Protocol: 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.

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)

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)

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)

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)

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

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• 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.