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 with foot pointing downwards
• Can carefully shower with waterproof cover over plaster cast

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 (with 4-5 wedges inside)
• Wear boot 24 hours a day
• Begin to remove first wedge after week 4 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