Achilles tendon ruptures can be a very frustrating rehab for both the patient and the clinician. The patient has to wear a boot of shame for 4-8 weeks and are very limited in the amount of activity they can perform. Clinicians are often frustrated since these surgeries require a very particular rehab protocol and are limited as to which interventions they can use.
However, one good thing about treating a achilles tendon repair is that you really only have to be worried about two things:
- Protecting the passive tension and integrity of the repaired Achilles tendon to prevent an insufficiency of the muscle-length tension relationship (avoid stretching past neutral for 3 months)
- Strengthening end-range plantarflexion strength
Avoid Insufficiency of the Achilles Tendon
Remember taking of the rubber bands off that new baseball glove that you have been trying to break in? They didn’t exactly recoil back to their normal shape. In fact, you had to throw them away most of the time because they lost their function. They were stretched out too much and the elasticity was now only mildly useful with a object much larger than your baseball glove.
Achilles tendon repair rehabilitation is very similar to this rubber band. The surgeon and the patient go through a lot of trouble to regain the passive tension and viscoelastic properties of the newly repaired tendon. The worst thing you can do as a physical therapist is to compromise the surgery by lengthening the achilles tendon in the first 3 months when the structure is vulnerable.
Why Not to Stretch
Stretching the tendon too early will cause the collagen to heal in an insufficient length. More specifically, pre-mature anatomical lengthening will increase tendon compliance, decrease viscoelastic properties, and a shift the muscle length-tension relationship to the right. Thus, the muscle would be unable to produce adequate force at shorter lengths. This increased tendon lengthening would also cause greater muscle shortening during muscle contraction, further preventing an optimal muscle-length tension relationship for force production.
Given the nature of the surgery and rehabillitation, I feel it is important to opt on side of caution when considering dorsiflexion ROM. You can always add ROM later in the course of recovery when the structure is completely healed, but you cannot put back the passive tension and elasticity in the tendon once it is over stretched.
This conservative approach will help keep the surgeon and the patient satisfied in the long run. Two keys to avoiding insufficiency and decreased function of the achilles tendon are:
- Do not stretch the achilles tendon past neutral for 3 months
- Add a heel-lift to footwear
Strengthen End-Range Plantarflexion
End-range plantarflexion strength goes hand in hand with the muscle-length tension relationship mentioned above. You can help to further accelerate your patients outcome by strengthening the gastroc-soleus complex in the end-range, shortened position. This is not only a safe intervention due to the absent passive tension placed on the structure, but it is a very functional ability for everyday activities (walking, stair negotiation, landing from a jump, etc.).
Mullaney et al studied the strength of end-range plantarflexion in 20 patients post-operatively after an Achilles tendon repair (mean 1.8 years). They found that there was a decrease in passive stiffness in dorsiflexion (see above) as well as a weakness in end-range plantarflexion strength. Testing end-range plantarflexion with a decline heel raise, they found that 14 out of 20 of the patients could not perform this task. The authors hypothisized that this was due to anatomical lengthening, increase tendon compliance, and insufficient rehab.
Interventions for End-Range Plantarflexion
To ensure that you are not apart of the “insufficient rehab” variable, strengthen your patients plantarflexors in the end-range position. There are two ways to do this: toe walking and decline heel raises. Toe walking may be a more advanced technique due to increased amount of weight bearing and stability required. Therefore, I would begin with a small angle of decline heel rises and progress as tolerated.
Achilles tendon repair rehabillitation can be a difficult process for both the clinician and patient. Preventing anatomical lengthening of the Achilles tendon will lead to greater satisfaction and function for your patient in the long run.
- Do not stretch past neutral into dorsiflexion for the first 3 months
- Add a heel lift into footwear
- Increase end-range plantarflexion strength (decline heel raises, toe walking)
Mullaney MJ, Mchugh MP,Tyler TF, et al. Weakness in End-Range Plantar Flexion After Achilles Tendon Repair. Am J Sports Med. 2006 Jul;34(7):1120-5
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