Achilles Tendon Rupture – The Different Rehabilitation Phases

For those who followed the NBA finals between the Toronto Raptors and Golden State Warriors, you would have seen Kevin Durant go down in Game 5 with an Achilles rupture injury. It is a horrific injury and it will be a long road to recovery for him. The optimal individualised treatment for patients with an Achilles tendon rupture still requires further research. Many of the current research explores the impact of the calf muscle recovery at different time intervals after an Achilles tendon rupture.

The latest evidence-based research suggests the rehabilitation for an Achilles tendon rupture can be divided into four phases. The progression of a patient is based on both the recovery of the patient and the time since the injury occurred. Pain after an Achilles tendon rupture is mostly not an issue; however, the dosage of activities must be closely monitored in order to avoid over-use injuries.

  1. Controlled mobilisation phase (0-8 weeks)

The injured foot is mobilised in a plantar flexed position for 6-8 weeks after injury. 2 weeks after injury, non-weightbearing plantarflexion exercises are introduced. Both active and passive ankle dorsiflexion will be limited to prevent tendon elongation.  Gradual progress to full weight-bearing within the first 6 weeks along with accelerated rehabilitation has been proven beneficial.

  1. Early mobilisation phase (6-12 weeks)

Patients are ready to commence a supervised exercise programme; close monitoring is required when loading the ankle as the risk of re-rupture of the Achilles tendon is at its greatest during this stage. The orthosis is worn during all weight-bearing activities for 6 to 8 weeks after injury. Partial weight-bearing without an orthosis is slowly introduced in this phase, however wearing regular shoes with bilateral heel lifts to decrease ground reaction force during functional activities is required. Stretching the tendon in dorsiflexion is not recommended in order to prevent elongation of the tendon. Introduction of active non-weight bearing ankle dorsiflexion that stretches the gastrocnemius and soleus muscle group with the knee extended and flexed.

  1. Late mobilisation phase (10-15 weeks)

The goal of this phase is to improve the strength and proprioception of the lower limbs. Initiate open- and close-chain, low-intensity resistance exercises at 8-10 weeks. Open-chain resistance exercises include the implementation of a resistance band. Bilateral progressing to unilateral close-chain exercises such as sitting heel raises with external load (25-50% of body weight) and standing heel-raises with the variation of concentric, eccentric and isometric contractions. A milestone during this phase is to perform at least 20 seated heel-raises with a load of 50% of body weight. Proprioception training and balance exercises are incorporated, progressing from bilateral to unilateral stance and from stable to unstable surfaces.

  1. Return to sport/work phase (3-12months)

The final phase of rehabilitation is directed towards returning the patient to pre-injury work function and demands of recreational and sporting activities, which begins around 12- 16 weeks. A more intensive resistance programme including dynamic proprioceptive exercises combined with eccentric resistance exercises of the gastrocnemius-soleus muscle group in weight-bearing positions and gradually progressing to plyometric exercises. Patients are able to gradually return to work or sport 5 to 6 months if the strength of the injured limb is relatively comparable to that of the contralateral limb.

Tendon elongation after an Achilles tendon rupture affects heel-raise height during a standing single-leg heel-raise. The current recommended treatment protocol suggest calf muscle performance is not restored completely in most patients, but some evidence indicates that regaining calf muscle performance within the first year after the injury is beneficial. However, calf muscle recovery takes a long time and improvements in heel-raise height in the injured limb are found up to 7 years after the injury. Early intervention such as a supervised exercise programme is vital for the recovery of an Achilles rupture injury. Contact the team of experienced Accredited Exercise Physiologists at Absolute Balance on 9244 5580 or email info@absolutebalance.com.au

Daniel Nguyen (B.Sc. Exercise Physiology)

Senior Accredited Exercise Physiologist (AES, AEP) (ESSAM)

 

Reference

Caroyln Kisner & Lynn Allen Colby. (2007). Therapeutic Exercsie 5th Edition. Foundations and Techniques, 782-786.

Brorsson, D. A. (n.d.). Calf muscle rehabilitation post Achilles tendon rupture. Physio Network.