Knee Surgery, Sports Traumatology, Arthroscopy (2021) 29:1617–1626

https://doi.org/10.1007/s00167-020-06391-w

ANKLE

No clinically relevant difference between operative and non‑operative

treatment in tendon elongation measured with the Achilles tendon
resting angle (ATRA) 1 year after acute Achilles tendon rupture
Allan Cramer1 · Ebrahim Rahdi1 · Maria Swennergren Hansen1,2 · Håkon Sandholdt3 · Per Hölmich1 ·
Kristoffer Weisskirchner Barfod1

Received: 28 August 2020 / Accepted: 24 November 2020 / Published online: 2 January 2021
© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2021

Abstract
Purpose Studies have shown that elongation of the injured Achilles tendon after acute Achilles tendon rupture (ATR) is
negatively associated with clinical outcomes. The difference between operative and non-operative treatment on the length of
the Achilles tendon is only sparsely investigated. The aim of the study was to investigate if the operative and non-operative
treatment of ATR had different effects on tendon elongation.
Methods The study was performed as a registry study in the Danish Achilles tendon database (DADB). The primary out-
come of the study was an indirect measure of Achilles tendon length: the Achilles tendon resting angle (ATRA) at 1-year
follow-up. The variable of interest was treatment (operative or non-operative).
Results From August 2015 to January 2019, 438 patients (154 operatively treated and 284 non-operatively treated) were
registered with full baseline data and had their ATRA correctly registered at 1-year follow-up in DADB. The analysis did
not show a clinically relevant nor statistically significant difference in ATRA between operative and non-operatively treated
patients at 1-year follow-up (mean difference − 1.2°; 95% CI − 2.5; 0.1; n.s) after adjustment for potential confounders.
Conclusion There were neither clinically relevant nor statistically significant differences in terms of the ATRA at 1-year
follow-up between the operative and non-operatively treated patients. This finding suggests that operative treatment does
not lead to a clinically relevant reduction in tendon elongation compared to non-operative treatment and it should therefore
not be used as an argument in the choice of treatment.
Level of evidence Level III.

Keywords Achilles tendon rupture · Operative · Non-operative · Conservative · Treatment · Achilles tendon resting angle ·
Clinical outcome · ATRA​· Achilles tendon length · Elongation · ATRS · Heel-rise height

Abbreviations
ATR​ Acute Achilles tendon rupture
Supplementary Information The online version contains
supplementary material available at https​://doi.org/10.1007/s0016​ DADB Danish Achilles tendon database
7-020-06391​-w. ATRA​ Achilles tendon resting angle
HRH Heel-rise height
* Allan Cramer
LSI Limb symmetry index
allancramer94@gmail.com
ATRS Achilles tendon total rupture score
1
Sports Orthopedic Research Center‑Copenhagen (SORC‑C), MRI Magnetic resonance imaging
Arthroscopic Center, Department of Orthopedic Surgery, RSA Stereo radiography
Copenhagen University Hospital, Amager-Hvidovre, RCT​ Randomized clinical trial
Kettegård Allé 30, 2650 Hvidovre, Denmark
2
ICC Intraclass correlation coefficient
Physical Medicine and Rehabilitation Research‑Copenhagen SEM Standard error of measurement
(PMR‑C), Department of Physical and Occupational
Therapy, Copenhagen University Hospital Amager-Hvidovre, CI Confidence interval
Hvidovre, Denmark
3
Clinical Research Center, Copenhagen University Hospital,
Hvidovre, Denmark

13
Vol.:(0123456789)
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Introduction
The incidence of acute Achilles tendon rupture (ATR) has
shown an increasing trend in the past decades The lat-
est reported incidence is 31–35 per 100.000/year [9, 14].
Though the treatment of ATR has been intensely studied,
the injury still causes sick leave and leads to permanently
reduced function for the majority of the patients [21, 28].
During the healing process after rupture, elongation
of the Achilles tendon can occur [7]. In recent years, the
measurement of the length of the ruptured Achilles ten-
don has gained interest, because studies have shown that
tendon elongation is negatively correlated to clinical out-
comes [13, 15]. The length of the Achilles tendon can
be measured by several different methods. These meth-
ods include: magnetic resonance imaging (MRI) [13],
ultrasound [11], stereo radiography (RSA) using tanta-
lum beads [24], and indirectly by measuring the Achilles
tendon resting angle (ATRA) [3] or the heel-rise height
(HRH) [25]. Over the past 20 years, the difference between
operative and non-operative treatment has been intensely
investigated. Despite this, knowledge about differences
in the two treatment options regarding elongation of the
Achilles tendon is limited. Two studies have investigated
the difference in elongation between operative and non-
operative treated patients measured by MRI [12, 23].
Heikkinen et al. [12] found, in a randomized clinical trial
(RCT), that the mean Achilles tendon length of the injured
limb was 19 mm longer after non-operative treatment com-
pared to operative treatment 18 months after ATR. Rosso
et al. [23] did not find a relative difference in the Achilles
tendon length, when comparing with the uninjured limb,
in a long-term follow-up study between the two treatment
options. Olsson et al. [22] investigated the difference in
HRH at 1-year follow-up in an RCT and showed no differ-
ence between the groups. Additionally, Schepull et al. [24]
did not find any difference between operative and non-
operative treated patients in tendon elongation measured
by RSA.
The aim of the present study was to investigate if
operative and non-operative treatment of ATR had dif-
ferent effects on tendon elongation measured by ATRA.
It was hypothesized that operative treatment will result in
less elongation of the Achilles tendon compared to non-
operative treatment. The present study differed from the
aforementioned studies by not excluding patients due to
criteria such as high age, comorbidities and time from
injury to treatment start. Therefore, this study will add
unique knowledge of how treatment choice (operative or
non-operative) affects tendon elongation in the general
population with ATR and thereby help medical profes-
sionals to decide the optimal treatment.
13
Knee Surgery, Sports Traumatology, Arthroscopy (2021) 29:1617–1626
Material and methods
Trial registration
Institutional review board (IRB) approval was given by the
Ethical Review Board of the Capital Region of Denmark
April 23, 2020, registration no. H-20028220. Approval from
the Danish Data Protection Agency of the Capital Region
of Denmark was given March 11, 2020, registration no.
P-2020-238.
The study was performed as a registry study in the Danish
Achilles tendon database (DADB).
The Danish Achilles tendon database (DADB)
In April 2012 the DADB was established. The DADB is a
nationwide prospective database with 11 orthopedic depart-
ments in Denmark registering data from patients with ATR.
Each department has its own treatment and rehabilitation
regime because no consensus has been made in DADB. The
content in DADB is described elsewhere [4].
A study investigating data in DADB found a high validity
in parameters entered at registration in DADB and a registra-
tion rate of 77% of patients with ATR registered in DADB
[4].
Study population
Data extraction from DADB was performed on January 1
2020. Patients registered in DADB from August 2015 to
January 2019 at five of the participating hospitals (Hvidovre
Hospital, Aalborg Hospital, Viborg Hospital, Hjørring Hos-
pital and Thisted Hospital) were included in the study. Reg-
istration of the clinical outcomes at 1-year follow-up was
initiated in August 2015 and took place at the five aforemen-
tioned hospitals. Patients registered in DADB later than 1st
of January 2019 would not have registered follow-up data at
1 year and are therefore not included.
Outcomes
Primary outcome
The primary outcome was the Achilles tendon resting angle
(ATRA) at 1-year follow-up, which is an indirect measure of
the length of the Achilles tendon [3]. ATRA was performed
as described by Hansen et al. [10, 11]. When measuring
ATRA, the patient lies in the prone position with the knee
flexed 90° and the ankle relaxed. The ATRA is measured by
using three reference points: 1. the 5th metatarsal head, 2.
the distal tip of the lateral malleolus, and 3. the head of the
fibula. The center of a goniometer is placed over the lateral
Knee Surgery, Sports Traumatology, Arthroscopy (2021) 29:1617–1626
malleolus and the two arms of the goniometer are pointing
towards the two reference points. The angle between the two
arms is measured in degrees without decimals. ATRA is
measured both on the uninjured leg and the injured leg [2].
The relative ATRA is calculated as the difference between
the uninjured and the injured leg [2]. A negative relative
ATRA indicates an elongation of the injured Achilles ten-
don. The more negative the relative ATRA is, the more is
the tendon elongated.
ATRA was measured by dedicated physiotherapists at the
5 hospitals. Two physiotherapists were responsible for the
collection of data at each hospital. During the study period,
an estimated 10–15 physiotherapists gathered data. Relative
ATRA has shown excellent reliability (intraclass correla-
tion coefficient (ICC) 0.85–0.96) and the standard error of
measurement (SEM) for intra and inter-reliability has been
calculated to be 1.1°–2.3° [11]. The ICC and SEM were
evaluated on a group of patients from the DADB included
in the present study [11]. Zellers et al. [29] investigated the
validity of relative ATRA and found a moderate relation-
ship to tendon elongation. A clinically relevant difference
for relative ATRA has not been defined, described or calcu-
lated in the literature. The SEM for the inter-rater reliability
(the degree of agreements among raters) is considered as the
best information we currently know about relative ATRA,
to base a clinically relevant difference on. This considera-
tion is based on that a clinically relevant difference in rela-
tive ATRA should not be less than the measurement error
between the physiotherapists who measure it. Therefore, in
the present study, a difference between groups in relative
ATRA lower than 2.3° is not considered clinically relevant.
Secondary outcomes
Heel-rise height (HRH) is an indirect measure of the Achil-
les tendon length and calf muscle strength [25, 26]. Before
the test, a warm-up session with 10 heel rises standing on
both legs is performed on the test box (box with 10° incline).
During the test, the patient is standing on one leg on the
test box resting two fingertips per hand on the wall. Meas-
uring tape (1 mm precision) is applied to the lower edge
of the calcaneus. While the patient stands flat on the foot,
the number on the measuring tape at the edge of the box
is noted. The patient is asked to raise his/her heel as high
as possible. At the highest point of the heel, the instructor
notates the number on the measuring tape at the edge of the
box. The difference between the two measures is defined as
the HRH. The test is performed on both legs starting with
the uninjured. Studies have shown good reliability of the test
and it seems to have a good validity for evaluating functional
deficits [25, 26]. The outcome is measured at 1-year follow-
up and is defined as the limb symmetry index (LSI) which is
calculated; (HRH on the injured leg/HRH on the uninjured
1619
leg) × 100%. An HRH (LSI) close to 100% indicates a good
treatment result [25].
Achilles tendon Total Rupture Score (ATRS) is a patient-
reported outcome measure used to evaluate symptoms and
limitations in function after ATR [19]. The baseline score
is obtained at inclusion in DADB by asking the patients to
recall their symptoms the week prior to the rupture. A 10
points difference between groups in ATRS is considered
clinically relevant [1, 19, 22].
Patient satisfaction with the result is measured on a
numerical rating scale (NRS) from 0 to 10, where 0 implies
not at all satisfied with the result and 10 implies very sat-
isfied with the result. The outcome is reported at 1-year
follow-up.
Patient satisfaction with the treatment is measured on a
numerical rating scale (NRS) from 0 to 10, where 0 implies
not at all satisfied with the treatment, and 10 implies very
satisfied with the treatment. The outcome is reported at
1-year follow-up.
Return to the same type of work was investigated by ask-
ing the patients two questions. First, the patient was asked
if he/she was at work prior to the injury. Only patients
answering yes to this question were included in the analysis
of this outcome. Second, the patients were asked if they had
resumed the same type of work on a full-time basis. The
outcome is reported at 1-year follow-up.
Return to the same type of sport was investigated by ask-
ing the patients two questions. First, the patient was asked if
he/she participated in sport prior to the injury. Only patients
answering yes to this question were included in the analysis
of this outcome. Second, the patients were asked if they have
returned to the same type of sport after injury. The outcome
is reported at 1-year follow-up.
Variables
The variable of interest was treatment (operative or non-
operative). Non-operative treatment is defined as; treatment
without the operation of the ruptured Achilles tendon.
Confounding variables
Sex (male/female) Age groups (< 35 years/35–
65 years/ > 65 years). Age was divided into groups based
on the possibility of a nonlinear association between age
and the outcomes. The cut-off point between the younger
and middle-aged group was based on the assumption that
patients younger than 35 years were more physically active.
The cut-off point between the middle-aged group and the
older group was set at 65 years to reflect the national age of
retirement and the lifestyle changes associated with giving
up work.
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1620
Comorbidity and treatment with medicine including,
diabetes (yes/no), hypertension (yes/no), rheumatic disease
(yes/no) and treatment with oral corticosteroids within the
last 6 months (yes/no).
Rehabilitation regime including initiation of ankle motion
(at week 1–3/at week 4 or later), weight-bearing allowed
(at week 1–2/at week 3/at week 4 or later), time in band-
age (less than 8 weeks/8 weeks/more than 8 weeks) and
choice of bandage (walker the whole period/cast the first
two weeks followed by walker). The different components
were divided into groups based on the possibility of a non-
linear association.
Time from injury to initiation of treatment (less than
5 days/5 days or more). Several RCTs have used more than
4 days from injury to initiation of treatment as an exclusion
criterion [1, 22]. Initiation of treatment is defined as when
the patients arrives in the emergency room where bandage
is applied.
Statistical analysis
Descriptive baseline characteristics were reported for opera-
tive and non-operatively treated patients regarding hospi-
tal, sex, age-group, comorbidities, medicine, rehabilitation
regime, time from injury to initiation of treatment and base-
line ATRS. The sample size was limited by the number of
patients registered in the DADB. Therefore, no sample size
calculation was performed prior to the initiation of the study.
Primary analysis
The difference in relative ATRA between operative and non-
operatively treated patients was examined by using a linear
mixed-effects model. In the model, the relative ATRA at
1-year follow-up was set as the outcome, the fixed effects
were the variable of interest (treatment) and the confounding
variables (sex, age-group, comorbidities, medicine, rehabili-
tation regime, time from injury to initiation of treatment).
The random effect was hospitals.
Secondary analysis
The difference in the secondary continuous outcomes at
1-year follow-up (HRH (LSI), ATRS at follow-up, change
in ATRS from baseline to follow-up, satisfaction with the
result and satisfaction with the treatment) between operative
and non-operatively treated patients were examined using
identical models as for the primary analysis for each of them.
The differences in the secondary dichotomous outcomes
at 1-year follow-up (return to the same type of work and
return to the same type of sport) between operative and
non-operatively treated patients were examined using logis-
tic mixed-effects models. For each of the two outcomes, a
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Knee Surgery, Sports Traumatology, Arthroscopy (2021) 29:1617–1626
model with the same fixed effects and random effect as the
primary analysis was performed.
Sensitivity analyses
In the study population, patients with a better outcome of
the injured limb compared to the uninjured limb in relative
ATRA and/or HRH (LSI) were excluded due to the assump-
tion of incorrect registration. In the sensitivity analysis, all
patients were included in identical analyses for each of the
outcomes.
The residuals for the models with continuous outcomes
were evaluated using Q-Q plots. All tests were two-sided.
The level of statistical significance was set at p < 0.05. No
Bonferroni corrections were applied. The analyses were con-
ducted using R 3.2.2 (R Foundation for statistical comput-
ing, Vienna, Austria).
Results
Nine-hundred and ninety-seven patients were registered
with ATR in DADB from August 2015 to January 2019
at the defined hospitals. Thirty-one were excluded due to
earlier rupture of the contralateral Achilles tendon or re-
rupture and 262 patients were excluded due to missing
baseline data. The registration of the rehabilitation regime
and time from rupture to treatment was initiated later than
2015, which explains the majority of the patients with miss-
ing baseline data. Of the remaining 704 patients, 438 had
correctly registered ATRA at 1-year follow-up and were
included in the study population (Fig. 1). One-hundred
and fifty-four patients were treated operatively (149 with
open surgery, 3 with minimally invasive surgery, and 2 with
unknown operation technique) and 284 patients were treated
non-operatively.
Descriptive baseline characteristics of the operative and
the non-operatively treated patients are presented in Table 1.
Baseline ATRS for the operative and non-operatively treated
patients were approximately the same. However, the opera-
tively treated patients were younger, were less likely to have
hypertension, were more likely to be in treatment with a cor-
ticosteroid, and had a long time from injury to initiation of
treatment compared to the non-operatively treated patients.
Additionally, the rehabilitation regimens for the operative
and non-operatively treated patients were different.
The primary analysis showed a statistically significant dif-
ference in favor of the operatively treated patients regarding
relative ATRA at 1-year follow-up in favor of the operatively
treated patients, but after adjustment for potential confound-
ers, the difference was not statistically significant (Table 2).
The secondary analyses showed a statistically significant dif-
ference in HRH (LSI) and in return to the same type of sport
Knee Surgery, Sports Traumatology, Arthroscopy (2021) 29:1617–1626 1621

Paents registered in DADB from

August 2015 to January 2019 at
the included hospitals (n=997)

Excluded due to rupture of the contralateral

Achilles tendon prior to the registraon in the
DADB or re-rupture (n=31)

Paents registered in the study

period without ATR prior to
Excluded due to missing baseline data (n=262)*
registraon (n=966)
• Missing registraon of baseline ATRS (n=8)
• Missing registraon of comorbidies (n=8)
• Missing registraon of treatment (n=216)
• Missing registraon of rehabilitaon regime
(n=251)
• Missing registraon of me from rupture to
treatment iniaon (n=195)
Paents with full registered
baseline data (n=704)
Excluded due to missing data on or incorrectly
registraon of ATRA at 1 year follow-up (n=266)
• Missing data on ATRA at 1 year follow-up
(n=225)
• Paents registered with be‡er ATRA on the
injured foot compared to the uninjured
(n=41)
Included in the primary study
populaon (n=438)

Fig. 1  Flow diagram of the study population. *Excluded patients can be part of more than one group (eg. the same patient can both have missing
data in registration of comorbidities and treatment)

in favor of the operatively treated patients, but after adjust-
ment for potential confounders, none of the estimates for the
secondary analyses were statistically significant (Tables 2
and 3). The sensitivity analyses did not show any relevant
differences compared to the primary and secondary analyses
(see Appendix 1).
Discussion
The most important finding of the present study was that
operative and non-operative treated patients did not show
a clinically relevant difference in ATRA at 1-year follow-
up. This finding suggests that operative treatment does not
lead to a clinically relevant reduction in tendon elongation
compared to non-operative treatment.
After adjustment for confounders, the difference in
relative ATRA at 1-year follow-up was − 1.2° in favor of
operatively treated patients with a 95% confidence interval
ranging from −2.5 to 0.1 and a p value of 0.06. The unad-
justed analysis showed a similar mean difference of − 1.3°,
however, this estimate was statistically significant (p = 0.02).
The p values were regarded as having minor importance
when interpreting the results because the calculated esti-
mates were not considered clinically relevant. A clinically
relevant difference for relative ATRA has not been defined in
the literature. In the present study, the clinically relevant dif-
ference was based on the SEM for the inter-rater reliability
(the degree of agreement among raters) and set at 2.3° [11].
One could argue that 2.3 is a rather arbitrary value for the
clinically relevant difference. From a realistic clinical per-
spective, it might be too low considering both the relatively

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Table 1  Descriptive baseline characteristics

Operative, n (%) Non-operative, n (%) Overall, n (%)

Number of patients 154 284 438

Hospital
Hvidovre 71 (46) 49 (17) 120 (27)
Aalborg 3 (2) 159 (56) 162 (37)
Viborg 80 (52) 30 (11) 110 (25)
Hjørring 0 (0) 28 (10) 28 (6)
Thisted 0 (0) 18 (6) 18 (5)
Sex
Male 118 (77) 223 (79) 341 (78)
Female 36 (23) 61 (21) 97 (22)
Age
< 35 years 32 (21) 52 (18) 84 (19)
35–65 years 109 (71) 178 (63) 287 (66)
> 65 years 13 (8) 54 (19) 67 (15)
Comorbidity and medicine
Diabetes
Yes 2 (1) 6 (2) 8 (2)
No 152 (99) 278 (98) 430 (98)
Hypertension
Yes 8 (5) 46 (16) 54 (12)
No 146 (95) 238 (84) 384 (88)
Rheumatic disease
Yes 4 (3) 8 (3) 12 (3)
No 150 (97) 276 (97) 426 (97)
Corticosteroid
Yes 7 (5) 7 (2) 14 (3)
No 147 (95) 277 (98) 424 (97)
Rehabilitation regime
Initiation of ankle motion
At week 1 to 3 36 (23) 199 (70) 235 (54)
At week 4 or later 118 (77) 85 (30) 203 (46)
Weight-bearing allowed
At week 1 and 2 48 (31) 8 (3) 56 (13)
At week 3 36 (23) 198 (70) 234 (53)
At week 4 or later 70 (45) 78 (27) 148 (34)
Time in bandage
Less than 8 weeks 41 (27) 5 (2) 46 (11)
8 weeks 68 (44) 182 (64) 250 (57)
More than 8 weeks 45 (29) 97 (34) 142 (32)
Choice of bandage
Walker the whole period 62 (40) 214 (75) 276 (63)
Cast the first two weeks followed by walker 92 (60) 70 (25) 162 (37)
Time from rupture to initiation of treatment
4 days or less 132 (86) 260 (92) 392 (89)
More than 4 days 22 (14) 24 (8) 46 (11)
ATRS at baseline, mean (median) [IQR] 88 (100) [93–100] 90 (100) [94–100] 89 (100) [94–100]

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Knee Surgery, Sports Traumatology, Arthroscopy (2021) 29:1617–1626 1623

Table 2  Primary and secondary Number Mean Unadjusted mean dif- p value Adjusted mean dif- p value
outcome analyses at 1-year ference (95% CI)a ference (95% CI)b
follow-up
Primary outcome
Relative ATRA​
Operative 154 − 5.9 Reference Reference
Non-operative 284 − 7.2 − 1.3° (− 2.2; − 0.5) 0.02 − 1.2° (− 2.5; 0.1) n.s
Secondary outcomes
HRH (LSI)
Operative 133 75.7 Reference Reference
Non-operative 248 66.6 − 9.3 (− 14.4; − 4.2) 0.0004 − 5.2 (− 12.5; 1.2) n.s
ATRS at 1 year
Operative 154 60.1 Reference Reference
Non-operative 284 57.7 0.2 (− 6.8; 6.0) n.s − 0.7 (− 7.5; 6.2) n.s
Change in ATRS from baseline to 1 year follow-up
Operative 154 − 28.0 Reference Reference
Non-operative 284 − 32.5 − 3.5 (− 10.8; 3.7) n.s − 5.0 (− 13.7; 3.8) n.s
Satisfaction with the result
Operative 154 6.9 Reference Reference
Non-operative 283 6.6 0.2 (− 0.6; 0.9) n.s 0.3 (− 0.4; 1.0) n.s
Satisfaction with the treatment
Operative 154 8.1 Reference Reference
Non-operative 283 8.2 0.2 (− 0.3; 0.6) n.s 0.0 (− 0.5; 0.6) n.s

CI confidence interval, ATRS Achilles tendon total rupture score, ATRA​ Achilles tendon resting angle,
HRH heel-rise height, LSI limb symmetry index
a
Linear mixed-effects model. The random effect was hospital
b
Linear mixed-effects model adjusted for sex, age group, rehabilitation regime, time from rupture to initia-
tion of treatment, comorbidities and treatment with corticosteroid. The random effect was hospital

Table 3  Return to same type of Returned, n Not returned, n Unadjusted odds p value Adjusted odds p value
work and sport at 1 year follow ratio (95% CI)a ratio (95% CI)b
up
Return to same type of work
Operative 123 13 Reference Reference
Non-operative 188 23 0.86 (0.41; 1.75) n.s 1.04 (0.34; 3.16) n.s
Return to same type of sport
Operative 49 79 Reference Reference
Non-operative 54 161 0.54 (0.34; 0.87) 0.01 0.75 (0.37; 1.47) n.s

CI confidence interval, n numbers

a
Logistic mixed effects model. The random effect was hospital
b
Logistic mixed effects model adjusted for sex, age group, rehabilitation regime, time from rupture to ini-
tiation of treatment, comorbidities and treatment with corticosteroid. The random effect was hospital

large elongation found in most studies [2] and the inherent
measurement error of the ATRA measurement (position-
ing of the patient’s knee and ankle joint, identification of
landmarks, application of the goniometer and reading of the
goniometer). Using the SEM for the inter-rater reliability as
a basis for the clinically relevant difference is not optimal,
but as the found difference was approximately half the SEM
it is highly unlikely that it, by any standard, would be of
clinical relevance. Studies are needed that define a clinically
relevant difference in relative ATRA by also including data
on other length measures, symptoms and function.
The results from the present study support the findings
from a long-term follow-up study by Rosso et al. [23], who
used MRI to show no relative difference in the Achilles
tendon length between operative and non-operative treat-
ment. However, the results contradict the finding from an
RCT by Heikkinen et al. [12] who found that non-opera-
tively treated patients had a statistically significantly longer

13
1624
Achilles tendon with a mean difference of 19 mm compared
to the operated patients at 18 months follow-up measured
by MRI. The difference between the findings of the pre-
sent study and the findings in the RCT by Heikkinen et al.
might be explained by many factors: First, the difference in
the method used for measuring the Achilles tendon length.
Heikkinen et al. used MRI where the present study used
the indirect measure ATRA. During operative treatment, the
anatomical reference points for length measuring by MRI
changes, but the resting angle Is not affected. Additionally,
MRI gives a more exact measure of the Achilles tendon
length compared to the indirect measure ATRA because
the resting angle might also be affected by other factors in
addition to the length such as capsular stiffness [2]. Sec-
ond, the studies differed in the way of assessing elongation.
Heikkinen et al. used an absolute measurement comparing
the operated patients with the non-operated patients, where
the present study used a relative measure comparing the
injured and uninjured limb of each patient. The length of
the Achilles tendon varies between individuals. Therefore,
the observed differences between groups in the study by
Heikkinen et al. might be a result of individual variations
in unbalanced groups. To account for the individual varia-
tions of the Achilles tendon length, a relative measure com-
paring the injured and uninjured limbs of the patients was
used in the present study. Third, the populations included in
the studies differed. The RCT by Heikkinen et al. contained
many exclusion criteria such as: over 65 years, diagnosed
with diabetes mellitus, delay in treatment start for more than
1 week, etc. The present study included all patients with
ATR except prior rupture of the contralateral Achilles ten-
don and/or re-rupture.
Operative treatment is thought to restore the anatomi-
cal properties of the tendon including the length. However,
although this is accomplished at the time of the operation,
the Achilles tendon can still elongate further in the follow-
ing months [15]. The elongation can be due to failure of the
suture material, slipping of the knots or necrosis around the
sutures. This might explain the elongation found in opera-
tive treatment.
Tendon elongation after ATR has been found to corre-
late negatively with functional outcomes [13, 15], however,
the results are conflicting. A recently published systematic
review investigating if an elongated tendon was associated
with worse clinical outcomes found fair evidence of an asso-
ciation with biomechanical parameters, but also that the cur-
rent evidence is insufficient to show that Achilles tendon
elongation has a negative influence on patient-reported out-
comes and strength [6].
The secondary outcomes of the present study showed
(after adjustment for potential confounders), a tendency
towards a better treatment result for the operatively treated
patients primarily in HRH (LSI) with a difference of 5.2%
13
Knee Surgery, Sports Traumatology, Arthroscopy (2021) 29:1617–1626
points, change in ATRS from baseline to 1-year follow-up
with a difference of 5.0 points and return to the same type
of sport with a reduced odds of returning of 25%. However,
none of the secondary outcomes were statistically signifi-
cant. The unadjusted estimates showed the same tendency
in favor of the operatively treated patients with a statisti-
cally significant difference in HRH (LSI) of 9.3% points and
in return to the same type of sport with a reduced odds of
returning of 46%.
Other studies have evaluated the difference in ATRS and
functional outcomes regarding heel-rise between opera-
tively and non-operatively treated patients after ATR. Two
RCTs investigated the difference in ATRS at 1-year follow-
up and found no clinically nor the statistically significant
difference between operative and non-operatively treated
patients [18, 22]. The same two studies also investigated
clinical outcomes. Nilsson-Helander et al. [18] found a
non-statistically significant better HRH difference (LSI) of
4% for the operatively treated patients at 1-year follow-up,
similar to the finding of the present study. Additionally, they
found a statistically significantly different heel-rise work test
indicating a better function for the operated patients [18].
Olsson et al. [22] did not find differences in the functional
outcomes regarding heel-rise work and height at 1-year
follow-up. Return to the sport has also been reported in
RCTs, a meta-analysis pooling these studies did not find
a statistically significant difference between operative and
non-operative treatment [5, 20].
Meta-analyses of RCTs investigating the differences
between the two treatment options have shown good evi-
dence for a lower rate of re-ruptures for operatively treated
patients but also a higher rate of other complications such
as infections and sural nerve injury [5, 20].
From a clinical perspective, the present study adds knowl-
edge to the decision-making process regarding the treatment
of ATR. The results suggest that less tendon elongation
should not be used as an argument for choosing operative
treatment rather than non-operative treatment.
The study was limited by the non–randomized setup.
Treatment choice was at some hospitals based on a standard
regime whereas at other hospitals, the patients were evalu-
ated individually, which results in a risk of confounding
and bias. To best control for the confounding, the analyses
were adjusted for sex, age group, comorbidities, medicine,
rehabilitation regime and time from rupture to treatment.
Other confounders such as smoking, alcohol consumption,
body mass index, other comorbidities and intake of medi-
cine were not adjusted for and might have influenced the
results. Additionally, the study was limited by the loss to
follow-up. Of the 704 patients with full baseline data reg-
istered in DADB in the study period, 438 patients (62%)
had a correctly registered ATRA at 1-year follow-up and
could thus be included. The loss to follow-up potentially
Knee Surgery, Sports Traumatology, Arthroscopy (2021) 29:1617–1626
increases the risk of selection bias, however, when compar-
ing baseline data for the study population with baseline data
for all patients with full baseline data registered in DADB,
no relevant differences are found (Appendix 3).
All departments in the DADB used a rehabilitation
regime with a fixed angle boot and wedges. Until 2018 the
standard wedges had a plateau for the calcaneus to allow for
a more comfortable weight-bearing. In 2017 it was shown
that wedges with a plateau resulted in a neutral position of
the calcaneus and therefore did not reduce the tension on the
healing tendon [8]. This might have influenced the results
for patients treated before 2018.
Another limitation was that the conclusions of the present
study were sensitive to what a clinically relevant difference
for relative ATRA was defined as. Additionally, it would
have been methodologically correct to perform a sample size
calculation prior to the initiation of the study.
The strength of the study was the broad inclusion crite-
ria reflecting the actual population acquiring ATR. Patients
were not excluded due to high age or comorbidities, which
is the case in the majority of the RCTs investigating ATR
[16, 17, 27]. Therefore, the results from the present study
are more generalizable for the average patient with ATR.
Moreover, the data is prospectively registered in a validated
database.
Conclusions
There were neither clinically relevant nor statistically signifi-
cant differences in terms of the ATRA at 1-year follow-up
between the operative and non-operatively treated patients.
This finding suggests that operative treatment does not lead
to a clinically relevant reduction in tendon elongation com-
pared to non-operative treatment and it should therefore not
be used as an argument in the choice of treatment.
Acknowledgements We would like to thank the following hospitals
in Denmark that have contributed data to the Danish Achilles ten-
don Database: Aalborg Hospital, Køge Hospital, Nykøbing Falster
Hospital, Amager-Hvidovre Hospital, Kolding Hospital, Vendsyssel
Hospital, Hjørring Hospital, Thy-Mors Hospital, Himmerland Farsø
Hospital, Viborg Regional Hospital, Randers Regional Hospital and
Slagelse Hospital.
Author contributions The authors (AC, ER, MSH, HS, PH, KWB)
designed the study and interpreted the data. AC, ER and HS made
the statistical analysis. AC and KWB wrote the first version of the
manuscript. All authors have critically revised the manuscript and have
approved the final version.
Compliance with ethical standards
Conflict of interest KWB is paid consultant for DJO Nordic. The rest
of the authors declare that they have no competing interests.
1625
Funding No funds were received.
Ethical approval Institutional review board (IRB) approval was given
by the Ethical Review Board of the Capital Region of Denmark April
23 2020, registration no. H-20028220. Approval from the Danish Data
Protection Agency of the Capital Region of Denmark was given March
11, 2020, registration no. P-2020-238.
Informed consent Informed consent was obtained from all study par-
ticipants.
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