Can Compression Therapy Help Improve Achilles Tendon Healing?

A recent study suggests a dual benefit for using intermittent pneumatic compression therapy after surgical repair of the ruptured Achilles tendon.¹

Alim and coworkers enrolled 150 patients in a randomized, prospective clinical trial after surgical repair of an acute rupture of the Achilles tendon.¹ The control group received the standard protocol of immediate immobilization in a plaster cast with the ankle positioned in equinus, keeping the operated extremity non-weightbearing for the first two postoperative weeks. The experimental group was immobile in a removable walking boot with heel lifts and were permitted to bear weight immediately on the operated extremity. This group also used mechanical bilateral intermittent pneumatic calf compression devices for a minimum of six hours per day. Patients had compression therapy for the first two weeks after surgery and then discontinued it.

Alim and coworkers evaluated tendon repair using a technique called microdialysis, which involves taking a needle biopsy of the tendon and then quantifying the markers for collagen types I and III as well as overall protein content.¹ This Level 1 study demonstrated that intermittent pneumatic compression therapy increased the quantity of markers for collagen type I by 70 percent in comparison to the non-treatment control group who were strictly immobile. The presence of collagen type I, which is stronger and more organized and mature than collagen type III, indicates improved healing of the surgically repaired tendon. Even in the contralateral, non-operated Achilles, compression therapy improved the type I collagen levels by over 40 percent in comparison to the control group.

The finding of higher levels of collagen type I markers in the non-injured Achilles tendon treated with intermittent compression therapy is somewhat surprising but may validate the effects of improved circulation, even in the non-operated limb. Since the non-injured limb was weightbearing in both treatment groups, the use of compression therapy, rather than weightbearing status, appears to be the primary reason that the collagen repair was superior in the experimental group.

One of the coauthors (Ackerman) had previously conducted research on laboratory rats showing that immobilization decreases the rate of repair of the Achilles tendon with lower levels of collagen type I.^2,3 Hence, a trend over the past 20 years is to begin early weightbearing and mobilization after Achilles tendon rupture, whether or not the treatment program involves surgical repair.^4,5

This new study from Alim and coworkers adds to the insights of previous studies showing that intermittent compression can improve tendon repair.^2,3,6 The authors speculate that compression therapy improves venous and arterial circulation and causes local histologic changes in the healing Achilles tendon such as increased neurovascular ingrowth and fibroblast proliferation.

Up until now, clinicians have utilized intermittent compression therapy as an intervention to prevent deep vein thrombosis (DVT).^7,8 Achilles tendon ruptures have an alarming high risk of DVT complication with reports in the literature showing an incidence of 36 to 50 percent regardless of surgical repair or non-operative treatment.^9,10 Researchers have shown that intermittent pneumatic compression, applied for the first two weeks after Achilles tendon rupture, decreases the risk of DVT by almost 50 percent.¹¹ 

The risk of DVT after Achilles tendon rupture is most likely due to the requirement for long-term immobilization while the tendon heals. Immobilization also slows the rate of tendon repair. Now there is evidence that besides helping prevent DVT complications, intermittent compression therapy may actually improve the rate of healing of the ruptured Achilles tendon.

References

1. Alim MA, Domeij-Arverud E, Nilsson G, et al. Achilles tendon rupture healing is enhanced by intermittent pneumatic compression upregulating collagen type I synthesis. Knee Surg Sports Traumatol Arthrosc. 2018; 26(7):2021–2029.
2. Bring DK, Reno C, Renstrom P, et al. Joint immobilization reduces the expression of sensory neuropeptide receptors and impairs healing after tendon rupture in a rat model. J Orthop Res. 2009;27(2):274–280.
3. Schizas N, Li J, Andersson T, et al. Compression therapy promotes proliferative repair during rat Achilles tendon immobilization. J Orthop Res. 2010; 28(7):852–858.
4. Soroceanu A, Sidhwa F, Arabi S, et al. Surgical vs nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials. J Bone Joint Surg Am. 2012;94(23):2136-2143.
5. Willits K, Amendola A, Bryant D, et al. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multi-center randomized trial using accelerated functional rehabilitation. J Bone Joint Surg Am. 2010;92(17):2767-2775.
6. Dahl J, Li J, Bring DK, Renstrom P, Ackermann PW. Intermittent pneumatic compression enhances neurovascular ingrowth and tissue proliferation during connective tissue healing: a study in the rat. J Orthop Res. 2007; 25(9):1185–1192.
7. Lieberman JR, Pensak MJ. Prevention of venous thromboembolic disease after total hip and knee arthroplasty. J Bone Joint Surg [Am]. 2013;95(19):1801–1811.
8. Kakkos SK, Warwick D, Nicolaides AN, Stansby GP, Tsolakis IA. Combined (mechanical and pharmacological) modalities for the prevention of venous thromboembolism in joint replacement surgery. J Bone Joint Surg [Br]. 2012;94(6):729–734.
9. Lapidus LJ, Rosfors S, Ponzer S, et al. Prolonged thromboprophylaxis with dalteparin after surgical treatment of Achilles tendon rupture: a randomized, placebo controlled study. J Orthop Trauma. 2007;21(1):52–57.
10. Nilsson-Helander K, Thurin A, Karlsson J, Eriksson BI. High incidence of deep venous thrombosis after Achilles tendon rupture: a prospective study. Knee Surg Sports Traumatol Arthrosc. 2009;17(10):1234–1238.
11. Domeij-Arverud E, Labruto F, Lati A, Nilsson G, Edman G, Ackermann PW. Intermittent pneumatic compression reduces the risk of deep vein thrombosis during post-operative lower limb immobilisation: a prospective randomised trial of acute ruptures of the Achilles tendon. Bone Joint J. 2015; 97-B(5):675–680.
12. Eisele R, Kinzl L, Koelsch T. Rapid-inflation intermittent pneumatic compression for prevention of deep venous thrombosis. J Bone Joint Surg [Am]. 2007;89(5):1050–1056.