1. Achilles Tendon Presented By: Jared Romero, Haley Bryson, & Justin Valdez

2. 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

3. Risk Factors
Athletes, runners, basketball players. Older adults in high demand sports. 1-15
~40 Years of Age 1,3-5, 7, 15
Fluoroquinolone Antiobiotics and Direct Steroid Injections into the tendon.3
Previous Achilles Tendon injury.

4. Surgical Procedure 2 Types of surgery to repair a torn Achilles.4-6
1) Open Surgery: Large, single incision.7
2) Percutaneous Surgery: surgeon makes several small incisions rather than one large one.8,9

5. Rehabilitation: Phase 1
Surgery to 4 weeks after surgery.
Precautions:
Avoid long periods of dependent positioning of the foot.11
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.

6. Phase 1: Weeks 1-4 ROM Exercises Stretching Strengthening
Foot stabilized
Active ROM exercises for toes, knee, and hip.
Elevate Leg
Stretching
Stretching of the hamstrings, gastrocnemius, soleus and quad.
Straight Leg Lifts
Hip Abduction
Strengthening
Isometric quad contractions
Isometric knee extensions w/ ball

7. Phase 1: Cardiovascular Endurance
Stationary Cycle
With brace on, ride a stationary bike for minutes a session if patient is able to without any pain.
Upper Body Ergometer
Continue to work on conditioning through the rehab process min a session.

8. Phase II Rehab: 4-8 weeks Goals
Begin weight bearing11, encouraging normalized gait through all steps. 1-3, 11, 12, 16-18
Increase ROM between 5° of dorsiflexion to 40° of plantar flexion 1-3, 11, 12, 16-18
Maintain Upper and Lower body strength, using exercises from phase I. 1-3, 11, 12, 16-18
Precautions
Slowly wean from the use of the boot11
Avoid over stretching the repair 1-3, 11, 12, 16-18
Activities that have a high impact should be avoided
PROM should be gentle, do not push too far 1-3, 11, 12, 16-18
Rehab appointments are daily with an ATC; outpatient clinic is 1-2x/week

9. Phase II Rehab: 4-8 weeks Treatment
If needed use of Grade I and II joint mobilizations at the talocrural joint, both anterior and posterior
Use applicable modalities 16-18
Maintaining previous training levels
Stretching/ ROM
PROM at the foot and ankle 16-18
AROM dorsiflexion to 0° 1-3, 11, 12, 16-18
Once patient is partial weight bearing they may begin using a BAPS board while sitting to increase AROM.11

10. Phase II Rehab: 4-8 Weeks Strengthening
Continue to strengthen all other areas of the body 16-18
4-6 weeks isometric ankle exercises in all directions 16-18
6-8 weeks add light resistance bands at the ankle in all directions 1-3, 11, 12, 16-18
Cardiovascular Endurance/ Gait
As the patient becomes partial weight bearing begin walking in the pool.12
Goal: normalized gait 1-3, 11, 12, 16-18
Once gait is normalized, power walking can be added for 30 mins per session.
Continue to use UBE and add the stationary bike
Work on proper gait technique, out of the water.12

11. Phase II Rehab: 4-8 weeks Proprioception
Begin single leg stance on uninjured leg
Double leg standing with eyes closed when FWB permitted 16-18
Tandem stance on floor

12. Phase III: 8-12 Weeks Goals
AROM between 15° of dorsiflexion and full plantar flexion16-18
Single leg heel raise with good control for 10 seconds16-18
Decrease pain with functional movements16-18
Full weight bearing16-18
Increase strength and endurance16-18
Precautions
Limit forceful impact activities until approx. 12 weeks. 1-3, 11, 12, 16-18
Avoid activities where over compensation may occur 1-3, 11, 12, 16-18
Rehab appointments are daily with ATC; 1x/ week outpatient setting16-18

13. Phase 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, 16-18
Dorsiflexion door stretch (strength) 16-18
Strengthening
Continue the use of tubing in all directions, increase reps at first then increase resistance 16-18
Begin doing bilateral heel raises; start unilateral around 10 weeks 1-3, 11, 12, 16-18
Standing squats w/ ball
Lunges & Reverse Lunges

14. Phase III: 8-12 weeks Cardiovascular Training:
Continue to use the stationary bike/ power walking in the pool (week 8)
30 minute warm up per session
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

15. Phase III: 8-12 weeks Proprioception Tandem Stance Balance board
Bosu ball tandem stance
Progress to single leg once single leg raise can be done: 16-18
Single leg stance
Single leg stance on bosu ball
Single leg stance on half foam roller

16. Phase 4: 12 weeks to completion of Rehab
Goals:
Jogging without pain for 2 miles.
Maintain regained ROM
Functional 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.

17. Phase IV Stretching/ROM Strengthening
Full ROM should be present prior to this phase
Maintain ROM with slant board work in Phase III each day prior to phase IV work.
Strengthening
Patient will progress from heel raises by adding ankle weights to increase resistance.
Continue with lunges but add weight as necessary

18. Phase 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 Endurance
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.
Weeks 12-14: strict jogging.
Weeks 14- finish: Sprinting will be added.

19. Phase IV Power Agility Speed
Body weight sprints of short yardage is required
build up to maximal effort by rehabs end
Sprints should be between 10 and 30 yards
Power
Power will be regained by taking simple movements such as the squat or a single leg skip and making it explosive
Squat jumps
Power skips
Agility
Figure 8 cone drills

20. References
Majewski 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):

21. References…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. Accessed September 18, 2013
University of Wisconsin Sports Medicine. Rehabilitation Guidelines for Achilles Tendon Repair. Accessed September 18, 2013.