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C OPYRIGHT
2017 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Tendon Length, Calf Muscle Atrophy, and Strength

Deficit After Acute Achilles Tendon Rupture
Long-Term Follow-up of Patients in a Previous Study
Juuso Heikkinen, MD, Iikka Lantto, MD, PhD, Juuso Piilonen, MS, Tapio Flinkkilä, MD, PhD, Pasi Ohtonen, MSc, Pertti Siira, PT,
Vesa Laine, MSc, Jaakko Niinimäki, MD, PhD, Prof, Ari Pajala, MD, PhD, and Juhana Leppilahti, MD, PhD, Prof

Investigation performed at the Division of Orthopaedic and Trauma Surgery, Department of Surgery, Oulu University Hospital,
Medical Research Center, University of Oulu, Oulu, Finland

Background: In this prospective study, we used magnetic resonance imaging (MRI) to assess long-term Achilles tendon
length, calf muscle volume, and muscle fatty degeneration after surgery for acute Achilles tendon rupture.
Methods: From 1998 to 2001, 60 patients at our center underwent surgery for acute Achilles tendon rupture followed
by early functional postoperative rehabilitation. Fifty-five patients were reexamined after a minimum duration of follow-
up of 13 years (mean, 14 years), and 52 of them were included in the present study. Outcome measures included
Achilles tendon length, calf muscle volume, and fatty degeneration measured with MRI of both the affected and the
uninjured leg. The isokinetic plantar flexion strength of both calves was measured and was correlated with the structural
findings.
Results: The Achilles tendon was, on average, 12 mm (95% confidence interval [CI] = 8.6 to 15.6 mm; p < 0.001) longer
(6% longer) in the affected leg than in the uninjured leg. The mean volumes of the soleus and medial and lateral
gastrocnemius muscles were 63 cm3 (13%; p < 0.001), 30 cm3 (13%; p < 0.001), and 16 cm3 (11%; p < 0.001) lower in
the affected leg than in the uninjured leg, whereas the mean volume of the flexor hallucis longus (FHL) was 5 cm3 (5%;
p = 0.002) greater in the affected leg, indicating FHL compensatory hypertrophy. The median plantar flexion strength for
the whole range of motion ranged from 12% to 18% less than that on the uninjured side. Finally, the side-to-side difference
in Achilles tendon length correlated substantially with the strength deficit (r = 0.51, p < 0.001) and with medial gas-
trocnemius (r = 0.46, p = 0.001) and soleus (r = 0.42, p = 0.002) muscle atrophy.
Conclusions: Increased Achilles tendon length is associated with smaller calf muscle volumes and persistent plantar
flexion strength deficits after surgical repair of Achilles tendon rupture. Strength deficits and muscle volume deficits are
partly compensated for by FHL hypertrophy, but 11% to 13% deficits in soleus and gastrocnemius muscle volumes and
12% to 18% deficits in plantar flexion strength persist even after long-term follow-up.
Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

D
espite surgical repair of acute Achilles tendon rupture,
calf muscle isokinetic strength does not usually return
to completely normal, instead showing an 8% to 20%
deficit compared with that of the uninjured leg after mid-term
to long-term follow-up1-5. Earlier studies have shown that the
triceps surae muscle undergoes volume atrophy and fatty de-
generation1,5,6. Increased Achilles tendon length, or elongation,
during rehabilitation has been proposed as a possible expla-
nation for these structural changes and for the strength deficit
after Achilles tendon rupture5,7,8.
Previous investigators assessed elongation of the Achilles
tendon after rupture by using metallic radiographic markers
that had been placed on both sides of the tendon ends during
surgery8,9. They reported that the Achilles tendon elongates
during the first 3 months postinjury, leading to up to 8 mm of
elongation at 1 year. However, reported correlations of tendon
elongation with plantar flexion strength have been controver-
sial. Pajala et al. found substantial correlation between Achilles
tendon elongation and ankle plantar flexion peak torque8,
whereas Kangas et al. found no correlation between elongation

Disclosure: This study was funded by the University of Oulu Graduate School, UniOGS. The Disclosure of Potential Conflicts of Interest forms are
provided with the online version of the article (http://links.lww.com/JBJS/E334).

J Bone Joint Surg Am. 2017;99:1509-15 d http://dx.doi.org/10.2106/JBJS.16.01491

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and a strength deficit9. In addition, we previously found that
the Achilles tendon elongates up to 3 mm from 1 to 14 years
after repair but total elongation measured on radiographs did
not correlate with any isokinetic strength parameters or with
clinical results at the time of long-term follow-up4.
New magnetic resonance imaging (MRI) and ultrasound
techniques allow researchers to compare Achilles tendon length
between affected and uninjured sides, and they are therefore
considered more accurate than techniques using metallic
markers5,7,10,11. However, the results from studies using these
new methods have not been consistent. Using ultrasound,
Silbernagel et al. showed that the side-to-side difference in Achilles
tendon length, measured from the calcaneal insertion to the
muscle-tendon junction of the medial head of the gastrocne-
mius, correlated substantially with heel-rise height deficits 1 year
postoperatively 7. Using MRI in a retrospective study with a 91-
month follow-up after treatment of Achilles tendon rupture,
Rosso et al. found that the Achilles tendon in the affected leg was
on average 1.8 cm longer than that on the unaffected side, but
they did not assess correlation with isokinetic calf muscle
strength5. They also found a 17% lower triceps surae muscle
volume, which correlated with peak torque deficit5,12. We are
not aware of any prospective long-term MRI studies of Achilles
tendon length, calf muscle volume, fatty degeneration, and
ankle plantar flexion strength.
The objective of the present study was to use MRI to
measure Achilles tendon length, calf muscle volume, and muscle
fatty degeneration after surgery for acute Achilles tendon rup-
ture. We also assessed whether these structural findings were
associated with the calf muscle strength deficits in the affected leg
at the time of long-term follow-up.
Materials and Methods
Study Design
T his study was conducted as a part of a long-term follow-up
study of patients in a previously published randomized
controlled trial comparing augmented and nonaugmented
surgical repair of Achilles tendon ruptures4. The original study
was registered at ClinicalTrials.gov (NCT02018224). The local
research ethics committee approved the original trial protocol
and the reexamination of the patients. All patients received
oral and written information about the trial and provided
informed consent to participate. The inclusion criteria were a
complete acute Achilles tendon rupture and an age of 18 to 65
years. The exclusion criteria were a delay of ‡1 week between
the rupture and treatment, local corticosteroid injection(s)
around the Achilles tendon within 6 months before the rup-
ture, a previous Achilles tendon rupture on the contralateral
side, an open Achilles tendon rupture, skin problems over
the Achilles tendon area, residence outside the country, and
diabetes mellitus.
Between October 1998 and January 2001, 83 patients were
screened for trial eligibility at our university teaching hospital.
Twenty-one patients were excluded, and 2 eligible patients de-
clined to participate. The remaining 60 patients were random-
ized into augmented and nonaugmented repair groups.
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The short-term (1-year) and long-term (14-year) clinical
results of this study were published previously4,8. We combined
the augmented and nonaugmented groups to investigate struc-
tural changes of the muscles and the Achilles tendon length after
surgical repair of Achilles tendon rupture4,8.
Patients
A total of 57 patients from the original study8 were contacted
between December 2013 and March 2014, and 55 of them were
included in the long-term cohort4. Of these 55 patients (48
male and 7 female; mean age and standard deviation [SD], 38 ±
8 years), 28 had nonaugmented and 27 had augmented surgical
repair. Two patients were excluded from the present analysis
because they had Achilles tendon rupture on the contralateral
side during the follow-up period, and another patient was
excluded because of MRI artifact in the analyses of muscle
volume and fatty degeneration. The participants underwent
MRI and isokinetic plantar flexion strength measurement of
both legs after an average of 14 ± 0.5 years, and a minimum of
13 years, of follow-up.
Operative Techniques
One surgeon performed all operations. For the nonaugmented
repairs, the tendon was operated on using the Krackow tech-
nique with 2 polydioxanone-0 absorbable sutures (PDS; Ethi-
con) and smaller 2-0 polyglactin appositional sutures (Vicryl;
Ethicon)13. The augmented procedure started with end-to-end
repair that was identical to the nonaugmented procedure. The
repair was then augmented with a 10-mm-wide central gas-
trocnemius aponeurosis flap that was turned down over the
suture line and stitched to the Achilles tendon with 2-0 Vicryl14.
The ankle was gently placed in a neutral position, and routine
skin closure was performed after the repair. Postoperatively, a
temporary below-the-knee rigid plaster splint was applied with
the ankle in a neutral position in all cases.
Postoperative Management
Postoperative treatment was identical for all patients. On the
first postoperative day, all patients received a Soft Cast indi-
vidual below-the-knee dorsal brace (3M) that allowed active
free plantar flexion of the ankle but restricted dorsiflexion to
neutral; this was worn for 3 weeks8. The patients were allowed
20 kg of weight-bearing for 3 weeks, half weight-bearing for 3
to 6 weeks, and full weight-bearing thereafter. The patients
were instructed to perform exercises according to a standard
rehabilitation program8.
Outcome Measures
Outcome measures included Achilles tendon length, calf muscle
volume, and fatty degeneration of the muscle in both the affected
and the uninjured leg. The isokinetic plantar flexion strengths of
the calf muscles were measured on both sides. MRI was per-
formed on the same day as, but before, the isokinetic strength
tests. The first author measured tendon length and the degree
of fatty degeneration, the third author measured muscle vol-
umes, and 2 physiotherapists measured calf muscle strength. All
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Fig. 1
Axial T1-weighted MRIs of both calves acquired 14 years after surgery for an Achilles tendon rupture. The cross-sectional area was measured on a
clinical workstation by manually drawing the region of interest around a muscle or muscle compartment. DF = deep flexors, FHL = flexor hallucis longus,
S = soleus, GM = gastrocnemius medialis, GL = gastrocnemius lateralis.

assessments were performed independently without knowledge
of the results of the other measurements.
MRI
MRI was performed on the affected and uninjured legs at the
same time, with the uninjured leg serving as a normal matched
control. The MRI was carried out with a 1.5-T imaging system
(MAGNETOM Aera; Siemens Healthcare). The imaging se-
quences included T1-weighted turbo spin echo (TSE) sagittal
images (a slice thickness of 4 mm, with a 0.8-mm interslice
gap) and axial images (a slice thickness of 4 mm, with a 1.6-mm
interslice gap). The T1-weighted sagittal images covered both
calves from the proximal part of the tibia to the distal part of
the calcaneus, and the T1-weighted axial images covered both
calves from the distal femoral condyles to the distal part of the
calcaneus. Patients were scanned in the supine position, and
their ankles were supported in the plantigrade position (the
ankle at a 90 angle and the knee at a 0 angle).
Achilles Tendon Length
The Achilles tendon length was measured in both the uninjured
and the affected leg with MRI as the distance from the most
distal part of the medial head of the gastrocnemius to the most
distal end of the Achilles tendon11. The most distal end of the
Achilles tendon was defined by the axial plane intersecting the
most cranial aspect of the calcaneal tuberosity. The difference
in tendon length was calculated by subtracting the length in
the uninjured leg from that in the affected leg. The relative
difference in tendon length was calculated as ([affected –
uninjured]/affected) · 100 to assess its correlation with iso-
kinetic deficits.
Calf Muscle Volume
The outline of each muscle was identified on axial MRIs, and the
cross-sectional area of the muscle or muscle compartment was
measured on every third axial slice from the femoral epicondyles
to the distal part of the calcaneus (Fig. 1)15. The muscle volume
was calculated using the formula for frustums of cones: h/3 ·
(A1 1 O[A1 · A2] 1 A2), where h is the height of the cylinder
(e.g., three 4-mm slices 1 1.6-mm interslice gaps = 16.8 mm),
and A1 and A2 are the cross-sectional areas at the 2 ends of the
cylinder. This method is a modification of the method described
by Rosso et al., who calculated volumes using a formula for
regular cylinders rather than frustums of cones5. The final
muscle volume was the sum of all cylinders measured in that
muscle. Muscle volumes were calculated (in cubic centimeters)
for each compartment, including the soleus, the medial and
lateral gastrocnemius muscles, the flexor hallucis longus (FHL),

TABLE I Calf Muscle Volume at a Mean of 14 Years After Surgery for Achilles Tendon Rupture

Mean Volume (SD) (cm3) Difference

Affected Leg Uninjured Leg Mean (SD)* (cm3) %† P Value

Soleus 429.1 (92.8) 492.1 (94.6) 63.0 (61.0) 12.8 <0.001

Medial gastrocnemius 207.7 (51.5) 237.3 (57.8) 29.7 (32.6) 12.5 <0.001
Lateral gastrocnemius 133.1 (36.0) 149.1 (39.3) 15.9 (20.0) 10.7 <0.001
FHL 101.4 (25.6) 96.7 (25.2) 24.6 (10.2) 4.8 0.002
Deep flexors 159.8 (35.4) 156.8 (35.0) 23.1 (13.5) 2.0 0.114

*Uninjured – affected. †([Uninjured – affected]/uninjured) · 100.

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TABLE II Calf Muscle Fatty Degeneration at a Mean of 14 Years After Surgery for Achilles Tendon Rupture

No. (% of Whole Study Group)

Soleus Medial Gastrocnemius Lateral Gastrocnemius
Goutallier Classification Uninjured Leg Affected Leg Uninjured Leg Affected Leg Uninjured Leg Affected Leg

0 6 (11.5) 1 (1.9) 10 (19.2) 4 (7.7) 21 (40.4) 12 (23.1)

1 35 (67.3) 17 (32.7) 31 (59.6) 28 (53.8) 26 (50.0) 33 (63.5)
2 11 (21.2) 32 (61.5) 11 (21.2) 19 (36.5) 5 (9.6) 6 (11.5)
3 0 2 (3.8) 0 1 (1.9) 0 1 (1.9)
4 0 0 0 0 0 0
Total 52 (100) 52 (100) 52 (100) 52 (100) 52 (100) 52 (100)
P value <0.001 <0.001 0.018

and the deep flexors (the digitorum longus and tibialis poste-
rior) in the posterior compartment. Side-to-side differences
were calculated by subtracting the volume in the affected leg
from that in the uninjured leg. Relative volume deficits were
calculated as ([uninjured – affected]/uninjured) · 100 to assess
their correlation with isokinetic deficits.
exact test was used for categorical data. The Spearman corre-
lation coefficient (r) was calculated to evaluate correlations.
Isokinetic strength results were analyzed with a linear mixed
model (LMM). Two-tailed p values are reported. Analyses were
performed with SPSS Statistics for Windows (version 21.0;
IBM) and SAS (version 9.4; SAS Institute).

Muscle Fatty Infiltration Results

The grading system described by Goutallier et al. and adapted
for MRI was used to classify muscle fatty degeneration16-18.
Fatty degeneration of the soleus, medial gastrocnemius, and
T he results of the 2 surgical techniques did not differ in terms
of Achilles tendon length, calf muscle volume, or fatty de-
generation (see Appendix).
lateral gastrocnemius in both calves was evaluated from the
axial MRI slice that showed the greatest cross-sectional area at Achilles Tendon Length
calf level of both legs. Grade 0 indicated no intramuscular fat; The mean Achilles tendon length was 199 mm in the affected
grade 1, some fatty streaks; grade 2, fat evident but less fat leg and 187 mm in the uninjured leg (mean difference of
than muscle; grade 3, equal amounts of fat and muscle tissue; 12 mm [6%], 95% confidence interval [CI] = 8.6 to 15.6 mm;
and grade 4, more fat than muscle tissue. Grades 0 and 1 were p < 0.001).
considered to reflect normal variations in the Goutallier
classification19-21.

Calf Muscle Strength

The isokinetic strength of both ankles was measured us-
ing a CON-TREX biomechanical test and training system
computer-based isokinetic dynamometer (CMV AG) at an
average of 14 years after surgery on the same day as, but after,
the MRI assessment. During testing, the patient was in the
supine position with the knee supported in extension4. Torque-
displacement curves from the best of 5 maximal repetitions
at an angular velocity of 60/s were used to calculate the
work-displacement curves for each 10 interval of the ankle
joint’s range of motion (210 to 30). Work-displacement
curves were expressed as the relative deficit, with the formula
([uninjured 2 affected]/uninjured) · 100%, and correlated
with the Achilles tendon elongation and calf muscle volume
deficit.
Fig. 2
Statistical Methods The median work-displacement deficits in plantar flexion of the affected
The Student t test or analysis of variance (ANOVA) was used leg compared with the control (uninjured) leg measured in 10 intervals
for comparisons of continuous variables between the uninjured after an average of 14 years of follow-up. The error bars indicate the
and affected legs, and the Pearson chi-square test or Fisher 25th and 75th percentiles.
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legs (p £ 0.018) (Table II). In the affected legs, the soleus muscle
TABLE III Correlation of Achilles Tendon Elongation with Plantar showed greater fatty degeneration than the medial and lateral
Flexion Strength and Muscle Volume
gastrocnemius muscles did (p < 0.001).
Achilles Tendon Elongation*†
Calf Muscle Strength
Work-displacement deficit‡ The median plantar flexion strength deficits of the affected
210 to <0 0.179, 0.20 legs, for the whole range of motion, ranged from 12% to 18%
0 to <10 0.38, 0.006 compared with uninjured side (Fig. 2).
10 to <20 0.51, <0.001
20 to <30 0.47, <0.001 Correlation
Muscle volume deficit‡ The difference in the Achilles tendon length correlated with the
Soleus 0.42, 0.002 ankle end-range plantar flexion strength deficit (r = 0.38 to 0.51,
Medial gastrocnemius 0.46, 0.001 p < 0.001 to p = 0.006) and with the soleus (r = 0.42, p = 0.002)
Lateral gastrocnemius 0.24, 0.08 and medial gastrocnemius (r = 0.46, p = 0.001) muscle volume
FHL 20.30, 0.031 deficits (Table III).
Deep flexors 20.06, 0.7 The soleus and medial gastrocnemius muscle volumes
correlated with the ankle end-range plantar flexion strength
*The values in this column are given as the rho, p values. deficit (r = 0.41 to 0.56, p < 0.001 to p = 0.003) (Table IV). The
†([Affected – uninjured]/affected) · 100. ‡([Uninjured – affected]/ FHL muscle volume correlated negatively with the mid-range
uninjured) · 100. plantar flexion strength deficit (r = –0.37 and –0.38, p = 0.008
and 0.006) and with the difference in Achilles tendon length
(r = –0.30, p = 0.031), indicating FHL muscle compensatory
Calf Muscle Volumes hypertrophy in response to a plantar flexion strength deficit
The mean soleus muscle volume in the affected leg was 13% and an Achilles tendon length difference (Tables III and IV).
lower (mean difference of 63 cm3, 95% CI = 43 to 78 cm3; p <
0.001), and the mean medial and lateral gastrocnemius muscle Discussion
volumes were 13% (mean difference of 30 cm3, 95% CI = 19 to
38 cm3; p < 0.001) and 11% lower (mean difference of 16 cm3,
95% CI = 10 to 21 cm3; p < 0.001), compared with the values
T he results of this study showed that, after rupture, the
Achilles tendon was on average 12 mm longer than the
contralateral uninjured tendon at the time of long-term follow-
for the uninjured leg (Table I). up despite surgical repair. In addition, the affected leg had 11%
The mean volume of the FHL was 5% higher (mean dif- to 13% lower triceps surae muscle volume compared with the
ference of 4.6 cm3, 95% CI = 1.6 to 7.3 cm3; p = 0.002) in the uninjured leg. Soleus and gastrocnemius muscle atrophy was
affected leg compared with uninjured leg, indicating compen- partly compensated for by 5% hypertrophy of the FHL. Fatty
satory hypertrophy of the FHL after Achilles tendon rupture degeneration—especially of the soleus muscle—was more
(Table I). There was no difference in the volume of the deep common in the affected leg than in the uninjured leg. The
flexors between the affected and uninjured legs (p = 0.114) difference in Achilles tendon length correlated substantially
(Table I). with the plantar strength deficit and with both gastrocnemius
and soleus muscle atrophy.
Muscle Fatty Degeneration Previous studies using metallic markers or ultrasound
Fatty degeneration of the soleus and gastrocnemius muscles have shown that the Achilles tendon elongates substantially
was more common in the affected legs than in the uninjured after surgery, but whether or not there was a correlation with

TABLE IV Correlation of Muscle Volume with Plantar Flexion Strength

Muscle Volume Deficit*†

Soleus Medial Gastrocnemius Lateral Gastrocnemius FHL Deep Flexors

Work-displacement deficit†
210 to <0 0.1, 0.53 0.21, 0.14 0.36, 0.010 20.13, 0.37 20.02, >0.9
0 to <10 0.43, 0.002 0.44, 0.001 0.49, <0.001 20.38, 0.006 20.08, 0.6
10 to <20 0.56, <0.001 0.52, <0.001 0.43, 0.002 20.37, 0.008 20.03, 0.81
20 to <30 0.52, <0.001 0.41, 0.003 0.27, 0.057 20.23, 0.114 20.05, 0.72

*The values in the table are given as the rho, p values. †([Uninjured – affected]/uninjured) · 100.
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isokinetic calf muscle strength or heel-rise height has been
controversial7-9. According to our results, the difference in Achilles
tendon length correlated with a plantar flexion deficit. Only
Rosso et al. has used MRI techniques that were similar to ours to
measure the difference in Achilles tendon length5. In their ret-
rospective study, with 91 months of follow-up, they found that
the affected Achilles tendon was an average of 18 mm longer
than the tendon on the uninjured side. Their treatment methods
included nonoperative management and open or percutaneous
surgery, and these differences in study design might explain the
slight differences between their results and ours. They did not
find any correlation between the difference in Achilles tendon
length and muscle volume, but they did not measure calf muscle
strength.
Immediate motion and early weight-bearing after surgi-
cal repair of Achilles tendon rupture are considered to improve
the early healing response of the tendon and prevent joint
stiffness without a substantial risk of Achilles tendon elonga-
tion22. In contrast to this common belief, we found increased
Achilles tendon length despite delayed weight-bearing in our
rehabilitation protocol. Valkering et al. defined Achilles tendon
elongation according to the difference in the dorsiflexion of the
2 ankles 2 weeks after surgery 22, which may explain the differ-
ence between their tendon elongation results and ours. In ad-
dition, our rehabilitation protocol allowed a greater range of
immediate active free plantar flexion of the ankle joint com-
pared with that of Valkering et al., which may have predisposed
our patients to Achilles tendon elongation. Although immedi-
ate weight-bearing with early motion promotes tendon healing,
it probably also promotes subtle Achilles tendon elongation
after surgery.
In earlier studies, computed tomography (CT) mea-
surements of the calf muscle cross-sectional area were used
to indirectly assess calf muscle volume after Achilles tendon
rupture, with estimates of calf muscle atrophy ranging from a
15% to a 25% cross-sectional deficit compared with the un-
injured leg1,6. Only Rosso et al. measured the actual muscle
volume using MRI in their retrospective study of 52 patients
with unilateral Achilles tendon rupture treated with open,
percutaneous, or nonoperative treatment5. After a mean of 91
months of follow-up, they found a 17% deficit in the triceps
surae muscle volume and marked fatty infiltration compared
with values for the uninjured leg, regardless of the treatment
method. Our results are comparable with those of Rosso et al.
in terms of calf muscle atrophy, and we also found a substantial
correlation between calf muscle volume and isokinetic plan-
tar flexion strength of the ankle1,12. Our long-term study also
showed that plantar flexion strength is partly restored by FHL
hypertrophy. Our results confirm the observations of Finni
et al., who previously suggested that early recovery of plantar
flexion torque may be due to FHL muscle compensation in
addition to normalization of triceps surae muscle function in
the short term23.
In addition to the calf muscles, the shoulder and thigh
muscles have also been reported to show persistent muscle
atrophy. Muscle atrophy of rotator cuff muscles is only partly
T E N D O N L E N G T H , C A L F M U S C L E A T R O P H Y, AND STRENGTH DEFICIT
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reversible, even after successful tendon repair24,25. Mille et al.
found up to a 20% isokinetic strength deficit in knee extension
after successful repair of quadriceps tendon ruptures26.
There are several possible explanations for fatty degener-
ation of calf muscles, including muscle fiber type distribution,
degree of immobilization, and Achilles tendon lengthening.
Differences in the distribution of type-I and II muscle fibers may
explain the finding that the soleus muscle had greater fatty de-
generation than the gastrocnemius muscle27-29. Type-I muscle fibers,
which are dominant in the soleus, are more vulnerable to immo-
bilization than are type-II fibers, which predominate in the gas-
trocnemius30-32. The greater fatty degeneration of the soleus may
also be related to ankle immobilization using a below-the-knee
dorsal brace. When ankle dorsiflexion is restricted to neutral,
function of the soleus muscle is minimal but the gastrocnemius,
which crosses the knee joint, remains active during weight-bearing.
Strengths of the present study included the homoge-
neous group of patients, standard rehabilitation protocol, and
average 14-year follow-up. In addition, all results were analyzed
using the uninjured leg as a control and all radiographic and
strength measurements were performed independently. Also,
the Goutallier classification adapted for MRI evaluation of
fatty degeneration has shown excellent reproducibility when
used to assess the calf muscles and rotator cuff16-18.
A weakness of our study was that we included 2 operative
techniques. Also, without baseline MRI, we were unable to assess
the exact cause of the tendon length difference. Another weak-
ness of the study is that only a single examiner measured tendon
length, fatty degeneration, and muscle volume. Finally, our es-
timates are based on presumed limb symmetry as described for
uninjured patients7.
In conclusion, a longer Achilles tendon may explain the
smaller calf muscle volume and persistent plantar flexion strength
deficit seen after surgical repair of Achilles tendon ruptures. The
strength deficit is partly compensated for by FHL muscle hy-
pertrophy, but a 11% to 13% deficit in soleus and gastrocnemius
muscle volume and a 12% to 18% deficit in plantar flexion
strength remain in the long term.
Appendix
Tables showing comparisons of the calf muscle volume,
Achilles tendon length, and calf muscle fatty degeneration
between the 2 surgical techniques are available with the online
version of this article as a data supplement at jbjs.org (http://
links.lww.com/JBJS/E335). n
Juuso Heikkinen, MD1
Iikka Lantto, MD, PhD1
Juuso Piilonen, MS1
Tapio Flinkkilä, MD, PhD1
Pasi Ohtonen, MSc1
Pertti Siira, PT1
Vesa Laine, MSc1
Jaakko Niinimäki, MD, PhD, Prof1
 1515
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O L U M E 99-A N U M B E R 18 S E P T E M B E R 20, 2 017
d d
Ari Pajala, MD, PhD1
Juhana Leppilahti, MD, PhD, Prof1
1Division of Orthopaedic and Trauma Surgery, Department of Surgery
(J.H., I.L., J.P., T.F., P.O., A.P., and J.L.), Department of Physical Medicine
and Rehabilitation (P.S. and V.L.), and Department of Diagnostic
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T E N D O N L E N G T H , C A L F M U S C L E A T R O P H Y, AND STRENGTH DEFICIT
AF T E R AC U T E AC H I L L E S T E N D O N RU P T U R E
Radiology, Institute of Diagnostics (J.N.), Oulu University Hospital,
Medical Research Center, University of Oulu, Oulu, Finland
E-mail address for J. Leppilahti: juhana.leppilahti@oulu.fi
ORCID iD for J. Leppilahti: 0000-0001-5778-246X
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