Achilles Tendon Repair

Osiris Ramirez
 Surgery procedure routes

Mini open repair [Least invasive]- ideal for acute tearing, separation in achilles tendon is minimal.
During this procedure the surgeon will make one 3 to 4 cm long incision on the back of your ankle
and 2 to 4 smaller vertical incisions around the long incision.3

Percutaneous surgery—During this minimally invasive procedure, the orthopedic surgeon makes
several small incisions and sews the two parts of the Achilles tendon back together. 3

Open surgery—The orthopedic surgeon makes a single large incision on the back of your leg and
sews the two parts of the Achilles tendon back together. 3
Surgery 3

procedure routes
 Indications:

● If all conservative treatment methods have been explored and the patient’s symptoms and pain
persist.
● Acute, complete rupture of achilles tendon 1
● The individual wishes to return to high-demand functional activities 1
● Chronic, previously undiagnosed or untreated complete rupture in which
● end-to-end apposition cannot be achieved by conservative means. 1
 Contraindications
Corticosteroids + Fluoroquinolone
●Antibiotics weaken the tendon and predispose the patient to ruptures,
increased risk of wound infection, and delayed healing of open wounds.
Smoking:
●Nicotine restricts blood flow, Small blood vessels mean less blood flow, and less blood flow
means less oxygen, and less oxygen can mean tissues die. This makes tissue healing slower.
Hemorrhagic disorders:
●blood clotting difficulties
Diabetes mellitus:
●diabetes may increase your risk for problems during or after your surgery, such as: Infection
after surgery (especially at the site of the surgery) Healing more slowly.
 Rehab post surgical repair varies due to:

● The type of surgery

● stage the patient was in → acute, sub acute, chronic
● stability of the repair
● intrinsic variables.
● 1

Surgical variations:

● ROM, WB, and initiation of strength training vary.

Rehab progress may differ from surgeon to surgeon and from patient to patient.
 Phase 1: Maximum Protection
1
These treatments options are appropriate during the first 2-4 weeks post-op. Goals:control pain and swelling,
allow for healing
●Education: Control pain, swelling,
●Gait
●Orthotics : Limit DF beyond 15-20 degrees
●Weight bearing restrictions at least 3 weeks
●ROM: 1-2 weeks post op
●strengthening of the uninvolved limb
1
Rehab Interventions: Exercises are done in supine or seated Toe flexion/extension Toe curls
Heel slides Hallux up, toes down Isometric glute sets
Precautions: DF 15-20 degrees Active DF/PF may be done with boot to prevent joint stiffness and soft
tissue adhesions in the affected ankle and foot. Watch for signs of infection at site. 1
Contraindications: No weight bearing on operated limb, Brace should not be removed [chance of
rerupture]. Exercises should not be done standing
Progression: exercise progression [initiation of WB,] until surgeon clearance.
Phase 2: Moderate protection
These treatments options are appropriate 4-6 weeks post-op. This phase extends to 12 weeks post-op.
Goals: Continue to protect repair, Reduce pain, improve scar mobility, regain ankle movement and strength

The patient is advanced to full WB or WBAT [CAM orthosis or walking boot is progressed to 0 degrees of dorsiflexion]

1
Rehab Interventions: 1
To Increase ROM
● Ankle joint mobs → Grade I +II
● Seated self stretch with towel: to increase ankle DF
● Supine gentle manual self stretch : to restore inversion/eversion, DF/PF, and toe extension
● Seated ankle ROM with foot on a wobble board or rocker board → initial proprioception

To increase strength and muscular endurance: Low load , High repetitions.

Begin with open chain exercises, then progress to closed chain in seated then standing , as well as uni-lateral to bi-lateral.

● SLR in supine: to maintain hamstring and quad strength -

● Open chain exercises with light resistance band for Hip, knee, ankle
● Bi-lateral mini squats and toe raises
Progress with external resistance as patient strength progresses

Precautions: Watch for signs of infection at site. Ankle range of motion (ROM) with respect to DF precautions.1

Contraindications: Avoid over-stressing the repair, avoid large movements in sagittal plane[any forceful PF while in a dorsiflexed position;
aggressive passive ROM; and impact activities]. 1
Phase 3: Minimum protection/ Return to function phase
These treatments options are appropriate 12-16 weeks post-op. 1

Goals: returning patient to pre-injury level of function

● Education: Importance on warmup and stretching

● Stretching: wall calf stretch, DF calf stretch
● Strength and muscular endurance

Rehab interventions: 1

-Uni-lateral standing resisted heel raises

-Plyometric training : lateral/diagonal jumping

-Balance/proprioception [EC, unstable surfaces, and adding caching element to exercise]

-Cardiovascular endurance; treadmill, agility drills

Precautions: Body mechanics; avoid rerupture ,Post-activity soreness should resolve within 24 hours

Contraindications: Pain during exercises, Avoid running with a limp

RTS requirements: Strength and ROM WNL, pain-free functional tasks, neuromuscular control, physician clearance
 Tests and measures

Thompson test: examines the integrity of the Achilles tendon by

squeezing the calf.
● Positive if the calf is squeezed and there is no PF motion reaction. 2

Range of motion testing: *DF: 20, PF: 40

MMT: ankle PF weight bearing and non weight bearing . 2

Figure 8 measurement:

● To measure swelling before and after [progression or regression] . 2

Interventions
Initial proprioception exercise:
Seated ankle motions on wobble board
● Help improve balance and coordination of the foot
and ankle
Instructions: 4

Begin seated with proper upright position

Bring affected foot onto the wobble board
Slowly move foot forward, backward, and side to side
*gradually begin to put more weight through the foot*
Begin with just affected leg on board, progress to
both legs.
 Interventions
Straight leg raise [SLR]in supine
●Helps maintain hamstring and quad strength
Instructions: 5

-Patient begins lying on back

-Bend unaffected leg to take pressure off your back
-On affected leg, tighten quad muscle[upper thigh]
and toes pointing
up towards the ceiling.
-Slowly lift the leg up in the air through a
comfortable range,
-hold for 2 seconds
-Slowly lower leg down
Evidence based- Efficacy of early controlled motion of the ankle compared with no motion after non-operative
treatment of an acute Achilles tendon rupture: study protocol for a randomized controlled trial

Main objective: Investigate if the early control motion of the ankle 3-8 weeks post-injury affects the patient-reported
outcome after non-operative treatment of acute Achilles tendon rupture compared to patients not allowed any
motion of the ankle. 6

● This was performed using Patients from 18 to 70 years of age; 130 patients total → randomized group. 6
● The study uses the patient-reported outcome measure, the Achilles tendon Total Rupture Score, as the
primary endpoint, as it is believed to be the best surrogate measure for the tendon’s actual capability to
function in everyday life. 6
Follow-up is performed at 4 months, 6 months, 1 year, and
2 years. The study’s primary endpoint is at the 12 months
follow-up.

The intervention: early controlled motion of the ankle

joint
 ● Non Operative treatment will be done before surgery to
avoid surgery complications
● Operative treatment is available when pain is persistent
● Contraindications for surgery
● Surgeon indications will vary for patients
● Orthosis post-op

Question:

What is the name of the test used to confirm an achilles tendon rupture?

Could you explain how it is determined to be a positive or negative?

 References

1. Therapeutic Exercise: Foundations and Techniques. 6th ed. F. A. Davis Company; 2013:880-887
2. Manske RC. In: Fundamental Orthopedic Management for the Physical Therapist Assistant. Fourth ed. St. Louis, MO:
Elsevier; 2016:280-287.
3. MendMeShop. Achilles Tendon Surgery and Post-Operative Rehabilitation. Post Surgery Rehabilitation - Achilles Tendonitis.
[Link] Accessed April 01, 2021.
4. Wobble Board Sitting Two Feet. YouTube; 2014. [Link] Accessed April 2,
2021.
5. YouTube. (2019). Straight Leg Raise - Knee Rehab. YouTube. [Link]

Article

6. Barfod KW, Hansen MS, Holmich P, Troelsen A, Kristensen MT. Efficacy of early controlled motion of the ankle
compared with no motion after non-operative treatment of an acute Achilles tendon rupture: study protocol for a
randomized controlled trial. Trials. 2016;17(1):564. Published 2016 Nov 29. doi:10.1186/s13063-016-1697-2