2Overview of Injury Thickest tendon in the body.1,2 Connects gastrocnemius, soleus, and plantaris to the calcaneus.1Commonly injured by sudden plantarflexion or dorsiflexion of ankle.2
3Risk FactorsAthletes, runners, basketball players. Older adults in high demand sports. 1-15~40 Years of Age 1,3-5, 7, 15Fluoroquinolone Antiobiotics and Direct Steroid Injections into the tendon.3Previous Achilles Tendon injury.
4Surgical Procedure 2 Types of surgery to repair a torn Achilles.4-6 1) Open Surgery: Large, single incision.72) Percutaneous Surgery: surgeon makes several small incisions rather than one large one.8,9
5Rehabilitation: Phase 1 Surgery to 4 weeks after surgery.Precautions:Avoid long periods of dependent positioning of the foot.11Avoid excessive walking and standingRehab appointments are 1-2x per weekAt end of phase 1: Goal is to have pain-free active dorsiflexion to 0 degrees.
6Phase 1: Weeks 1-4 ROM Exercises Stretching Strengthening Foot stabilizedActive ROM exercises for toes, knee, and hip.Elevate LegStretchingStretching of the hamstrings, gastrocnemius, soleus and quad.Straight Leg LiftsHip AbductionStrengtheningIsometric quad contractionsIsometric knee extensions w/ ball
7Phase 1: Cardiovascular Endurance Stationary CycleWith brace on, ride a stationary bike for minutes a session if patient is able to without any pain.Upper Body ErgometerContinue to work on conditioning through the rehab process min a session.
8Phase II Rehab: 4-8 weeks Goals Begin weight bearing11, encouraging normalized gait through all steps. 1-3, 11, 12, 16-18Increase ROM between 5° of dorsiflexion to 40° of plantar flexion 1-3, 11, 12, 16-18Maintain Upper and Lower body strength, using exercises from phase I. 1-3, 11, 12, 16-18PrecautionsSlowly wean from the use of the boot11Avoid over stretching the repair 1-3, 11, 12, 16-18Activities that have a high impact should be avoidedPROM should be gentle, do not push too far 1-3, 11, 12, 16-18Rehab appointments are daily with an ATC; outpatient clinic is 1-2x/week
9Phase II Rehab: 4-8 weeks Treatment If needed use of Grade I and II joint mobilizations at the talocrural joint, both anterior and posteriorUse applicable modalities 16-18Maintaining previous training levelsStretching/ ROMPROM at the foot and ankle 16-18AROM dorsiflexion to 0° 1-3, 11, 12, 16-18Once patient is partial weight bearing they may begin using a BAPS board while sitting to increase AROM.11
10Phase II Rehab: 4-8 Weeks Strengthening Continue to strengthen all other areas of the body 16-184-6 weeks isometric ankle exercises in all directions 16-186-8 weeks add light resistance bands at the ankle in all directions 1-3, 11, 12, 16-18Cardiovascular Endurance/ GaitAs the patient becomes partial weight bearing begin walking in the pool.12Goal: normalized gait 1-3, 11, 12, 16-18Once gait is normalized, power walking can be added for 30 mins per session.Continue to use UBE and add the stationary bikeWork on proper gait technique, out of the water.12
11Phase II Rehab: 4-8 weeks Proprioception Begin single leg stance on uninjured legDouble leg standing with eyes closed when FWB permitted 16-18Tandem stance on floor
12Phase III: 8-12 Weeks Goals AROM between 15° of dorsiflexion and full plantar flexion16-18Single leg heel raise with good control for 10 seconds16-18Decrease pain with functional movements16-18Full weight bearing16-18Increase strength and endurance16-18PrecautionsLimit forceful impact activities until approx. 12 weeks. 1-3, 11, 12, 16-18Avoid activities where over compensation may occur 1-3, 11, 12, 16-18Rehab appointments are daily with ATC; 1x/ week outpatient setting16-18
13Phase III: 8-12 Weeks Stretching/ ROM Use foam pad to increase ROM and stretch (proprioception)Use grade III and IV posterior joint mobilizations as needed to increase mobility for dorsiflexion. 1-3, 11, 12, 16-18Dorsiflexion door stretch (strength) 16-18StrengtheningContinue the use of tubing in all directions, increase reps at first then increase resistance 16-18Begin doing bilateral heel raises; start unilateral around 10 weeks 1-3, 11, 12, 16-18Standing squats w/ ballLunges & Reverse Lunges
14Phase III: 8-12 weeks Cardiovascular Training: Continue to use the stationary bike/ power walking in the pool (week 8)30 minute warm up per sessionProgress to:Elliptical (week 9)Rowing (week 10)Power walking on the treadmill or jogging in the pool (week 11)Jogging may start at week
15Phase III: 8-12 weeks Proprioception Tandem Stance Balance board Bosu ball tandem stanceProgress to single leg once single leg raise can be done: 16-18Single leg stanceSingle leg stance on bosu ballSingle leg stance on half foam roller
16Phase 4: 12 weeks to completion of Rehab Goals:Jogging without pain for 2 miles.Maintain regained ROMFunctional and sport specific movements with no pain.Plyometrics without pain.Return to play with no pain.Precautions:Ease into more impacted movements.Progress only when pain is absent.Avoid overcompensation.
17Phase IV Stretching/ROM Strengthening Full ROM should be present prior to this phaseMaintain ROM with slant board work in Phase III each day prior to phase IV work.StrengtheningPatient will progress from heel raises by adding ankle weights to increase resistance.Continue with lunges but add weight as necessary
18Phase IV Plyometrics Cardiovascular Endurance Once able to complete weighted heel raises progress to double leg hops.Progress to single leg hops.Progress to lateral double leg hops.Progress to lateral single leg hops.Cardiovascular EndurancePatient must be able to jog on a flat surface for up to 2 miles with no pain in order to progress to next level of running drills.Weeks 12-14: strict jogging.Weeks 14- finish: Sprinting will be added.
19Phase IV Power Agility Speed Body weight sprints of short yardage is requiredbuild up to maximal effort by rehabs endSprints should be between 10 and 30 yardsPowerPower will be regained by taking simple movements such as the squat or a single leg skip and making it explosiveSquat jumpsPower skipsAgilityFigure 8 cone drills
20ReferencesMajewski M, Schaeren S, Kohlhaas U, Ochsner P. Postoperative rehabilitation after percutaneous Achilles tendon repair: Early functional therapy versus cast immobilization. Disability & Rehabilitation. October 30, 2008;30(20-22):Suchak, Amar A., et al. Postoperative rehabilitation protocols for Achilles tendon ruptures: a meta-analysis. Clinical orthopaedics and related research 2006; 445:Amin N, Old A, Tabb L, Garg R, Toossi N, Cerynik D. Performance Outcomes After Repair of Complete Achilles Tendon Ruptures in National Basketball Association Players. American Journal Of Sports Medicine. August 2013;41(8):Henríquez H, Muñoz R, Carcuro G, Bastías C. Is percutaneous repair better than open repair in acute achilles tendon rupture?. Clinical Orthopaedics & Related Research. April 2012;470(4):Hrnack S, Crates J, Barber F. Primary Achilles Tendon Repair with Mini-Dorsolateral Incision Technique and Accelerated Rehabilitation. Foot & Ankle International. October 2012;33(10):Gigante A, Moschini A, Verdenelli A, Torto M, Ulisse S, Palma L. Open versus percutaneous repair in the treatment of acute Achilles tendon rupture: a randomized prospective study. Knee Surgery, Sports Traumatology, Arthroscopy. February 2008;16(2):Willits K, Amendola A, Kirkley A, et al. Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures: A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation. Journal Of Bone & Joint Surgery, American Volume. December 2010;92-A(17):Talbot J, Williams G, Bismil Q, Shaw D, Schilders E. Results of Accelerated Postoperative Rehabilitation Using Novel “Suture Frame” Repair of Achilles Tendon Rupture. Journal Of Foot & Ankle Surgery. March 2012;51(2):
21References…Continued Lui T. Endoscopic Achilles Tenolysis for Management of Heel Cord Pain after Repair of Acute Rupture of Achilles Tendon. Journal Of Foot & Ankle Surgery. 2013;52(1):Maquirriain J. Achilles tendon rupture: avoiding tendon lengthening during surgical repair and rehabilitation. The Yale Journal Of Biology And Medicine. September 2011;84(3):Suchak A, Bostick G, Beaupré L, Durand D, Jomha N. The influence of early weight-bearing compared with non-weight-bearing after surgical repair of the Achilles tendon. Journal Of Bone & Joint Surgery, American Volume. September 2008;90(9):Speck M, Klaue K. Early full weightbearing and functional treatment after surgical repair of acute Achilles tendon rupture. American Journal of Sports Medicine ; 26(6):Lee S, Sileo M, McHugh M, et al. Cyclic Loading of 3 Achilles Tendon Repairs Simulating Early Postoperative Forces. American Journal Of Sports Medicine. April 2009;37(4):Loudon J. Early Motion of the Ankle After Operative Treatment of a Rupture of the Achilles Tendon: A.. Physical Therapy. November 1999;79(11):1096.Gallas J. Proprioceptive and strength deficits of the lower leg following Achilles tendon rupture and repair. Orthopaedic Physical Therapy Practice. December 2011;23(4):Houlgum PA, Perrin DH, eds. Therapeutic Exercise For Musculoskeletal Injuries. Champaign, Il: Human Kinetics; 2010.Massachusetts General Hospital. Achilles Tendon Repair Surgery Rehabilitation Protocol.http://www.massgeneral.org/ortho/services/sports/rehab/Achilles%20repair%20rehabilitation%20protocol.pdf. Accessed September 18, 2013University of Wisconsin Sports Medicine. Rehabilitation Guidelines for Achilles Tendon Repair. Accessed September 18, 2013.