ACHILLES TENDON REPAIR CLINICAL PRACTICE GUIDELINE

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ACHILLES TENDON REPAIR

CLINICAL PRACTICE GUIDELINE

Background

Achilles tendon repair is performed after injury occurs to the Achilles tendon. The injury is often accompanied

by an audible and palpable pop with limited ability to push off of the injured limb. For best outcomes, the

Achilles tendon repair is typically performed within 2 weeks of the injury and recovery is expected to take

between 6 to 9 months. Return to sport may take 9 to 12 months depending on the severity of injury and nature

of the sport the patient desires to play.

These rehabilitation recommendations are based upon the guidance of content experts and evidence-based

practice. Progression through each phase is based on the patient demonstrating readiness by achieving

functional criteria rather than the time elapsed from surgery. The times frames identified for each phase of

rehabilitation are approximate times for the average patient, NOT concrete guidelines for progression.

Disclaimer

Progression is time and criterion-based, dependent on soft tissue healing, patient demographics, and clinician

evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

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Summary of Recommendations

Risk Factors

for Rupture

• Age (30-50 years)

• Male

• Fluoroquinolone use

Precautions

1. Recommend WBAT in protective device at post-op week 2 (NWB days 0-14 or as directed)

2. No aggressive stretching of Achilles or gastrocnemius-soleus complex before 12 weeks

Outcome

Tools

Collect the Lower Extremity Functional Scale (LEFS) at each visit.

Consider collecting one of the following outcome tools. Be consistent with which outcome tool is

collected each visit.

1. The Foot and Ankle Ability Measure (FAAM)

2. The Achilles Tendon Total Rupture Score (ATRS)

Criteria to

Discharge

Walking Boot

1. ROM: Able to achieve 0˚ DF

2. Weight Bearing: Demonstrates pain-free ambulation without antalgic gait

3. Timeframe: Full discharge from boot and heel lifts by Week 8

Criteria to

Initiate

Return to

Running and

Jumping

1. ROM: 95% symmetry ROM (DF/PF) compared to uninvolved limb

2. Anthropometrics: 95% symmetry calf circumference at 10 cm distal to tibial tubercle

compared to uninvolved limb

3. Weight Bearing: Normalized gait and jogging mechanics

4. Strength: 25 single leg heel raises with heel height within 20% of uninvolved limb

5. Timeframe: Initiate between Weeks 12-16

Criteria for

Return to

Sport

1. ROM: 95% symmetry ROM (DF/PF) compared to uninvolved limb

2. Weight Bearing: Normalized gait and jogging mechanics

3. Strength: <10% plantarflexor asymmetry at 0˚ DF and <25% asymmetry at 20˚ PF with

handheld dynamometer compared to uninvolved limb (Appendix A)

4. Neuromuscular Control: 90% symmetry between limbs on Y-balance test with appropriate

lower extremity mechanics

5. Functional Hop Testing: 90% symmetry SL hop testing (Appendix B)

6. Physician Clearance

7. Timeframe: Initiate between 6-9 months

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Red Flags

Red flags are signs/symptoms that require immediate referral for re-evaluation.

Red Flags

• Signs of DVT (Refer directly to ED)

o Localized tenderness along the distribution of deep venous system

o Entire LE swelling

o Calf swelling >3cm compared to asymptomatic limb

o Pitting edema

o Collateral superficial veins

Protection Phase (Post-op - 2 weeks)

Precautions

• Maintain post-operative splint or cast per surgeon (if splint or cast is not removable, then

treatment will only be initiated at proximal joints)

• NWB x 2 weeks (or as directed by surgeon)

ROM

• Joint mobilizations: improve accessory motion at subtalar, distal tibiofibular, midfoot, and

forefoot joints as needed

• Initiate PROM

o PF as tolerated

o DF to minimal stretch, DO NOT aggressively stretch

*Only performed if patient is in removable splint or cast

Weight

Bearing

• NWB x 2 weeks (or as directed by surgeon)

o Refer to surgeon’s post-operative report or office visit note for specific instructions on

weight bearing

Therapeutic

Exercise

• Initiate foot intrinsic exercises:

o Toe taps

o Arch doming

o Toe spreading

• Towel crunches

• Ankle AROM/alphabets

• SLR 4-way

*All exercises should be pain-free; only performed if patient is in removable splint or cast

Goals

• Reduce edema

• Ensure closure of incision

• Educate on DVT/thromboembolism

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Early Loading Phase (2-6 weeks)

Precautions

• DF P/AROM to minimal stretch, DO NOT aggressively stretch

ROM

• Initiate pain-free AROM plantarflexion, inversion, eversion; continue PROM

• Joint mobilizations: improve accessory motions at subtalar, distal tibiofibular, midfoot, and

forefoot joints as needed

Weight

Bearing

• Initiate WBAT with crutches in CAM walker boot starting post-op Week 2

o 2 heel lifts: remove 1 lift every 1-2 weeks per surgeon’s note

• Discharge crutches by Week 4

• Week 4: Initiate weight shifts out of boot as tolerated

Therapeutic

Exercise

• Submaximal ankle isometrics all planes

• Seated heel raises

• BAPS board seated as tolerated

• Recumbent bike with CAM boot

• Gluteal and lumbopelvic strength and stability

• Initiate at 4 weeks:

o Progressive resisted PF, inversion, and eversion with theraband

o Seated heel raises with light weight

o Initiate balance/proprioceptive training on stable surface once able to weight bear in

neutral ankle position out of boot

o Standing BAPS board as tolerated: PWB  FWB

o Light weight double leg press

All exercises should be pain-free

Other

Suggested

Interventions

• May initiate soft tissue mobilization and incisional mobility after adequate wound closure

• Pool therapy may begin at post-op week 4 (if wound closed and able to weight bear in

neutral ankle position out of boot)

• Neuromuscular Electrical Stimulation at 4 weeks in standing when patient able to equally

bear weight

Goals

• Initiate ankle strengthening

• DF P/AROM to 0˚ with knee extended

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Strength Phase (6-12 weeks)

Precautions

• DF P/AROM to minimal stretch, DO NOT aggressively stretch

ROM

• Achieve full PROM/AROM plantarflexion, inversion, eversion

• Joint mobilizations: improve accessory motion at subtalar, distal tibiofibular, midfoot, and

forefoot joints as needed

Weight

Bearing

• Week 8: Begin to wean out of boot, initiate walking in shoe/neutral ankle position

o Use of heel wedges (≤2) in shoe as needed: start with number of wedges where no

pain is felt and patient demonstrates proper gait mechanics, remove as able

Therapeutic

Exercise

• Initiate balance training on unstable surfaces

• Continue BAPS standing as tolerated within pain-free ROM, increasing level as able

• Closed chain hip and knee strengthening per patient’s tolerance

• Recumbent bike in shoe

• Initiate calf raise progression on shuttle:

o Double leg

 2 up 1 down  single leg

o Starting position: neutral ankle  dorsiflexion

• Week 8: Initiate standing heel raise progression as able

o Double leg  2 up 1 down  single leg

o Starting position: neutral ankle  dorsiflexion

• Week 10:

o Initiate step holds with focus on lower extremity alignment and balance (within available

DF)

o Initiate heel taps (within available DF)

All exercises should be pain-free

Criteria to

Discharge

Walking Boot

1. ROM: Able to achieve 0˚ DF

2. Weight Bearing: Demonstrates pain-free ambulation without antalgic gait

3. Timeframe: Full discharge from boot and heel lifts by Week 8

Goals

• Initiate weight bearing strengthening exercises

• Gradual wean from boot and lifts with goal of ambulation in supportive shoe by Week 8

• > 10 single leg heel raises with heel height within 20% of uninvolved limb

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Return to Function Phase (12 weeks – Return to Sport/Activity)

Precautions

• None

ROM

• May initiate gastrocnemius-soleus complex stretching as needed to restore DF ROM

• Joint mobilizations and soft tissue mobility as needed

Weight

Bearing

• Normalized gait mechanics

• Reciprocal pattern with stair ascent and descent

Therapeutic

Exercise

• Emphasize strengthening at end-range PF

o Heel raises on decline board (starting in plantarflexed position)

o Resisted inversion and eversion in plantarflexed position (theraband or ankle weight)

o DL heel raises with theraband pulls into ankle inversion and eversion

o Toe walking

• Heels raises in knee flexion

• Continued progression of strength/stability/balance exercise on stable and unstable

surfaces to correct altered mechanics

• Initiate plyometric progression:

o Shuttle press: DL  alternating  SL

o FWB: DL straight plane  diagonal plane  rotational  tuck jumps  SL

• Step/hop holds for training on lower extremity landing mechanics for jogging

• Resisted jogging in place with resistance in all planes

• Sports specific exercise/agility progression, emphasis on proper mechanics

Criteria to

Initiate

Return to

Running and

Jumping

1. ROM: 95% symmetry ROM (DF/PF) compared to uninvolved limb

2. Anthropometrics: 95% symmetry calf circumference at 10 cm distal to tibial tubercle

compared to uninvolved limb

3. Weight Bearing: Normalized gait and jogging mechanics

4. Strength: 25 single leg heel raises with heel height within 20% of uninvolved limb

5. Timeframe: Initiate between Weeks 12-16

Criteria for

Return to

Sport

1. ROM: 95% symmetry ROM (DF/PF) compared to uninvolved limb

2. Weight Bearing: Normalized gait and jogging mechanics

3. Strength: <10% plantarflexor asymmetry at 0˚ DF and <25% asymmetry at 20˚ PF with

handheld dynamometer compared to uninvolved limb (Appendix A)

4. Neuromuscular Control: 90% symmetry between limbs on Y-balance test with appropriate

lower extremity mechanics

5. Functional Hop Testing: 90% symmetry SL hop testing (Appendix B)

6. Physician Clearance

7. Timeframe: Expected time frame between 6-9 months

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Appendix A: Hand-Held Dynamometry for Ankle Plantarflexion

Position

• Patient in long-sit position on non-slip floor with foot against wall; barefoot

• Knee is fully extended

Placement

• Hand-held dynamometer placed between wall and foot, against plantar surface of foot just

proximal to the metatarsal heads

• Stabilize lower leg just proximal to ankle as needed

Protocol

• Testing performed at 0° DF and 20° PF

• 3 isometric contractions performed in each position lasting 3-5 seconds each

•

Minimum 10 second rest between trials, 1 minute rest between testing angles

•

Take average of the 3 trials at each angle

•

Determine symmetry index for each angle: (involved/uninvolved)*100 = % symmetry

Goal

• 0° DF: < 10% asymmetry between limbs

• 20° PF: < 25% asymmetry between limbs

*Measurements obtained via hand-held dynamometry with always yield lower values than formal Biodex testing. The

numbers obtained from hand-held dynamometry are best utilized to determine level of symmetry between involved and

uninvolved limbs versus as an accurate representation of force production.

References

Marmon, Adam R, Federico Pozzi, Ali H Alnahdi, and Joseph A Zeni. (2013). “The Validity of Plantarflexor Strength

Measures Obtained through Hand-Held Dynamometry Measurements of Force.” International journal of sports

physical therapy 8(6): 820–27.

Orishimo, Karl F et al. (2018). “Can Weakness in End-Range Plantar Flexion After Achilles Tendon Repair Be

Prevented?” Orthopaedic journal of sports medicine 6(5): 2325967118774031.

Spink, Martin J., Mohammad R. Fotoohabadi, and Hylton B. Menz. (2010). “Foot and Ankle Strength Assessment Using

0° dorsiflexion

20° plantarflexion

For OSUWMC USE ONLY. To license, please

contact the OSU Technology Commercialization

Office at https://tco.osu.edu.

Hand-Held Dynamometry: Reliability and Age-Related Differences.” Gerontology 56(6): 525–32.

Appendix B: Single Leg Hop Series

For OSUWMC USE ONLY. To license, please

contact the OSU Technology Commercialization

Office at https://tco.osu.edu.

For OSUWMC USE ONLY. To license, please

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Office at https://tco.osu.edu.

Author: Tessa Kasmar, PT, DPT, OCS

Reviewers: Adam Groth MD, Timothy Miller MD, Kevin Martin MD, Tiffany Marulli, PT, DPT, OCS; Lucas

VanEtten, PT, DPT, OCS, Victoria Otto, PT, DPT

Completion date: May 2020

References

Achten, J., Parsons, N. R., Kearney, R. L., Maia Schlüssel, M., Liew, A. S., Dutton, S., … Costa, M. L. (2017). Cast versus

functional brace in the rehabilitation of patients treated non-operatively for a rupture of the Achilles tendon: protocol

for the UK study of tendo achilles rehabilitation (UK STAR) multi-centre randomised trial. BMJ Open, 7(10),

e019628. https://doi.org/10.1136/bmjopen-2017-019628

Agres, A. N., Gehlen, T. J., Arampatzis, A., Taylor, W. R., Duda, G. N., & Manegold, S. (2018). Short-term functional

assessment of gait, plantarflexor strength, and tendon properties after Achilles tendon rupture. Gait and Posture,

62(March), 179–185. https://doi.org/10.1016/j.gaitpost.2018.03.007

Bäcker, H. C., Yenchak, A. J., Trofa, D. P., & Vosseller, J. T. (2018). Strength Measurement After Achilles Tendon Repair.

Foot and Ankle Specialist, XX(X), 1–9. https://doi.org/10.1177/1938640018819779

Brumann, M., Baumbach, S., Mutschler, W., & Polzer, H. (2014). Accelerated rehabilitation following Achilles tendon

repair after acute rupture - Development of an evidence-based treatment protocol. Injury, 45(11), 1782–1790.

Chiodo, C. P., Glazebrook, M., Bluman, E. M., Cohen, B. E., Femino, J. E., Giza, E., … American Academy of

Orthopaedic Surgeons. (2010). Diagnosis and treatment of acute Achilles tendon rupture. The Journal of the

American Academy of Orthopaedic Surgeons, 18(8), 503–510. Retrieved from

http://www.ncbi.nlm.nih.gov/pubmed/20675643

Eliasson, P., Agergaard, A.-S., Couppé, C., Svensson, R., Hoeffner, R., Warming, S., … Magnusson, S. P. (2018). The

Ruptured Achilles Tendon Elongates for 6 Months After Surgical Repair Regardless of Early or Late Weightbearing

in Combination With Ankle Mobilization: A Randomized Clinical Trial. The American Journal of Sports Medicine,

46(10), 2492–2502. https://doi.org/10.1177/0363546518781826

Huang, J., Wang, C., Ma, X., Wang, X., Zhang, C., & Chen, L. (n.d.). Rehabilitation Regimen After Surgical Treatment of

Acute Achilles Tendon Ruptures A Systematic Review With Meta-analysis.

https://doi.org/10.1177/0363546514531014

Maffulli, G., del Buono, A., Richards, P., Oliva, F., & Maffulli, N. (2017). Conservative, minimally invasive and open

surgical repair for management of acute ruptures of the achilles tendon: A clinical and functional retrospective study.

Muscles, Ligaments and Tendons Journal, 7(1), 46–52. https://doi.org/10.11138/mltj/2017.7.1.046

Maffulli, N., Tallon, C., Wong, J., Peng Lim, K., & Bleakney, R. (2003). Early Weightbearing and Ankle Mobilization after

Open Repair of Acute Midsubstance Tears of the Achilles Tendon. The American Journal of Sports Medicine, 31(5),

692–700. https://doi.org/10.1177/03635465030310051001

Martin, R. L., Chimenti, R., Cuddeford, T., Houck, J., Matheson, J. W., Mcdonough, C. M., … Torburn, L. (2018). Clinical

Practice Guidelines Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision

2018 Summary of Recommendations. J Orthop Sports Phys Ther, 48(5), 1–38.

https://doi.org/10.2519/jospt.2018.0302

McCormack, R., & Bovard, J. (2015). Early functional rehabilitation or cast immobilisation for the postoperative

management of acute Achilles tendon rupture? A systematic review and meta-analysis of randomised controlled

trials. British Journal of Sports Medicine, 49(20), 1329–1335. https://doi.org/10.1136/bjsports-2015-094935

Mullaney, M., Tyler, T. F., McHugh, M., Orishimo, K., Kremenic, I., Caggiano, J., & Ramsey, A. (2011). Electromyographic

analysis of the triceps surae muscle complex during achilles tendon rehabilitation program exercises. Sports Health,

3(6), 543–546. https://doi.org/10.1177/1941738111416911

Orishimo, K. F., Schwartz-Balle, S., Tyler, T. F., McHugh, M. P., Bedford, B. B., Lee, S. J., & Nicholas, S. J. (2018). Can

Weakness in End-Range Plantar Flexion After Achilles Tendon Repair Be Prevented? Orthopaedic Journal of Sports

Medicine, 6(5), 2325967118774031. https://doi.org/10.1177/2325967118774031

Saxena, A., Ewen, B., & Maffulli, N. (n.d.). Rehabilitation of the Operated Achilles Tendon: Parameters for Predicting

Return to Activity. https://doi.org/10.1053/j.jfas.2010.10.008

Spennacchio, P., Vascellari, A., Cucchi, D., Canata, G. L., & Randelli, P. (2016). Outcome evaluation after Achilles tendon

ruptures. A review of the literature. Joints, 4(1), 52–61. https://doi.org/10.11138/jts/2016.4.1.052

Zhao, J.-G., Meng, X.-H., Liu, L., Zeng, X.-T., & Kan, S.-L. (2017). Early functional rehabilitation versus traditional

immobilization for surgical Achilles tendon repair after acute rupture: a systematic review of overlapping meta-

analyses. Scientific Reports, 7, 39871. https://doi.org/10.1038/srep39871