The short-term clinical effects of accelerated rehabilitation following open surgery for acute Achilles tendon rupture based on ultrasonography monitoring: a retrospective cohort study

The short-term clinical effects of accelerated rehabilitation following open surgery for acute Achilles tendon rupture based on ultrasonography monitoring: a retrospective cohort study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The short-term clinical effects of accelerated rehabilitation following open surgery for acute Achilles tendon rupture based on ultrasonography monitoring: a retrospective cohort study Yuan Cao, Shan Gao, Bo Zhao, Xiuzhi Li, Xiaoyu Norman Pan, Yang Lv, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7126491/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 29 Sep, 2025 Read the published version in Journal of Orthopaedic Surgery and Research → Version 1 posted 19 You are reading this latest preprint version Abstract Background Individualized rehabilitation after acute Achilles tendon rupture (AATR) repair is important. The aim of this study was to evaluate and compare the short-term clinical effects of different rehabilitation processes following open surgery for AATR based on ultrasonography (US) monitoring. Methods This study included 80 patients (mean age, 32.0 ± 4.4 years) who underwent open surgery for AATR repair. The patients were categorised into two groups (accelerated rehabilitation group, AR, and conventional rehabilitation group, CR) according to whether postoperative rehabilitation relied on US monitoring. All patients received the same suture technique and immobilisation duration; they were clinically examined at 2, 4, 6, 8, 10, 12, 14, and 16 weeks postoperatively, with a final follow-up at a mean of 18.8 months. The primary outcome was the recovery time for the one-leg heel-rise height (OHRH). Secondary outcomes included the time required to return to range of motion(ROM) and light exercise (LE), the clinical function scores, and complications. Data regarding the surgical duration, the visual analogue scale (VAS) score for pain, the Achilles tendon Total Rupture Score (ATRS), and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale score were also collected. Results The recovery times for OHRH and LE were significantly shorter in group AR than in group CR (P < 0.05). The VAS scores decreased over time, reaching 0 in both groups by 10 weeks. ATRS and the AOFAS Ankle-Hindfoot scale score increased across both groups over time, showing significant between-group differences from 4 to 14 weeks(P < 0.05) and 4 to 8 weeks(P < 0.05). The mean scores were better in group AR than in group CR. Three re-ruptures (3.8%) were observed, and all complications were resolved at the last follow-up, with no significant between-group differences. Conclusions Rehabilitation under Ultrasonography monitoring safely accelerates recovery after acute Achilles tendon repair, improving short-term outcomes without increasing pain or re-rupture risk. Acute Achilles tendon rupture Individualized rehabilitation Ultrasonography monitoring Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Acute Achilles tendon rupture (AATR) is a common musculoskeletal injury, with an incidence rate ranging from 8 to 32 cases per 100,000 individuals annually[ 1 ]. Following AATR, patients often experience prolonged limitations in tendon-loading activities, which may persist for over a decade or even become permanent if left untreated[ 2 ]. The optimal treatment strategy for AATR remains a subject of debate. Numerous studies have compared surgical and non-surgical interventions for acute Achilles tendon rupture[ 3 ]. While surgical repair carries inherent risks, including wound infection and other perioperative complications, non-surgical management is associated with a relatively higher re-rupture rate[ 4 ]. However, for young and physically active individuals, particularly athletes with high functional demands, surgical intervention may facilitate a faster recovery[ 5 ]. Following standard surgical repair of AATR, postoperative protocols typically involve restricted weight-bearing and immobilization with a brace for at least six weeks[ 6 ]. Our previous research[ 7 ] suggested that immobilization for two weeks postoperatively may represent the optimal strategy for early rehabilitation. Nevertheless, premature initiation of rehabilitation exercises after Achilles tendon repair may increase the risk of complications, including re-rupture[ 8 ]. After brace removal, rehabilitation should be accelerated in a controlled manner to optimize early functional recovery. However, few studies have systematically investigated evidence-based rehabilitation protocols following brace removal, particularly regarding individualized interventions to minimize complications. Diagnostic imaging plays a crucial role in assessing tendon healing post-repair. Ultrasonography (US) and magnetic resonance imaging (MRI) are commonly employed modalities, with US offering distinct advantages in terms of accessibility, cost-effectiveness, and dynamic evaluation of tendon integrity[ 9 ]. Ciszkowska-Łysoń et al.[ 10 ] proposed a dynamic US-based assessment to evaluate Achilles tendon tension during rehabilitation. Elevated tendon tension observed via US may indicate potential separation at the repair site, suggesting an increased risk of re-rupture if aggressive rehabilitation is pursued. Therefore, individualized rehabilitation protocols guided by US monitoring may significantly improve early postoperative outcomes. Building upon our prior findings, we conducted a retrospective cohort study to evaluate and compare the short-term clinical outcomes of different rehabilitation strategies following open surgical repair of AATR, utilizing US monitoring to guide intervention. Materials and methods The study protocol was approved by the ethics committee of Peking University Third Hospital. Informed consent was signed by each enrolled patient. Design and population This retrospective cohort study enrolled 87 patients who underwent surgical treatment for AATR at our university hospital between March 2022 and May 2023. Each patient provided written consent prior to enrollment in the study. Among these patients, 7 were lost to follow-up, and 80 patients (92.0%) were included in the final analysis. A radiologist conducted an ultrasound examination of the Achilles tendon preoperatively to confirm the diagnosis and detail the site and extent of the rupture. The inclusion criteria were as follows: (1) age of 18 to 60 years, (2) closed injury, and (3) AATR (< 7 days since tendon rupture). The exclusion criteria were as follows: (1) partial ATR; (2) patients with Achilles tendon re-rupture; (3) diseases that may affect functional test results, such as diabetes, neuropathy, and autoimmune disease; and (4) patients with other peri-ankle diseases, including ankle osteoarthritis, and other ligament injuries. All the patients were divided into an accelerated rehabilitation group (AR group) and a conventional rehabilitation group (CR group) based on whether dynamic US monitoring was conducted during the rehabilitation period. Surgical procedure Patients were placed in the prone position and operated on under spinal anaesthesia using a tourniquet. The Achilles tendon resting angle (ATRA) on both sides was measured before disinfection. The ATRA is the angle between the long axis of the fibula and the line from the tip of the fibula to the head of the fifth metatarsal [ 11 ]. An incision was made posteromedial to the midline of the Achilles tendon at the level of the rupture in a longitudinal fashion, and the paratenon was divided to identify the rupture. With the ankle placed in a neutral position, the tendon was repaired using the Krackow locking loop technique with two W4843 (ETHIBOND of Johnson & Johnson, US) nonabsorbable sutures and the modified Kessler suture technique with two REF223114 (ORTHOCORD of Depuy Synthes, US) nonabsorbable sutures. The sutures were carefully placed away from the rupture site, and the tendon was sutured to a healthy tendon to enhance the stability of the repair (Fig. 1 ). Subsequently, six figure-eight sutures (four for the dorsal, two for the ventral) were placed with 2-0-gauge absorbable sutures to reinforce the broken ends. The ATRA on the affected side was measured again to determine whether the repair was suitable, and it was confirmed to be reduced and smaller than that on the contralateral leg. Following tension and strength testing of the ankle, the peritenon and subcutaneous tissues were approximated with 2-0-gauge and 3-0-gauge absorbable sutures, respectively, and the skin was closed with a skin stapler. Following wound binding, a below-knee brace with a wedge was applied with the ankle in a 30-degree plantar flexion position in all patients for 2 weeks. All patients underwent surgery performed by the same surgeon using the same operative technique. Postoperative rehabilitation and Data collection All patients underwent rehabilitation exercises after the removal of the immobilisation brace. In the CR group, at 0–2 weeks after brace removal, patients were instructed to perform moderate plantar flexion and dorsiflexion of the ankle and stand up (partial weightbearing) for 1 h every day. From 2 to 4 weeks after brace removal, ankle exercises remained consistent, with the standing time increased to 2 h per day. Simultaneously, the patients were instructed to perform deep squat exercises. Four to 6 weeks after brace removal, they were instructed to perform double-legged heel raises and walk fewer than 1000 steps on flat ground. Between 6 and 8 weeks after brace removal, the patients were advised to perform one-leg heel raises and limit walking to less than 2000 steps on flat ground. When the patients could successfully perform one-leg heel raises, they were instructed to jog 2 weeks later. 4 weeks after successfully performing jogging, the patients were allowed to perform more vigorous training. In the AR group, patients underwent US examination, which was performed by a radiologist who had 15 years of experience performing musculoskeletal ultrasonography, 2 weeks postoperatively after the brace was removed. All US examinations were performed using a 9-MHz to 15-MHz linear-array transducer (HIVISION, G0201500101431, China). The patient was in a prone position with both feet at rest, placed beyond the edge of the examination table to allow for unrestricted foot movement. A linear transducer is applied to the Achilles tendon above the calcaneal tuberosity to obtain the image of the longitudinally arranged tendon fibre and the junction of ruptured Achilles tendon tissue in the normal resting position. A main anechoic zone could be found at the junction. Then, the image was obtained again in extreme dorsiflexion. The radiologist observed whether the anechoic zone was enlarged compared to that in the natural position. If it was enlarged, it was considered that there was a tendency of separation at the junction of ruptured Achilles tendon tissue, and the examination was concluded. If there was no obvious change in the anechoic zone, the patient was instructed to do a deep squat and obtain the image again to observe whether there was a tendency of separation in the deep squat position. If the US results showed no tendency of separation in the deep squat position, the patient would then directly perform ankle mobilisation exercises, and the standing time increased to 2 h per day with deep squat exercises at 0–2 weeks after brace removal (Fig. 2 ). The subsequent rehabilitation plan was also advanced by two weeks. The rehabilitation plan for patients with a tendency to separation in the extreme dorsiflexion position or deep squat position was the same as that of the CR group (Fig. 3 , Table 1 ). Table 1 Rehabilitation Protocol Patients whose US results showed no tendency of separation in the AR group Patients in the CR group or those whose US results showed a tendency of separation in the AR group 0–2 weeks after removing the brace Ankle mobilisation Ankle mobilisation Standing up for 2 h per day Standing up for 1 h per day Deep squat 2–4 weeks after removing the brace Double-legged heel raises Ankle mobilisation Walking less than 1000 steps on flat ground Standing up for 2 h per day Deep squat 4–6 weeks after removing the brace One-legged heel raises Double-legged heel raises Walking less than 2000 steps on flat ground Walking less than 1000 steps on flat ground 6–8 weeks after removing the brace One-legged heel raises Walking less than 2000 steps on flat ground 2 weeks after successfully performing one-leg heel raises Jogging Jogging 4 weeks after successfully performing jogging More vigorous training More vigorous training AR, accelerate rehabilitation group; CR, conventional rehabilitation group. Patients attended follow-up visits at 2, 4, 6, 8, 10, 12, 14, and 16 weeks and at the final follow-up after surgery. During follow-up, all patients were evaluated by the same surgeon. The surgical duration and complications, such as superficial infection, re-rupture, and deep venous thrombosis (DVT), were recorded. Dorsiflexion and plantar flexion were measured using a handheld goniometer. The recovery time for the range of motion (ROM) was recorded when it was similar to that for the contralateral leg. The heel-rise height was measured as the distance from the ground to the heel when the patient lifted the heel while keeping the knee straight. The recovery time for the one-leg heel-rise height (OHRH) was recorded when the heel-rise height index (HRHI = involved/uninvolved ×100) reached 50% [ 12 ]. The time to return to light exercise (LE), which included rapid walking and jogging, was noted. The recovery times for OHRH were the primary endpoint, while the time to return to LE and the clinical Function scores were the secondary outcomes. Clinical scores, including the visual analogue scale (VAS) score for pain, American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale score [ 13 ], and Achilles tendon Total Rupture Score (ATRS) [ 14 ] were also recorded to evaluate subjective pain and functional status. VAS measures pain on a 10-cm scale, with the status ranging from no pain (extreme left) to the worst possible pain (extreme right). The patients marked their current pain levels on the scale, and the score was accordingly recorded. The AOFAS Ankle-Hindfoot Scale, which was recorded after 6 weeks postoperatively, assigned a maximum score of 100 points (90–100 points, excellent; 75–89 points, good; 50–74 points, fair; and < 50 points, poor). The ATRS, which was recorded after 6 weeks postoperatively, was a patient-reported tool designed to measure the outcomes after AATR repair. The questionnaire comprises 10 questions to assess symptoms and the level of physical activity, with answers evaluated on an 11-point Likert scale (scores ranging from 0 to 10, with a maximum possible score of 100; higher scores indicate a better health status). Statistical analysis All statistical analyses were performed using SPSS version 27.0 (IBM Corp., Armonk, NY, USA). Data are reported as mean ± standard error of the mean unless otherwise noted. Continuous variables were compared using an independent sample t-test when the variables were approximately normally distributed, and non-normally distributed variables were analyzed using the Mann-Whitney U test. The chi-square test or Fisher’s exact test (n < 40 or t < 1) was used to evaluate categorical parameters between the two groups. Statistical significance was set at p < 0.05. Results Group characteristics In total, 80 patients with unilateral complete AATR were included (73 male and 7 female patients; mean age, 32.0 years, range, 19–40 years). There were no significant between-group differences in sex, age, Body Mass Index (BMI), surgical duration, distance from the rupture site to the Achilles tendon insertion site, and gap distance of the rupture site (Table 1 ). In the AR group, 24 patients whose ultrasound images showed no tendency of separation accelerated their rehabilitation process (Fig. 4 ). Table 1 Group Characteristics AR Group CR Group P value Number of Patients 40 40 Age 31.1 ± 4.5 32.9 ± 4.2 0.051 Sex (Male/Female) 37/3 36/4 Body Mass Index 25.2 ± 1.6 24.9 ± 1.7 0.444 Operation Time 32.4 ± 4.0 31.3 ± 4.5 0.206 GDRS 1.7 ± 0.9 1.8 ± 1.0 0.600 DRSTI 4.5 ± 0.6 4.7 ± 0.5 0.443 Data represent the mean [SD]; AR, accelerated rehabilitation; CR, conventional rehabilitation; GDRS, gap distance of the rupture site; DRSTI, distance from the rupture site to the Achilles tendon insertion Recovery times The mean recovery time for ROM was 5.8 ± 1.9 weeks in the AR group and 6.3 ± 1.6 weeks in the CR group. The mean recovery times for OHRH were 11.6 ± 2.1 and 12.1 ± 1.4 weeks in the AR group and the CR group, respectively. The mean time to return to LE was 17.2 ± 1.7 and 18.3 ± 2.2 weeks in the two groups. AR Group showed significantly shorter recovery times for OHRH and LE than those in the other group (P < 0.05; Table 2 ). There was no significant difference in recovery time for ROM between the two groups. Table 2 Recovery Time AR Group CR Group P value (n = 40) (n = 40) ROM 5.8 ± 1.9 6.3 ± 1.6 0.108 OHRH 11.6 ± 2.1 12.1 ± 1.4 0.032 LE 17.2 ± 1.7 18.3 ± 2.2 0.006 Data represent the mean [SD]; AR, accelerated rehabilitation; CR, conventional rehabilitation; ROM, range of motion; OHRH, one-leg heel-rise height; LE, light exercise. Outcome scores The VAS score for pain significantly decreased from 2 to 8 weeks, and reached 0 in all four groups after 10 weeks. No significant differences in VAS score were found between the two groups (Table 3 ). The mean ATRS in both groups increased over time. Significant differences were found between the two groups from weeks 4 to 14 (P < 0.05, Table 4 ), with the mean scores in the AR group being higher than those in the other group. The mean AOFAS Ankle-Hindfoot Scale score increased over time in both groups, with significant differences observed between the two groups from weeks 4 to 8 (P < 0.05, Table 5 ), and the mean scores in the AR Group were higher than those in the other group. At the last follow-up, only the functional recovery of the patients was assessed. No outcome scores were obtained. Table 3 Visual Analogue Scale (VAS) for Pain Time (weeks) AR Group CR Group P value (n = 40) (n = 40) 2 2.0 ± 0.9 1.9 ± 0.8 0.872 4 0.9 ± 1.1 0.6 ± 0.8 0.410 6 0.4 ± 0.9 0.1 ± 0.4 0.209 8 0.1 ± 0.3 0.1 ± 0.2 0.646 Data represent the mean [SD]. AR, accelerated rehabilitation; CR, conventional rehabilitation. Table 4 Achilles Tendon Total Rupture Score (ATRS) Time (weeks) AR Group CR Group P value (n = 40) (n = 40) 2 19.9 ± 4.1 20.6 ± 5.3 0.969 4 36.2 ± 9.7 28.4 ± 5.7 < 0.001 6 61.0 ± 12.3 52.2 ± 6.8 < 0.001 8 76.1 ± 9.7 69.7 ± 5.1 < 0.001 10 87.2 ± 8.4 82.1 ± 4.6 < 0.001 12 93.8 ± 5.8 91.6 ± 4.0 < 0.001 14 96.7 ± 2.8 96.1 ± 2.0 0.003 16 97.6 ± 1.3 97.8 ± 0.9 0.838 Data represent the mean [SD]. AR, accelerated rehabilitation; CR, conventional rehabilitation. Table 5 American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scores Time (weeks) AR Group CR Group P value (n = 40) (n = 40) 2 53.6 ± 3.8 54.3 ± 2.9 0.346 4 67.6 ± 7.9 60.1 ± 4.8 < 0.001 6 77.8 ± 11.7 68.9 ± 7.4 0.001 8 94.9 ± 9.8 92.9 ± 7.9 < 0.001 10 98.5 ± 4.3 98.8 ± 3.6 0.887 12 99.4 ± 1.7 99.7 ± 0.9 0.611 14 99.4 ± 1.6 99.7 ± 0.9 0.617 16 99.5 ± 1.6 99.7 ± 0.9 0.648 Data represent the mean [SD]. AR, accelerated rehabilitation group; CR, conventional rehabilitation group. Complications A total of 3 complications (3/80, 3.8%) were observed in the study, including one (1/40, 2.5%) in the AR Group and two (2/40, 5.0%) in the CR Group. All three complications were re-ruptures, which occurred at 10 weeks after surgery and were diagnosed through clinical examination and a positive Thompson’s test. No infections were observed across all groups. No significant differences in complication rates were observed between the two groups (P = 0.556). At the last follow-up, all patients had recovered without complications. Discussion Current rehabilitation paradigms following Achilles tendon rupture emphasize early mobilization to mitigate muscle atrophy and functional impairment[ 15 ]. Traditional postoperative protocols recommended at least six weeks of immobilization. However, emerging clinical evidence suggests that reducing immobilization duration may facilitate earlier functional recovery. The biological basis for this approach lies in collagen composition dynamics: native Achilles tendon consists predominantly of mechanically robust type I collagen, whereas repaired tendon tissue initially contains weaker type III collagen. Prolonged immobilization may impede type I collagen synthesis and maturation, while controlled mechanical loading appears to promote its production, thereby enhancing tendon healing[ 16 ]. Our previous investigation[ 7 ] demonstrated that two weeks of postoperative immobilization following open AATR repair represents an optimal strategy for early rehabilitation, yielding satisfactory clinical outcomes with minimal discomfort. Building upon these findings, we sought to develop and evaluate a more accelerated rehabilitation protocol while maintaining patient safety. This study was therefore designed to extend our prior research by investigating the efficacy of an ultrasonography-guided accelerated rehabilitation program. One of the most crucial issues in AATR treatment is the incidence of re-rupture. Arner et al[ 17 ] found that 53% of patients with Achilles tendon rupture occurred when the knee joint was hyperextended while pushing off the ground with the front foot during weight-bearing, such as athletes sprinting or jumping, and 27% occurred during sudden or rough ankle dorsiflexion movements, such as falls on stairs or falls from heights. Thus, it is necessary to strictly control the starting time of the ankle dorsiflexion movement while bearing weight, such as deep squatting, during the postoperative rehabilitation period. With no validated guidelines, the rehabilitation process after surgery decisions largely rest on the clinical judgment and collaboration between the clinician and patient[ 18 ]. Patients typically demonstrate strong motivation for early rehabilitation initiation following brace removal, aiming to expedite return to occupational and daily activities. However, premature or excessive mechanical loading may significantly increase the risk of postoperative complications, particularly re-rupture, due to compromised tendon integrity during the early healing phase[ 8 ]. Consequently, individualized rehabilitation protocols guided by evidential diagnostic assessment assume critical importance in optimizing recovery outcomes while minimizing adverse events. Current clinical practice utilizes both US and MRI for postoperative monitoring of Achilles tendon healing following AATR repair [ 9 – 10 ]. The US has emerged as the preferred imaging modality for routine follow-up examinations due to its distinct advantages of clinical accessibility, cost-effectiveness, and diagnostic reliability[ 19 ]. Notably, Ciszkowska-Łysoń et al.[ 10 ] developed an innovative dynamic US assessment protocol to quantitatively evaluate Achilles tendon tension during plantarflexion maneuvers. When there is tension in the Achilles tendon, a linear arrangement of tendon fibers and a main anechoic zone at the junction can be observed on the image. In our study, the ankle joint was dorsiflexed to increase tension, so as to observe whether there was any size change in the anechoic zone. When the range of the anechoic zone increased compared to that in the rest position, it was considered that there was a tendency of separation at the junction of ruptured Achilles tendon tissue. We also used this to distinguish whether the patient had further accelerated rehabilitation exercises. The patients could directly practice deep squat after removing the brace if there is no tendency of separation. A review investigating surgical interventions for acute ATR reported re-rupture rates of 3.6–8.3%[20]. Comparatively, our study reported a relatively low re-rupture rate of 3.8% (3/80). All three re-rupture cases in this study resulted from accidental falls or sudden traumatic events rather than protocol-guided rehabilitation exercises. These incidents occurred during unprotected dorsiflexion movements while not wearing the protective brace. Although no statistically significant difference in re-rupture rates was demonstrated between groups, the AR group exhibited a numerically lower incidence compared to the conventional rehabilitation group. These findings suggest that the accelerated recovery protocol can be implemented with an acceptable safety profile. The other most important aspect of AATR treatment is Achilles tendon elongation. An effective way to evaluate Achilles tendon elongation is the heel-rise test[ 12 ]. Hoeffner et al[20] conducted a randomized controlled trial about Achilles tendon elongation. 48 patients with a surgically repaired AATR were randomized to 2 groups: the standard group received the currently accepted rehabilitation, and the delayed group received the same rehabilitation except that initial loading was delayed by 6 weeks. Finally, they concluded that delayed loading was not superior to standard loading in reducing the heel-rise height difference at 1 year. The total excursion capacity of the musculotendinous unit is primarily determined by muscle fiber length, suggesting that deficits in heel-rise height may reflect alterations in tendon and fascicle length rather than muscular strength deficits[ 22 – 23 ]. This biomechanical principle implies that early rehabilitation exercises are unlikely to induce significant tendon elongation. In our cohort, all patients initiated weight-bearing rehabilitation following brace removal at 2 weeks postoperatively. During the rehabilitation period, we observed progressive improvement in the OHRH. Among patients with normal recovery, the OHRH index reached approximately 50% of preoperative values by 3 months post-surgery. Notably, the AR group demonstrated more rapid OHRH recovery compared to conventional rehabilitation. However, a limitation of our study was the lack of systematic assessment of long-term Achilles tendon elongation. This study demonstrated considerable inter-individual variability in recovery trajectories. Comparative analysis revealed significantly shorter mean recovery times for both OHRH and LE measurements in the AR group compared to the CR group, suggesting more rapid functional recovery with the accelerated protocol. This was further supported by superior short-term clinical functional scores in the AR cohort. The VAS scores showed no significant intergroup differences, indicating that the accelerated protocol did not exacerbate postoperative discomfort. While the ATRS demonstrated statistically significant between-group differences from 10 to 14 weeks postoperatively, the AOFAS Ankle-Hindfoot scale failed to show similar discrimination. This discrepancy may be attributable to fundamental differences in scale composition: the ATRS relies exclusively on patient-reported subjective measures, whereas the AOFAS incorporates both subjective and objective clinical assessments. Several important limitations should be acknowledged in this investigation. First, the study design was constrained by being a single-center retrospective cohort analysis with a relatively small sample size. These methodological characteristics necessitate validation through larger-scale, multicenter, prospective randomized controlled trials to substantiate our findings. Second, the demographic composition of our cohort exhibited a significant male predominance, potentially introducing sex-related bias that may limit the generalizability of our results to female populations. Third, the ultrasonographic assessment of tendon separation tendency relied principally on the subjective interpretation of the examining radiologist, representing a potential source of diagnostic variability. This highlights the need for developing more standardized, objective criteria for ultrasound evaluation of tendon healing. Additionally, the current study employed outcome measures that included subjective components. Future investigations would benefit from incorporating more objective, validated assessment tools. Finally, our follow-up period was insufficient to evaluate long-term outcomes, particularly regarding potential Achilles tendon elongation. Extended longitudinal studies are warranted to fully characterize the temporal progression of postoperative recovery. Conclusion Rehabilitation under Ultrasonography monitoring safely accelerates recovery after acute Achilles tendon repair, improving short-term outcomes without increasing pain or re-rupture risk. Abbreviations AATR acute Achilles tendon rupture US ultrasonography AR accelerated rehabilitation CR conventional rehabilitation OHRH one-leg heel-rise height ROM range of motion LE light exercise VAS visual analogue scale ATRS Achilles tendon Total Rupture Score AOFAS American Orthopaedic Foot and Ankle Society MRI magnetic resonance imaging ATRA Achilles tendon resting angle DVT deep venous thrombosis HRHI heel-rise height index BMI Body Mass Index GDRS gap distance of the rupture site DRSTI distance from the rupture site to the Achilles tendon insertion Declarations Ethics approval and consent to participate The study protocol was approved by the ethics committee of Peking University Third Hospital (Approval Number: IRB00006761-M2020315). Informed consent was signed by each enrolled objective. Consent for publication ： Not applicable Availability of data and materials ： The datasets used and analysed during the current study are available from the corresponding author on reasonable request. Competing interests : The authors declare that they have no competing interests Funding : This work was supported by Fund progrmas: National Key R&D Program of China (grant no. 2023YFC2508804); Capital health development research project（grant no.2022-2-4096）；Peking University Third Hospital (grant no. BYSYZHKC117) Authors' contributions ： YC, SG, BZ, XL, XP, YL and FZ were all involved with the conception and design of the study, acquisition of data, analysis and interpretation of data, and drafting and revision of the article. All authors read and approved the final manuscript. Acknowledgements : Not applicable. References Irfan SA, Ahmed S, Ashkar A, et al. Comparative effectiveness of weight-bearing strategies on functional recovery in acute Achilles tendon rupture: A network meta-analysis. Foot Ankle Surg Published online March. 2025;5. 10.1016/j.fas.2025.02.013 . Mansfield K, Dopke K, Koroneos Z, et al. Achilles Tendon Ruptures and Repair in Athletes-a Review of Sports-Related Achilles Injuries and Return to Play. Curr Rev Musculoskelet Med. 2022;15(5):353–61. 10.1007/s12178-022-09774-3 . Lameire DL, Ramelli L, Halai M, et al. Outcomes of operative and nonoperative management of myotendinous Achilles tendon ruptures: a systematic review. BMC Musculoskelet Disord. 2025;26(1):71. 10.1186/s12891-025-08286-8 . Acevedo D, Garcia JR, Grewal RS, et al. Comparison of rerupture rates after operative and nonoperative management of Achilles tendon rupture in older populations: Systematic review and meta-analysis. J Orthop. 2024;52:112–8. 10.1016/j.jor.2024.02.034 . Published 2024 Feb 22. Kim U, Choi YS, Jang GC et al. Early rehabilitation after open repair for patients with a rupture of the Achilles tendon[J]. Injury 2017,48(7):1710–3. 10.1016/j.injury.2017.04.050 Carter TR, Fowler PJ, Blokker C. Functional postoperative treatment of Achilles tendon repair. Am J Sports Med. 1992;20(4):459–62. 10.1177/036354659202000417 . Cao Y, Gao S, Cui Z et al. Comparison of different immobilisation durations following open surgery for acute achilles tendon rupture: a prospective cohort study. J Orthop Surg Res. 2024;19(1):497. Published 2024 Aug 21. 10.1186/s13018-024-04970-y Saxena A, Giai Via A, Grävare Silbernagel K, et al. Current Consensus for Rehabilitation Protocols of the Surgically Repaired Acute Mid-Substance Achilles Rupture: A Systematic Review and Recommendations From the GAIT Study Group. J Foot Ankle Surg. 2022;61(4):855–61. 10.1053/j.jfas.2021.12.008 . Alabau-Dasi R, Dominguez-Maldonado G, Ortega-Avila AB et al. Validation of Fixed Ultrasonography for Achilles Tendon Assessment: A Reliability Study. Diagnostics (Basel). 2024;14(19):2221. Published 2024 Oct 5. 10.3390/diagnostics14192221 Ciszkowska-Łysoń B, Zdanowicz U, Śmigielski R. The ultrasonographic dynamic heel-rise test of the Achilles tendon. J Ultrason. 2021;21:e260–6. 10.15557/JoU.2021.0043 . Carmont MR, Grävare Silbernagel K, Brorsson A, et al. The Achilles tendon resting angle as an indirect measure of Achilles tendon length following rupture, repair, and rehabilitation. Asia Pac J Sports Med Arthrosc Rehabil Technol. 2015;2(2):49–55. 10.1016/j.asmart.2014.12.002 . Mansfield K, Dopke K, Koroneos Z, et al. Achilles Tendon Ruptures and repair in Athletes-a review of sports-related Achilles injuries and return to play. Curr Rev Musculoskelet Med. 2022;15(5):353–61. 10.1007/s12178-022-09774-3 . Kitaoka HB, Alexander IJ, Adelaar RS, et al. Clinical Rating systems for the Ankle-Hindfoot, midfoot, Hallux, and lesser toes. Foot Ankle Int. 1997;18(3):187–8. 10.1177/107110079701800315 . Nilsson-Helander K, Thomeé R, Silbernagel KG, et al. The Achilles tendon total rupture score (ATRS): development and validation. Am J Sports Med. 2007;35(3):421–6. 10.1177/0363546506294856 . Liu X, Dai TJ, Li BL, et al. Early functional rehabilitation compared with traditional immobilization for acute Achilles tendon ruptures: a meta-analysis. Bone Joint J. 2021;103(6):1021–30. 10.1302/0301-620X.103B6.BJJ-2020-1890.R1 . Liang W, Zhou C, Deng Y, et al. The current status of various preclinical therapeutic approaches for tendon repair. Ann Med. 2024;56(1):2337871. 10.1080/07853890.2024.2337871 . Arner O, Lindholm A. Subcutaneous rupture of the Achilles tendon; a study of 92 cases. Acta Chir Scand Suppl. 1959;116(Supp 239):1–51. Wise PM, King JL, Stauch CM, et al. Outcomes of NCAA defensive football players following Achilles tendon repair. Foot Ankle Int. 2020;41(4):398–402. 10.1177/1071100719899072 . Shivapatham G, Richards S, Bamber J Ultrasound Measurement of Local Deformation in the Human Free Achilles Tendon Produced by Dynamic Muscle-Induced Loading: A Systematic Review. Ultrasound Med Biol., Hoeffner R, Agergaard AS, Svensson RB Tendon Elongation and Function After [20], Seow D, Yasui Y, Calder JDF et al. Treatment of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis of Complication Rates With Best- and Worst-Case Analyses for Rerupture Rates. Am J Sports Med. 2021;49(13):3728–3748. doi:10.1177/0363546521998284. Delayed or Standard Loading of Surgically Repaired Achilles Tendon Ruptures. A Randomized Controlled Trial. Am J Sports Med. 2024;52(4):1022–31. 10.1177/03635465241227178 . Khair RM, Stenroth L, Cronin NJ, et al. Muscle-tendon morphomechanical properties of non-surgically treated Achilles tendon 1-year post-rupture. Clin Biomech (Bristol Avon). 2022;92:105568. 10.1016/j.clinbiomech.2021.105568 . Baxter JR, Hullfish TJ, Chao W. Functional deficits may be explained by plantarflexor remodeling following Achilles tendon rupture repair: preliminary findings. J Biomech. 2018;79:238–42. 10.1016/j.jbiomech.2018.08.016 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 29 Sep, 2025 Read the published version in Journal of Orthopaedic Surgery and Research → Version 1 posted Editorial decision: Revision requested 11 Aug, 2025 Reviews received at journal 09 Aug, 2025 Reviews received at journal 08 Aug, 2025 Reviews received at journal 05 Aug, 2025 Reviews received at journal 03 Aug, 2025 Reviewers agreed at journal 31 Jul, 2025 Reviews received at journal 31 Jul, 2025 Reviewers agreed at journal 30 Jul, 2025 Reviewers agreed at journal 30 Jul, 2025 Reviewers agreed at journal 29 Jul, 2025 Reviewers agreed at journal 28 Jul, 2025 Reviewers agreed at journal 28 Jul, 2025 Reviews received at journal 27 Jul, 2025 Reviewers agreed at journal 27 Jul, 2025 Reviewers agreed at journal 24 Jul, 2025 Reviewers invited by journal 22 Jul, 2025 Editor assigned by journal 15 Jul, 2025 Submission checks completed at journal 15 Jul, 2025 First submitted to journal 15 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7126491","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":488955310,"identity":"0f5d5d72-5ca2-4830-abbc-60f9ec4de2d5","order_by":0,"name":"Yuan Cao","email":"","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yuan","middleName":"","lastName":"Cao","suffix":""},{"id":488955311,"identity":"723edbd1-6fb1-46a9-957c-5ed1f8adb5cd","order_by":1,"name":"Shan Gao","email":"","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":false,"prefix":"","firstName":"Shan","middleName":"","lastName":"Gao","suffix":""},{"id":488955312,"identity":"01adf2d2-998f-4a27-9c26-dd966c91ba27","order_by":2,"name":"Bo Zhao","email":"","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":false,"prefix":"","firstName":"Bo","middleName":"","lastName":"Zhao","suffix":""},{"id":488955313,"identity":"b45c149b-36a7-40ca-b743-952c9c469969","order_by":3,"name":"Xiuzhi Li","email":"","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xiuzhi","middleName":"","lastName":"Li","suffix":""},{"id":488955314,"identity":"533a2a3f-bec2-4ade-b9d0-98b63a9f6fa9","order_by":4,"name":"Xiaoyu Norman Pan","email":"","orcid":"","institution":"Harvard Medical School","correspondingAuthor":false,"prefix":"","firstName":"Xiaoyu","middleName":"Norman","lastName":"Pan","suffix":""},{"id":488955317,"identity":"822c6d9b-e849-4328-b54a-ada36f4ad273","order_by":5,"name":"Yang Lv","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxklEQVRIiWNgGAWjYBACPgjFJsfPzHzwAVFa2KA6jSXb2ZINSNEil7jhPI+ZAHFaJHIMPxf8MmPcfJjBjIGhxiaaGC3G0jP70pjNDjOkPWA4lpbbQFALzxkDad6eY2xALccNGBsOE6XF+Ddvz38e42bGNgnitLD3mEnz/GCTMGBmZiNWS1uZNW8Dm4HEYTZmgwRi/AKMwc23ef6w1ff3n//44EONDWEtDAwcBgyMbVB2AmHlIMD+gIHhD3FKR8EoGAWjYIQCAJUzNxwa6etiAAAAAElFTkSuQmCC","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":true,"prefix":"","firstName":"Yang","middleName":"","lastName":"Lv","suffix":""},{"id":488955318,"identity":"de05ccad-88eb-44b8-95de-dca5e595f534","order_by":6,"name":"Fang Zhou","email":"","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":false,"prefix":"","firstName":"Fang","middleName":"","lastName":"Zhou","suffix":""}],"badges":[],"createdAt":"2025-07-15 05:38:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7126491/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7126491/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13018-025-06282-1","type":"published","date":"2025-09-29T15:57:55+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":87700911,"identity":"c4b8b30f-b708-45cb-84d5-14a75c7f4d7b","added_by":"auto","created_at":"2025-07-28 07:23:10","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":235432,"visible":true,"origin":"","legend":"\u003cp\u003eDiagram of our suture technique\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7126491/v1/4ccb4cfb41dd8d73cfe05201.png"},{"id":87700916,"identity":"1e33aee1-4e16-4dea-8d82-94c2c183214b","added_by":"auto","created_at":"2025-07-28 07:23:10","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":535567,"visible":true,"origin":"","legend":"\u003cp\u003ea. A main anechoic zone was found in normal resting position (between the two red arrows), and the tendon fibres appeared undulated in the dynamic imaging (the curved red lines indicate the wavy course of the fibres) b. The anechoic zone was enlarged in extreme dorsiflexion (between the two red arrows), and evident fibrillar structure of the tendon fibres was appeared (red short lines).\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7126491/v1/661e402b3a144d1d496b3cff.jpeg"},{"id":87701995,"identity":"d95bc4bf-3c99-43b0-b9b8-a950466e412f","added_by":"auto","created_at":"2025-07-28 07:31:10","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":356986,"visible":true,"origin":"","legend":"\u003cp\u003ea. A main anechoic zone was found in normal resting position (between the two red arrows), and the tendon fibres appeared undulated in the dynamic imaging (the curved red lines indicate the wavy course of the fibres) b. No obvious change in the anechoic zone in extreme dorsiflexion (between the two red arrows), and evident fibrillar structure of the tendon fibres was appeared (red short lines). c. No obvious change in the anechoic zone in deep squat position (between the two red arrows).\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7126491/v1/54d8c2ec0c782545ac4494c5.jpeg"},{"id":87701994,"identity":"464a6cd8-7009-444c-b979-d5882e953b7b","added_by":"auto","created_at":"2025-07-28 07:31:10","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":44878,"visible":true,"origin":"","legend":"\u003cp\u003eA flow diagram of the research.\u003c/p\u003e\n\u003cp\u003eAATR, Acute Achilles tendon rupture; AR, accelerated rehabilitation; CR, conventional rehabilitation; US, ultrasonography\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7126491/v1/16ab6d101d007b48ba04ac6e.png"},{"id":92884020,"identity":"a6c2921d-65f7-460d-8a72-5dc11b8c02a4","added_by":"auto","created_at":"2025-10-06 16:12:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2155797,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7126491/v1/f3c931d1-8203-460f-9298-2e7e16f72afa.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The short-term clinical effects of accelerated rehabilitation following open surgery for acute Achilles tendon rupture based on ultrasonography monitoring: a retrospective cohort study","fulltext":[{"header":"Background","content":"\u003cp\u003eAcute Achilles tendon rupture (AATR) is a common musculoskeletal injury, with an incidence rate ranging from 8 to 32 cases per 100,000 individuals annually[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Following AATR, patients often experience prolonged limitations in tendon-loading activities, which may persist for over a decade or even become permanent if left untreated[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The optimal treatment strategy for AATR remains a subject of debate. Numerous studies have compared surgical and non-surgical interventions for acute Achilles tendon rupture[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. While surgical repair carries inherent risks, including wound infection and other perioperative complications, non-surgical management is associated with a relatively higher re-rupture rate[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, for young and physically active individuals, particularly athletes with high functional demands, surgical intervention may facilitate a faster recovery[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFollowing standard surgical repair of AATR, postoperative protocols typically involve restricted weight-bearing and immobilization with a brace for at least six weeks[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Our previous research[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] suggested that immobilization for two weeks postoperatively may represent the optimal strategy for early rehabilitation. Nevertheless, premature initiation of rehabilitation exercises after Achilles tendon repair may increase the risk of complications, including re-rupture[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. After brace removal, rehabilitation should be accelerated in a controlled manner to optimize early functional recovery. However, few studies have systematically investigated evidence-based rehabilitation protocols following brace removal, particularly regarding individualized interventions to minimize complications.\u003c/p\u003e\u003cp\u003eDiagnostic imaging plays a crucial role in assessing tendon healing post-repair. Ultrasonography (US) and magnetic resonance imaging (MRI) are commonly employed modalities, with US offering distinct advantages in terms of accessibility, cost-effectiveness, and dynamic evaluation of tendon integrity[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Ciszkowska-Łysoń et al.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] proposed a dynamic US-based assessment to evaluate Achilles tendon tension during rehabilitation. Elevated tendon tension observed via US may indicate potential separation at the repair site, suggesting an increased risk of re-rupture if aggressive rehabilitation is pursued. Therefore, individualized rehabilitation protocols guided by US monitoring may significantly improve early postoperative outcomes.\u003c/p\u003e\u003cp\u003eBuilding upon our prior findings, we conducted a retrospective cohort study to evaluate and compare the short-term clinical outcomes of different rehabilitation strategies following open surgical repair of AATR, utilizing US monitoring to guide intervention.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003e The study protocol was approved by the ethics committee of Peking University Third Hospital. Informed consent was signed by each enrolled patient.\u003c/p\u003e\u003cp\u003e\u003cb\u003eDesign and population\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis retrospective cohort study enrolled 87 patients who underwent surgical treatment for AATR at our university hospital between March 2022 and May 2023. Each patient provided written consent prior to enrollment in the study. Among these patients, 7 were lost to follow-up, and 80 patients (92.0%) were included in the final analysis. A radiologist conducted an ultrasound examination of the Achilles tendon preoperatively to confirm the diagnosis and detail the site and extent of the rupture. The inclusion criteria were as follows: (1) age of 18 to 60 years, (2) closed injury, and (3) AATR (\u0026lt;\u0026thinsp;7 days since tendon rupture). The exclusion criteria were as follows: (1) partial ATR; (2) patients with Achilles tendon re-rupture; (3) diseases that may affect functional test results, such as diabetes, neuropathy, and autoimmune disease; and (4) patients with other peri-ankle diseases, including ankle osteoarthritis, and other ligament injuries.\u003c/p\u003e\u003cp\u003eAll the patients were divided into an accelerated rehabilitation group (AR group) and a conventional rehabilitation group (CR group) based on whether dynamic US monitoring was conducted during the rehabilitation period.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSurgical procedure\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePatients were placed in the prone position and operated on under spinal anaesthesia using a tourniquet. The Achilles tendon resting angle (ATRA) on both sides was measured before disinfection. The ATRA is the angle between the long axis of the fibula and the line from the tip of the fibula to the head of the fifth metatarsal [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. An incision was made posteromedial to the midline of the Achilles tendon at the level of the rupture in a longitudinal fashion, and the paratenon was divided to identify the rupture. With the ankle placed in a neutral position, the tendon was repaired using the Krackow locking loop technique with two W4843 (ETHIBOND of Johnson \u0026amp; Johnson, US) nonabsorbable sutures and the modified Kessler suture technique with two REF223114 (ORTHOCORD of Depuy Synthes, US) nonabsorbable sutures. The sutures were carefully placed away from the rupture site, and the tendon was sutured to a healthy tendon to enhance the stability of the repair (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Subsequently, six figure-eight sutures (four for the dorsal, two for the ventral) were placed with 2-0-gauge absorbable sutures to reinforce the broken ends. The ATRA on the affected side was measured again to determine whether the repair was suitable, and it was confirmed to be reduced and smaller than that on the contralateral leg. Following tension and strength testing of the ankle, the peritenon and subcutaneous tissues were approximated with 2-0-gauge and 3-0-gauge absorbable sutures, respectively, and the skin was closed with a skin stapler. Following wound binding, a below-knee brace with a wedge was applied with the ankle in a 30-degree plantar flexion position in all patients for 2 weeks. All patients underwent surgery performed by the same surgeon using the same operative technique.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePostoperative rehabilitation and Data collection\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAll patients underwent rehabilitation exercises after the removal of the immobilisation brace. In the CR group, at 0\u0026ndash;2 weeks after brace removal, patients were instructed to perform moderate plantar flexion and dorsiflexion of the ankle and stand up (partial weightbearing) for 1 h every day. From 2 to 4 weeks after brace removal, ankle exercises remained consistent, with the standing time increased to 2 h per day. Simultaneously, the patients were instructed to perform deep squat exercises. Four to 6 weeks after brace removal, they were instructed to perform double-legged heel raises and walk fewer than 1000 steps on flat ground. Between 6 and 8 weeks after brace removal, the patients were advised to perform one-leg heel raises and limit walking to less than 2000 steps on flat ground. When the patients could successfully perform one-leg heel raises, they were instructed to jog 2 weeks later. 4 weeks after successfully performing jogging, the patients were allowed to perform more vigorous training.\u003c/p\u003e\u003cp\u003eIn the AR group, patients underwent US examination, which was performed by a radiologist who had 15 years of experience performing musculoskeletal ultrasonography, 2 weeks postoperatively after the brace was removed. All US examinations were performed using a 9-MHz to 15-MHz linear-array transducer (HIVISION, G0201500101431, China). The patient was in a prone position with both feet at rest, placed beyond the edge of the examination table to allow for unrestricted foot movement. A linear transducer is applied to the Achilles tendon above the calcaneal tuberosity to obtain the image of the longitudinally arranged tendon fibre and the junction of ruptured Achilles tendon tissue in the normal resting position. A main anechoic zone could be found at the junction. Then, the image was obtained again in extreme dorsiflexion. The radiologist observed whether the anechoic zone was enlarged compared to that in the natural position. If it was enlarged, it was considered that there was a tendency of separation at the junction of ruptured Achilles tendon tissue, and the examination was concluded. If there was no obvious change in the anechoic zone, the patient was instructed to do a deep squat and obtain the image again to observe whether there was a tendency of separation in the deep squat position. If the US results showed no tendency of separation in the deep squat position, the patient would then directly perform ankle mobilisation exercises, and the standing time increased to 2 h per day with deep squat exercises at 0\u0026ndash;2 weeks after brace removal (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The subsequent rehabilitation plan was also advanced by two weeks. The rehabilitation plan for patients with a tendency to separation in the extreme dorsiflexion position or deep squat position was the same as that of the CR group (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eRehabilitation Protocol\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePatients whose US results showed no tendency of separation in the AR group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePatients in the CR group or those whose US results showed a tendency of separation in the AR group\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0\u0026ndash;2 weeks after removing the brace\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnkle mobilisation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAnkle mobilisation\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStanding up for 2 h per day\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStanding up for 1 h per day\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDeep squat\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e2\u0026ndash;4 weeks after removing the brace\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDouble-legged heel raises\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAnkle mobilisation\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWalking less than 1000 steps on flat ground\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStanding up for 2 h per day\u003c/p\u003e\u003cp\u003eDeep squat\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e4\u0026ndash;6 weeks after removing the brace\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOne-legged heel raises\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDouble-legged heel raises\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWalking less than 2000 steps on flat ground\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWalking less than 1000 steps on flat ground\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e6\u0026ndash;8 weeks after removing the brace\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOne-legged heel raises\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWalking less than 2000 steps on flat ground\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2 weeks after successfully performing one-leg heel raises\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eJogging\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eJogging\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4 weeks after successfully performing jogging\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMore vigorous training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMore vigorous training\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAR, accelerate rehabilitation group; CR, conventional rehabilitation group.\u003c/p\u003e\u003cp\u003ePatients attended follow-up visits at 2, 4, 6, 8, 10, 12, 14, and 16 weeks and at the final follow-up after surgery. During follow-up, all patients were evaluated by the same surgeon. The surgical duration and complications, such as superficial infection, re-rupture, and deep venous thrombosis (DVT), were recorded. Dorsiflexion and plantar flexion were measured using a handheld goniometer. The recovery time for the range of motion (ROM) was recorded when it was similar to that for the contralateral leg. The heel-rise height was measured as the distance from the ground to the heel when the patient lifted the heel while keeping the knee straight. The recovery time for the one-leg heel-rise height (OHRH) was recorded when the heel-rise height index (HRHI\u0026thinsp;=\u0026thinsp;involved/uninvolved \u0026times;100) reached 50% [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The time to return to light exercise (LE), which included rapid walking and jogging, was noted. The recovery times for OHRH were the primary endpoint, while the time to return to LE and the clinical Function scores were the secondary outcomes. Clinical scores, including the visual analogue scale (VAS) score for pain, American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale score [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], and Achilles tendon Total Rupture Score (ATRS) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] were also recorded to evaluate subjective pain and functional status. VAS measures pain on a 10-cm scale, with the status ranging from no pain (extreme left) to the worst possible pain (extreme right). The patients marked their current pain levels on the scale, and the score was accordingly recorded. The AOFAS Ankle-Hindfoot Scale, which was recorded after 6 weeks postoperatively, assigned a maximum score of 100 points (90\u0026ndash;100 points, excellent; 75\u0026ndash;89 points, good; 50\u0026ndash;74 points, fair; and \u0026lt;\u0026thinsp;50 points, poor). The ATRS, which was recorded after 6 weeks postoperatively, was a patient-reported tool designed to measure the outcomes after AATR repair. The questionnaire comprises 10 questions to assess symptoms and the level of physical activity, with answers evaluated on an 11-point Likert scale (scores ranging from 0 to 10, with a maximum possible score of 100; higher scores indicate a better health status).\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eAll statistical analyses were performed using SPSS version 27.0 (IBM Corp., Armonk, NY, USA). Data are reported as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard error of the mean unless otherwise noted. Continuous variables were compared using an independent sample t-test when the variables were approximately normally distributed, and non-normally distributed variables were analyzed using the Mann-Whitney U test. The chi-square test or Fisher\u0026rsquo;s exact test (n\u0026thinsp;\u0026lt;\u0026thinsp;40 or t\u0026thinsp;\u0026lt;\u0026thinsp;1) was used to evaluate categorical parameters between the two groups. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cb\u003eGroup characteristics\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn total, 80 patients with unilateral complete AATR were included (73 male and 7 female patients; mean age, 32.0 years, range, 19\u0026ndash;40 years). There were no significant between-group differences in sex, age, Body Mass Index (BMI), surgical duration, distance from the rupture site to the Achilles tendon insertion site, and gap distance of the rupture site (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In the AR group, 24 patients whose ultrasound images showed no tendency of separation accelerated their rehabilitation process (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eGroup Characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAR Group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCR Group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of Patients\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32.9\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.051\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex (Male/Female)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37/3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36/4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBody Mass Index\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.444\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperation Time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.206\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGDRS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.600\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDRSTI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.443\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eData represent the mean [SD];\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAR, accelerated rehabilitation; CR, conventional rehabilitation; GDRS, gap distance of the rupture site; DRSTI, distance from the rupture site to the Achilles tendon insertion\u003c/p\u003e\u003cp\u003e\u003cb\u003eRecovery times\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe mean recovery time for ROM was 5.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9 weeks in the AR group and 6.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6 weeks in the CR group. The mean recovery times for OHRH were 11.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1 and 12.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4 weeks in the AR group and the CR group, respectively. The mean time to return to LE was 17.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7 and 18.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2 weeks in the two groups. AR Group showed significantly shorter recovery times for OHRH and LE than those in the other group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05; Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e). There was no significant difference in recovery time for ROM between the two groups.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eRecovery Time\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAR Group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCR Group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eROM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e5.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e6.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.108\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOHRH\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e11.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e12.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.032\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e17.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e18.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.006\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eData represent the mean [SD];\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAR, accelerated rehabilitation; CR, conventional rehabilitation; ROM, range of motion; OHRH, one-leg heel-rise height; LE, light exercise.\u003c/p\u003e\u003cp\u003e\u003cb\u003eOutcome scores\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe VAS score for pain significantly decreased from 2 to 8 weeks, and reached 0 in all four groups after 10 weeks. No significant differences in VAS score were found between the two groups (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The mean ATRS in both groups increased over time. Significant differences were found between the two groups from weeks 4 to 14 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05, Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e4\u003c/span\u003e), with the mean scores in the AR group being higher than those in the other group. The mean AOFAS Ankle-Hindfoot Scale score increased over time in both groups, with significant differences observed between the two groups from weeks 4 to 8 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05, Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e5\u003c/span\u003e), and the mean scores in the AR Group were higher than those in the other group. At the last follow-up, only the functional recovery of the patients was assessed. No outcome scores were obtained.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eVisual Analogue Scale (VAS) for Pain\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTime (weeks)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAR Group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCR Group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e1.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.872\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e0.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e0.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.410\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e0.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e0.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.209\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e0.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e0.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.646\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eData represent the mean [SD].\u003c/p\u003e\u003cp\u003eAR, accelerated rehabilitation; CR, conventional rehabilitation.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAchilles Tendon Total Rupture Score (ATRS)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTime (weeks)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAR Group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCR Group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e19.9\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e20.6\u0026thinsp;\u0026plusmn;\u0026thinsp;5.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.969\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e36.2\u0026thinsp;\u0026plusmn;\u0026thinsp;9.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e28.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e61.0\u0026thinsp;\u0026plusmn;\u0026thinsp;12.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e52.2\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e76.1\u0026thinsp;\u0026plusmn;\u0026thinsp;9.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e69.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e87.2\u0026thinsp;\u0026plusmn;\u0026thinsp;8.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e82.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e93.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e91.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e96.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e96.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e97.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e97.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.838\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eData represent the mean [SD].\u003c/p\u003e\u003cp\u003eAR, accelerated rehabilitation; CR, conventional rehabilitation.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAmerican Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scores\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTime (weeks)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAR Group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCR Group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e53.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e54.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.346\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e67.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e60.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e77.8\u0026thinsp;\u0026plusmn;\u0026thinsp;11.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e68.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e94.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e92.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e98.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e98.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.887\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e99.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e99.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.611\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e99.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e99.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.617\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e99.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e99.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.648\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eData represent the mean [SD].\u003c/p\u003e\u003cp\u003eAR, accelerated rehabilitation group; CR, conventional rehabilitation group.\u003c/p\u003e\u003cp\u003e\u003cb\u003eComplications\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA total of 3 complications (3/80, 3.8%) were observed in the study, including one (1/40, 2.5%) in the AR Group and two (2/40, 5.0%) in the CR Group. All three complications were re-ruptures, which occurred at 10 weeks after surgery and were diagnosed through clinical examination and a positive Thompson\u0026rsquo;s test. No infections were observed across all groups. No significant differences in complication rates were observed between the two groups (P\u0026thinsp;=\u0026thinsp;0.556). At the last follow-up, all patients had recovered without complications.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eCurrent rehabilitation paradigms following Achilles tendon rupture emphasize early mobilization to mitigate muscle atrophy and functional impairment[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Traditional postoperative protocols recommended at least six weeks of immobilization. However, emerging clinical evidence suggests that reducing immobilization duration may facilitate earlier functional recovery. The biological basis for this approach lies in collagen composition dynamics: native Achilles tendon consists predominantly of mechanically robust type I collagen, whereas repaired tendon tissue initially contains weaker type III collagen. Prolonged immobilization may impede type I collagen synthesis and maturation, while controlled mechanical loading appears to promote its production, thereby enhancing tendon healing[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Our previous investigation[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] demonstrated that two weeks of postoperative immobilization following open AATR repair represents an optimal strategy for early rehabilitation, yielding satisfactory clinical outcomes with minimal discomfort. Building upon these findings, we sought to develop and evaluate a more accelerated rehabilitation protocol while maintaining patient safety. This study was therefore designed to extend our prior research by investigating the efficacy of an ultrasonography-guided accelerated rehabilitation program.\u003c/p\u003e\u003cp\u003eOne of the most crucial issues in AATR treatment is the incidence of re-rupture. Arner et al[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] found that 53% of patients with Achilles tendon rupture occurred when the knee joint was hyperextended while pushing off the ground with the front foot during weight-bearing, such as athletes sprinting or jumping, and 27% occurred during sudden or rough ankle dorsiflexion movements, such as falls on stairs or falls from heights. Thus, it is necessary to strictly control the starting time of the ankle dorsiflexion movement while bearing weight, such as deep squatting, during the postoperative rehabilitation period. With no validated guidelines, the rehabilitation process after surgery decisions largely rest on the clinical judgment and collaboration between the clinician and patient[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Patients typically demonstrate strong motivation for early rehabilitation initiation following brace removal, aiming to expedite return to occupational and daily activities. However, premature or excessive mechanical loading may significantly increase the risk of postoperative complications, particularly re-rupture, due to compromised tendon integrity during the early healing phase[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Consequently, individualized rehabilitation protocols guided by evidential diagnostic assessment assume critical importance in optimizing recovery outcomes while minimizing adverse events.\u003c/p\u003e\u003cp\u003eCurrent clinical practice utilizes both US and MRI for postoperative monitoring of Achilles tendon healing following AATR repair [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The US has emerged as the preferred imaging modality for routine follow-up examinations due to its distinct advantages of clinical accessibility, cost-effectiveness, and diagnostic reliability[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Notably, Ciszkowska-Łysoń et al.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] developed an innovative dynamic US assessment protocol to quantitatively evaluate Achilles tendon tension during plantarflexion maneuvers. When there is tension in the Achilles tendon, a linear arrangement of tendon fibers and a main anechoic zone at the junction can be observed on the image. In our study, the ankle joint was dorsiflexed to increase tension, so as to observe whether there was any size change in the anechoic zone. When the range of the anechoic zone increased compared to that in the rest position, it was considered that there was a tendency of separation at the junction of ruptured Achilles tendon tissue. We also used this to distinguish whether the patient had further accelerated rehabilitation exercises. The patients could directly practice deep squat after removing the brace if there is no tendency of separation. A review investigating surgical interventions for acute ATR reported re-rupture rates of 3.6\u0026ndash;8.3%[20]. Comparatively, our study reported a relatively low re-rupture rate of 3.8% (3/80). All three re-rupture cases in this study resulted from accidental falls or sudden traumatic events rather than protocol-guided rehabilitation exercises. These incidents occurred during unprotected dorsiflexion movements while not wearing the protective brace. Although no statistically significant difference in re-rupture rates was demonstrated between groups, the AR group exhibited a numerically lower incidence compared to the conventional rehabilitation group. These findings suggest that the accelerated recovery protocol can be implemented with an acceptable safety profile.\u003c/p\u003e\u003cp\u003eThe other most important aspect of AATR treatment is Achilles tendon elongation. An effective way to evaluate Achilles tendon elongation is the heel-rise test[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Hoeffner et al[20] conducted a randomized controlled trial about Achilles tendon elongation. 48 patients with a surgically repaired AATR were randomized to 2 groups: the standard group received the currently accepted rehabilitation, and the delayed group received the same rehabilitation except that initial loading was delayed by 6 weeks. Finally, they concluded that delayed loading was not superior to standard loading in reducing the heel-rise height difference at 1 year. The total excursion capacity of the musculotendinous unit is primarily determined by muscle fiber length, suggesting that deficits in heel-rise height may reflect alterations in tendon and fascicle length rather than muscular strength deficits[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. This biomechanical principle implies that early rehabilitation exercises are unlikely to induce significant tendon elongation. In our cohort, all patients initiated weight-bearing rehabilitation following brace removal at 2 weeks postoperatively. During the rehabilitation period, we observed progressive improvement in the OHRH. Among patients with normal recovery, the OHRH index reached approximately 50% of preoperative values by 3 months post-surgery. Notably, the AR group demonstrated more rapid OHRH recovery compared to conventional rehabilitation. However, a limitation of our study was the lack of systematic assessment of long-term Achilles tendon elongation.\u003c/p\u003e\u003cp\u003eThis study demonstrated considerable inter-individual variability in recovery trajectories. Comparative analysis revealed significantly shorter mean recovery times for both OHRH and LE measurements in the AR group compared to the CR group, suggesting more rapid functional recovery with the accelerated protocol. This was further supported by superior short-term clinical functional scores in the AR cohort.\u003c/p\u003e\u003cp\u003eThe VAS scores showed no significant intergroup differences, indicating that the accelerated protocol did not exacerbate postoperative discomfort. While the ATRS demonstrated statistically significant between-group differences from 10 to 14 weeks postoperatively, the AOFAS Ankle-Hindfoot scale failed to show similar discrimination. This discrepancy may be attributable to fundamental differences in scale composition: the ATRS relies exclusively on patient-reported subjective measures, whereas the AOFAS incorporates both subjective and objective clinical assessments.\u003c/p\u003e\u003cp\u003eSeveral important limitations should be acknowledged in this investigation. First, the study design was constrained by being a single-center retrospective cohort analysis with a relatively small sample size. These methodological characteristics necessitate validation through larger-scale, multicenter, prospective randomized controlled trials to substantiate our findings. Second, the demographic composition of our cohort exhibited a significant male predominance, potentially introducing sex-related bias that may limit the generalizability of our results to female populations. Third, the ultrasonographic assessment of tendon separation tendency relied principally on the subjective interpretation of the examining radiologist, representing a potential source of diagnostic variability. This highlights the need for developing more standardized, objective criteria for ultrasound evaluation of tendon healing. Additionally, the current study employed outcome measures that included subjective components. Future investigations would benefit from incorporating more objective, validated assessment tools. Finally, our follow-up period was insufficient to evaluate long-term outcomes, particularly regarding potential Achilles tendon elongation. Extended longitudinal studies are warranted to fully characterize the temporal progression of postoperative recovery.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eRehabilitation under Ultrasonography monitoring safely accelerates recovery after acute Achilles tendon repair, improving short-term outcomes without increasing pain or re-rupture risk.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eAATR\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eacute Achilles tendon rupture\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eUS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eultrasonography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eAR\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eaccelerated rehabilitation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eCR\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003econventional rehabilitation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eOHRH\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eone-leg heel-rise height\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eROM\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003erange of motion\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eLE\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003elight exercise\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eVAS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003evisual analogue scale\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eATRS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAchilles tendon Total Rupture Score\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eAOFAS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAmerican Orthopaedic Foot and Ankle Society\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eMRI\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003emagnetic resonance imaging\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eATRA\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAchilles tendon resting angle\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eDVT\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003edeep venous thrombosis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eHRHI\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eheel-rise height index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBody Mass Index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eGDRS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003egap distance of the rupture site\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eDRSTI\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003edistance from the rupture site to the Achilles tendon insertion\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the ethics committee of Peking University Third Hospital (Approval Number: IRB00006761-M2020315). Informed consent was signed by each enrolled objective.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e：\u003c/em\u003e\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e：\u003c/em\u003e\u003c/strong\u003eThe datasets used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e: \u0026nbsp;\u003c/em\u003e\u003c/strong\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e: \u0026nbsp;\u003c/em\u003e\u003c/strong\u003eThis work was supported by Fund progrmas: National Key R\u0026amp;D Program of China (grant no. 2023YFC2508804); Capital health development research project（grant no.2022-2-4096）；Peking University Third Hospital (grant no. BYSYZHKC117)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors' contributions\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e：\u003c/em\u003e\u003c/strong\u003eYC, SG, BZ, XL, XP, YL and FZ were all involved with the conception and design of the study, acquisition of data, analysis and interpretation of data, and drafting and revision of the article. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eIrfan SA, Ahmed S, Ashkar A, et al. Comparative effectiveness of weight-bearing strategies on functional recovery in acute Achilles tendon rupture: A network meta-analysis. Foot Ankle Surg Published online March. 2025;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.fas.2025.02.013\u003c/span\u003e\u003cspan address=\"10.1016/j.fas.2025.02.013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMansfield K, Dopke K, Koroneos Z, et al. Achilles Tendon Ruptures and Repair in Athletes-a Review of Sports-Related Achilles Injuries and Return to Play. Curr Rev Musculoskelet Med. 2022;15(5):353\u0026ndash;61. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s12178-022-09774-3\u003c/span\u003e\u003cspan address=\"10.1007/s12178-022-09774-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLameire DL, Ramelli L, Halai M, et al. Outcomes of operative and nonoperative management of myotendinous Achilles tendon ruptures: a systematic review. BMC Musculoskelet Disord. 2025;26(1):71. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12891-025-08286-8\u003c/span\u003e\u003cspan address=\"10.1186/s12891-025-08286-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAcevedo D, Garcia JR, Grewal RS, et al. Comparison of rerupture rates after operative and nonoperative management of Achilles tendon rupture in older populations: Systematic review and meta-analysis. J Orthop. 2024;52:112\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jor.2024.02.034\u003c/span\u003e\u003cspan address=\"10.1016/j.jor.2024.02.034\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Published 2024 Feb 22.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKim U, Choi YS, Jang GC et al. Early rehabilitation after open repair for patients with a rupture of the Achilles tendon[J]. Injury 2017,48(7):1710\u0026ndash;3. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.injury.2017.04.050\u003c/span\u003e\u003cspan address=\"10.1016/j.injury.2017.04.050\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCarter TR, Fowler PJ, Blokker C. Functional postoperative treatment of Achilles tendon repair. Am J Sports Med. 1992;20(4):459\u0026ndash;62. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/036354659202000417\u003c/span\u003e\u003cspan address=\"10.1177/036354659202000417\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCao Y, Gao S, Cui Z et al. Comparison of different immobilisation durations following open surgery for acute achilles tendon rupture: a prospective cohort study. J Orthop Surg Res. 2024;19(1):497. Published 2024 Aug 21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13018-024-04970-y\u003c/span\u003e\u003cspan address=\"10.1186/s13018-024-04970-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSaxena A, Giai Via A, Gr\u0026auml;vare Silbernagel K, et al. Current Consensus for Rehabilitation Protocols of the Surgically Repaired Acute Mid-Substance Achilles Rupture: A Systematic Review and Recommendations From the GAIT Study Group. J Foot Ankle Surg. 2022;61(4):855\u0026ndash;61. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1053/j.jfas.2021.12.008\u003c/span\u003e\u003cspan address=\"10.1053/j.jfas.2021.12.008\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlabau-Dasi R, Dominguez-Maldonado G, Ortega-Avila AB et al. Validation of Fixed Ultrasonography for Achilles Tendon Assessment: A Reliability Study. Diagnostics (Basel). 2024;14(19):2221. Published 2024 Oct 5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/diagnostics14192221\u003c/span\u003e\u003cspan address=\"10.3390/diagnostics14192221\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCiszkowska-Łysoń B, Zdanowicz U, Śmigielski R. The ultrasonographic dynamic heel-rise test of the Achilles tendon. J Ultrason. 2021;21:e260\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.15557/JoU.2021.0043\u003c/span\u003e\u003cspan address=\"10.15557/JoU.2021.0043\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCarmont MR, Gr\u0026auml;vare Silbernagel K, Brorsson A, et al. The Achilles tendon resting angle as an indirect measure of Achilles tendon length following rupture, repair, and rehabilitation. Asia Pac J Sports Med Arthrosc Rehabil Technol. 2015;2(2):49\u0026ndash;55. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.asmart.2014.12.002\u003c/span\u003e\u003cspan address=\"10.1016/j.asmart.2014.12.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMansfield K, Dopke K, Koroneos Z, et al. Achilles Tendon Ruptures and repair in Athletes-a review of sports-related Achilles injuries and return to play. Curr Rev Musculoskelet Med. 2022;15(5):353\u0026ndash;61. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s12178-022-09774-3\u003c/span\u003e\u003cspan address=\"10.1007/s12178-022-09774-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKitaoka HB, Alexander IJ, Adelaar RS, et al. Clinical Rating systems for the Ankle-Hindfoot, midfoot, Hallux, and lesser toes. Foot Ankle Int. 1997;18(3):187\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/107110079701800315\u003c/span\u003e\u003cspan address=\"10.1177/107110079701800315\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNilsson-Helander K, Thome\u0026eacute; R, Silbernagel KG, et al. The Achilles tendon total rupture score (ATRS): development and validation. Am J Sports Med. 2007;35(3):421\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0363546506294856\u003c/span\u003e\u003cspan address=\"10.1177/0363546506294856\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLiu X, Dai TJ, Li BL, et al. Early functional rehabilitation compared with traditional immobilization for acute Achilles tendon ruptures: a meta-analysis. Bone Joint J. 2021;103(6):1021\u0026ndash;30. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1302/0301-620X.103B6.BJJ-2020-1890.R1\u003c/span\u003e\u003cspan address=\"10.1302/0301-620X.103B6.BJJ-2020-1890.R1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLiang W, Zhou C, Deng Y, et al. The current status of various preclinical therapeutic approaches for tendon repair. Ann Med. 2024;56(1):2337871. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/07853890.2024.2337871\u003c/span\u003e\u003cspan address=\"10.1080/07853890.2024.2337871\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eArner O, Lindholm A. Subcutaneous rupture of the Achilles tendon; a study of 92 cases. Acta Chir Scand Suppl. 1959;116(Supp 239):1\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWise PM, King JL, Stauch CM, et al. Outcomes of NCAA defensive football players following Achilles tendon repair. Foot Ankle Int. 2020;41(4):398\u0026ndash;402. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1071100719899072\u003c/span\u003e\u003cspan address=\"10.1177/1071100719899072\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShivapatham G, Richards S, Bamber J Ultrasound Measurement of Local Deformation in the Human Free Achilles Tendon Produced by Dynamic Muscle-Induced Loading: A Systematic Review. Ultrasound Med Biol., Hoeffner R, Agergaard AS, Svensson RB Tendon Elongation and Function After [20], Seow D, Yasui Y, Calder JDF et al. Treatment of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis of Complication Rates With Best- and Worst-Case Analyses for Rerupture Rates. Am J Sports Med. 2021;49(13):3728\u0026ndash;3748. doi:10.1177/0363546521998284.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDelayed or Standard Loading of Surgically Repaired Achilles Tendon Ruptures. A Randomized Controlled Trial. Am J Sports Med. 2024;52(4):1022\u0026ndash;31. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/03635465241227178\u003c/span\u003e\u003cspan address=\"10.1177/03635465241227178\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKhair RM, Stenroth L, Cronin NJ, et al. Muscle-tendon morphomechanical properties of non-surgically treated Achilles tendon 1-year post-rupture. Clin Biomech (Bristol Avon). 2022;92:105568. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.clinbiomech.2021.105568\u003c/span\u003e\u003cspan address=\"10.1016/j.clinbiomech.2021.105568\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBaxter JR, Hullfish TJ, Chao W. Functional deficits may be explained by plantarflexor remodeling following Achilles tendon rupture repair: preliminary findings. J Biomech. 2018;79:238\u0026ndash;42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jbiomech.2018.08.016\u003c/span\u003e\u003cspan address=\"10.1016/j.jbiomech.2018.08.016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Acute Achilles tendon rupture, Individualized rehabilitation, Ultrasonography monitoring","lastPublishedDoi":"10.21203/rs.3.rs-7126491/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7126491/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eIndividualized rehabilitation after acute Achilles tendon rupture (AATR) repair is important. The aim of this study was to evaluate and compare the short-term clinical effects of different rehabilitation processes following open surgery for AATR based on ultrasonography (US) monitoring.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis study included 80 patients (mean age, 32.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4 years) who underwent open surgery for AATR repair. The patients were categorised into two groups (accelerated rehabilitation group, AR, and conventional rehabilitation group, CR) according to whether postoperative rehabilitation relied on US monitoring. All patients received the same suture technique and immobilisation duration; they were clinically examined at 2, 4, 6, 8, 10, 12, 14, and 16 weeks postoperatively, with a final follow-up at a mean of 18.8 months. The primary outcome was the recovery time for the one-leg heel-rise height (OHRH). Secondary outcomes included the time required to return to range of motion(ROM) and light exercise (LE), the clinical function scores, and complications. Data regarding the surgical duration, the visual analogue scale (VAS) score for pain, the Achilles tendon Total Rupture Score (ATRS), and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale score were also collected.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe recovery times for OHRH and LE were significantly shorter in group AR than in group CR (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The VAS scores decreased over time, reaching 0 in both groups by 10 weeks. ATRS and the AOFAS Ankle-Hindfoot scale score increased across both groups over time, showing significant between-group differences from 4 to 14 weeks(P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and 4 to 8 weeks(P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The mean scores were better in group AR than in group CR. Three re-ruptures (3.8%) were observed, and all complications were resolved at the last follow-up, with no significant between-group differences.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eRehabilitation under Ultrasonography monitoring safely accelerates recovery after acute Achilles tendon repair, improving short-term outcomes without increasing pain or re-rupture risk.\u003c/p\u003e","manuscriptTitle":"The short-term clinical effects of accelerated rehabilitation following open surgery for acute Achilles tendon rupture based on ultrasonography monitoring: a retrospective cohort study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-28 07:23:05","doi":"10.21203/rs.3.rs-7126491/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-11T07:55:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-09T06:03:03+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-08T14:03:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-05T16:15:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-03T14:57:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"230640730832959734453178463957446440971","date":"2025-07-31T11:15:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-31T06:05:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"46951415119592734626904429928017060283","date":"2025-07-30T16:55:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"154931174373902799766487297633819091683","date":"2025-07-30T06:50:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"318209599855308380665178768456368616907","date":"2025-07-29T19:14:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"268005059721304818494607411045034334217","date":"2025-07-28T09:50:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"205018561058260014220122389864001202872","date":"2025-07-28T08:37:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-27T15:43:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"275498426204217767537758007023500827546","date":"2025-07-27T15:22:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"153759432608805796751943807325305486214","date":"2025-07-24T05:41:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-22T05:12:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-16T02:09:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-16T01:08:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Orthopaedic Surgery and Research","date":"2025-07-15T05:32:11+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bb6ba4cc-cf99-4d9b-bce8-85a4e3fbb999","owner":[],"postedDate":"July 28th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-06T16:07:07+00:00","versionOfRecord":{"articleIdentity":"rs-7126491","link":"https://doi.org/10.1186/s13018-025-06282-1","journal":{"identity":"journal-of-orthopaedic-surgery-and-research","isVorOnly":false,"title":"Journal of Orthopaedic Surgery and Research"},"publishedOn":"2025-09-29 15:57:55","publishedOnDateReadable":"September 29th, 2025"},"versionCreatedAt":"2025-07-28 07:23:05","video":"","vorDoi":"10.1186/s13018-025-06282-1","vorDoiUrl":"https://doi.org/10.1186/s13018-025-06282-1","workflowStages":[]},"version":"v1","identity":"rs-7126491","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7126491","identity":"rs-7126491","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}