Advertisement

The influence of the Covid pandemic on the epidemiology of Achilles tendon ruptures in east Shropshire, United Kingdom.

Open AccessPublished:November 11, 2022DOI:https://doi.org/10.1016/j.jisako.2022.10.002

      Abstract

      Objectives

      Management strategies of the Covid pandemic included isolation to prevent transmission. This study aimed to determine if the pandemic of 2020 influenced the epidemiology of Achilles Tendon Rupture (ATR).

      Methods

      The demographics of presentations from the local population to xxx hospital, Shropshire, United Kingdom with an ATR were analysed and compared together with the season, month, and year of the injury.

      Results

      From 2009 to 2019 there was no significant change in the incidence of ATR over time with mean (SD) incidence of 13.3 per 100,000. In 2020, there was a decrease in injuries with an incidence of 8.4 per 100,000, with an increase in 2021 to 22.4 per 100,000. In 2021, there was an increase in injuries from March with numbers maintained until October.
      The most common activity of ATR was Team sport (36.2%), followed by Activities of Daily Living (28.9%), Other physical activities (21.0%) and Racket sports (13.9%). In 2020 there was the lowest number of injuries sustained in Team and Racket sports, however in 2021 they accounted for over half of Injuries.

      Conclusions

      There were significantly more patients sustaining ATR in 2021, the year after the covid pandemic and mandatory isolation. This was considered to be related to altered activity and Team and Racket sports during 2020.

      Levels of evidence

      IV Case series.

      Keywords

      • Achilles tendon ruptures commonly occur during sport and exercise activity.
      • Ruptures typically occur with the resumption of unaccustomed activity.
      • During the year of the covid pandemic there was a decrease in injuries with an incidence of 8.4 per 100,000, with an increase to 22.4 per 100,000 the subsequent year.
      • In 2020 there was the lowest number of injuries sustained in Team and Racket sports, however in 2021 they accounted for over half of Injuries.

      1. Introduction

      Patients sustaining an Achilles tendon rupture (ATR) are typically in their mid to late 40s and tend to sustain ruptures during sports activity[
      • Carmont M.R.
      • Silbernagel K.G.
      • Edge A.
      • Mei-Dan O.
      • Karlsson J.
      • Maffulli N.
      Functional Outcome of Percutaneous Achilles Repair: Improvements in Achilles Tendon Total Rupture Score During the First Year.
      ,
      • Maffulli N.
      • Waterston S.W.
      • Squair J.
      • Reaper J.
      • Douglas A.S.
      Changing incidence of Achilles tendon rupture in Scotland: a 15-year study.
      ,
      • Jozsa L.
      • Kvist M.
      • Balint B.J.
      • Reffy A.
      • Jarvinen M.
      • Lehto M.
      • et al.
      The role of recreational sport activity in Achilles tendon rupture.
      ]. In North America, Korea and Scandinavia the incidence of ATR is increasing[
      • Möller A.
      • Astron M.
      • Westlin N.
      Increasing incidence of Achilles tendon rupture.
      ,
      • Nyyssönen T.
      • Lüthje P.
      • Kröger H.
      The Increasing Incidence and Difference in Sex Distribution of Achilles Tendon Rupture in Finland in 1987–1999.
      ,
      • Raikin S.M.
      • Garras D.N.
      • Krapchev P v
      Achilles tendon injuries in a United States population.
      ,
      • Huttunen T.T.
      • Kannus P.
      • Rolf C.
      • Felländer-Tsai L.
      • Mattila V.M.
      Acute achilles tendon ruptures: incidence of injury and surgery in Sweden between 2001 and 2012.
      ,
      • Mattila V.M.
      • Huttunen T.T.
      • Haapasalo H.
      • Sillanpää P.
      • Malmivaara A.
      • Pihlajamäki H.
      Declining incidence of surgery for Achilles tendon rupture follows publication of major RCTs: evidence-influenced change evident using the Finnish registry study.
      ,
      • Lemme N.J.
      • Li N.Y.
      • DeFroda S.F.
      • Kleiner J.
      • Owens B.D.
      Epidemiology of Achilles Tendon Ruptures in the United States: Athletic and Nonathletic Injuries From 2012 to 2016.
      ,
      • Yasui Y.
      • Tonogai I.
      • Rosenbaum A.J.
      • Shimozono Y.
      • Kawano H.
      • Kennedy J.G.
      The Risk of Achilles Tendon Rupture in the Patients with Achilles Tendinopathy: Healthcare Database Analysis in the United States.
      ,
      • Park H.-G.
      • Youn D.
      • Baik J.-M.
      • Hwang J.H.
      Epidemiology of Achilles Tendon Rupture in South Korea: Claims Data of the National Health Insurance Service from 2009 to 2017.
      ,
      • Sheth U.
      • Wasserstein D.
      • Jenkinson R.
      • Moineddin R.
      • Kreder H.
      • Jaglal S.B.
      The epidemiology and trends in management of acute Achilles tendon ruptures in Ontario, Canada.
      ] at increasing rates of 2.4% per year for the last 30 years[
      • Lantto I.
      • Heikkinen J.
      • Flinkkilä T.
      • Ohtonen P.
      • Leppilahti J.
      Epidemiology of Achilles tendon ruptures: increasing incidence over a 33-year period.
      ]. However, in other series from Denmark and Japan, no change in the incidence is reported over the last two decades[
      • Ganestam A.
      • Kallemose T.
      • Troelsen A.
      • Barfod K.W.
      Increasing incidence of acute Achilles tendon rupture and a noticeable decline in surgical treatment from 1994 to 2013. A nationwide registry study of 33,160 patients.
      ,
      • Yamaguchi S.
      • Kimura S.
      • Akagi R.
      • Yoshimura K.
      • Kawasaki Y.
      • Shiko Y.
      • et al.
      Increase in Achilles Tendon Rupture Surgery in Japan: Results From a Nationwide Health Care Database.
      ]. The increase in incidence of rupture, greatest in those over 60 years of age[
      • Huttunen T.T.
      • Kannus P.
      • Rolf C.
      • Felländer-Tsai L.
      • Mattila V.M.
      Acute achilles tendon ruptures: incidence of injury and surgery in Sweden between 2001 and 2012.
      ] was thought to be due to increased numbers of older patients taking part in sports activity[
      • Ganestam A.
      • Kallemose T.
      • Troelsen A.
      • Barfod K.W.
      Increasing incidence of acute Achilles tendon rupture and a noticeable decline in surgical treatment from 1994 to 2013. A nationwide registry study of 33,160 patients.
      ] however in Ho et al's[
      • Ho G.
      • Tantigate D.
      • Kirschenbaum J.
      • Greisberg J.K.
      • Vosseller J.T.
      Increasing age in Achilles rupture patients over time.
      ] meta-analysis no correlation with over time was noted for those who sustained a rupture during athletic activity.
      The predominant sport during which Injuries were sustained varies between countries[
      • Carmont M.R.
      • Silbernagel K.G.
      • Edge A.
      • Mei-Dan O.
      • Karlsson J.
      • Maffulli N.
      Functional Outcome of Percutaneous Achilles Repair: Improvements in Achilles Tendon Total Rupture Score During the First Year.
      ,
      • Jozsa L.
      • Kvist M.
      • Balint B.J.
      • Reffy A.
      • Jarvinen M.
      • Lehto M.
      • et al.
      The role of recreational sport activity in Achilles tendon rupture.
      ,
      • Sheth U.
      • Wasserstein D.
      • Jenkinson R.
      • Moineddin R.
      • Kreder H.
      • Jaglal S.B.
      The epidemiology and trends in management of acute Achilles tendon ruptures in Ontario, Canada.
      ,
      • Scott A.
      • Grewal N.
      • Guy P.
      The seasonal variation of Achilles tendon ruptures in Vancouver, Canada: a retrospective study.
      ], but commonly involve competitive team sports such as football[
      • Carmont M.R.
      • Silbernagel K.G.
      • Edge A.
      • Mei-Dan O.
      • Karlsson J.
      • Maffulli N.
      Functional Outcome of Percutaneous Achilles Repair: Improvements in Achilles Tendon Total Rupture Score During the First Year.
      ] or basketball [
      • Raikin S.M.
      • Garras D.N.
      • Krapchev P v
      Achilles tendon injuries in a United States population.
      ,
      • Caldwell J.-M.E.
      • Lightsey H.M.
      • Trofa D.P.
      • Swindell H.W.
      • Greisberg J.K.
      • Vosseller J.T.
      Seasonal Variation of Achilles Tendon Injury.
      ], or racket sports e.g. badminton[
      • Möller A.
      • Astron M.
      • Westlin N.
      Increasing incidence of Achilles tendon rupture.
      ,
      • Saarensilta I.A.
      • Edman G.
      • Ackermann P.W.
      Achilles tendon ruptures during summer show the lowest incidence, but exhibit an increased risk of re-rupture.
      ] and squash. The seasonal variation in ruptures differs with some studies reporting increased ATR in the spring and summer[
      • Scott A.
      • Grewal N.
      • Guy P.
      The seasonal variation of Achilles tendon ruptures in Vancouver, Canada: a retrospective study.
      ,
      • Caldwell J.-M.E.
      • Lightsey H.M.
      • Trofa D.P.
      • Swindell H.W.
      • Greisberg J.K.
      • Vosseller J.T.
      Seasonal Variation of Achilles Tendon Injury.
      ,
      • Maempel J.F.
      • White T.O.
      • Mackenzie S.P.
      • McCann C.
      • Clement N.D.
      The epidemiology of Achilles tendon re-rupture and associated risk factors: male gender, younger age and traditional immobilising rehabilitation are risk factors.
      ,
      • Suchak A.A.
      • Bostick G.
      • Reid D.
      • Blitz S.
      • Jomha N.
      The Incidence of Achilles Tendon Ruptures in Edmonton, Canada.
      ] and others the autumn and winter[
      • Ganestam A.
      • Kallemose T.
      • Troelsen A.
      • Barfod K.W.
      Increasing incidence of acute Achilles tendon rupture and a noticeable decline in surgical treatment from 1994 to 2013. A nationwide registry study of 33,160 patients.
      ,
      • Saarensilta I.A.
      • Edman G.
      • Ackermann P.W.
      Achilles tendon ruptures during summer show the lowest incidence, but exhibit an increased risk of re-rupture.
      ]. High incidences in the autumn and winter from Scandinavia are thought to reflect the increased amount of high-risk sporting activity occurring indoors during seasons with little daylight[
      • Saarensilta I.A.
      • Edman G.
      • Ackermann P.W.
      Achilles tendon ruptures during summer show the lowest incidence, but exhibit an increased risk of re-rupture.
      ].
      The pandemic caused by the SARS-COV 2 virus started during the spring of 2020. The majority of countries adopted measures to minimise spread to protect the population from infection and reduce the impact on healthcare services[
      • Saadat S.
      • Rawtani D.
      • Hussain C.M.
      Environmental perspective of COVID-19.
      ]. This involved the wearing of face masks, use of sanitizing hand gel and isolation into household groups. Social isolation was enforced in many countries with non-essential work activity stopped and the cessation of team sports activity[

      Timeline of UK coronavirus lockdowns, March 2020 to March 2021. Institute for Government n.d. https://www.instituteforgovernment.org.uk/charts/uk-government-coronavirus-lockdowns (accessed December 22, 2021).

      ]. The resumption of sports activity following a period of lack of participation was noted by Simmonds as factor for ATR[
      • SIMMONDS F.A.
      The diagnosis of the ruptured Achilles tendon.
      ]. Following the 2011 NFL Lockout lasting five months, 10 ATRs occurred during the first 10 days of training camps and two further ruptures pre-season[
      • Myer G.D.
      • Faigenbaum A.D.
      • Cherny C.E.
      • Heidt R.S.
      • Hewett T.E.
      Did the NFL Lockout Expose the Achilles Heel of Competitive Sports?.
      ].
      The aim of this study was to estimate the incidence of ATR per year over time and to determine any variation over the calendar year and to see if the lockdowns of the covid pandemic were associated with a change in the epidemiology of ATR. Secondary aims were to determine if there was any variation in the mechanism of rupture in older patients sustaining ATR.

      2. Methods

      From February 2009 patients presenting to the XX Hospital in East Shropshire and diagnosed with an Achilles tendon rupture were collated in a database. The Research and Innovation Department of the XX Hospital National Health Service (NHS) Trust deemed this research to be service evaluation and ethical approval was not required. Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research. From NHS England, the local population served by XXH was estimated to be 250,000, living in a mixture of urban and rural areas[

      Joint Strategic Needs Assessment Guidance. Document Number 08773. NHS England 2019. https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf (accessed January 21, 2022).

      ].
      Diagnosis of Achilles tendon rupture was made on the history of a pop to the Achilles tendon with a subsequent inability to perform walking with a single heel-rise. Tendon discontinuity on examination was indicated by a palpable gap to the Achilles tendon for mid-substance tears, an absence of ankle plantar flexion on manually squeezing the calf muscle and increased ankle dorsiflexion resting position, termed the Achilles Tendon Resting Angle (ATRA)[
      • Carmont M.R.
      • Silbernagel K.G.
      • Edge A.
      • Mei-Dan O.
      • Karlsson J.
      • Maffulli N.
      Functional Outcome of Percutaneous Achilles Repair: Improvements in Achilles Tendon Total Rupture Score During the First Year.
      ,
      • Maffulli N.
      The clinical diagnosis of subcutaneous tear of the Achilles tendon. A prospective study in 174 patients.
      ]. Patients with acute, chronic, mid-substance, distal and musculotendinous ATR were all included.
      Tears at the musculotendinous junction were diagnosed with a history consistent with rupture, an increased ATRA and calf circumference compared with the non-injured side and tenderness at the rupture site[
      • SIMMONDS F.A.
      The diagnosis of the ruptured Achilles tendon.
      ,
      • Carmont M.R.
      • Grävare Silbernagel K.
      • Brorsson A.
      • Olsson N.
      • Maffulli N.
      • Karlsson J.
      The Achilles tendon resting angle as an indirect measure of Achilles tendon length following rupture, repair, and rehabilitation.
      ]. A palpable gap may or may not be present at the rupture site. A muscle-tendon junction tear was confirmed by ultrasonography performed by a Musculoskeletal Radiologist.
      Chronic ATR were diagnosed using the same features and the patient was unable to perform a single heel rise. Increased ankle dorsiflexion and reduced push off during gait may also be noted. Imaging was also used to identify tendon end separation with chronic ATR. Patient interview determined the likely date of rupture.
      The dates on which ruptures occurred were categorised according to the northern hemisphere seasons: Spring 1st March until the 31st May, Summer 1st June to 31st August, Autumn 1st September to 30th November, Winter 1st December to 28th February. The activities during which the rupture occurred were defined as Team sports e.g. football, netball, basketball, cricket, field hockey, Racket sports usually played on a court e.g. badminton, tennis. Other physical activities usually did not have a competitive element and included attending a gym for fitness e.g. classes and weight training, farm activities such as tending to sheep, forestry and finally Activities of Daily Living included walking, climbing stairs/steps, pushing cars, dancing, playing with children.
      The dates of national lockdowns were determined from a United Kingdom (UK) government website[

      Timeline of UK coronavirus lockdowns, March 2020 to March 2021. Institute for Government n.d. https://www.instituteforgovernment.org.uk/charts/uk-government-coronavirus-lockdowns (accessed December 22, 2021).

      ]. In the UK, three national lockdowns were implemented. The first commenced on the 26th March 2020 with outdoor recreation permitted on the 13th May. The second the 5th November with a gradual easing from the 25th December. Finally, the third commenced on the 6th January 2021 with release of restrictions on the 8th March and group indoor gym exercises commencing on the 17th May.
      Analysis: Data was collated on a spreadsheet (Excel, Microsoft, Redmond, WA). The numbers of patients injured per month was noted over time. Non-parametric data was presented according to median (Inter-quartile Range (IQR)). Patients who sustained subsequent contralateral rupture were included for each rupture of the Achilles tendon. Patients who sustained a re-rupture of the Achilles tendon were included for the first rupture only. Statistical analysis (SPSS Version 28 IBM Corp, Armonk, NY) was performed using Crosstabs and Chi-squared using additional layers for Activity and Age groupings. Significance was taken to be p < 0.05.

      3. Results

      From February 2009 to August 2022, 436 patients sustained a rupture of the Achilles tendon. The mean (SD) age was 48 (14) years with the majority of patients peaking in the mid 40s and a second smaller peak in the late 60s (Figure 1). The ratio of males to females was 5:1.
      Figure 1
      Figure 1The frequency (n) of the age of patients at presentation with ATR from 2009-2022.
      For the years 2009 to 2019 there was no significant change in the incidence of Achilles tendon rupture over time with mean (SD) incidence of 13.3 per 100,000. In 2020, there was a decrease in injuries with an incidence of 8.4 per 100,000, followed by an increase in 2021 to 22.4 per 100,000 (Figure 2).
      Figure 2
      Figure 2The number of patients presenting per year with ATR, noting the pandemic in 2020 and an increase in presentations in 2021.
      Overall, most injuries occurred during the summer (32.0%), then spring (25.4%) and autumn (23.2%), with least injuries during the winter (19.3%). Over half of presentations occurred in the spring and summer seasons in most years with a peak during May, June and July, the late spring and early summer (Figure 3, Figure 4). When ATRs were compared per month, ruptures in 2020 occurred mainly within the median interquartile range with the exception of a peak in April. In 2020, monthly rupture rate fell below the IQR during the summer month of July and there was an increase in injuries in September. In 2021 there was an increase in injuries from March with numbers maintained above the IQR until October. In the first half of 2022 the number of injures returned to within the IQR (Figure 4).
      Figure 3
      Figure 3The number of injuries sustained per season from 2009-2021. Over half of presentations occurred in the spring and summer seasons in most years.
      Figure 4
      Figure 4The variation in Achilles Tendon Rupture over the year. The median line represents the median number (IQR) of ATR occurring per month for the years 2009-2019, together with presentations per month in the years 2020, 2021 and 2022. Release from the third lockdown occurred at the end of March 2021.
      In terms of age, there was a gradual increase in numbers of patients with ATR aged 65 years and over time from 2009-2019. The numbers aged 65 years and over did not decrease in 2020 (5.1%) or increase in 2021 (13.5%) (Figure 5).
      Figure 5
      Figure 5The numbers of patients with Achilles Tendon Rupture <65 and ≥ 65 years of age over time.
      Between 2009-2022 the most common activity of injury was Team sport (36.2%), then injuries sustained during ADL (28.9%), Other physical activities (21.0%) and racket sports (13.9%). It was most common for injuries to occur in competitive team sports, however in 2014, 2017, 2018, and 2020 most injuries were sustained in ADL and Other activities. In 2021 following the release of lockdown, Team and Racket sports accounted for over half of Injuries (Figure 6).
      Figure 6
      Figure 6Activities during which Achilles Tendon Ruptures were sustained from 2009-2021.
      From 2009-2019 there was no significant change with time for activity (p=0.48), age (p=0.06), or gender(p=0.435). However, there was a significant difference with more ATRs presenting in the months: May 14.3%, June 9.7% and July 12.5% (p=0.014) however for seasonal distribution according to the dates used there was no significant difference (p=0.13)). When activity and age were compared over this time period there was no significant difference neither in the <65 (p=0.79) nor in the >65 (p=0.719) age groups.
      For the years 2009-2021, there was also no significant difference between the activity (p=0.233), age (p=0.052) or gender (p=0.286). Similar to the earlier period, there was a significant difference with more ATRs presenting in the months: May 13.9%, June 10.3% and July 11.7% (p=0.044) however for seasonal distribution according to the dates used there was no significant difference (p=0.171)). When activity and age were compared, there were significant differences between age groups, with more ruptures occurring during Team (45.7%) and Racket sports (10.9%) in the <65 years age group (p=0.038) compared with the >65years age group (p=0.882), where the predominant injurious activity was ADL 57.1%.

      4. Discussion

      The most important finding of this study was that there were significantly more patients sustaining ATR in 2021, the year after the covid pandemic. More specifically there was also a sudden increase in ATR in April 2021 and this peak continued over the subsequent 6 months. The peak in injury during the spring of 2021 coincided with the release of a lockdown in the UK at the end of March 2021.
      During 2020, there was a lower number of overall ATR, and particularly in those related to Team and Racket sports, however this was similar to numbers experienced in 2018. This was similar to a pattern of presentations reported at a US Orthopaedic clinic with 24 ruptures presenting in 2019 and 3 ruptures in 2020 (p=0.019)[
      • Mehta N.
      • Hur E.
      • Michalski J.
      • Fitch A.
      • Sayari A.
      • Bohl D.D.
      • et al.
      Impact of COVID-19 on Pathology Presenting to a Foot and Ankle Clinic.
      ] The lower number of ATR would be expected since there was no competitive team sport or racket sport participation during this period within the UK. There was also no change in numbers of ATR in the older age group patients or ruptures sustained during ADL and Other activities. This would again be expected as ADLs continued, and many people adopted Other new exercise activities to which they were unaccustomed such as on-line exercise activity[
      • Benzing V.
      • Nosrat S.
      • Aghababa A.
      • Barkoukis V.
      • Bondarev D.
      • Chang Y.-K.
      • et al.
      Staying Active under Restrictions: Changes in Type of Physical Exercise during the Initial COVID-19 Lockdown.
      ]. These unaccustomed activities may have placed them at increased risk of ATR. This was again similar to the epidemiology reported at hospitals in the United States[
      • Staunton P.
      • Gibbons J.P.
      • Keogh P.
      • Curtin P.
      • Cashman J.P.
      • O’Byrne J.M.
      Regional trauma patterns during the COVID-19 pandemic.
      ]. These new activities were virtual gym for classes just performed in isolation which were categorised as Other in this study. There was a small, but not significant, increase in the number of competitive sports activities following the lifting of separate lockdown exercise restrictions during the autumn of 2021 year.
      In 2021, there was an increase in the overall number of ATR. The largest increase occurred following the release of the last lockdown on the 8th March and also coincided with the peak in ruptures during the spring and summer from 2009-2019. The size of this peak was larger than any other year suggesting that the resumption of activity following the lockdown may have been a factor. Altered tendon loading activity during the preceding year may have influenced the biomechanical characteristics of patient’s tendons increasing the susceptibility to rupture. Despite an exercise programme during covid related lockdown, professional football players were found to have higher body fat percentage but an increased lower body strength.[
      • Parpa K.
      • Michaelides M.
      The impact of COVID-19 lockdown on professional soccer players’ body composition and physical fitness.
      ] The general population however undertook a 31% reduction in physical activity also increased BMI during lockdown world-wide[
      • Urzeala C.
      • Duclos M.
      • Chris Ugbolue U.
      • Bota A.
      • Berthon M.
      • Kulik K.
      • et al.
      COVID-19 lockdown consequences on body mass index and perceived fragility related to physical activity: A worldwide cohort study.
      ]. It is possible that there was greater participation in competitive Team sports following the release of Team sport restrictions after these sports had not been available during the previous year, however the proportion of ruptures occurring during this activity, did not increase compared with previous years.
      During the first half of 2022, injuries returned towards the pre-covid pattern with numbers of rupture per month falling towards the IQR and a spike in incidence during the early spring.
      The effects of a rapid resumption of loading activity can have a dramatic effect on the incidence of ATR. In 2011, NFL players were unable to participate in the usual 14-week pre-season preparations, a period termed “The NFL lockout”. After the lockout, players undertook a training camp and rapidly returned to competition over 17 days. Ten ATRs occurred during the first 12 days and a further two over the next 17 days of competition[
      • Myer G.D.
      • Faigenbaum A.D.
      • Cherny C.E.
      • Heidt R.S.
      • Hewett T.E.
      Did the NFL Lockout Expose the Achilles Heel of Competitive Sports?.
      ]. During 2020 and 2021, care, specifically due to the covid pandemic, was taken to avoid such injury in basketball and gymnastics in addition to concerns over returning to exercise following covid infection and measures to mitigate virus spread[
      • Patel T.S.
      • McGregor A.
      • Cumming S.P.
      • Williams K.
      • Williams S.
      Return to competitive gymnastics training in the UK following the first COVID-19 national lockdown.
      ,
      • Bourdas D.I.
      • Zacharakis E.D.
      • Travlos A.K.
      • Souglis A.
      Return to Basketball Play Following COVID-19 Lockdown.
      ].
      The incidence of ruptures prior to 2020 in our locality remained steady, similar to studies reporting incidences in Denmark and Japan[
      • Ganestam A.
      • Kallemose T.
      • Troelsen A.
      • Barfod K.W.
      Increasing incidence of acute Achilles tendon rupture and a noticeable decline in surgical treatment from 1994 to 2013. A nationwide registry study of 33,160 patients.
      ,
      • Yamaguchi S.
      • Kimura S.
      • Akagi R.
      • Yoshimura K.
      • Kawasaki Y.
      • Shiko Y.
      • et al.
      Increase in Achilles Tendon Rupture Surgery in Japan: Results From a Nationwide Health Care Database.
      ]. There was however a gradual increase in numbers of patients with ATR aged 65 years and over with time. This is similar to others studies from Korea, North America and Scandinavia [
      • Möller A.
      • Astron M.
      • Westlin N.
      Increasing incidence of Achilles tendon rupture.
      ,
      • Raikin S.M.
      • Garras D.N.
      • Krapchev P v
      Achilles tendon injuries in a United States population.
      ,
      • Huttunen T.T.
      • Kannus P.
      • Rolf C.
      • Felländer-Tsai L.
      • Mattila V.M.
      Acute achilles tendon ruptures: incidence of injury and surgery in Sweden between 2001 and 2012.
      ,
      • Mattila V.M.
      • Huttunen T.T.
      • Haapasalo H.
      • Sillanpää P.
      • Malmivaara A.
      • Pihlajamäki H.
      Declining incidence of surgery for Achilles tendon rupture follows publication of major RCTs: evidence-influenced change evident using the Finnish registry study.
      ,
      • Lemme N.J.
      • Li N.Y.
      • DeFroda S.F.
      • Kleiner J.
      • Owens B.D.
      Epidemiology of Achilles Tendon Ruptures in the United States: Athletic and Nonathletic Injuries From 2012 to 2016.
      ,
      • Yasui Y.
      • Tonogai I.
      • Rosenbaum A.J.
      • Shimozono Y.
      • Kawano H.
      • Kennedy J.G.
      The Risk of Achilles Tendon Rupture in the Patients with Achilles Tendinopathy: Healthcare Database Analysis in the United States.
      ,
      • Park H.-G.
      • Youn D.
      • Baik J.-M.
      • Hwang J.H.
      Epidemiology of Achilles Tendon Rupture in South Korea: Claims Data of the National Health Insurance Service from 2009 to 2017.
      ,
      • Sheth U.
      • Wasserstein D.
      • Jenkinson R.
      • Moineddin R.
      • Kreder H.
      • Jaglal S.B.
      The epidemiology and trends in management of acute Achilles tendon ruptures in Ontario, Canada.
      ,
      • Ganestam A.
      • Kallemose T.
      • Troelsen A.
      • Barfod K.W.
      Increasing incidence of acute Achilles tendon rupture and a noticeable decline in surgical treatment from 1994 to 2013. A nationwide registry study of 33,160 patients.
      ,
      • Caldwell J.-M.E.
      • Lightsey H.M.
      • Trofa D.P.
      • Swindell H.W.
      • Greisberg J.K.
      • Vosseller J.T.
      Seasonal Variation of Achilles Tendon Injury.
      ,
      • Saarensilta I.A.
      • Edman G.
      • Ackermann P.W.
      Achilles tendon ruptures during summer show the lowest incidence, but exhibit an increased risk of re-rupture.
      ] in which a gradual overall increase in the number of ruptures was reported, but with the greatest increase in elderly patients. This increase in the elderly was attributed increased participation in sporting activity. In this study the numbers sustaining ATR aged 65 years and over did not significantly decrease in 2020 or significantly increase in 2021. There was no significant increase in the numbers of >65 years sustaining a rupture in any specific sport activities from 2009-2021 and ruptures were most commonly sustained during ADLs in this age group.
      Limitations of this study are that, in common with other epidemiological studies, it must be appreciated that the overall population cannot be counted and the value is an estimation. Similarly, it is possible that some patients may not have presented to XXX following their rupture. These include those who attended private healthcare providers, however in the locality of the study this is unlikely. During the 2020 pandemic year local private practice was not available with all hospital services being provided for the public healthcare. In 2021, local private practice resumed and theoretically patients with ruptures could have been lost to collection via this route. Additionally, a small number of patients may have sustained a rupture and not yet presented due to a delay in recognition. The loss of patients would result in the recorded incidence in 2021 being an under-estimation. Further limitations include that some patients sustaining rupture may have been missed due to a lack of referral to the first author’s practice in 2009. This may explain the relatively low number of ATRs in that year compared with the subsequent years.
      An additional consideration of this study might be related to the categorisation of different activities during which injury occurred. Participation in competitive Team sports e.g. football, netball, and Racket sports is clear. Activities of Daily Living included walking, walking on stairs and dancing. Going to the gym for exercise or a work out covers a range of activities of different intensity, as does running and so these were categorised as Other. Similarly, Other was used as the category for ATR sustained during rural activities involving farm vehicles and animals. A decrease in the proportion of ATR sustained during ADL in the older age groups in this study, would suggest as increase in activity participation in the older patients but would not be a direct cause and effect.
      The principal long-term effects of the SARS-CoV-2 virus are related to the heart, lungs and brain however long-term fatigue and reduced activity may occur[
      • Haryalchi K.
      • Olangian-Tehrani S.
      • Asgari Galebin S.M.
      • Mansour-Ghanaie M.
      The importance of myocarditis in Covid-19.
      ]. Patients were not specifically asked whether they had been infected with the virus. It is possible that the increase in ATR could have been influenced by the direct or indirect effect of virus infection rather than altered activity related to lockdown. Many patients may have had virus, however been relatively asymptomatic.
      During the year 2021 there was a significant increase in ATR potentially associated with changes in activity during the preceding year. Participation in sport and physical activity may return to previous patterns over the year ahead however the effect of these changes on ATR are yet to be fully appreciated.

      5. Conclusions

      There were significantly more patients sustaining ATR in 2021 the year after the covid pandemic and mandatory home isolation in east Shropshire in the UK. This was considered to be related to altered activity and competitive team and racket sports during 2020. The peak in injury during the spring of 2021 coincided with the release of a lockdown at the end of March 2021 in the United Kingdom.

      Competing interests

      MRC can confirm, on behalf of all the authors, that there are no competing interests.

      Contributorship

      MRC devised the study, collected the data and co-wrote the paper. FM & KF assisted with data analysis and technical aspects of the paper writing. CH, AB and KNH assisted with data analysis and co-wrote the paper.

      Funding

      MRC has received bursaries for Achilles tendon research from the British Orthopaedic Foot and Ankle Society (BOFAS) and the British Association of Sport and Exercise Medicine (BASEM).

      Ethical approval information

      This study has been deemed to be service evaluation.

      Data sharing statement

      Data are available upon reasonable request.

      Patient involvement

      Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

      Declaration of interests

      The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:
      Michael Carmont reports financial support was provided by British Orthopaedic Foot and Ankle Society. Michael Carmont reports financial support was provided by British Association of Sport and Exercise Medicine.

      Uncited References

      [
      • Roopnarinesingh R.
      • Kenyon R.
      • Turley L.
      • Feeley A.
      • Bayer T.
      • Merghani K.
      Achilles’ tendon rupture dancing the ‘Jerusalema’ – A case series.
      ].

      References

        • Carmont M.R.
        • Silbernagel K.G.
        • Edge A.
        • Mei-Dan O.
        • Karlsson J.
        • Maffulli N.
        Functional Outcome of Percutaneous Achilles Repair: Improvements in Achilles Tendon Total Rupture Score During the First Year.
        Orthop J Sports Med. 2013; 12325967113494584https://doi.org/10.1177/2325967113494584
        • Maffulli N.
        • Waterston S.W.
        • Squair J.
        • Reaper J.
        • Douglas A.S.
        Changing incidence of Achilles tendon rupture in Scotland: a 15-year study.
        Clin J Sport Med. 1999; 9: 157-160https://doi.org/10.1097/00042752-199907000-00007
        • Jozsa L.
        • Kvist M.
        • Balint B.J.
        • Reffy A.
        • Jarvinen M.
        • Lehto M.
        • et al.
        The role of recreational sport activity in Achilles tendon rupture.
        The American Journal of Sports Medicine. 1989; 17: 338-343https://doi.org/10.1177/036354658901700305
        • Möller A.
        • Astron M.
        • Westlin N.
        Increasing incidence of Achilles tendon rupture.
        Acta Orthop Scand. 1996; 67: 479-481https://doi.org/10.3109/17453679608996672
        • Nyyssönen T.
        • Lüthje P.
        • Kröger H.
        The Increasing Incidence and Difference in Sex Distribution of Achilles Tendon Rupture in Finland in 1987–1999.
        Scandinavian Journal of Surgery. 2008; 97: 272-275https://doi.org/10.1177/145749690809700312
        • Raikin S.M.
        • Garras D.N.
        • Krapchev P v
        Achilles tendon injuries in a United States population.
        Foot Ankle Int. 2013; 34: 475-480https://doi.org/10.1177/1071100713477621
        • Huttunen T.T.
        • Kannus P.
        • Rolf C.
        • Felländer-Tsai L.
        • Mattila V.M.
        Acute achilles tendon ruptures: incidence of injury and surgery in Sweden between 2001 and 2012.
        Am J Sports Med. 2014; 42: 2419-2423https://doi.org/10.1177/0363546514540599
        • Mattila V.M.
        • Huttunen T.T.
        • Haapasalo H.
        • Sillanpää P.
        • Malmivaara A.
        • Pihlajamäki H.
        Declining incidence of surgery for Achilles tendon rupture follows publication of major RCTs: evidence-influenced change evident using the Finnish registry study.
        British Journal of Sports Medicine. 2015; 49: 1084-1086https://doi.org/10.1136/bjsports-2013-092756
        • Lemme N.J.
        • Li N.Y.
        • DeFroda S.F.
        • Kleiner J.
        • Owens B.D.
        Epidemiology of Achilles Tendon Ruptures in the United States: Athletic and Nonathletic Injuries From 2012 to 2016.
        Orthop J Sports Med. 2018; 62325967118808238https://doi.org/10.1177/2325967118808238
        • Yasui Y.
        • Tonogai I.
        • Rosenbaum A.J.
        • Shimozono Y.
        • Kawano H.
        • Kennedy J.G.
        The Risk of Achilles Tendon Rupture in the Patients with Achilles Tendinopathy: Healthcare Database Analysis in the United States.
        Biomed Res Int. 2017; 20177021862https://doi.org/10.1155/2017/7021862
        • Park H.-G.
        • Youn D.
        • Baik J.-M.
        • Hwang J.H.
        Epidemiology of Achilles Tendon Rupture in South Korea: Claims Data of the National Health Insurance Service from 2009 to 2017.
        Clin Orthop Surg. 2021; 13: 539-548https://doi.org/10.4055/cios20255
        • Sheth U.
        • Wasserstein D.
        • Jenkinson R.
        • Moineddin R.
        • Kreder H.
        • Jaglal S.B.
        The epidemiology and trends in management of acute Achilles tendon ruptures in Ontario, Canada.
        The Bone & Joint Journal. 2017; 99-B: 78-86https://doi.org/10.1302/0301-620X.99B1.BJJ-2016-0434.R1
        • 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: e133-e138https://doi.org/10.1111/sms.12253
        • Ganestam A.
        • Kallemose T.
        • Troelsen A.
        • Barfod K.W.
        Increasing incidence of acute Achilles tendon rupture and a noticeable decline in surgical treatment from 1994 to 2013. A nationwide registry study of 33,160 patients.
        Knee Surg Sports Traumatol Arthrosc. 2016; 24: 3730-3737https://doi.org/10.1007/s00167-015-3544-5
        • Yamaguchi S.
        • Kimura S.
        • Akagi R.
        • Yoshimura K.
        • Kawasaki Y.
        • Shiko Y.
        • et al.
        Increase in Achilles Tendon Rupture Surgery in Japan: Results From a Nationwide Health Care Database.
        Orthopaedic Journal of Sports Medicine. 2021; 9232596712110341https://doi.org/10.1177/23259671211034128
        • Ho G.
        • Tantigate D.
        • Kirschenbaum J.
        • Greisberg J.K.
        • Vosseller J.T.
        Increasing age in Achilles rupture patients over time.
        Injury. 2017; 48: 1701-1709https://doi.org/10.1016/j.injury.2017.04.007
        • Scott A.
        • Grewal N.
        • Guy P.
        The seasonal variation of Achilles tendon ruptures in Vancouver, Canada: a retrospective study.
        BMJ Open. 2014; 4e004320https://doi.org/10.1136/bmjopen-2013-004320
        • Caldwell J.-M.E.
        • Lightsey H.M.
        • Trofa D.P.
        • Swindell H.W.
        • Greisberg J.K.
        • Vosseller J.T.
        Seasonal Variation of Achilles Tendon Injury.
        JAAOS: Global Research and Reviews. 2018; 2: e043https://doi.org/10.5435/JAAOSGlobal-D-18-00043
        • Möller A.
        • Astron M.
        • Westlin N.
        Increasing incidence of Achilles tendon rupture.
        Acta Orthop Scand. 1996; 67: 479-481https://doi.org/10.3109/17453679608996672
        • Saarensilta I.A.
        • Edman G.
        • Ackermann P.W.
        Achilles tendon ruptures during summer show the lowest incidence, but exhibit an increased risk of re-rupture.
        Knee Surg Sports Traumatol Arthrosc. 2020; 28: 3978-3986https://doi.org/10.1007/s00167-020-05982-x
        • Maempel J.F.
        • White T.O.
        • Mackenzie S.P.
        • McCann C.
        • Clement N.D.
        The epidemiology of Achilles tendon re-rupture and associated risk factors: male gender, younger age and traditional immobilising rehabilitation are risk factors.
        Knee Surgery, Sports Traumatology, Arthroscopy. 2022; https://doi.org/10.1007/s00167-021-06824-0
        • Suchak A.A.
        • Bostick G.
        • Reid D.
        • Blitz S.
        • Jomha N.
        The Incidence of Achilles Tendon Ruptures in Edmonton, Canada.
        Foot & Ankle International. 2005; 26: 932-936https://doi.org/10.1177/107110070502601106
        • Saadat S.
        • Rawtani D.
        • Hussain C.M.
        Environmental perspective of COVID-19.
        Sci Total Environ. 2020; 728138870https://doi.org/10.1016/j.scitotenv.2020.138870
      1. Timeline of UK coronavirus lockdowns, March 2020 to March 2021. Institute for Government n.d. https://www.instituteforgovernment.org.uk/charts/uk-government-coronavirus-lockdowns (accessed December 22, 2021).

        • SIMMONDS F.A.
        The diagnosis of the ruptured Achilles tendon.
        Practitioner. 1957; 179: 56-58
        • Myer G.D.
        • Faigenbaum A.D.
        • Cherny C.E.
        • Heidt R.S.
        • Hewett T.E.
        Did the NFL Lockout Expose the Achilles Heel of Competitive Sports?.
        Journal of Orthopaedic & Sports Physical Therapy. 2011; 41: 702-705https://doi.org/10.2519/jospt.2011.0107
      2. Joint Strategic Needs Assessment Guidance. Document Number 08773. NHS England 2019. https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf (accessed January 21, 2022).

        • Maffulli N.
        The clinical diagnosis of subcutaneous tear of the Achilles tendon. A prospective study in 174 patients.
        Am J Sports Med. 1998; 26: 266-270https://doi.org/10.1177/03635465980260021801
        • Carmont M.R.
        • Grävare Silbernagel K.
        • Brorsson A.
        • Olsson N.
        • Maffulli N.
        • Karlsson J.
        The Achilles tendon resting angle as an indirect measure of Achilles tendon length following rupture, repair, and rehabilitation.
        Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology. 2015; 2: 49-55https://doi.org/10.1016/j.asmart.2014.12.002
        • Mehta N.
        • Hur E.
        • Michalski J.
        • Fitch A.
        • Sayari A.
        • Bohl D.D.
        • et al.
        Impact of COVID-19 on Pathology Presenting to a Foot and Ankle Clinic.
        Foot & Ankle Orthopaedics. 2020; 5 (2473011420S0035)https://doi.org/10.1177/2473011420S00354
        • Benzing V.
        • Nosrat S.
        • Aghababa A.
        • Barkoukis V.
        • Bondarev D.
        • Chang Y.-K.
        • et al.
        Staying Active under Restrictions: Changes in Type of Physical Exercise during the Initial COVID-19 Lockdown.
        International Journal of Environmental Research and Public Health. 2021; 1812015https://doi.org/10.3390/ijerph182212015
        • Roopnarinesingh R.
        • Kenyon R.
        • Turley L.
        • Feeley A.
        • Bayer T.
        • Merghani K.
        Achilles’ tendon rupture dancing the ‘Jerusalema’ – A case series.
        International Journal of Surgery Case Reports. 2021; 87106368https://doi.org/10.1016/j.ijscr.2021.106368
        • Staunton P.
        • Gibbons J.P.
        • Keogh P.
        • Curtin P.
        • Cashman J.P.
        • O’Byrne J.M.
        Regional trauma patterns during the COVID-19 pandemic.
        Surgeon. 2021; 19: e49-e52https://doi.org/10.1016/j.surge.2020.08.003
        • Parpa K.
        • Michaelides M.
        The impact of COVID-19 lockdown on professional soccer players’ body composition and physical fitness.
        Biol Sport. 2021; 38: 733-740https://doi.org/10.5114/biolsport.2021.109452
        • Urzeala C.
        • Duclos M.
        • Chris Ugbolue U.
        • Bota A.
        • Berthon M.
        • Kulik K.
        • et al.
        COVID-19 lockdown consequences on body mass index and perceived fragility related to physical activity: A worldwide cohort study.
        Health Expect. 2021; https://doi.org/10.1111/hex.13282
        • Patel T.S.
        • McGregor A.
        • Cumming S.P.
        • Williams K.
        • Williams S.
        Return to competitive gymnastics training in the UK following the first COVID-19 national lockdown.
        Scand J Med Sci Sports. 2022; 32: 191-201https://doi.org/10.1111/sms.14063
        • Bourdas D.I.
        • Zacharakis E.D.
        • Travlos A.K.
        • Souglis A.
        Return to Basketball Play Following COVID-19 Lockdown.
        Sports (Basel). 2021; 9https://doi.org/10.3390/sports9060081
        • Haryalchi K.
        • Olangian-Tehrani S.
        • Asgari Galebin S.M.
        • Mansour-Ghanaie M.
        The importance of myocarditis in Covid-19.
        Health Sci Rep. 2022; 5: e488https://doi.org/10.1002/hsr2.488