Journal of Orthopaedics 23 (2021) 46–51

Contents lists available at ScienceDirect

Journal of Orthopaedics
journal homepage: www.elsevier.com/locate/jor

A qualitative assessment of return to sport following Achilles tendon repair

Joshua G. Peterson *, Vehniah K. Tjong , Mitesh P. Mehta , Bailey N. Goyette , Milap Patel ,
Anish R. Kadakia
Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, 676 North St. Clair Street, Suite 1350, Chicago, IL, 60611, USA

A R T I C L E I N F O A B S T R A C T

Keywords: Studies have demonstrated successful return to sport rates following Achilles tendon rupture and repair. The
Qualitative interviews purpose of this study is to understand the subjective intrinsic and extrinsic motivational factors influencing an
Achilles tendon rupture athlete’s return to pre-injury level of sport following Achilles tendon repair. Qualitative, semi-structured in­
Achilles tendon repair
terviews of 23 athletes who had undergone Achilles tendon repair were conducted and analyzed to derive codes,
Return to sport
categories, and themes. Three major themes affecting return to sport were elucidated from the interviews:
personal motivation, shift in focus, and confidence in healthcare team. These findings can direct healthcare
teams on how to better guide patients post-operatively.

1. Introduction
Achilles tendon ruptures are most frequently acute injuries. One
common mechanism is unexpected dorsiflexion and strong push-off of
the foot in conjunction with calf contraction and knee extension.37 Re­
covery options for Achilles tendon rupture include open surgery, mini­
mally invasive techniques, percutaneous repair such as Percutaneous
Achilles Repair System (PARS), and nonsurgical treatment.31 PARS has
been shown to have similar re-rupture rates relative to open surgery but
has a lower likelihood of post-operative infection and sural neuritis and
is therefore the preferred choice for many surgeons to help patients
recover and return to sport.1,12,16,21,27,40
The discussion regarding recovery and return to sport is especially
relevant as Achilles tendon rupture incidence has increased both in the
general population and in specific sports such as major league baseball
(MLB).15,19,22,23,38 Studies done on Achilles tendon repair show variable
return to play rates ranging from 62% to 96%.13,20,38,45,48 It is important
to note, however, that return to play is defined differently across studies
and sometimes not at all. A systematic review by Zellers et al.48 esti­
mated a return to sport rate of 77% or less due to this variation. Athletic
performance post-surgery has also been researched with some studies
reporting decreased ability in professional athletes the first year after
repair followed by a rebound in athletic performance after two
years.38,45
While quantitative research about Achilles tendon repair and return
to sport has been growing,13,20,38,45,48 a qualitative assessment of athlete
reasoning for return to sport has not yet been explored. Qualitative
research on the subjective motivational factors influencing an athlete’s
decision to return to sport after other orthopaedic surgeries is a growing
body of literature that has importantly informed what drives return to
sport and players’ versions of a “successful surgery.”5,10,33,44 With such
varied return to sport rates, patients with Achilles tendon injuries may
be misled by anecdotal information leading to confusion about their
expected outcomes. Misunderstanding reasons why other athletes with
Achilles tendon ruptures have or have not returned to sport may also
cause patients to set inappropriate goals causing an unnecessarily
negative experience. Thus, this study aimed to understand the subjective
intrinsic and extrinsic motivational factors influencing an athlete’s re­
turn to pre-injury level of sport following Achilles tendon repair.
2. Materials and methods
2.1. Participants
Patients between 18 and 60 years of age who had undergone primary
Achilles tendon repair following rupture while participating in a sport
were eligible for the study. Surgery was performed at a single university-
associated hospital by a single fellowship-trained orthopaedic surgeon
between 2013 and 2018. All patients underwent surgery via PARS and
had a minimum two-year follow up. Those who had been treated over
seven years ago were excluded from the study to decrease recall bias.
Approval from the university’s Institutional Review Board was granted

* Corresponding author.
E-mail address: joshua.peterson@northwestern.edu (J.G. Peterson).

https://doi.org/10.1016/j.jor.2020.12.010
Received 23 October 2020; Accepted 20 December 2020
Available online 24 December 2020
0972-978X/© 2020 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.
J.G. Peterson et al.
before study commencement.
2.2. Recruitment and data collection
This study followed a similar methodology to other qualitative as­
sessments of return to sport.28,29,41–44 Recruitment was performed in
two phases. Eligible patients were initially contacted via mail and email,
followed by a telephone inquiry. Informed consent was obtained from
willing participants and interviews were scheduled. A single interviewer
trained in qualitative methods (J.G.P.) conducted 30 to 45-minute
audio-recorded telephone interviews using a study specific question
guide derived from a review of sports medicine, psychology, and qual­
itative return to sport literature.4,34,36,42–44 Interviews employed the
method of active passivity, meaning participants were not interrupted
unless discussions deviated significantly from the aim of the in­
terviews.25 Alphanumeric identifiers were assigned to each patient
during interview transcription to preserve anonymity.
Semi-structured interviews were utilized to elucidate patient-derived
themes and concepts regarding the decision to return to sport after
Achilles tendon repair. The interviews consisted of open-ended ques­
tions with an iterative approach to the question guide, giving the
interviewer freedom to probe deeper into patients’ responses and
allowing patients to express their thoughts more thoroughly. The
detailed information gathered from each interview was a unique feature
of this qualitative study that could not be obtained via quantitative
means alone.
The interviews were supplemented by Patient-Reported Outcome
Measurement Information System (PROMIS) scores. PROMIS domains
include Physical Function (PF) and Pain Interference (PI), administered
as Computer Adaptive Tests (CATs).17,18 Data is reported as T-scores
ranging between zero and 100 with 50 representing the physical func­
tion and pain interference of a healthy subset of the United States gen­
eral population for reference. Functional improvement in patients has a
positive correlation to PF T-scores while PI T-scores are inversely
correlated with improvements in a patient’s reported pain.11 PROMIS
surveys were administered and collected using the REDCap electronic
data capture tool.14
2.3. Data analysis
Sport participation was defined by three categories: type of sport,
level of competition (i.e., recreational, varsity college/university, pro­
fessional), and frequency of activity. Identical pre-injury and post-injury
values were required in all three categories for a patient to classify as
having returned to sport. Not returning to sport was defined as never
achieving an equivalent status as described above at any post-operative
timepoint. Sample size was determined when data saturation was ob­
tained, meaning that collection stopped once new explanations, themes,
and concepts no longer emerged from the interviews.26 Three members
of the research team (J.G.P., V.K.T., M.P.M.) applied the method used by
Strauss and Corbin39 of open coding, axial coding, and selective coding
to each of the transcribed interviews.24 Specific phrases or ideas from
the raw data were then grouped into commonalities that reflected cat­
egories. These categories were connected to classify them as broader
themes. The themes generated from this analysis became the
patient-generated factors influencing an athlete’s decision to return to
sport following Achilles tendon repair. Data analysis was performed
using the R programing language (R Project for Statistical Computing; R
Foundation). Welch’s t-test and Pearson’s Chi-squared test with Yates’
continuity correction were used to determine statistical significance of
demographic data and PROMIS scores, defined as results with a p value
less than 0.05.
3. Results
A total of 48 patients met the inclusion criteria for this study. Two
47
Journal of Orthopaedics 23 (2021) 46–51
patients declined participation, and 23 were unable to be contacted.
Data saturation was reached after 23 patients were interviewed: Six
(26%) returned to pre-injury level of sport as defined above (same type,
level, and frequency of sport) while 17 (74%) did not. All patients
participated in recreational-level sports. Study participation and patient
demographics are outlined in Fig. 1 and Table 1.
Three distinct themes were generated from the semi-structured in­
terviews that described the motivators affecting return to sport after
surgery: personal motivation, shift in focus, and confidence in health­
care team.
3.1. Personal motivation
All patients mentioned an inner drive helping them push through the
challenges of rehab to return to physical activity. Though only six of 23
patients returned to their previous type, level, and frequency of sport
participation, all 23 returned to physical activity (defined as any
consistent form of exercise) and felt that their personal desire to do so
was critical to their success. Patients referred to themselves as “positive,
optimistic, and methodical to heal right” (patient A4), “resilient and
passionate” (A10), “self-motivated” (B6), and “fully committed” (B11).
Sports and physical fitness were key to the well-being and identity of
many patients as they expressed, “I was determined with the number
one goal to return to sport” (A12); “I remained active and competitive
with staying in shape as a big priority” (B2); “I was dedicated and
motivated to return to sport as it is important to my mental health” (B9);
and “I never even considered the possibility of not returning to sport so I
was patient, perseverant, and stayed in tune with my body” (B4). Others
were also determined to continue physical activity but more open to
adjusting as needed by saying, “I wanted to be active but also smart with
a knowledge of my limits” (A7); “I am competitive and gained confi­
dence over time” (A11); and “I trusted in the process and that I would be
able to stay in shape” (B8). One unique example was a patient who
works in the fitness industry. She stated, “As a manager, I wasn’t
required to return to physical activity for work, but fitness is my life, so I
kept a positive attitude and knew I just had to do it to stay well and
continue teaching classes I enjoy. I haven’t done the specific exercise
that injured me since, but I am still very active and enjoying my work”
(B5).
3.2. Shift in focus
As mentioned previously, only six of 23 patients returned to their
pre-injury level of sport even though all returned to athletic activity
(which included any consistent exercise). The primary reason for this
was a shift in focus which encompasses aging, moving to a new location,
evolving life priorities, time constraints, and the realization that certain
activities are not worth the possibility of reinjury. Patients that
mentioned aging stated, “I am in my 40’s now and have a kid and just
wanted to back off” (A3); “I turned 40 and decided I couldn’t compete
anymore like when I was in college and it was time to give up soccer”
(A6); “I’m in my 50’s and my body just isn’t what it used to be so I have
no need to continue competing” (B6); and “I’m in a different stage of life
now so I have less time for recreational sports” (A8). Other patients
noted that they were injured doing something that they hadn’t done
before or never was important to them such as “I was trying to do 30
things before I turned 30 and a gymnastics class was the first one. I tore
my Achilles and realized it was a bad idea for my body” (B4); “My
teenage son was running up a warped wall (like on the show American
Ninja Warrior) and I tried it against my better judgment; that never was
something important to me” (B11); and “Basketball and other court
sports simply aren’t very significant to me so I didn’t return” (A10).
Another subset mentioned a lack of opportunity to participate in the
sport they were injured in, so they shifted to other options. Examples
include: “It is hard to find a court partner for squash and my work
schedule doesn’t line up well” (B9); “I moved to the suburbs where there
J.G. Peterson et al. Journal of Orthopaedics 23 (2021) 46–51

Fig. 1. Study Participation *Wrong number, change of address, and no answer after repeated calls. **Patients with identical type of sport, level of competition, and
frequency of activity before and after injury.

an important factor in their recovery. Those who felt total trust in the
Table 1
skill and experience of their surgeon said, “I really trust my surgeon – I
Patient Demographics. Data are reported as n (%) or as mean ± SD with p values
feel that he is the best one out there” (B1); “My surgeon gave me
calculated using Welch’s t-test. Abbreviations: y is year(s), no. is number, mo is
month(s).
outstanding care and got me in very quickly” (B7); “The doctor sup­
ported me with an aggressive recovery” (B5); and “Because I trusted my
CHARACTERISTIC PATIENTS WHO PATIENTS WHO p
doctor and he helped me set appropriate expectations, I felt I could do
RETURNED TO DID NOT RETURN value
PRE-INJURY TO PRE-INJURY my part as well” (A9). Patients also felt encouraged and helped by their
SPORT (n = 6) SPORT (n = 17) physical therapists, stating, “Physical therapy was very valuable to me
Age, y 37.2 ± 12.2 38.9 ± 8.0 0.76
so I never missed an appointment and worked hard throughout” (B2); “I
Age group, no. of 0.92 told my physical therapist my goal was to completely return to physical
patients activity and they helped me continue until I was no longer limping at all”
18-39 y 4 (30.8) 9 (69.2) (B5); “I set my expectations with my therapist from the beginning that I
40-60 y 2 (20) 8 (80)
wanted to get back to sports rather than just be able to walk again and
Sex 1
Male 5 (26.3) 14 (73.7) they helped me stay engaged and work hard to reach that goal” (B6); and
Female 1 (25) 3 (75) “I went to a therapist I had worked with for other injuries and through
Type of Sport 0.90 aggressive and personalized rehab I was able to get way ahead of
Basketball 2 (33.3) 4 (66.7) schedule such that I was completely functional 12 weeks out. I was very
Soccer 1 (20) 4 (80)
Paddle tennis/Tennis 1 (20) 4 (80)
happy with the result” (B7). When asked what advice they would give
Working Out 1 (50) 1 (50) patients who ruptured their Achilles tendon and were considering sur­
Other (Football, 1 (20) 4 (80) gery, 17 of 23 patients (74%) focused on the importance of getting the
Gymnastics, Water best surgeon and physical therapist and completely committing to the
Skiing, Volleyball,
full treatment regimen.
Warped Wall)
Length of post-surgery 15.3 ± 6.9 13.3 ± 5.1 0.53
recovery, mo 3.4. Secondary outcomes
Mean time since 36.3 ± 12.1 60.4 ± 17.1 <0.01
surgery, mo
Table 2 summarizes the secondary outcome measures. In comparing
the cohorts that did and did not return to sport, there was no significant
are fewer people who play basketball, plus my wife doesn’t want me difference in PROMIS PF pre-operative (P = 0.27), PF 12-month post-
playing competitive sports anymore with my injury history” (B8); and “I operative (P = 0.81), PI pre-operative (P = 0.81), or PI 12-month
moved to Colorado where volleyball is less common, but I’m very post-operative (P = 0.12) scores. Each group saw both scores trend to­
involved in other sports such as trail running and skiing” (B7). A factor ward or past 50, with mean changes in PF (P = 0.30) and PI (P = 0.16)
commonly involved in the shift in focus for patients is fear of injury, as greater in those who did not return to sport, though this was not sta­
15 of 23 patients (65%) mentioned fear of reinjury and/or injuring their tistically significant.
contralateral Achilles tendon. Interestingly, four of six patients (67%)
who returned to sport expressed fear while 11 of 17 (65%) who did not 4. Discussion
return to sport expressed fear (P = 1). 19 of 23 patients (83%) said they
met their recovery expectations: five of six (83%) who returned to sport Three themes affecting return to sport after Achilles tendon repair
(the one that did not said it took longer than expected to recover) and 14 were derived from patient interviews in this study: personal motivation,
of 17 (82%) who did not return to sport (two citing that they cannot jog shift in focus, and confidence in healthcare team.
like they expected to be able to and one citing an infection post-surgery)
(P = 1).
4.1. Personal motivation

3.3. Confidence in healthcare team A unique finding in this study is that while only six of 23 patients
returned to their previous type, level, and frequency of sport, all
The majority of patients cited confidence in their surgeon and returned to physical activity and cited personal motivation as a major
physical therapist, along with other members of the healthcare team, as driving factor. Qualitative studies on return to sport following ACL

48
J.G. Peterson et al. Journal of Orthopaedics 23 (2021) 46–51

Table 2 sport as previously defined.

PROMIS Scores. Data are reported as mean T-scores ± SD with p values calcu­
lated using Welch’s t-test. Abbreviations: PROMIS, Patient-Reported Outcome 4.2. Shift in focus
Measurement Information System; PF, Physical Function; PI, Pain Interference;
Δ, Delta. *Three participants from the qualitative portion of the study who did
A shift in focus was the primary reason the patients of this study cited
not return to sport did not complete a follow-up survey and were excluded from
for not returning to sport. As previously stated, 83% of patients felt that
the PROMIS score analysis.
they met their recovery expectations with no significant difference (P =
DESCRIPTION OVERALL PATIENTS WHO PATIENTS WHO p 1) between those who did and did not return to sport. This may suggest
(n = 20)* RETURNED TO DID NOT value
PRE-INJURY RETURN TO
that patients were satisfied with their outcome even if they did not re­
SPORT (n = 6) PRE-INJURY turn to their pre-injury type, level, and frequency of sport because they
SPORT (n = 14)* adjusted their expectations early on. Some patients in this study changed
Pre-operative 47.7 (18.4) 54.4 (16) 44.8 (19.2) 0.27 sports simply due to lack opportunity, moving to a new location, or new
PROMIS PF time constraints but were still pleased with their ability to return to
Score physical activity and participate in sports. With this information, sur­
12-Month Post- 58.4 (8.5) 57.5 (11.4) 58.7 (7.4) 0.81 gical success for an athlete may depend on their personal goals and in­
operative
PROMIS PF
tentions rather than if they returned to the sport that they were injured
Score in. Helping athletes set appropriate expectations for their age, priorities,
Mean Δ in 10.7 (20.8) 3.1 (19.7) 13.9 (21.2) 0.30 and lifestyle can help increase patient satisfaction. This same idea has
PROMIS PF been expressed in returning to sport after ACL reconstruction, with a
Score
focus on goal-reprioritization and decreasing negative emotions to keep
Pre-operative 53.1 (11.7) 52.2 (10.6) 53.5 (12.5) 0.81
PROMIS PI patients satisfied with rehab and help them maintain a positive outlook
Score on their progress toward returning to physical activity.6
12-Month Post- 48.8 (5.9) 46.4 (6.2) 41.3 (5.2) 0.12 Change in priorities is also a common theme in athletes not returning
operative to sport across many injuries including knee, elbow, hip, and shoulder
PROMIS PI
Score
surgeries.28,42–44 Said changes for ACL reconstruction include an
Mean Δ in − 10.2 − 5.8 (6.9) − 12.2 (12.3) 0.16 emphasis on education, change in career paths, lack of time, and family
PROMIS PI (11.1) commitments.5,32,44 Athletes returning from shoulder injury have noted
Score that aging largely prevented them from returning to sport, recognizing
that their bodies simply aren’t what they used to be.43 This was sup­
ported by the many athletes in this study stating that turning 30, 40, or
reconstruction have found that many who did not return to sport felt
50 caused them to realize that they could no longer do what they used to.
they had a more cautious personality type, while most who did return
Another common factor leading to reprioritization after recovery from
classified themselves as self-motivators and very competitive.5,44 This
an injury is fear of reinjury.30,32,44 65% of participants in the current
difference may be due to the nature of the injuries in that the ACL is a
study mentioned that they are wary of reinjury or injury to the contra­
deep ligament providing knee stability while the Achilles tendon is
lateral Achilles tendon, however there was not a significant difference
crucial to power in any lower limb movement by nature of attaching the
(P = 1) between those that did and did not return to sport. These results
calf muscles to the calcaneus. Another factor may be a discrepancy in
suggest that fear did not affect whether athletes returned to their prior
age at time of rupture, as patients tend to rupture their Achilles tendon at
type/level/frequency of sport. A final example of adjusting expectations
an older age on average. Because of this, many patients with an Achilles
explained by Ardern et al.3 is that athletes recovering from ACL recon­
tendon rupture may reset their expectations for future athletic activity
struction who ended up returning to sport had pre-operatively estimated
and still feel very motivated while measuring success differently.
that they would return significantly faster than those who did not. This
Another study by Conti et al.8 interviewed professional basketball
once again demonstrates that differing priorities and expectations often
players who felt that motivation was essential to them returning to their
factor into return to sport. It is also of note that this study showed a
prior physical conditions after injury. They said motivation is “funda­
much lower return to sport rate (26%) than seen in the literature
mental in managing the challenges, setbacks and difficulties associated
(77%).48 This may be due to the strict definition of return to play that
with the rehabilitation time-frame.” Patients recovering from Achilles
this study employed, the small sample size, and the cohort of patients
Tendon tears similarly felt that there were various hurdles to overcome
that included only recreational athletes with an average age of 38.43
during the recovery process and that their determination and competi­
years.
tiveness helped them return to physical fitness.
Other studies on ACL reconstruction have shown that self-
4.3. Confidence in healthcare team
confidence, motivation, and optimism affect surgical outcomes.2,10,33
Everhart et al.10 goes on to surmise that “assessment of these factors to
Another important recovery factor cited by the majority of patients
gauge a patient’s psychological “readiness” for sports-related knee sur­
was having confidence in their healthcare team with an emphasis on
gery has the potential to help guide individualized treatment recom­
their orthopaedic surgeon and physical therapist. As previously stated,
mendations.” This idea that surgical success is intricately tied to
when asked what specific advice they would give other patients who
personality traits of the patient and that physicians can assist patients in
ruptured their Achilles tendon and were considering surgery, 74% of
their recovery process before a procedure is performed is one that should
participants emphasized the importance of finding the best orthopaedic
be further studied to empower patients of all personality types to return
surgeon and physical therapist and committing to the full treatment
to the physical form they desire. Research on hip arthroscopy for fem­
regimen. This parallels findings in similar studies in patients who un­
oroacetabular impingement and ulnar collateral ligament (UCL) recon­
derwent ACL reconstruction.5,33 Several participants in the study by
struction have also demonstrated the crucial role of self-efficacy in
Burland et al.5 felt that establishing good rapport with their physical
return to sport.28,42 The current study strengthens the notion that
therapist was paramount in their recovery. One participant in that study
self-efficacy and motivation are important in the successful return to
remarked, “If you don’t have a relationship with them, I don’t think
athletic activity following a wide array of injuries, though also demon­
you’d actually put in the work, and they wouldn’t put in the work with
strates that one can possess these attributes and feel that they have
you”. Paterno et al.33 helped to establish the importance of the
succeeded in their physical recovery even if they have not returned to
patient-physical therapist relationship in recovery from ACL

49
J.G. Peterson et al.
reconstruction. They defined some of the specific roles that a physical
therapist can play in a patient’s successful recovery: motivator, guide,
booster of confidence, fosterer of perseverance, and coordinator of care.
A qualitative return to sport study of professional basketball players
further noted the vital role of athletic trainers and other sports medicine
professionals.8 The study defined specific types of assistance provided by
these individuals including informational, emotional, and motivational
support. They showed the benefit of sports medicine professionals
informing patients of and elucidating potential return to sport scenarios
during the recovery period. This is supported by the current study, as
many patients commented on how helpful it was to discuss their current
situation and goals for future athletic activity with their surgeon and
physical therapist. Various other studies have also exhibited the positive
influence, both psychological and physical, that medical professionals
can have on athletes as they recover from injury. This includes
increasing resilience and adherence to rehab, meeting psychological
needs via open communication, providing a better understanding of the
big picture to motivate patients to work hard, and getting patients
actively involved in recovering from their injury to help them address
relevant psychological aspects.3,7,9,35,46 One example of the power of a
solid patient-therapist relationship from this study was the patient who
cited working with a physical therapist who had already helped him
recover from various injuries. He was very appreciative of the aggressive
and personalized rehab plan his therapist provided him and was the
quickest patient to return to athletics. With this wealth of evidence, it is
apparent that building rapport with patients is critical for healthcare
teams to effectively bring them towards satisfying recovery.
4.4. Secondary outcomes
The lack of statistical significance between the cohorts that did and
did not return to sport supports the assertion that factors other than
physical function and pain can affect return to sport following Achilles
tendon repair. This demonstrates that while quantitative measures are
important to assess, qualitative factors motivating return to sport play a
key role in players’ decisions and are critical to evaluate. As previously
stated, the most common reason for patients not returning to sport in
this study was a shift in focus including aging, moving to a new location,
lack of opportunity, and differing priorities. These factors affect both
patients who do and do not return to sport. The greater change in both
physical function and pain interference in those who did not return to
sport is intriguing because, though not statistically significant, it could
suggest that their greater overall improvement helped them meet their
expectations at the same rate as those who did return to sport.
4.5. Limitations
Despite the strength of qualitative methods obtaining in-depth an­
swers from patients, there were several limitations to this study. The
patient population was restricted to a single academic surgeon and had
sampling biases. The study population only included recreational ath­
letes, making it less generalizable to varsity and professional athletes.
Participation bias also is present as patients who agreed to be inter­
viewed may hold different views from those who declined or could not
be contacted. The lack of patient sex diversity could isolate the results to
the male athlete; however, a study by Vosseller et al.47 demonstrated
that at one institution the male to female ratio of Achilles tendon rup­
tures was 5.39:1 which is comparable to the 4.75:1 ratio of the current
study. Recall bias and social desirability bias, in which patients want to
appear stronger or more confident than in reality, may have also been
involved because of the nature of interviews. The small sample size
required to reach data saturation also diminishes PROMIS score statis­
tical strength. Further investigations would benefit from adding vali­
dated surveys regarding psychological factors affecting return to sport in
conjunction with a larger sample size and multiple standardized follow
up PROMIS score timepoints to demonstrate change in PI and PF over
50
Journal of Orthopaedics 23 (2021) 46–51
time.
5. Conclusion
This study delineates personal motivation, shift in focus, and confi­
dence in healthcare team as three main themes influencing a patient’s
return to pre-injury level of sport following Achilles tendon repair.
Helping patients set appropriate expectations for return to sport and
encouraging them through the challenges of rehab to reach their goals
are critical to facilitating a positive experience. The study brings to light
how an athlete may not return to pre-injury type, level, and frequency of
sport after surgery while still meeting their expectations and feeling
satisfied with their care and recovery if given appropriate tools, assis­
tance, and advice. These findings can also help healthcare teams better
educate patients throughout their post-operative journey.
CRediT authorship contribution statement
Joshua G. Peterson: Writing - original draft, Investigation,
Conceptualization, Visualization, Project administration. Vehniah K.
Tjong: Methodology, Resources, Conceptualization, Supervision.
Mitesh P. Mehta: Investigation, Validation, Writing - original draft,
Formal analysis. Bailey N. Goyette: Investigation, Writing - original
draft. Milap Patel: Supervision, Investigation, Resources. Anish R.
Kadakia: Supervision, Investigation, Resources.
Declaration of competing interest
None.
No outside funding or grants were received that assisted in this study.
No authors have proprietary interests in the materials described in this
study. Informed consent was obtained from subjects for this study.
Northwestern University IRB: STU00209802.
References
1 Alcelik I, Diana G, Craig A, Loster N, Budgen A. Minimally invasive versus open
surgery for acute achilles tendon ruptures A systematic review and meta-analysis.
Acta Orthop Belg. 2017;83(3):387–395.
2 Ardern CL. Anterior cruciate ligament reconstruction-not exactly a one-way ticket
back to the preinjury level: a review of contextual factors affecting return to sport
after surgery. Sport Health. 2015;7(3):224–230.
3 Ardern CL, Taylor NF, Feller JA, Whitehead TS, Webster KE. Psychological responses
matter in returning to preinjury level of sport after anterior cruciate ligament
reconstruction surgery. Am J Sports Med. 2013;41(7):1549–1558.
4 Bauman J. Returning to play: the mind does matter. Clin J Sport Med. 2005;15(6):
432–435.
5 Burland JP, Toonstra J, Werner JL, et al. Decision to return to sport after anterior
cruciate ligament reconstruction, Part I: a qualitative investigation of psychosocial
factors. J Athl Train. 2018;53(5):452–463.
6 Burland JP, Toonstra JL, Howard JS. Psychosocial barriers after anterior cruciate
ligament reconstruction: a clinical review of factors influencing postoperative
success. Sport Health. 2019;11(6):528–534.
7 Clement D, Arvinen-Barrow M, Fetty T. Psychosocial responses during different
phases of sport-injury rehabilitation: a qualitative study. J Athl Train. 2015;50(1):
95–104.
8 Conti C, di Fronso S, Pivetti M, et al. Well-come back! Professional basketball players
perceptions of psychosocial and behavioral factors influencing a return to pre-injury
levels. Front Psychol. 2019;10:222.
9 Covassin T, Crutcher B, Bleecker A, et al. Postinjury anxiety and social support
among collegiate athletes: a comparison between orthopaedic injuries and
concussions. J Athl Train. 2014;49(4):462–468.
10 Everhart JS, Best TM, Flanigan DC. Psychological predictors of anterior cruciate
ligament reconstruction outcomes: a systematic review. Knee Surg Sports Traumatol
Arthrosc. 2015;23(3):752–762.
11 Gilley J, Bell R, Lima M, et al. Prospective patient reported outcomes (PRO) study
assessing outcomes of surgically managed ankle fractures. Foot Ankle Int. 2020;41(2):
206–210.
12 Grassi A, Amendola A, Samuelsson K, et al. Minimally invasive versus open repair for
acute achilles tendon rupture: meta-analysis showing reduced complications, with
similar outcomes, after minimally invasive surgery. J Bone Joint Surg Am. 2018;100
(22):1969–1981.
13 Grassi A, Rossi G, D’Hooghe P, et al. Eighty-two per cent of male professional football
(soccer) players return to play at the previous level two seasons after Achilles tendon
rupture treated with surgical repair. Br J Sports Med. 2020;54(8):480–486.
J.G. Peterson et al.
14 Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap)-a
metadata-driven methodology and workflow process for providing translational
research informatics support. J Biomed Inf. 2009;42(2):377–381.
15 Holm C, Kjaer M, Eliasson P. Achilles tendon rupture-treatment and complications: a
systematic review. Scand J Med Sci Sports. 2015;25(1):e1–10.
16 Hsu AR, Jones CP, Cohen BE, et al. Clinical outcomes and complications of
percutaneous achilles repair system versus open technique for acute achilles tendon
ruptures. Foot Ankle Int. 2015;36(11):1279–1286.
17 Hung M, Baumhauer JF, Latt LD, et al. Validation of PROMIS ® Physical Function
computerized adaptive tests for orthopaedic foot and ankle outcome research. Clin
Orthop Relat Res. 2013;471(11):3466–3474.
18 Hung M, Clegg DO, Greene T, Weir C, Saltzman CL. A lower extremity physical
function computerized adaptive testing instrument for orthopaedic patients. Foot
Ankle Int. 2012;33(4):326–335.
19 Huttunen TT, Kannus P, Rolf C, Felländer-Tsai L, Mattila VM. Acute achilles tendon
ruptures: incidence of injury and surgery in Sweden between 2001 and 2012. Am J
Sports Med. 2014;42(10):2419–2423.
20 Jack 2nd RA, Sochacki KR, Gardner SS, et al. Performance and return to sport after
achilles tendon repair in national football league players. Foot Ankle Int. 2017;38
(10):1092–1099.
21 Kołodziej L, Bohatyrewicz A, Kromuszczyńska J, Jezierski J, Biedroń M. Efficacy and
complications of open and minimally invasive surgery in acute Achilles tendon
rupture: a prospective randomised clinical study–preliminary report. Int Orthop.
2013;37(4):625–629.
22 Lantto I, Heikkinen J, Flinkkilä T, Ohtonen P, Leppilahti J. Epidemiology of Achilles
tendon ruptures: increasing incidence over a 33-year period. Scand J Med Sci Sports.
2015;25(1):e133–138.
23 Leppilahti J, Puranen J, Orava S. Incidence of Achilles tendon rupture. Acta Orthop
Scand. 1996;67(3):277–279.
24 Lingard L, Albert M, Levinson W. Grounded theory, mixed methods, and action
research. BMJ. 2008;337:a567.
25 Malterud K. Qualitative research: standards, challenges, and guidelines. Lancet.
2001;358(9280):483–488.
26 Marshall MN. Sampling for qualitative research. Fam Pract. 1996;13(6):522–525.
27 McGee R, Watson T, Eudy A, et al. Anatomic relationship of the sural nerve when
performing Achilles tendon repair using the percutaneous Achilles repair system, a
cadaveric study. Foot Ankle Surg. 2020. https://doi.org/10.1016/j.fas.2020.05.011.
28 Mehta MP, Tjong VK, Peterson JG, Christian RA, Gryzlo SM. A qualitative assessment
of return to sport following ulnar collateral ligament reconstruction in baseball
players. J Orthop. 2020;21:258–264.
29 Morgan AM, Fernandez CE, Terry MA, Tjong V. A qualitative assessment of return to
sport in collegiate athletes: does gender matter? Cureus. 2020;12(8):e9689.
30 Nwachukwu BU, Adjei J, Rauck RC, et al. How much do psychological factors affect
lack of return to play after anterior cruciate ligament reconstruction? A systematic
review. Orthop J Sports Med. 2019;7(5), 2325967119845313.
31 Patel MS, Kadakia AR. Minimally invasive treatments of acute achilles tendon
ruptures. Foot Ankle Clin. 2019;24(3):399–424.
51
Journal of Orthopaedics 23 (2021) 46–51
32 Patel NK, Sabharwal S, Hadley C, Blanchard E, Church S. Factors affecting return to
sport following hamstrings anterior cruciate ligament reconstruction in non-elite
athletes. Eur J Orthop Surg Traumatol. 2019;29(8):1771–1779.
33 Paterno MV, Schmitt LC, Thomas S, et al. Patient and parent perceptions of
rehabilitation factors that influence outcomes after anterior cruciate ligament
reconstruction and clearance to return to sport in adolescents and young adults.
J Orthop Sports Phys Ther. 2019;49(8):576–583.
34 Podlog L, Dimmock J, Miller J. A review of return to sport concerns following injury
rehabilitation: practitioner strategies for enhancing recovery outcomes. Phys Ther
Sport. 2011;12(1):36–42.
35 Podlog L, Dionigi R. Coach strategies for addressing psychosocial challenges during
the return to sport from injury. J Sports Sci. 2010;28(11):1197–1208.
36 Podlog L, Eklund RC. Returning to competition after a serious injury: the role of self-
determination. J Sports Sci. 2010;28(8):819–831.
37 Rose NGW, Green TJ. Ankle and foot. In: Rosen’s Emergency Medicine: Concepts and
Clinical Practice [Internet]. vol. 9. Elsevier; 2018:634–658.
38 Saltzman BM, Tetreault MW, Bohl DD, et al. Analysis of player statistics in major
league baseball players before and after achilles tendon repair. HSS J. 2017;13(2):
108–118.
39 Strauss A, Corbin J. Basis of Qualitative Research: Grounded Theory Procedures and
Techniques. 1. Newbury Park, CA: Sage Publications; 1990.
40 Tejwani NC, Lee J, Weatherall J, Sherman O. Acute achilles tendon ruptures: a
comparison of minimally invasive and open approach repairs followed by early
rehabilitation. Am J Orthoped. 2014;43(10):E221–E225.
41 Tjong VK, Baker HP, Cogan CJ, et al. Concussions in ncaa varsity football athletes: a
qualitative investigation of player perception and return to sport. J Am Acad Orthop
Surg Glob Res Rev. 2017;1(8). e070.
42 Tjong VK, Cogan CJ, Riederman BD, Terry MA. A qualitative assessment of return to
sport after hip arthroscopy for femoroacetabular impingement. Orthop J Sports Med.
2016;4(11), 2325967116671940.
43 Tjong VK, Devitt BM, Murnaghan ML, Ogilvie-Harris DJ, Theodoropoulos JS.
A qualitative investigation of return to sport after arthroscopic bankart repair:
beyond stability. Am J Sports Med. 2015;43(8):2005–2011.
44 Tjong VK, Murnaghan ML, Nyhof-Young JM, Ogilvie-Harris DJ. A qualitative
investigation of the decision to return to sport after anterior cruciate ligament
reconstruction: to play or not to play. Am J Sports Med. 2014;42(2):336–342.
45 Trofa DP, Miller JC, Jang ES, et al. Professional athletes’ return to play and
performance after operative repair of an achilles tendon rupture. Am J Sports Med.
2017;45(12):2864–2871.
46 Truong LK, Mosewich AD, Holt CJ, et al. Psychological, social and contextual factors
across recovery stages following a sport-related knee injury: a scoping review. Br J
Sports Med. 2020;54(19):1149–1156.
47 Vosseller JT, Ellis SJ, Levine DS, et al. Achilles tendon rupture in women. Foot Ankle
Int. 2013;34(1):49–53.
48 Zellers JA, Carmont MR, Grävare Silbernagel K. Return to play post-Achilles tendon
rupture: a systematic review and meta-analysis of rate and measures of return to
play. Br J Sports Med. 2016;50(21):1325–1332.