title: Dynamic ultrasound assessment of the effects of knee and ankle position on Achilles tendon apposition following acute rupture.
abstract: BACKGROUND
  Previous reports have suggested that knee flexion improves tendon edge apposition following acute rupture of the Achilles tendon. The aim of the present study was to determine, with use of ultrasonography, the effects of knee and ankle position on the Achilles tendon gap distance in patients with an acute rupture.
  
  
  METHODS
  Twenty-six patients with a unilateral acute complete Achilles tendon rupture that had been confirmed with ultrasonography were recruited within a week after the injury. The mean age at the time of presentation was forty-one years. Ultrasound measurements included the location of the rupture and the gap distance between the superficial tendon edges with the ankle in neutral and the knee extended. The gap distance was sequentially measured with the foot in maximum equinus at the ankle and with 0°, 30°, 60°, and 90° of knee flexion.
  
  
  RESULTS
  The mean distance of the rupture from the calcaneal enthesis was 52 mm (range, 40 to 76 mm). The mean gap distance with the ankle in neutral and the knee extended was 12 mm (95% confidence interval, 10 to 13 mm). This distance decreased to 5 mm (95% confidence interval, 4 to 7 mm) when the foot was placed in maximum ankle equinus with 0° of knee flexion and to 4 mm (95% confidence interval, 3 to 5 mm) with 30° of knee flexion, 3 mm (95% confidence interval, 2 to 4 mm) with 60° of knee flexion, and 2 mm (95% confidence interval, 1 to 2 mm) with 90° of knee flexion. Expressing the reduction in gap distance with each successive position as a percentage of the gap distance with the knee extended and the ankle in neutral revealed a mean reduction of 55.7%, 64.4%, 75.4%, and 84.8% with maximum ankle equinus and 0°, 30°, 60°, and 90° of knee flexion, respectively. The difference in gap distance between each of these positions was significant (p < 0.05).
  
  
  CONCLUSIONS
  Maximum ankle equinus alone significantly reduces the gap distance after acute Achilles tendon rupture. Increasing knee flexion further reduces the gap distance by small increments that, although significant, may not be clinically important.
authors.affiliation: Division of Orthopaedic Surgery, Leicester General Hospital, Leicester, United Kingdom. qureshi123@doctors.org.uk
authors.forename: Assad A
authors.initials: AA
authors.lastname: Qureshi
authors.forename: Talal
authors.initials: T
authors.lastname: Ibrahim
authors.forename: Winston J
authors.initials: WJ
authors.lastname: Rennie
authors.forename: Andrew
authors.initials: A
authors.lastname: Furlong
mesh_terms: D000125:Achilles Tendon / Q000000981:diagnostic imaging / Q000293:injuries*; D000208:Acute Disease; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000843:Ankle Joint / Q000502:physiology; D002370:Casts, Surgical; D015331:Cohort Studies; D016001:Confidence Intervals; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015601:Injury Severity Score; D007719:Knee Joint / Q000502:physiology; D008297:Male; D008875:Middle Aged; D010808:Physical Examination / Q000379:methods; D011446:Prospective Studies; D016059:Range of Motion, Articular / Q000502:physiology*; D020127:Recovery of Function; D012421:Rupture / Q000000981:diagnostic imaging / Q000628:therapy; D013708:Tendon Injuries / Q000000981:diagnostic imaging* / Q000628:therapy*; D016896:Treatment Outcome; D014463:Ultrasonography; D055815:Young Adult