Achilles Tendon Repair Protocol
The following protocol is subdivided into four general phases:
- Phase I: Acute Post-op (subtitles A and B)
- Phase II: Early Rehabilitation
- Phase III: Advanced Rehabilitation
- Phase IV: Specificity of Sport or Activity
Each of these phases needs to be followed closely, but modified as necessary in order to meet the needs of each individual patient. Phases may overlap by one to two weeks or so, depending on the healing rate, severity of injury, and previous level or activity of each unique patient.
Phase I: Acute Post-Op
Patient is casted immediately following surgery. Cast is removed following the first week. Range of motion exercises are performed in the cast room and then the patient is re-casted in slight plantar flexion.
Patient is re-casted again at 2 weeks post-op and range of motion exercises are performed again in the cast room. Weight bearing status is partial weight bearing in cast.
Phase II: 3(4) to 6(8) weeks
Weight bearing status if full weight bearing in boot. The patient is placed into a boot at this time with a 9/16th heel lift. The boot allows for full plantar flexion range of motion, and dorsiflexion is limited to 0 degrees. At this time, physical therapy is initiated. A night splint is issued for protection during sleep. Full weight bearing is boot is critical. The boot with heel lift can be modified with certain exercises by having a lift under patient’s heel while barefoot on the BAPS, trampoline, etc.
- No stretching greater than 0 degrees dorsiflexion
- No barefoot walking
- Gentle plantar flexion strengthening, non-weight bearing position with Theraband or manually
- Decrease pain.
- Decrease edema and inflammation.
- Increase range of motion in all planes, except for dorsiflexion, which is limited
- Restore soft tissue flexibility.
- Full weight bearing with boot.
- Increase strength in intrinsic muscles and extrinsic muscles in the foot and ankle.
- Maintain cardiovascular fitness and level of fitness as appropriate for each individual patient.
A. Land (one time per week)
- Modalities to decrease pain and decrease swelling
- Electrical stimulation
B. Cardiovascular Exercise: to maintain cardiovascular fitness
- UBE (with boot)
- Stationary bike (with boot)
- Aquatic therapy
C. Mobilization: to increase soft tissue flexibility and joint mobility
- Soft tissue massage, where indicated
- Gentle mobs on Achilles tendon
- Joint mobilization (hindfoot, midfoot and forefoot)
D. Strengthening exercises (intrinsic and extrinsic muscle strengthening concentrically and eccentrically and hip/knee joint muscles)
- Theraband (DF, INV, EV)
- Very gentle gastrocnemius strengthening with manual resistance
- Towel curls
- Windshield Wipers
- Multi-hip weight machine
- Wall squats (with boot)
- Swiss ball exercises for hamstring strengthening
- BAPS board sitting/ stand with heel lift
- Balance exercises (single limb stance with heel lift)
Pool (two times per week)
- Gait training; heel raises; deep water exercises (for cardiovascular and lower extremity strengthening)
Apply ice to the involved ankle/ calf following aquatic therapy
Phase III – Advanced Rehabilitation:
6 to 8 weeks (2 months)
- In phase III, the boot is discharged and the patient is progressed into wearing a shoe with a lift.
Weight bearing status = full weight bearing.
- The night splint is usually discharged at this time.
- Being gentle stretching into dorsiflexion.
- Pool is discharged to one time per week; land two times per week.
- Increase aggressiveness with plantar flexion strengthening.
- No barefoot walking
- Stretching into dorsiflexion must be gentle
- Minimal swelling
- Range of motion = within normal limits
- Increase gastrocnemius/ soleus strength and endurance
Land (two times per week)
- Continue with modalities as needed
- Progress with cardiovascular exercises
- Continue with ankle/ foot mobs (soft tissue and bony as needed)
- Increase aggressiveness with Achilles mobilization
Progress with exercises in Phase II
- Increase gastrocnemius and soleus strengthening
- PNF; TB; begin slowly with sit heel raises, advance to standing at end of phase, negatives when tolerated Step downs/ up
- Stairmaster (retro)
- Weight equipment: leg press, soleus strengthening on NK
- table and hamstring curls
- Walking on treadmill
- Closed kinetic chain exercises with sports cord
- Gait training with shoe
- BAPS standing
- Trampoline weight shifts/ balancing
Pool (one time per week)
- Plyometrics in pool
- Jogging in shallow water
- Continue high level exercise in deep water for lower extremity strengthening and cardiovascular fitness
- Squat jumps with emphasis on plantar flexion
- Increase aggressiveness of plantar flexion strengthening
Phase IV – Specificity of Sport Activity:
- Patient needs to continue to wear lift in shoe.
- Advance strengthening program.
- Pool is discharged at this time.
- Continue to closely assess and monitor integrity of Achilles tendon.
- Return to work
- Return to specific sport
Land (three times per week)
A. Strengthening exercises/ proprioceptive trainin
- Plantar flexion strengthening on Biodex for increased power, strength, and endurance
- Jogging on treadmill
- Pedal stepping on Stairmaster
- Squat jumps on trampoline with emphasis on plantarflexion
- Running drills with sports cord
- Progress to higher level with BAPS board and chain reaction exercises
- Work simulation/ conditioning program as appropriate
- Advanced conditioning on Fitter and Slideboard
- Advanced level strengthening and proprioceptive training with sports cord
- Sports specific training
To achieve a successful rehabilitation, there must be a good rapport established between the physician, therapist and patient. The rehabilitation process may vary for each individual patient according to their healing rate and motivation level.