Functional Rehabilitation Protocol

Weeks 0 to 2

Following repair of the tendon intraoperatively, the patient is placed into a bulky splint in 20 degrees of plantarflexion in order to minimize swelling and maximize skin perfusion.31 The patient is non-weight bearing on the operative side and is instructed to keep the leg elevated in order to minimize wound complications.

Week 2

At 2 weeks, the postoperative splint is removed and the patient is placed into a removable cam walker. The goal at this time is to allow the patient to begin weight bearing with the ankle held in 20 degrees of plantarflexion. This can be accomplished by placing a (-)20 degrees of dorsiflexion block in the boot itself or by placing wedges in the boot to place the ankle in 20 degrees of plantarflexion with the boot itself at neutral. Placing the boot itself in 20 degrees equinus leads to a significant disturbance in the patient's gait. The patient is effectively ambulating with an equinus contracture and lengthened lower extremity. This can lead to knee pain secondary to the recurvatum thrust placed on the knee. Also, contralateral hip and low back pain can ensue secondary to the significant leg-length discrepancy. To prevent this, the boot should be fit in a neutral dorsiflexion block, allowing full plantarflexion and utilizing heel lifts to place the ankle in 20 degrees of plantarflexion to protect the repair.

Table 9.1. Postoperative functional rehabilitation protocol after acute Achilles tendon rupture.

Week Weight-bearing status Range-of-motion (ROM) exercise

Strength exercise

Therapy adjuncts

Aqua therapy

Non-weight bearing

Progressive, partial in boot with wedges to maintain 20 degrees of equinus

Progress to weight bearing as tolerated


Dorsiflexion (-20 degrees)/plantar-flexion (full); circumduction (both directions); two sets of 20 repetitions each exercise

Continue ROM from week 2; begin ankle stretch to neutral with towel

Full in brace with wedges to maintain 10 degrees of equinus

Progress to shoe weight bearing as tolerated with a 5- degree wedge

Continue ROM from previous weeks; ankle stretch with towel with knee extended and at 40 degrees of flexion

Continued stretching as previously outlined


Isometric inversion/eversion; toe curls with towel and weight; hamstring curls in prone with boot; two sets of 10 repetitions for each exercise

Isometric inversion/eversion and dorsiflexion/plantarflexion, two sets of 20 repetitions; light band-resisted exercises begin, two sets of 10 repetitions; prone knee flexion, two sets of 10 repetitions; stationary bike with boot at low resistance

Continue isometric exercise as outlined in week 3; increase resistive band exercise at three sets of 20 repetitions; hamstring curls with light resistance at three sets of 20 repetitions

Stationary bike without boot with increased resistance; continued isotonic and isometric exercises; weight shifting and unilateral balance exercise seated on therapeutic ball; closed chain Partial Weight Bearing (PWB) strengthening of plantar flexors (0 degrees to full plantarflex-ion); seated heel raises, and hamstring curl with light resistance; open chain strengthening with medium resistive band; begin stair stepper with involved limb only


Cryotherapy; soft tissue/scar mobilization

Cryotherapy; soft tissue/scar mobilization

Cross-fiber massage begun; ultrasound, iontophoresis, and electrical stimulation to decrease inflammation and scar formation

Soft tissue mobilization; modalities to control edema and pain

None None

No weight bearing utilizing a flotation device; range of motion, walking, and running initiated

Continue therapy as outlined in week 3

Excellent for initiation of weight bearing in obese patients; walking in water and standing heel raises (waist deep or greater); flutter kick with kick-board

8-10 Weight bearing in shoe full Continue as needed to ensure time with heel 5- degree neutral dorsiflexion is achieved wedge

Stationary bike with increasing Continued as needed Continue as outlined progress to standing heel raises; progress to standing balance exercise in tandem and single limb support (close eyes to increase difficulty)

resistance; eccentric focused above; initiate plyometrics and conditioning exercises strengthening of plantar flexors; band-resisted exercises advancing to heavy band as tolerated;

A formal physical therapy program is then begun under the direct supervision of the therapist. Range-of-motion exercises from 20 degrees plantarflexion to full plantarflexion are started, along with circumduction (both clockwise and counterclockwise). Strengthening exercises with isometric inversion and eversion, with the ankle held in 20 degrees plantarflexion, are begun. Toe curls with towels and weight along with hamstring curls are initiated (Fig. 9.1). All exercises are performed in two sets with 10 repetitions per set. Cryotherapy is utilized in order to minimize swelling.

Week 3

Weight bearing in the boot with heel lifts places the ankle in 10 degrees of plantarflexion. Soft tissue and scar mobilization is performed. Initiation of a stationary bike with the boot in place at low resistance comes next. Aqua therapy may be implemented using a flotation device to prevent weight bearing on the operative leg. Range-of-motion exercises are continued from week 2 in order to increase dorsiflexion to neutral using a strap or towel (Fig. 9.2).

Strength exercises are continued with the addition of isometric dorsiflexion and plantarflexion exercises. Light resisted band inversion, eversion, dorsiflexion, and plantarflexion exercises are implemented over the course of week 3 (Fig. 9.3). The frequency is increased to two sets with 20 repetitions per set.

Fig. 9.1. Toe curls utilizing a towel and weight

Fig. 9.2. A towel is used to gently perform a dorsiflexion stretch to the Achilles tendon
Fig. 9.3. Resistive band exercise for plantarflexion strength Week 4

Weight bearing in the boot at the neutral position is initiated. Gentle, cross-fiber massage to the Achilles is performed along with ultrasound, phonophoresis, and electrical stimulation to decrease inflammation and adhesion formation. The stationary bike and aqua therapy continue as outlined in week 3.

Continued stretching of the Achilles tendon is performed using a towel. Stretching while standing is initiated only if the patient has not achieved neutral dorsi-flexion. Strengthening continues, and the resistance of the bands is increased. Hamstring curls are continued to facilitate gastrocnemius muscle strength without flexing the ankle and stressing the repair. Exercise now increases to three sets with 20 repetitions per set.

Week 6

The use of the boot is now discontinued, and weight bearing is permitted in a shoe with a 5-degree heel lift. Modalities and soft tissue mobilization are continued as outlined in week 4.

A significant increase in patient activity is now initiated. Use of a stationary bicycle is allowed without the boot, and resistance is increased as tolerated along with use of a stair stepper. Closed chain strengthening of the gastroc-soleus complex is initiated using seated heel raises, and hamstring curls with light resistance. Gait training with a concentration on weight shifting from heel-to-toe and side-to-side shifting begins.

Aqua therapy is progressed. This is ideal for obese patients, as it decreases the tensile stress on the repair. Aqua therapy also helps athletes maintain their conditioning. Therapy is performed in water that is at least waist deep and begins with standing heel raises and walking. Flutter kicking with a kickboard is begun, while fins are utilized to increase resistance.

Week 8

Therapy is continued with a focus on increasing the strength of the gastroc-soleus complex. Isotonic exercises are continued with an increasing eccentric bias. Standing balance exercises in tandem is begun and progresses to single leg support (Fig. 9.4). Aqua therapy is continued with the addition of plyomet-rics in waist-deep water. Plyometrics involves the lengthening of a muscle, followed by its immediate contraction. This results in a very powerful force that can injure the muscle and should be performed under the supervision of a therapist.

Week 10

The heel lift is now no longer required (Table 9.2.). Squats are begun with moderated resistance in order to prevent excessive dorsiflexion of the ankle. Standing heel raises are continued with a focus on single limb concentric and eccentric strengthening. Resisted walking is initiated using free motion machines, pulleys, and bands. Use of an elliptical trainer is excellent for improving strength and range of motion at this time.

Aqua therapy is progressed to include aerobic conditioning. In athletes, this type of therapy focuses on plyometrics. Plyometric exercise, which is excellent to increase the explosive power of the athlete, is unsafe to perform outside of the pool.

Week 12

Therapy is focused on graduating the patient to normal activity. The initiation of jogging and plyometric training outside of the pool is begun if the patient is able to perform a single limb heel rise 10 times with a low pain rating. Aqua therapy is continued as needed in obese patients who may have a slightly delayed recovery.

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