Aggressive Athletic Rehab for Achilles Tendon

(Functional Program for Achilles Tendon Ruptures)

A modern strategy for treating an Achilles tendon rupture non-surgically is a progressive functional rehabilitation protocol. This protocol can also be applied to patients who have undergone surgery to repair their Achilles tendon rupture. Early mobilization following an Achilles tendon rupture repair is the hallmark of this functional rehabilitation protocol. The goals of this functional program for Achilles tendon ruptures include limiting lower extremity muscle atrophy, while also improving the strength and organization of the healing Achilles tendon. The protocol starts with an initial period of immobilization (7-14 days) to allow for some early healing of the Achilles tendon. Patients are then encouraged to actively move their ankle through a series of exercises designed to contract the calf muscle and to move the Achilles, but doing so in a manner that does not put a significant force through the healing Achilles tendon. Patients still have to significantly limit activity, but rather than using a cast, patients are using a removable boot or brace. This program, has potential advantages and disadvantages:

Advantages

• Faster recovery
• Less calf strength is lost
• Less leg strength is lost

Disadvantages

• Risk of stretching out the repaired Achilles. If the Achilles tendon elongates it will be weak and a revision surgery may be necessary.
• A potentially high re-rupture rate (where the Achille re-tears at a later date)

An example of Aggressive Functional program for treating Achilles Tendon ruptures is below:

Accelerated Rehabilitation Program for the Non-Operative Management of Achilles Tendon

(May also be applied to patients who have undergone a surgical repair of their Achilles rupture)

Traditional conservative (non-operative) treatment of acute Achilles tendon ruptures consisted of casting (with the foot point down) and immobilization for a minimum of 6 weeks. A more modern accelerated rehabilitation program has been developed. this protocol consists of specific exercises, combined with explicit instructions for graduated weight bearing, the use of heel lifts, and bracing. Results of this protocol when performed correctly demonstrate improved recovery essentially equivalent to the results seen in patients treated with surgery -without the risks associated with surgery.

The outline for the exercises, bracing, and weight-bearing for the treatment of Achilles tendon ruptures is as follows (adapted from Willets et al, Journal of Bone and Joint Surgery (JBJS) 2011):

Week 0-2: Immobilization Phase

The ankle is braced at 20 degrees of plantar flexion (or a 2 cm lift is placed under the heel in a boot-type brace). No weight is placed on the foot. In the case of patients who have undergone a surgical repair of their Achilles tendon rupture, a wound check will occur after this immobilization phase.

Week 2-4: Limited Weight-bearing, Early motion

The ankle remains braced in plantar flexion. Exercises begin, several times per day out of the brace or boot. The exercises consist of gentle downward motion of the ankle, taking care not to stretch the Achilles tendon past neutral (90 degrees). Also, inversion and eversion of the ankle is performed, again with the ankle pointing slightly downward (plantar flexion).

25% weight-bearing in a boot with a heel lift is allowed at week 2-3

50% weight-bearing in a boot with a heel lift is allowed at week 3-4

Week 4-6: Gradually increasing weight-bearing, continued controlled motion

Increased weight-bearing is permitted. The exercises continue as above. The boot or brace is still worn day and night. A large heel lift to ensure the ankle stays point downward continues to be used.

75% weight-bearing in a boot with a heel lift is allowed at week 4-5

100% weight-bearing in a boot with a heel lift is allowed at week 5-6

Week 6-8: Full protected weight-bearing, continued ankle motion adding some resistance

The heel lift is removed and brace wear continues. Exercises progress, with slow stretching of the tendon past 90 degrees. Some strengthening of the calf occurs with the addition of resistance exercises.

Full weight-bearing is allowed in a walker boot with the heel lift removed

Week 8-12: Gradual transition to shoes, continued range of motion and strengthening exercises

The boot or brace is gradually weaned, using crutches only as needed. Range of motion, strength, and proprioception are gradually optimized.

October 13th, 2023

sp/10.13.23