LONDON FOOT & ANKLE SURGERY
Mr Andy Roche MSc FRCS (Tr & Orth) Consultant Orthopaedic and Trauma Surgeon specialising
in Foot and Ankle Surgery and Reconstruction

Achilles Tendon Rupture – Operative treatment rehabilitation guidelines

0-2 WEEKS          REST (PHASE 1)


Goals 

  • Rest, recovery and mobilise non-weight bearing safely on crutches

Immobilisation

  • Plaster cast/Rigid boot with foot pointing downwards 20 (with 3 wedges inside - 22/16/10, more if needed)
  • Can carefully shower with waterproof cover over plaster cast/boot 

Physiotherapy

  • Elevate limb as much as possible
  • Wear boot 24 hours a day
  • Pain control
  • Maintain hip/knee/toe movement

2-4 WEEKS          EASY WALKING (PHASE 2)


Goals 

  • Weight-bearing as pain allows using the crutches
  • Begin early, gentle ankle plantarflexion exercises
  • Maintain core/upper limb/hip/knee strength

Immobilisation

  • Rigid walking boot with foot pointing downwards 20 (with 3 wedges inside)
  • Wear boot 24 hours a day
  • Begin to remove first wedge by week 3 and weekly thereafter
  • Can shower out of boot with dressing on, as long as very careful not to stand stand/stumble on foot, otherwise leave boot on with waterproof covering

Physiotherapy

  • Can weight-bear with crutches as discomfort allows in boot 
  • Maintain spinal/hip/knee/toe range of movement
  • Can remove boot for exercises to gently actively plantarflex foot from position in boot to full range plantarflexion 
  • Can dorsiflex back to position in the boot but not beyond
  • Scar/FHL/FDL/Tib Post tendons massage
  • Swelling control

4 – 8 WEEKS          WALKING (PHASE 3)


Goals

  • Gradual loss of crutches as balance etc improves
  • Active ankle movement through available range of plantarflexion from position foot held in boot 
  • Regain full inversion and eversion in available plantarflexion range                                        
  • Aim for plantigrade ankle by 5-6 weeks
  • Wean out of boot in week 7-8 and place heel raise in shoe

Immobilisation

  • Rigid walking boot with wedges being removed weekly to achieve plantigrade position
  • Can shower out of boot as long as very careful not to stand heavily/stumble on foot, otherwise leave boot on with waterproof covering

Physiotherapy

  • Can remove one wedge per week until foot flat in the boot
  • Can perform active resisted plantarflexion, eversion and inversion with theraband
    • Can actively dorsiflex foot ONLY to position allowed by boot 
  • Seated heel raises
  • Maintain hip/knee/toe range of movement
  • Exercise bike with boot on
  • Gait re-education
    • No knee hyperextension to compensate for lack of ankle dorsiflexion

8-12 weeks          EASY ACTIVE (PHASE 4)


Goals

  • Normal walking careful not to push into too much dorsiflexion
  • Increase ankle and lower limb muscle strength  

Immobilisation

  • Shoe with heel raise, no need for boot anymore
  • Shower carefully so as not to stumble/forcefully dorsiflex ankle 

Physiotherapy

  • Strengthening
    • Continue active resisted theraband exercises; plantarflex through full range  
    • Allow dorsiflexion to return naturally
    • Continue resisted inversion and eversion through range
    • Exercise bike with boot on
  • Proprioceptive rehabilitation
    • Single leg stand
    • Supervised wobble board

12-20 weeks          ACTIVE (PHASE 5)


Goals

  • Mastering proprioceptive control in wearing normal footwear. 
  • Aim for normal dorsiflexion 
  • Sports specific drills 

Immobilisation

  • Normal shoes with good heel support 
  • Shower carefully so as not to stumble/forcefully dorsiflex ankle 

Physiotherapy – Tailored and monitored by physio

  • Theraband exercises
    • Full active ankle range of movement with dorsiflexion as tolerated
  • Progess muscle strengthening from open chain to closed chain
  • Proprioceptive rehabilitation
    • Single leg stance, eyes closed, wobble board/ BOSU
    • Double heel raise progress to single heel raise
  • Concentric/Eccentric
    • Gastrocsoleus conditioning
    • Single heel raises
    • Dorsiflexion equal to contralateral side, no need to push to extreme  
  • Closed chain
    • Trampette jogging, jumps, hops
    • Plyometric Squats, Plyometric Lunges
    • Hopping, Mini hurdle jumps/ hops
    • Straight line running
    • Introduce cutting/side to side/ carioca/ figure of 8 runs
    • Acceleration-deceleration running drills, sports specific rehabilitation

SOME PATIENTS MAY INTRODUCE FULL PHASE SLIGHTLY EARLIER THAN 20 WEEKS 

>20 weeks          FULL (PHASE 6)


Goals

  • Resumption of normal sporting activity

Immobilisation

  • Normal shoe-wear

Physiotherapy

  • Normal activity
  • Explosive actions and return to sport
  • Chelsea & Westminster Hospital NHS
  • The Lister Hospital, Chelsea
  • Fortius Clinic
  • Bupa Cromwell Road