Achilles Tendon Repair

Allison Granot, MPT, OCS, CSCS Achilles Tendon Repair

GENERAL PRINCIPLES

This protocol for Achilles tendon repair is designed to provide the rehabilitation professional with a general guideline for patient care with the AlterG Anti-Gravity Treadmill. As such, it should be stressed that this is only a protocol and should not be a substitute for professional clinical decision-making regarding a patient’s progression. Progression should be individualized based upon each patient’s specific needs, pain level, physical examination, functional progress, and presence of any complications. 

Download Protocol for printing. 

Contact A Rep

PRECAUTIONS AND CONTRAINDICATIONS

  • Signs of infection, including increased redness, swelling, pain and temperature
  • Neurovascular complications, including DVT
  • Increased swelling, redness, pain
  • Positive Homans’ sign
  • Re-rupture
  • Excessive laxity in the Achilles tendon and/or excessive dorsiflexion
  • No running or jumping until four months post-op

PHASE I (IMMEDIATE)

Week 3 post-op – Week 8 post-op

Self care management if approved by physician

Goals:

  • Out of boot when pain free, usually at 8-10 weeks post-op
  • No pain at rest
  • Dorsiflexion to neutral

Treatment Options:

  • In boot at all times except during exercise
  • Modalities:
    • Rest
    • Ice
    • Compression
    • Elevation
  • Manual Therapy:
    • May begin self scar mobilization at 5-6 weeks if approved by primary physician and incision has fully healed
  • Therapeutic Exercise:
    • AROM only – plantarflexion, inversion, eversion
    • NWB and with towel
    • Stationary bike with no resistance, in boot, if approved by primary physician may begin as early as week 1

PHASE II (EARLY POST-OPERATIVE PHASE)

Week 9 post-op – Week 11 post-op

Initiate outpatient Physical Therapy

Goals:

  • Ankle ROM: dorsiflexion: 10 degrees, plantarflexion: 45 degrees, inversion: 30 degrees, eversion: 15 degrees
  • Ankle dorsiflexion and plantar flexion strength to manual muscle testing (MMT): 4/5
  • Minimal swelling in foot and ankle
  • Full weight bearing in athletic shoes
  • Normal gait in the AlterG Anti-Gravity Treadmill

Treatment Options:

  • Modalities:
    • Ice, elevation and compression
    • Pulsed to continuous ultrasound as needed for scar tissue and adhesions
    • Electrical stimulation as needed for pain and swelling
  • Manual Therapy:
    • Soft tissue mobilization to decrease edema
    • Cross friction massage to scar
    • Soft tissue mobilization techniques to plantar fascia and flexor hallucis longus
    • Great toe stretching
    • Ankle mobilization to subtalar joint and talocrural joint
  • Therapeutic Exercise:
    • Stationary Bike
    • Ankle theraband/tubing exercises for dorsiflexion, plantarflexion, inversion and eversion
    • Towel curls and towel sweeps – non-weighted initially and progress to weighted as tolerated
    • Gentle towel stretch to calf in long sitting
    • Single leg balance, static
    • Standing bilateral heel raise
    • BAPS board seated
    • Hip and knee strengthening in open chain and on the leg press
    • NOTE: Any closed-kinetic chain therapeutic exercises can be performed in the AlterG Anti-Gravity Treadmill to decr. pain and decr. difficulty. Starting body weight will allow for painfree performance of the exercise with normal mechanics.
  • Gait Training:
    • AlterG Anti-Gravity Treadmill
      • Double leg calf raises at 30-50% body weight
      • Single leg calf raises at 30% body weight if able
        • Starting body weight should allow for:
          • Painfree movement
          • Normal gait pattern
          • Full heel height with calf raises (both single and double)
      • Gait training/ambulation at 30-50% body weight for 10-15 minutes
        • Increase body weight as tolerated using the guidelines above

PHASE III (INTERMEDIATE PHASE)

Week 12 post-op – Week 14 post-op

Goals:

  • Ankle ROM: dorsiflexion: 15 degrees, plantarflexion: equal to non-operative side
  • Minimal to no effusion
  • Manual muscle testing for ankle dorsiflexion and plantar flexion: 4+/5
  • Normal gait pattern at 100% weight bearing

Treatment Options:

  • Manual Therapy:
    • Cryotherapy, ultrasound and electrical stimulation as needed
  • Therapeutic Exercise:
    • Continue to progress exercises in Phase II as tolerated
    • Progress to a standing calf stretch
    • Progress balance/proprioception exercises to more dynamic activities and use of unstable surfaces, i.e. foam pads, BOSU
    • Continue to progress gluteus, hip and knee strengthening
      • Use Swiss ball
      • Side stepping exercises with elastic tubing
    • Calf raises on leg press
    • Standing single leg heel raises
    • May begin outdoor cycling at 3 months post-op
    • NOTE: Any closed-kinetic chain therapeutic exercises
      can be performed in the AlterG Anti-Gravity Treadmill to decr. pain and decr. difficulty. Starting body weight will allow for painfree performance of the exercise with normal mechanics
  • Gait Training:
    • AlterG Anti-Gravity Treadmill
      • Double leg calf raises at 50-85% body weight
      • Single leg calf raises at 50-85% body weight
        • Progress AlterG body weight by 1-5% at each visit as tolerated maintaining guidelines
          • Painfree movement
          • Normal gait pattern
          • Full heel height with calf raises
        • Gait training/ambulation at 50-85% body weight 15-20 min

PHASE IV (ADVANCED PHASE)

Week 15 post-op – Week 16+ post-op

Goals:

  • Normal ankle ROM
  • Ankle strength to manual muscle testing (MMT): 5/5
  • No swelling in foot and ankle
  • Able to run in AlterG at 85% body weight painfree with a normal gait pattern

Treatment Options:

  • Modalities:
    • Ice as needed post exercise
  • Manual Therapy:
    • Continue with phase III manual therapy as needed
  • Therapeutic Exercise:
    • Step downs
    • Lunges
    • Eccentrics
    • Walk/jog progression outdoors once able to jog in AlterG Anti-Gravity Treadmill at 85% body weight
    • Hopping, jumping, plyometrics after 16 weeks post-op
    • NOTE: Any closed-kinetic chain therapeutic exercises can be performed in the AlterG Anti-Gravity Treadmill to decr. pain and decr. difficulty. Starting body weight will allow for painfree performance of the exercise with normal mechanics.
  • Gait Training:
    • AlterG Anti-Gravity Treadmill
      • Single leg calf raises at 75-85 or 90% body weight
      • Begin a walk/jog progression at 75% body weight and progress to 85 -90%
        • Start with 2 minutes of walking, 30-60 seconds of running for 10 minutes total
        • Decrease walking time by 15-30 seconds and increase running time by 15-30 seconds as tolerated by patient at 75%
        • Once able to run at 75% body weight for 10- 15 min, start increasing body weight only to 85-90% then increase speed at given body weight
        • In summary, work on speed and running time, before increasing body weight (according to above parameters).
    • Full body weight running on treadmill or soft surfaces outdoors for 10 min and progress as tolerated

    Download Protocol to see Table

  • Walk/Jog Progression
    • Decrease walk time by 15-30 sec and incr. jog time as tolerated.
    • Once running is tolerated for 10-15 min at 75% BW, incr. weight to 85-90% BW.
    • Once 10-15 min at 85-90% is tolerated, incr. running speed to desired level.
    • If patient is able to run at 85% BW painfree and with normal mechanics, may be ready for returning to overground running.