Editor’s Spotlight/Take 5: Return to Running After Achilles Tendon Repair: How Do US Navy Service Members’ Physical Readiness Tests Change After Undergoing an Achilles Tendon Repair?

Cory Janney MDWe may love all our children the same, but I definitely don’t love all tendons the same. As a knee arthroplasty surgeon, I’m no great fan of the patellar tendon, since ruptures of this tendon after knee replacement remain one of the worst unsolved problems of my subspecialty. And as an aging (or maybe aged) athlete, I’ve also developed a real antipathy for the Achilles tendon. One of my own seems to want to go the way of all flesh well before the rest of me is quite ready to do so. I’m not alone in this, apparently. In any 2-year period, about 10% of runners will develop Achilles tendinopathy [4]. Even more dispiritingly, 1 in 2 will get it at some point in their lives [10], and 20% of those unfortunates will remain persistently symptomatic 10 years later [3]. When the Achilles tendon ruptures—as it does more commonly than any other tendon in athletes [5]—life turns the dial to the right: It’s not just pain, which might or might not have been present before these acute-on-chronic injuries, but rather a hard set of treatment choices (fix or not; how to fix [6]), a protracted convalescence, and a lot of worry. Those worries are worse for competitive or passionate athletes, and worse still for those who need a certain level of physical ability to remain employed, including but not limited to those who serve in the uniformed services of their countries. In this month’s Clinical Orthopaedics and Related Research®, we have some good news on this front, albeit with some caveats. A study from a group of United States Navy surgeons [12] found that while service members who had undergone repair generally ran and biked more slowly on the first Navy Physical Readiness Test they took after surgery than they did on the one before the injury, the differences were not as large as one might expect. The mean pace was about 40 seconds slower on a 1.5-mile (2.4-kilometer) run, but the mean mile pace remained below 8 minutes even after surgery, and runners got back almost half of the 40 seconds they lost on the second test they took, suggesting continued improvement out to a year or more. For those who took the fitness test on a stationary bike, the difference after surgery was measurable but pretty inconsequential: about 10 seconds slower on a roughly 13-minute test. Most importantly, perhaps, was that more than 98% of sailors who took fitness tests after Achilles tendon repair passed those tests. But it’s worth noting that almost a third of individuals changed from running to an alternative cardiovascular assessment after surgery, and that almost half the individuals who had surgery couldn’t be analyzed because they had not taken a test during the study eligibility period—suggesting they weren’t back to that level of training yet or that they had left the Navy [12]. You may not treat patients with Achilles tendinopathy, and you may not repair them when they pop, but the epidemiology of these problems suggests that you’ve either experienced them or know someone dear who has. For that reason, you won’t want to miss the chance to learn how to put these discoveries into practice in the Take 5 interview that follows with Cory Janney MD, senior author of “Return to Running After Achilles Tendon Repair: How Do US Navy Service Members’ Physical Readiness Tests Change After Undergoing an Achilles Tendon Repair?” [12]. You’ll then want to read the full article, which is part of the Selected Proceedings from last year’s Society of Military Orthopaedic Surgeons annual meeting [9] featured in this issue of CORR®. The team at CORR is proud to be the official journal of SOMOS. Take 5 Interview with Cory Janney MD, senior author of “Return to Running After Achilles Tendon Repair: How Do US Navy Service Members’ Physical Readiness Tests Change After Undergoing an Achilles Tendon Repair?” Seth S. Leopold MD:Congratulations on this well-done study. It certainly was a big effort, which caused me to wonder: What sparked your interest in this topic? Was it a particular patient encounter, or was there some other reason why it was so important to you? Cory Janney MD: Thank you very much for giving me the opportunity to discuss this paper further. I have always genuinely been curious about helping patients recover from an Achilles tendon rupture, whether treated operatively or nonoperatively. I’ve noticed the pendulum has swung to nonoperative management largely because of the Willits protocol [13] and other functional rehabilitation programs [1, 2], but one of the largest deficits in orthopaedic research on this topic is related to actual functional outcomes measurements. This means patients ask us for specific information that we can’t provide, because the data we have on functional outcomes isn’t good enough. For example, one question that we get a lot in the military is whether someone will be able to return to running, as this is a required component for some service members to remain on active duty. We already know that service members can have a great outcome with nonoperative management of an Achilles tendon tear; they are able to return to duty at the same rate of their surgically treated counterparts, although approximately 1.5 months later [8]. However, it is very difficult for us to provide an accurate prediction of a patient's ability to return to a specific activity, such as running, after either treatment approach. And for some patients—like those in the Marine Corps—being able to run is a requirement for return to duty, as Marines cannot perform alternative cardio events during the Physical Readiness Test like patients in the Navy or other branches can. Now, our paper at least shows patients that they may be able to return to running after surgery if they adhere to their rehabilitation, although initially they will be slower [12]. Hopefully further research will allow us to make more informed choices about surgical versus nonsurgical care, as that would help us better counsel our patients as they choose which healing pathway to pursue. Dr. Leopold:For me, a big question mark here seemed to be that the sailors who returned to full duty (that is, the ones who could take the Physical Readiness Test sometime within a couple years after surgery) came back pretty strong and kept improving for a while after surgery—out to a year or more. But a large subset didn’t come back; about half of those who had surgery couldn’t or didn’t take a fitness test or had left the Navy. In light of that, what is the “right” set of expectations to have following surgical treatment for Achilles tendon ruptures? Dr. Janney: This is an interesting component of the study. Some of those patients did not take their Physical Readiness Test for an extended period of time because they were continuing to rehabilitate to the point where they knew they could pass it. Failing the Physical Readiness Test is much more detrimental to their careers than waiving it until they know they can pass it, and patients are able to waive this test for two cycles with a surgeon’s recommendation. It is likely that during this time period, some patients decided to separate from the military or their contracts may have ended. This is one of many reasons why it is difficult to establish the right set of expectations for patients. We have good evidence to help us advise professional athletes about returning to sports after this operation, but those data don’t generalize well to people who are active but who are not professional athletes. There often are financial incentives to motivate professional athletes through their recoveries, along with other resources such as in-depth nutrition care, physical therapy, and trainers—resources that our military service members do not have. I think our paper [12] provides some guidance for these other populations, which has been difficult to find before. Dr. Leopold:Do you have any tricks for helping patients “get it” when you try to set expectations prior to surgery? Dr. Janney: I know a lot of my foot and ankle colleagues are very similar to me in that they have “canned” discussion points for the operations they perform commonly. The military patient population is often young and very active, and most of the patients I see follow some kind of professional sport. So I often ask my patients what happened when one of their favorite athletes had an Achilles rupture, and then I’ll ask how long it took that professional athlete to return to play, if he or she did. This gives me the chance to remind my patients that professional athletes have access to resources that most “regular people” don’t have access to. This helps me advise them that they are facing a lengthy recovery with a lot of therapy, all in an attempt to get them back to their prior level of activity. For the most part, I think most patients really do “get it.” There can be a level of frustration if they develop functional lengthening or difficulty with pushoff, but I find it is important at every visit to reemphasize that this is a long process of recovery, regardless of whether surgical or nonsurgical care was chosen, and I celebrate the small successes they make in their rehabilitation to help reframe their thought processes. Dr. Leopold:One can’t assume that findings drawn from mixed populations of men and women would apply equally to both men and women. Your study—like most on this topic—evaluated far more men than women, because that’s the epidemiology of this injury. But it also contained patients whose mean age might be 10 to 15 years younger than the average for patients with this injury [7], suggesting that older patients might have been disproportionately represented among those who couldn’t be evaluated or who left the Navy. What would it take to get larger numbers of women to evaluate in a study like this, or to see how older service members (or older recreational athletes) fare following this procedure? Would it be possible to perform a study like yours that pools results from the other armed forces to look at those groups? Dr. Janney: I think one option would be to redo the study in a few years, which would allow us to analyze a larger patient population. Recent data suggest women represent 17.7% of our active-duty service members [11], and the Achilles tendon rupture risk appears to be lower in women service members like it is in civilian populations. A larger patient population may give us the opportunity to determine if women fare differently from men on their fitness tests, or to evaluate older service members. However, pooling results from the other armed forces would be a difficult approach, as their annual or biannual fitness requirements are different. For example, the Marine Corps requires their service members to complete a Physical Fitness Test (which involves a 3-mile run) and a Combat Fitness Test (which requires a component of sprinting and maneuvering under fire). The Army and Air Force have different requirements, as well, and these differences would substantially limit our ability to generalize and compare the data. Dr. Leopold:This goes beyond what you studied, but it’s related, since most Achilles tears occur in tendinopathic tendons. I wonder if Achilles tendinopathy may be a problem of similarly large scope to tendon rupture. Although it’s perhaps not as debilitating as surgical recovery is in most patients, it’s so much more common that in aggregate, it may sideline as many sailors and recreational athletes as do tendon ruptures. What’s your observation on this point, and how do you keep your patients with Achilles tendinopathy in the game? Dr. Janney: That is a fantastic question and one that I often discuss with residents. We see patients with Achilles tendinopathy and plantar fasciitis, and symptoms from these conditions can be really limiting. I have found that it is incredibly important to identify the causative factor for the Achilles tendinopathy and/or the plantar fasciitis because an overwhelming majority of my patients with noninsertional or insertional Achilles tendinopathy have a gastrocnemius contracture. Most times, the very first portion of my physical exam (aside from directly observing the foot and ankle) is performing a range of motion test with a good Silverskiold exam (that is, comparing ankle dorsiflexion with the knee extended versus flexed; greater ankle dorsiflexion with knee flexion indicates gastrocnemius tightness). If gastrocnemius contracture can be managed through intervention with physical therapy, utilization of bracing such as a night splint, and a good home exercise program, the Achilles tendon symptoms will often substantially improve. If a patient is unable to obtain good range of motion with therapy after a reasonable period of time, I will sometimes offer an endoscopic gastrocnemius recession, which can offload the Achilles tendon and may help the pain improve enough to allow a faster return to full activity.