Overview of Injury Thickest tendon in the body. 1,2 Connects gastrocnemius, soleus, and plantaris to the calcaneus. 1 Commonly injured by sudden plantarflexion or dorsiflexion of ankle. 2
Risk Factors Athletes, runners, basketball players. Older adults in high demand sports ~40 Years of Age 1,3-5, 7, 15 Fluoroquinolone Antiobiotics and Direct Steroid Injections into the tendon. 3 Previous Achilles Tendon injury.
Surgical Procedure 2 Types of surgery to repair a torn Achilles ) Open Surgery: Large, single incision. 7 2) Percutaneous Surgery: surgeon makes several small incisions rather than one large one. 8,9
Rehabilitation: Phase 1 Surgery to 4 weeks after surgery. Precautions: o Avoid long periods of dependent positioning of the foot. 11 o Avoid excessive walking and standing Rehab appointments are 1-2x per week At end of phase 1: Goal is to have pain-free active dorsiflexion to 0 degrees.
Phase 1: Weeks 1-4 ROM Exercises o Foot stabilized o Active ROM exercises for toes, knee, and hip. o Elevate Leg Stretching o Stretching of the hamstrings, gastrocnemius, soleus and quad. Straight Leg Lifts Hip Abduction Strengthening Isometric quad contractions Isometric knee extensions w/ ball
Phase 1: Cardiovascular Endurance Stationary Cycle o With brace on, ride a stationary bike for minutes a session if patient is able to without any pain. Upper Body Ergometer o Continue to work on conditioning through the rehab process min a session.
Phase II Rehab: 4-8 weeks Goals o Begin weight bearing 11, encouraging normalized gait through all steps. 1-3, 11, 12, o Increase ROM between 5° of dorsiflexion to 40° of plantar flexion 1-3, 11, 12, o Maintain Upper and Lower body strength, using exercises from phase I. 1-3, 11, 12, Precautions o Slowly wean from the use of the boot 11 o Avoid over stretching the repair 1-3, 11, 12, o Activities that have a high impact should be avoided o PROM should be gentle, do not push too far 1-3, 11, 12, Rehab appointments are daily with an ATC; outpatient clinic is 1-2x/week
Phase II Rehab: 4-8 weeks Treatment o If needed use of Grade I and II joint mobilizations at the talocrural joint, both anterior and posterior o Use applicable modalities o Maintaining previous training levels Stretching/ ROM o PROM at the foot and ankle o AROM dorsiflexion to 0° 1-3, 11, 12, o Once patient is partial weight bearing they may begin using a BAPS board while sitting to increase AROM. 11
Phase II Rehab: 4-8 Weeks Strengthening o Continue to strengthen all other areas of the body o 4-6 weeks isometric ankle exercises in all directions o 6-8 weeks add light resistance bands at the ankle in all directions 1-3, 11, 12, Cardiovascular Endurance/ Gait o As the patient becomes partial weight bearing begin walking in the pool. 12 Goal: normalized gait 1-3, 11, 12, Once gait is normalized, power walking can be added for 30 mins per session. o Continue to use UBE and add the stationary bike o Work on proper gait technique, out of the water. 12
Phase II Rehab: 4-8 weeks Proprioception o Begin single leg stance on uninjured leg o Double leg standing with eyes closed when FWB permitted o Tandem stance on floor
Phase III: 8-12 Weeks Goals o AROM between 15° of dorsiflexion and full plantar flexion o Single leg heel raise with good control for 10 seconds o Decrease pain with functional movements o Full weight bearing o Increase strength and endurance Precautions o Limit forceful impact activities until approx. 12 weeks. 1-3, 11, 12, o Avoid activities where over compensation may occur 1-3, 11, 12, Rehab appointments are daily with ATC; 1x/ week outpatient setting 16-18
Phase III: 8-12 Weeks Stretching/ ROM o Use foam pad to increase ROM and stretch (proprioception) o Use grade III and IV posterior joint mobilizations as needed to increase mobility for dorsiflexion. 1-3, 11, 12, o Dorsiflexion door stretch (strength) Strengthening o Continue the use of tubing in all directions, increase reps at first then increase resistance o Begin doing bilateral heel raises; start unilateral around 10 weeks 1-3, 11, 12, o Standing squats w/ ball o Lunges & Reverse Lunges
Phase III: 8-12 weeks Cardiovascular Training: o Continue to use the stationary bike/ power walking in the pool (week 8) 30 minute warm up per session o Progress to: Elliptical (week 9) Rowing (week 10) Power walking on the treadmill or jogging in the pool (week 11) Jogging may start at week
Phase III: 8-12 weeks Proprioception o Tandem Stance o Balance board o Bosu ball tandem stance o Progress to single leg once single leg raise can be done: Single leg stance Single leg stance on bosu ball Single leg stance on half foam roller
Phase 4: 12 weeks to completion of Rehab Goals: o Jogging without pain for 2 miles. o Maintain regained ROM o Functional and sport specific movements with no pain. o Plyometrics without pain. o Return to play with no pain. Precautions: o Ease into more impacted movements. o Progress only when pain is absent. o Avoid overcompensation.
Phase IV Stretching/ROM o Full ROM should be present prior to this phase o Maintain ROM with slant board work in Phase III each day prior to phase IV work. Strengthening o Patient will progress from heel raises by adding ankle weights to increase resistance. o Continue with lunges but add weight as necessary
Phase IV Plyometrics o Once able to complete weighted heel raises progress to double leg hops. o Progress to single leg hops. o Progress to lateral double leg hops. o Progress to lateral single leg hops. Cardiovascular Endurance o Patient 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. o Weeks 12-14: strict jogging. o Weeks 14- finish: Sprinting will be added.
Phase IV Speed o Body weight sprints of short yardage is required o build up to maximal effort by rehabs end o Sprints should be between 10 and 30 yards Power o Power will be regained by taking simple movements such as the squat or a single leg skip and making it explosive o Squat jumps o Power skips Agility o Figure 8 cone drills
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