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Achilles tendon rupture is a relatively common clinical sports injury, which ranks the third in the most common tendon ruptures. According to epidemiological statistics, incidence rate of Achilles tendon injury is 0.18‰^[1], which has a growing tendency with the popularity of competitive sports and entertainments^[2]. The reports on Achilles tendon rupture have been increasing since 1950s. The Achilles tendon is prone to rupture in exercises, especially when tap dancing. The athletic people are most exposed to tendon rupture. The patients need a long time to rest and can not participate in sports, which brings both economic losses and health complications for patients^[3-4]. Therefore, the treatment and rehabilitation of Achilles tendon injury correctly has especially importance.  The objective of the present study is to explore the safety and efficacy of early isokinetic rehabilitation training for postoperatively patients with Achilles tendon ruptures, and to provide evidence for early rehabilitation in patients with Achilles tendon ruptures.

Biomechanics of the Achilles tendon Achilles tendon is a typical structure of “muscle - tendon - bone system”. Tendons transmit force from muscle to bone and act as a buffer by absorbing external force to limit muscle damage. Tendons exhibit high mechanical strength and good flexibility to perform their function. The mechanical behavior of collagen depends on the number and types of intromolecular and intermolecular bonds^[7-9]. Force of 9 000 N, corresponding to 12.5 folds body weight, has been recorded in the human Achilles tendon during running^[10-13]. There is a high risk of Achilles tendon rupture when the muscles are in the eccentric exercises. Treatment protocol for Achilles tendon injury Achilles tendon ruptures are common, but there is no agreed protocol for their management^[14-19]. There are essentially two schools of thought in the management of Achilles tendon ruptures^[1]. The first school believes that the safer option is non-operative treatment. The second school believes that surgery provides better results. Some of them advocate minimally invasive or percutaneous repair, which can restore the continuity and tension of the Achilles tendon. Rehabilitation for patients after repair of Achilles tendon ruptures Achilles tendon is a hypocellular and hypovascular tissue that heals slowly and usually repairs through scar formation. The healing process may last for several months and even years, and injured tendons never recover the functional properties of health and normal tendons. In general, most would opt for operative management followed by below-the-knee cast immobilization in patients. The cast is applied with the ankle in plantar flexion for 2 weeks, and another nonweightbearing cast with the ankle in less equinus is applied for a further 2 weeks. The cast is removed at 6 weeks after the operation and weightbearing is begun. The protocol can get good results; however, there are more complications due to a long time ankle fixation, such as long time rehabilitation, muscles and cartilage atrophy, joint stiffness, high re-rupture rate. Isokinetic muscle strength is based on the process of adjustment along with the corresponding resistance, so that the whole joint moves according to a pre-set speed, and in the course of the campaign only muscle tension and the torque output increases^[20]. It has been shown that tendons are able to respond to mechanical forces by altering their structure and mechanical characteristics^[21-23]. This process has been referred to as tissue mechanical adaptation or mechanotransduction. It is now clear that the amount and type of mechanical loading is very crucial in this process. Appropriate mechanical loading can result in positive change in Achilles tendon, leading to improved performance. Appropriate stress stimulation enable repaired collagen to transform into type Ⅰ collagen fibers. As a constant speed of movement, the muscles can not generate acceleration, so isokinetic training is the safest rehabilitation method. The safety of early isokinetic rehabilitation is ensured by the suture strength during surgery and self-repair of the Achilles tendon for 4 weeks postoperatively. In this study, there is no re-rupture and Achilles tendon extension case which proves it is safe for rehabilitation in early stage. Isokinetic training is a form of mechanical loading that has become very popular in rehabilitation of patients with sports injuries. Closed-chain rehabilitation of the ankle has greater advantage compared with traditional rehabilitation. This rehabilitation training can involve the entire muscle - tendon motor units and is more efficient. Isokinetic exercise can promote the Achilles tendon collagen fiber hypertrophy and hyperplasia^[24-26], to make new collagen fibers and nerves mature, and to make type Ⅲ collagen turn into type Ⅰ which increases the strength and flexibility of the Achilles tendon. In the traditional Achilles tendon rehabilitation program, the repair is prone to form scar collagen. Collagen elasticity and ability to withstand stress are poor, resulting in Achilles tendon lengthening during rehabilitation lately or even Achilles tendon re-rupture^[27]. Ankle flexion and extension can promote the active muscle contraction of lower limb and eccentric strength. Early isokinetic rehabilitation of the ankle is able to prevent muscle and cartilage atrophy, reducing intra-articular fibrin exudation and the swelling time, improving ankle range of activities^[28-29]. There were no statistical significances in isokinetic evaluation of the data between the injured and uninjured sides (P > 0.05). This study demonstrates that, compared with traditional rehabilitation programs, early rehabilitation of Achilles tendon rupture is safe, which can reduce the patient recovery time, but not increase the risk of Achilles tendon re-rupture.

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