• To allow the tendon to heal, reducing pain, swelling and inflammation.

• To restore the tendon and muscles to their original flexibility, strength and power.

• To gradually return to normal activity and training levels.

Abbreviations

This document is for physiotherapists within Frimley Health NHS Foundation Trust treating patients who have suffered an Achilles tendon rupture. This guideline is a mixture of rehabilitation research combined with previous clinical experience from clinical specialist physiotherapists into rehabilitation of this injury. This guideline should be implemented with future appropriate patients to increase the chances of a successful progressive rehabilitation plan, guiding patients back to their functional goals safely.

There are two methods of treatment - surgery, and conservative. The speed at which a patient can progress with the rehabilitation will vary. Time frames should be considered approximate according to actual progression based upon clinical presentation.

If it is an Achilles reconstruction for late presentation of a rupture, although the principles are the same, be prepared that rehab will be slower.

Recovery is a slow and gradual process and any attempt to rush it may result in re-rupture of the tendon.

Return to sport in most cases will take 8-12 months, however this can be longer.

These guidelines can be applied to both conservative and surgical repair of the achilles tendon.

• Avoid forceful active + passive ROM for 12 weeks post injury

• No running, advanced jumping, ballistic activities for approximately 5 months

At 6 weeks the scar is undergoing remodelling and vascularisation, patients should start Physiotherapy at this point to avoid tendon contracture and prolonged ankle stiffness.

This is a long injury to rehabilitate! Set regular mini goals for patient to maintain adherence and motivation.

Please note: Rehabilitation timeframes are from when patient presented to ED and put in equinus cast. Patient should be provided with Vacoped protocol by plaster room with dates of boot changes.

6-9 Weeks

• Initial Physio appointment, the main aim is to ensure patient is achieving neutral / plantargrade and using boot correctly.

• Complete ATRS.

• Patient still in Vacoped boot until 9 weeks.

• Advice re skin care – moisturise daily.

• If surgical patient, encourage regular scar message if wound fully healed.

• Ensure patient coming out of boot *NWB ONLY* to wash and dry lower limb regularly.

• Relative rest, ice and elevation to help swelling.

• Patient likely mobilising with elbow crutches – is allowed to weight bear as tolerated in boot. Ensure walking with heel-toe gait in boot. Can wean crutches if achieving plantar grade and maintains correct gait pattern when crutch removed.

• Active ROM to be done hourly to aid tendon repair. For the first week this should be done with the knee flexed over a pillow. Patient can remove boot at night and for plantarflexion, inversion and eversion exercises, but ensure boot is worn whenever WB. Patient can start gentle NWB dorsiflexion but re-iterate to not over-stretch.

• Can start NWB gluteal, quadricep, hamstring exercises to maintain rest of lower limb strength.

9-12 weeks

Warn patient that most re-ruptures occur in this phase!

• The patient should come out of the vacoped boot at 9/52. Pt can be provided with heel pads from plaster room if needed. Thick heeled shoes can help if irritable tendon. Wean heel pads over few weeks when back wearing normal shoes.

• Advise patients to avoid extreme dorsiflexion of the ankle combined with active plantar flexion e.g. ladders/high steps.

• Can still wear boot when mobile outdoors in high risk/busy areas.

• Advise the patient they will not return to sports which involve running till 5 – 12 months – this will depend on passing return to activity criteria.

• Daily moisturising of skin and elevate/ice to control swelling as needed

Outpatient physiotherapy guidelines

• ROM exercises of the ankle and foot with the knee extended.

• Refrain from forceful or sustained stretching – may give gentle towel dorsiflexion stretch and gentle lunge on step. Excessive stretching can lead to tendon healing long and losing elastic properties long term.

• When plantar grade has been achieved, wean off crutches.

• Wean into regular shoe as comfortable. Encourage use of supportive trainers. May get tarsalgia in first month out of boot due to increase in load and toe flexion.

• Gait re-education, encouraging heel strike and toe off for calf propulsion.

• Seated calf raise – three times a day, aim for 20 reps. Encourage mid foot mobility and ensure minimal pain.

• Begin ankle theraband exercises in all directions – avoid over-stretching into dorsiflexion.

• Introduce proprioceptive exercises on 1 leg such as supported single leg balance work.

• Avoid explosive or ballistic movements as this may lead to a re-rupture.

• Hydrotherapy or exercise in a local pool can be useful in this phase if struggling with land-based exercises. However, no swimming advised till 12/52.

• If post-surgical, take care of the scar; any break down of the scar, refer patient back to orthopedic clinic as soon as possible.

3-5 months

• Can progress to standing straight and bent knee calf stretches but only to where comfortable. Don’t push into pain if irritable.

• Start bilateral standing straight and bent knee heel raises – three times a day, aim for 12 reps building towards single leg heel raise.

• Exercise progressions towards single leg heel raise:

• Increased load bilateral straight knee and bent knee heel raises

• Biased weightbearing eccentric heel drops to affected side

• Progress to single leg eccentric lowering when can maintain isometric hold in full plantarflexion on affected leg.

• Introduce CV fitness e.g bike/swim. Progressively strengthen other muscle groups such as quadriceps, hamstrings, glutes, core. For example, squat, deadlift, forward lunge, machines in gym.

• Plyometrics – from 4 months - start 2 leg pogo’s, skipping when can double leg heel raise pain free. Progress to bilateral counter movement and broad jump if symptoms remain settled.

• From 4/12 start to add heel raises off step past plantar grade if tolerated.

5+ months

Dependent on patient goals can PIFU or discharge patient if they are close to normal function. Continue rehab if has high level goals e.g. return to sport.

• Progress to single leg heel raising if able. Increase load of exercises to build unilateral strength in calf complex.

• Return to run checklist:

• 5/12 post injury

• No pain in ADLS

• Can walk with no limp or pain for 30 mins

• Dorsiflexion 80% LSI on Knee to wall/inclinometer testing

• Achieve 10 x single leg heel raise with good correct form or 70% LSI calf strength on VALD/Handheld Dynamometer

• Plyometric ability - jog on spot 1 min, bound x 10, hop x 10 with no pain.

• Provide return to run progressive plan: Return to Running Guidelines After Injury

• Progress to single leg Plyometrics – single leg vertical, horizontal, triple hop as able.

• Introduce more dynamic balance/proprioception exercises e.g. uneven surfaces, star balance excursion. Add COD/agility if straight line running for 15 minutes/3K with minimal discomfort.

• Introduce sport specific exercises dependent on patient goals.

• Progress agility/COD running – add acceleration/deceleration/hill running.

• Progress to higher level sport specific exercises.

• Progress single leg power – e.g. single leg counter movement jump (height), single leg forward jump (distance), triple jumps (distance), box jumps.

• Single leg endurance lateral hops.

Return to sport criteria

• ATRS > 95/100.

• 95% LSI in single leg hop tests (use VALD force deck if available).

• 95% star balance excursion test.

• Completed 1 month of non-contact training before return to competitive sport.

Warn patient that the calf is likely to be slightly weaker than previously. Also, it can take over 12 months to fully recover and return to similar pre-injury performance level. Re-iterate importance of continued strengthening work to reduce re-injury rate.

How long until I am back to full fitness?

Most athletes can expect to be out of competition for 8 - 12 months post rupture.

Calf muscle recovery takes a long time and improvements in heel-rise height in the injured limb are found up to 7 years after the injury (Brorsson et al 2018).

This is increased to 12 months if the rupture was a delayed presentation or immobilized in plaster.

Brorsson A, Grävare Silbernagel K, Olsson N and Nilsson Helander K. (2018) ‘Calf Muscle Performance Deficits Remain 7 Years After an Achilles Tendon Rupture’, The American Journal of Sports Medicine, 46(2):470-477. Available at: https://doi.org/10.1177/03635465177370

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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