Rehabilitation Protocol Following Achilles Tendon Repair Surgery

Goals:

• Protect the surgical repair and wound healing
• Manage pain and swelling
• Prevent complications (e.g., deep vein thrombosis)
• Maintain proximal muscle activity and cardiovascular fitness

Interventions:

• Immobilize ankle in plantarflexion using a short leg splint, cast or CAM boot with 3 heel wedges (~6 cm total) to maintain equinus position.
• Non-weightbearing (NWB) or partial weightbearing (PWB) as per surgeon’s advice; most protocols allow no WB during this phase.
• Patient education on wound care and signs of infection
• Initiate isometric exercises for hip, knee, and core muscles
• Submaximal plantarflexion isometric contractions in boot or cast at end range plantarflexion to stimulate calf muscle activation without stressing repair.
• Use cryotherapy and elevation to manage swelling and pain
• Blood flow restriction training (BFRT) can be initiated on ipsilateral or contralateral limb to preserve muscle mass.

Boot Wearing Schedule:

• CAM boot with 3 heel wedges continuously (day and night)

In-Home Tips for Patients:

• Keep the limb elevated as much as possible to reduce swelling
• Avoid active dorsiflexion or stretching beyond neutral
• Practice gentle toe curls and isometric calf contractions in boot
• Maintain cardiovascular fitness with upper body exercises
• Monitor wound for redness, discharge, or increased pain

Exercise Examples for Physiotherapists:

• Hip abduction/adduction isometrics
• Quadriceps sets and straight leg raises
• Seated plantarflexion isometrics with boot on (biofeedback encouraged)
• Breathing and core stabilization exercises
• Initiate BFRT with low-load exercises (e.g., straight leg raises)

Milestones / Precautions:

– No active or passive dorsiflexion past neutral
– Monitor for infection, DVT
– Maintain ankle & foot hygiene

Goals:

• Gradual Progress to full weightbearing (FWB) safely
• Initiate controlled ankle range of motion (ROM) avoiding dorsiflexion beyond neutral
• Continue pain and swelling management
• Maintain proximal and global strength

Interventions:

• Transition from NWB to tolerable FWB in CAM boot with heel wedges; WBAT typically allowed by 3 weeks, FWB by 6 weeks.
• Ankle active ROM exercises initiated, limiting dorsiflexion to neutral with knee flexed to 90° to avoid tendon elongation.
• Avoid passive dorsiflexion stretching until after 12 weeks.
• Begin gentle soft tissue mobilization around scars once healed
• Proximal strengthening and cardiovascular exercises continue
• Maintain heel wedges in boot; reduce 1 wedge per week starting at week 5 (total 3-4 weeks wearing wedges).
• Continue BFRT focusing on plantarflexors and proximal muscles.

Boot Wearing Schedule:

• CAM boot with gradually decreasing heel wedges: starting week 4, one wedge off every week (from 3 wedges to none by week 6)

In-Home Tips for Patients:

• Use crutches as needed to assist with WB progression
• Perform ankle pumps and gentle active ROM within limits
• Monitor for signs of elongation (feel tightness but no pain)
• Continue elevation and icing as needed
• Encourage compliance with weightbearing restrictions and exercise progression

Exercise Examples for Physiotherapists:

• Active ankle plantarflexion and dorsiflexion to neutral (knee flexed)
• Seated ankle isotonic exercises with elastic bands
• Double-leg heel raises in boot (partial weightbearing)
• Hip and core strengthening progressions
• Aquatic therapy or stationary cycling with boot on (~week 4–6)
• Submaximal isometric plantarflexion
• Neuromuscular electrical stimulation (NMES) for gastrocnemius activation

Milestones / Precautions:

– Avoid passive calf stretching
– Monitor resting ankle tension as proxy for tendon elongation
– Avoid premature full dorsiflexion

Goals:

• Normalize gait mechanics
• Restore ankle dorsiflexion gradually without overstressing repair
• Improve calf muscle strength and endurance
• Progress proprioceptive training

Interventions:

• Transition to athletic shoe with heel lift (~1.5–3 cm)
• Gradual reduction of heel lift height under supervision
• Initiate double-leg heel raises progressing through full ROM.
• Begin single-leg heel raises around week 10–12 if tolerated.
• Proprioceptive exercises such as balance board, single-leg stance, and perturbation training.
• Continue aquatic therapy and use of anti-gravity treadmill if available.
• Avoid aggressive stretching beyond dorsiflexion neutral until after 12 weeks.

Boot Wearing Schedule:

• Discontinue boot around 8 weeks (as per orthopedic team recommendation), transition to sneaker with heel lift (~1.5–3 cm).
• Use sneaker with heel lift during gait training until full ROM and strength achieved.

In-Home Tips for Patients:

• Focus on quality of gait; avoid limping or compensatory patterns
• Perform balance exercises safely near support
• Continue controlled calf strengthening avoiding pain
• Use compression socks and elevate limb to reduce swelling

Exercise Examples for Physiotherapists:

• Double-leg heel raises, progressing to slow eccentric lowering
• Single-leg heel raises (supported initially)
• Balance exercises: single-leg stance on stable and unstable surfaces
• Seated and standing calf strengthening with increasing load
• Stationary bike without boot, elliptical
• Initiate low-impact cardiovascular training (swimming, walking, Elliptical, stair climbing, treadmill walking)

Goals:

• Restore full ankle ROM including dorsiflexion
• Achieve calf muscle strength >70–80% limb symmetry index (LSI)
• Initiate plyometric and running progression
• Improve neuromuscular control and endurance

Interventions:

• Remove heel lift when ankle dorsiflexion reaches near normal
• Progressive resistance exercises for calf with emphasis on eccentric loading.
• Plyometric training introduction with low amplitude activities (e.g., pogo jumps, ladder drills).
• Running progression starting typically at 12–16 weeks post-op based on strength and control.
• Continue proprioceptive and balance training with dynamic challenges
• Monitor tendon elongation via clinical signs and resting ankle position.

Boot Wearing Schedule:

• No boot; normal shoe wear with gradual reduction of heel lift as ROM improves.

In-Home Tips for Patients:

• Continue gradual loading and plyometric drills as instructed
• Avoid sudden increases in activity to prevent overloading
• Focus on movement quality to prevent compensatory patterns
• Use ice and compression after higher load days if needed

Exercise Examples for Physiotherapists:

• Single-leg heel raises progressing to multiple repetitions
• Plyometric drills: Ladder drills, band-assisted pogo jumps, box jumps, drop jumps (progressive), triple extension drills
• Running progression (typically from 12-16 weeks)
• Running drills: straight-line jogging, gradual increase in volume
• Functional strengthening: lunges, step-ups, mini-squats, Bulgarian split squats, hip strengthening
• Use force plates or biofeedback devices to assess and train symmetry

Milestones / Precautions:

– Achieve controlled gait mechanics
– Strength benchmarks before running: 1.5-2.0x body weight seated plantarflexion
– Use aquatic and anti-gravity treadmill as needed

Goals:

• Achieve >90% strength and endurance compared to contralateral side
• Progress training volume and sport-specific skills
• Safely return to full sports participation

Interventions:

• Isokinetic and isometric strength testing to confirm readiness (>90% LSI recommended)
• Advanced plyometric and agility drills with reactive components
• Sport-specific training under supervision
• Monitoring workload and fatigue to prevent reinjury

Boot Wearing Schedule:

• None

In-Home Tips for Patients:

• Adhere strictly to progression guidelines
• Pay attention to pain or swelling after activity
• Maintain strength and flexibility programs
• Communicate concerns promptly with therapist or surgeon

Exercise Examples for Physiotherapists:

• High-level plyometrics: drop jumps, bounding
• Reactive agility drills and neurocognitive training (drop vertical jumps, RSI monitoring)
• Progressive running drills including changes in direction and speed
• Strength and conditioning focusing on power (e.g., loaded calf raises)
• Isokinetic/isometric strength testing
• On-field/court sport-specific drills and conditioning
• Functional testing: single-leg hop, heel-rise endurance tests
• Neurocognitive and reactive training to prepare for sport demands

 Milestones / Precautions:

– Strength: >90% LSI and 1.5-2.0x BW plantarflexion force
– Heel-rise endurance >90% LSI
– Monitor for calf endurance deficits and tendon elongation
– Progressive chronic load management

• Early Weightbearing & Mobilization: Immediate or early weightbearing (within first 1–2 weeks) with controlled ankle motion is safe, does not increase re-rupture risk, and may accelerate functional recovery
• Tendon Elongation: Tendon elongation continues for up to 6 months postoperatively regardless of early or late weightbearing protocols and is a key factor influencing long-term function
• Blood Flow Restriction Training (BFRT): BFRT during early rehab can preserve muscle strength and promote hypertrophy with low loads, beneficial when high-load exercises are contraindicated
• Use of Biofeedback & Objective Measures: Devices such as force plates and isokinetic dynamometers provide valuable feedback for strength and symmetry and should be incorporated when possible
• Gradual Reduction of Heel Wedges: Heel wedges in boots and shoes help protect the repair by maintaining slight plantarflexion; a gradual reduction over 4–6 weeks is crucial to avoid elongation
• Avoid Excessive Dorsiflexion Stretching: Passive dorsiflexion stretching should be avoided until at least 12 weeks to prevent tendon elongation
• Long-Term Rehabilitation: Full recovery of muscle strength, endurance, and patient-reported function may take 12 months or longer
• Return to Sport (RTS) as a Continuum: RTS should be considered a progressive continuum with objective testing guiding decisions rather than time alone

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