one tendon elongation). The mean pre- and postoperative Achilles Tendon Total Rupture Score was 29.5 ± 3.7 (20-38) and 79.3 ± 18.5 (20-98) points, respectively. The increase was significant (p < .01). In conclusion, immediate full weightbearing and ankle motion exercise after repair of acute Achilles tendon rupture can provide a good rehabilitation option with a low re-rupture rate and satisfactory functional results.

Functional assessment and rehabilitation protocol in acute patients affected by SARS-CoV-2 infection hospitalized in the Intensive Care Unit and in the Medical Care Unit.

Coronavirus disease (COVID-19) is characterized by different clinical pictures that may require prolonged hospitalization and produce disabilities challenging the recovery of previous independence. The aim is to evaluate the impact of an early assisted rehabilitation program on the functional status of an acutely hospitalized population affected by COVID-19. Single-institution retrospective longitudinal study. Inpatient intensive care units (ICU) and medical care units (MCU). Acute COVID-19 patients. General information was collected; age-adjusted Charlson Comorbidity Index was used for comorbidities. Duration of hospital stay, the length of stay in ICU and/or MCU, the length of the rehabilitative treatment, and the destination at the discharge were collected. Evaluation was performed when patients were clinically stable (T0), and at hospital discharge (T1); for subjects enrolled in ICU functional status was assessed at the time of transfer to the MCU. Muscle strength of the four limbs was measured with the Medical Research Council (MRC) sum-score. Functional status was assessed using the 3-item Barthel Index (BI-3) and the General Physical Mobility Score (GPMS). Early assisted-tailored rehabilitation protocol was applied in ICU and in MCU: the aims were the maintenance (or recovery) of the range of motion and of the strength and the recovery of sitting/standing position and gait. We evaluated 116 patients (mean age 65, SD 11) (65% male), 68 in ICU (mean age 60, SD 10), 48 in MCU (mean age 73, SD 9). At discharge, BI-3 and GPMS significantly improved in both ICU (P<0.001) and MCU (P<0.001) subgroups of patients. MRC sum-score significantly improved in ICU patients (P<0.001). Patients hospitalized in ICU had a significantly longer hospital stay. At discharge, patients admitted to the ICU reach a functional state that is close to that of patients admitted to the MCU. The results suggest that an early assisted rehabilitation program may be helpful in improving the short-term functional status of an acutely hospitalized population affected by COVID-19, with discharge at home of 48% CLINICAL REHABILITATION IMPACT: this study focuses on a functional assessment method to be used to identify the rehabilitation needs and verify the results of an early rehabilitation protocol applied to the acute COVID-19 patient admitted to ICU and MCU.

The Achilles tendon: Management of acute and chronic conditions.

The prevalence of acute and chronic conditions of the Achilles tendon is increasing among an ageing, active population. These conditions are a common cause of presentation to general practitioners and allied health practitioners. Achilles tendon injuries have a bimodal demographical presentation, with acute injuries commonly occurring in younger people and chronic conditions presenting in patients who are elderly. The aims of this article are to discuss management ofacute Achilles tendon ruptures in the primary care setting, explain the risks associated with calcaneal tuberosity fracture and discuss non-operative and surgical management of acute and chronic overload conditions of the Achilles tendon. Achilles tendon injuries can be divided into acute ruptures and chronic overuse injuries. Both can be debilitating, with significant morbidity for patients; fortunately, both types of injuries respond well to non-operative interventions, with only a small proportion requiring surgery. Management of acute Achilles tendon rupture has evolved, with increasing evidence that non-operative management is appropriate providing patients participate in a functional rehabilitation protocol. Chronic conditions such as the sequalae of an untreated rupture or Achilles tendinopathy can be debilitating but often respond well to non-operative management.

Targeting rehabilitation to improve outcomes after total knee arthroplasty in patients at risk of poor outcomes: randomised controlled trial

ObjectiveTo evaluate whether a progressive course of outpatient physiotherapy offers superior outcomes to a single physiotherapy review and home exercise based intervention when targeted at patients with a predicted poor...

Systematic Review of Nonoperative Functional Protocols for Acute Achilles Ruptures Utilizing a Formal Rehabilitation Protocol Showing Lowest Rerupture Rates.

To lay out a comprehensive protocol for practitioners and physical therapists that has the lowest rerupture rates for nonoperative treatment of acute Achilles ruptures. Relevant articles were searched in PubMed, CINAHL Plus, and Cochrane Library using keyword combinations: nonoperative AND/OR Achilles rupture AND functional AND/OR protocol or functional AND/OR rehabilitation. To be included in the full analysis, the studies had to have detailed functional protocols with physical therapy program details and outcome scores of rupture rates and/or Achilles Tendon Rupture Score (ATRS). We ultimately found 7 articles that fit our inclusion criteria for analysis. All of them had rerupture rates, and 4 had ATRS scores and functional protocols with mention of formal physical therapy programs. Lowest rerupture rates were found in strict functional rehabilitation protocols that were full weightbearing in boot immediately at full equinus or 30° plantar flexed. They started active range of motion at 5 to 8 weeks and started formal physical therapy at 10 weeks.Levels of Evidence: Level III: Evidence obtained from well-designed non-experimental descriptive studies.

Achilles Tendon Rupture: Double the Trouble

Introduction: Achilles tendon is the strongest tendon in the body . Achilles tendon rupture is a debilitating ankle injury especially among the athletes. We would like to highlight an unusual case of acute dual-level injuries of the Achilles tendon. Case report: A 30-year-old footballer presented with left ankle injury during a football tournament. Examination revealed tenderness at posterior left heel, palpable gap at Achilles tendon region and positive Thompson test. Radiological assessment showed dual-level injuries of the Achilles tendon-proximally was a rupture at musculotendinous junction and distally was an avulsion calcaneal fracture. We performed a mini-open approach Achilles tendon reconstruction for this patient. First, we reconstructed the distal avulsion calcaneal fracture using double row anchor sutures technique. Next, we repaired the proximal ruptured Achilles tendon using percutaneous Achilles reconstruction system (PARS) from Arthrex. Postoperatively, patient was put on functional rehabilitation protocol. At present, patient recovers well and regains back the Achilles tendon function. In conclusion, segmental Achilles tendon injury is rare and its surgical treatment can be challenging and must be well-planned.

Nonoperative Management of Achilles Tendon Rupture: A Clinical Debate

To analyze the effectiveness of nonoperative modern management in patients with ruptured tendo-Achilles when compared with operative management. Ruptured tendo-Achilles is a common pathology presenting to the orthopedic department. It mostly occurs during spontaneous activity in active male patients between the age of 30 and 40. Traditional nonoperative management consisted of a period of nonweight-bearing in an equinus cast for 6 weeks. When comparing this nonoperative management regime with operative repair of tendo-Achilles ruptures, many studies found that rerupture rates increased, and peak strength decreased in the nonoperative group. We look at the results of nonoperative management when the accelerated functional rehabilitation protocol is used compared to operative management. In a patient with a ruptured tendo-Achilles, employing nonoperative management using the accelerated functional rehabilitation protocol was comparable with operative management. In multiple high-level studies, both groups showed no difference in rerupture rates, peak strength, return to work, return to sport, patient satisfaction, range of movement, and clinical and functional outcome. One study demonstrated improved exercise at high velocity in the operative group in the short-term; however, the clinical significance of this is yet to be analyzed. Operative management of ruptured tendo-Achilles carries risks that are difficult to manage, in particular wound breakdown requiring subsequent revision surgery and tendon transfers. It was previously proven that operative management had decreased rerupture rates and improved strength. It has now been proven that when using the accelerated functional rehabilitation protocol, results are comparable to the operative group, without going through the risks of surgery. Our group recommends strong consideration toward employing nonoperative management of ruptured tendo-Achilles using the accelerated functional rehabilitation protocol over operative management. Exceptions to consider are open injuries from lacerations, avulsion from the calcaneal attachment, or strong wishes from the patient, such as an elite athlete. Al-Dadah K, Ramesh P. Nonoperative Management of Achilles Tendon Rupture: A Clinical Debate. J Foot Ankle Surg (Asia Pacific) 2020;7(1):10–13.

Healing, Pain and Function after Midshaft Clavicular Fractures: A Systematic Review of Treatment with Immobilization and Rehabilitation.

To systematically evaluate the scientific literature examining the efficacy of nonoperative management for midshaft clavicular fractures, specifically looking at the effect of immobilization and/or functional rehabilitation. TYPE: Systematic review. MEDLINE (PubMed), EMBASE, CINAHL databases were searched. Inclusion criteria included adult patients enrolled in a controlled study evaluating bony healing, pain and/or function-related improvements after a strict nonoperative treatment plan for management of midshaft clavicle fractures. A total of 10 articles were included in the study. Only four studies contained level I evidence; four studies were prospective case series without a control, and one was a retrospective case series without a control. Half of studies used a strict immobilization period, and most utilized a period of functional rehabilitation. There were no direct comparisons between rehabilitation protocols. Studies without a strict immobilization period had a nonunion rate of 5% to 24% and residual pain in 35% to 83% of patients compared to studies with a strict immobilization period with a nonunion rate of 3% to 29% and residual pain in 14% to 49% of patients. Studies including functional rehabilitation protocol reported functional as measured by the Constant Shoulder Score of 87.8 to 96, out of a maximum of 100 representing no functional limitations, and nonunion rates of 12% to 25% compared to 81 to 85 and 3% to 29% in those without a rehabilitation protocol. No studies directly examine the effect of immobilization and functional rehabilitation on clinical outcomes for midshaft clavicular fractures. Future studies are needed to better elucidate the most effective treatment. I.