The Achilles tendon is a strong fibrous cord that connects the muscles in your calf to the heel bone (calcaneus). Rupture usually involves a sudden, quick movement where there is a forceful stretch of the tendon or a contraction of the muscles, e.g., jumping, sprinting, or pushing off. This occurs most often in sports that require a lot of stopping and starting such as tennis, basketball, netball, football, and squash.
Once an Achilles tendon rupture has been diagnosed through clinical assessment, your Physiotherapist will talk you through the potential options of rehabilitation. During the past few years, there has been a shift in the research and clinical guidelines toward more accelerated rehabilitation and early weightbearing, which appears to produce improved tendon healing. Non-operative treatment of Achilles tendon ruptures offers the benefit of no further disruption of blood flow to the healing site, and early mechanical loading and mobilization of the ankle/tendon. Mechanical loading through weight-bearing, controlled range of motion exercises and appropriate use of a moonboot (compared to prolonged casting) have been proven to reduce the rate of re-ruptures. With current treatment protocols, re-rupture rates are fairly low, with recent studies finding a range of 0-7%.
Loading of the tendon needs to be carefully monitored – aggressive loading may result in tendon elongation, whereas prolonged immobilization underloads the healing tendon and leads to reduced long-term outcomes. Therefore, it is important that you work alongside your Physiotherapist to ensure an appropriate loading program.
Progression of Achilles tendon rehabilitation is influenced by multiple factors. Progression is initially time-based and moves towards functional/goal guidelines. The protocol is designed to give you a guide around what functional goals are needed to help achieve a successful return to activity. Factors such as age, gender, previous level of function and goals of the individual all influence the structure of the rehabilitation program, which can be further tailored to each individual.
Below is a guideline of the multiple steps involved in navigating a successful non-operative Achilles rupture rehabilitation with the goals of each outlined below:
Phase 1: Acute Phase 2: Control and capacity Phase 3: Strength and accumulation Phase 4: Sport preparation and return to play
Acute Phase:
Patients who undergo non-operative management of an Achilles tendon rupture, should be immobilised in a back slap/temporary cast for 2 weeks, in maximum passive ankle plantarflexion/toes pointing down. 2+ heel raises inside your cast is usually required. Using bilateral crutches, please refrain from weight-bearing through the cast.
Control and Capacity Phase:
This phase is about gradually loading the tendon, whilst gently improving the range of motion at the ankle. It is important that all exercises in this phase, and weight bearing are pain-free, and that you understand to decrease your activity if you notice any pain, swelling or tension on the injured side. Communication between yourself and the Physiotherapist is paramount in this phase, to deal with any potential complications or setbacks, thus you will likely see your Physiotherapist weekly.
Following two weeks of immobilisation in a cast, you will be placed in a moonboot in maximum passive plantarflexion – a similar position to what you were in the cast (about 40degrees). You will gradually increase weight-bearing status over a period of 4 weeks, with the aid of bilateral crutches. Additionally, your Physiotherapist will gradually remove the wedges as able over this time.
Week 6 usually consists of just the moonboot and full weight-bearing. After this week you will move into a sport shoe, even indoors.
During this phase it is encouraged to commence active ankle plantarflexion and dorsiflexion below 90 degrees of ankle dorsiflexion (neutral). Additionally, inversion and eversion may be performed below neutral. It is extremely important that passive range does not exceed neutral for the first 8 weeks of tendon healing.
While weaning from the moonboot, it is imperative to do this gradually with a step to gait initially, so as to not lengthen the Achilles tendon. You are encouraged to wear shoes at all times, even indoors, and avoid shoes with a low heel profile. Patients can lengthen their stride gradually over the next few weeks as the tendon lengthens naturally.
Between weeks 8-12 you can commence active plantarflexion exercises.
Strength and Accumulation Phase:
This phase of the rehabilitation process aims to build strength in the Achilles tendon – calf complex. This coupled with continued strengthening of the rest of the limb helps to form the strong foundation blocks to introduce sports specific movement and training in the next phase. This phase will likely be the longest of your rehabilitation, as clinically most patients are unable to do a single leg calf raise until 4 months post-injury.
During walking, the Achilles tendon undergoes loading equivalent to approximately three body weights. However, these loads can exceed 12 body weights during running, highlighting the large increase in tendon loading mechanics that patients must tolerate before fully returning to high demand activities.
It is worth noting that research has shown most re-ruptures occur between weeks 10-16 post-injury. This is due to patients regaining a more normal activity pattern and undertaking activities that could lead to a slip, trip, or rapid dorsiflexion.
Sport preparation and Return to play Phase:
This phase of the rehabilitation process introduces running, higher loads and change of direction. This is done in a graduate method in a controlled, safe environment to ensure successful progression. This phase also incorporates sport specific movement back into rehab and integrates the athlete back into a sport/team environment. Clinically, most athletes do not meet the requirements to return to sport til 9-12 months post-injury.
For more information on the Foundation Clinic Non-Operative Achilles Protocol email [email protected], or phone 07 579 5601.
