PoSt achilleS tenDon SURGical RePaiR - Galway Clinic

ACHILLES TENDON SURGICAL REPAIR
PHYSIOTHERAPY PROTOCOL & PATIENT INFORMATION

Welcome to the GalWay clinic
This information booklet has been designed to provide guidelines on the physiotherapy
rehabilitation following Achilles tendon repair.
You may further your reading by using the references and links provided at the end of this
booklet and discuss any queries with your physiotherapist and/or orthopaedic surgeon.
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Achilles Tendon

PoSt achilleS tenDon SURGical RePaiR
The Achilles tendon is generally considered to be the strongest and largest tendon in the body and
can withstand forces high enough to allow the performance of many activities such as running,
jumping, toe-standing, stair climbing (1).
However, due to a relatively poor blood supply the tendon is not very resilient to repetitive micro
trauma and thus irritation, degeneration and rupture can occur. (1). Ruptures commonly occur
spontaneously in healthy active individuals aged between 30 to 50 years. There does not have to be
a history of calf or heel pain. Often, a sudden eccentric or lengthening force applied to a dorsiflexed
foot can cause rupture.
Deconditioning, advancing age and over exertion are all risk factors (1). It is generally considered that
surgery is the preferred choice with a smaller chance of re-rupture when compared to conservative
management (2,3). However, the risk of infection may be higher.
RecommenDation PRioR to Rehabilitation
Physiotherapy may not be required in the acute phase of healing but is crucial once adequate healing
has taken place – normally around six weeks post surgery.
Part of the role of your Chartered Physiotherapist will be to translate the following guidelines into
a straightforward format for you to gain from. The better you are informed the more likely you will
recover and be able to prevent recurrence of your injury.
The following guidelines are for chartered physiotherapists treating patients post Achilles tendon
repair.
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PhySiotheRaPy GUiDelineS foR achilleS
Rehabilitation PoSt SURGeRy
Always liaise with the orthopaedic surgeon or the Galway Clinic physiotherapy team for any specific
post operative instructions.
StaGe i: 0 - 8 WeekS
A cast for serial splinting is normally applied for approximately the first six weeks before being
removed. The patient may be non-weight bearing (NWB) or partial weight bearing (PWB) during this
time.
A walking cast/or boot may be used at weeks 6 to 10 to prevent overuse during normal activities of
daily living.
StaGe 1: 7 - 8 WeekS
1. Assess the incision site for signs of adequate healing and/or signs of infection.
2. Control swelling with elevation as required. (PRICE, cryo-cuff therapy).
3. Use oily cream or emollients to prevent drying of scar.
4. Begin gentle active and passive range of movement exercises. Light stretches to
first point of resistance only.
Please refer to stage I of the advice sheet attached at the end of these guidelines.
5. Begin gentle manual therapy as required to mobilise stiff joints e.g. the subtalar
joint. Use soft tissue massage as appropriate.
6. Also consider global core stability, hip and knee strengthening exercises. Stretch
gluteal, hamstring and quadriceps muscle groups.
you should be able to progress to resisted ankle exercises usually after Week 8.
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StaGe ii : 8 - 12 WeekS
1. Walking cast/boot may be removed. A heel raise may be applied to accommodate
lack of dorsiflexion if needed.
2. Gait re-education.
3. Towel-calf stretch (gastrocnemius/soleus/tibialis posterior) stretch 10-30 seconds by
three daily. It is important not to reproduce pain. Progress to standing
gastrocnemius, soleus, tibialis posterior stretches.
4. Theraband exercises, inversion, eversion, plantiflexion, dorsiflexion performed in
sets of 3 x 15 repetitions each.
5. Sitting calf raises. Progress to bilateral standing calf raises (as a guide, start with
25% effort on affected side). Aim to perform 12 repetitions by 3 sets three-four
times a week.
6. Begin bilateral ‘eccentric’ calf raises. As above but ensure heels SLOWLY descend to
neutral level. Aim to perform 5 repetitions by 3 sets three-four times a week.
7. Begin neuromuscular exercises, e.g. unilateral leg balance, wobble board, podiatron
(electronic wobble board).
8. Bilateral standing, small knee joint bends to approximately 45º of knee flexion.
Progress to unilateral small knee bends.
9. Step ups, step downs on 5cm step height. Front/sideways/back as able.
10. Gymnasium rehabilitation, begin light cycle ergometer or cross-trainer if ankle
range allows, leg press, quadriceps bench bilateral to unilateral, swimming.
StaGe iii : 12 WeekS onWaRDS
WeekS 12 - 16
1. Ensure gait is normal without any aids.
2. Ensure full range of ankle joint movement.
3. Ensure satisfactory mobility in the subtalar joint, compare with the opposite side.
4. Continue with gymnasium workouts.
5. Continue with cycle, stepper, cross-trainer, leg press/calf press
6. Swimming,
7. Outdoor cycling
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WeekS 16 onWaRDS
Progress to unilateral gastrocnemius/soleus/tibialis posterior strengthening in standing.
May begin rowing at the gymnasium.
confiRm With oRthoPaeDic SURGeon oR GalWay clinic
PhySiotheRaPy team:
Jogging to Running
Agility Drills
Jumping / Hopping
Plyometrics
oveRall oUtlook (1)
1. The majority of people may return to normal activity levels with either surgical or
non-surgical treatment.
2. Most studies indicate a better outcome with surgery.
3. Athletes can expect a faster return to activity with a lower incidence of injury
recurrence.
4. Typically as the rupture site heals, a small lump may remain from the scarring.
5. Weight bearing commonly begins at about six weeks with a heel support.
6. Returning to running or athletics is traditionally in approximately four to six months.
However, with motivation and rigorous physiotherapy, some elite athletes may
return to athletics as early as 3 months after injury.
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aDvice Sheet of SamPle exeRciSeS:
Part of the role of your chartered physiotherapist will be to explain, demonstrate and
ensure you have correct technique when performing the following sample exercises.
The better you are informed the more likely you will recover and be able to prevent
recurrence of your injury.
StaGe i (6-8 WeekS)
Begin gentle active range of motion exercises.
light stretches to first point of resistance (without pain).
Core stability exercises. Liaise with your chartered physiotherapist, e.g. buttocks muscles
(gluteus medius, maximus), Abdominals, Bridging, Straight Leg Raise, Inner Range
Quadriceps, Hamstrings, Quadriceps and Gluteal stretches.
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StaGe ii (8 - 12 WeekS)
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Progress to
calf/Soleus stretching.
Goal: aim for 3 sets of 30 second stretches daily.
theraband strengthening exercises:
a) Dorsiflexion b) Plantarflexion
c) Inversion d) Eversion
Goal: aim for 3 sets of 15 repetitions 3 x week.

StaGe ii (continUeD)
Progress from seated calf raises to bilateral standing raises. Start with only 25% effort on
affected side. Goal: aim for 3 sets of 12 repetitions 3 x week.
Begin bilateral ‘eccentric’ calf raises. As above but ensure heels SLOWLY descend to
neutral level.
Goal: aim to perform 5 repetitions by 3 sets three-four times a week.
Beginning balance exercises on one leg with eyes open, one leg standing on pillow with
eyes open, progress to eyes closed.
Do not forget: Step ups/step downs & small knee bends.
Gymnasium work may include:
Light cycle ergometer, Cross-trainer, Bilateral leg press & Swimming.
note: stop if you feel any sharp pain or if your calf, ankle or foot becomes hot or swollen.
Seek advice from your chartered physiotherapist or general practitioner immediately.
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StaGe iii (Week 16 onWaRDS)
Confirm with your Orthopaedic Surgeon or chartered physiotherapist before you
commence more dynamic activities e.g.:
Jogging to running
Dynamic Balance training and Agility drills
Jumping/hopping, Plyometrics
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StaGe iv (21-26 WeekS)
An isokinetic test may be performed in the
Galway Clinic to help clarify the time to return to
sporting or manual activities. Isokinetic Testing is a
computerised and therefore objective measurement
of muscle strength and endurance. It will help us
assess and therefore address the presence of any
potential problems associated with muscle strength,
muscle imbalance, flexibility, posture and patterns
of movement that may delay return to sporting or
manual activity.
RefeRenceS
References:
1. Marano, Henry M.D. (2005), ‘Achilles tendon rupture’,
http://www.emedicine.com/SPoRtS/fulltopic/topic1.htm, pp1.-10
2. Lo IK, Kirkley A, Nonweiler B, Kumbhare, DA (1997), ‘Operative versus non- operative
treatment of acute achilles tendon ruptures: a quantitative overview.’,
Clinical Journal of Sports Medicine, 7(3):207-211)
3. Bhandari M et al (2002), ‘Treatment of acute Achilles tendon ruptures:
A Systematic overview and metaanalysis’, Clinical Orthopaedics and
related research, 400:190-200.
Other useful sites
National Institute of Clinical Excellence (NICE)
http://www.nice.org.uk
Best Treatments (British medical Journal)
http://www.besttreatments.co.uk/btuk/home.html
Glossary:
NWB - Non-Weight Bearing
PWB - Partial Weight Bearing
ADL - Activities of Daily Living
PRICE - Protection, Rest, Ice, Compression, Elevation
Dorsiflexion - The turning of the foot or the toes upward
Plantarflexion - The turning of the foot or toes downward
Eccentric - The lengthening of a tendon under tension.
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The Galway Clinic
oRthoPaeDic & SPoRtS chaRteReD PhySiotheRaPy
Doughiska, Co. Galway, Ireland
Phone: + 353 (0)91 785 450/457 Fax: + 353 (0)91 785 453 E-Mail: physio@galwayclinic.com
www.galwayclinic.com