Open Repair

Earlier protocols for postoperative rehabilitation after Achilles repair advocated cast immobilization for periods of 6 to 8 weeks with the ankle in equinus. The ankle was placed in progressive dorsiflexion at 2-week intervals. After cast removal, the patient began range-of-motion exercises with a physical therapist. Some authors even advocated a long-leg cast; however, Sekiya et al31 used a cadaveric study to disprove that knee position caused displacement of the Achilles tendon with the ankle plantarflexed. These results suggest that the nonoperative treatment of Achilles tendon ruptures requires immobilization in maximal ankle plantar flexion and that immobilization of the knee may not be necessary to achieve tendon-edge apposition.

The detrimental effects of immobilization on tendon and bone healing are well documented. The long-term immobilization of joints while tendons are healing slows the recovery of injured tendons. The remodeling of new collagen fibrils is impeded as well. The flexor tendon work of Gelberman et al32

showed that early mobilization leads to increased organization at the repair site and increases strength. Mobilization also decreases muscle atrophy and promotes collagen fiber polymerization.

There have now been more reports of favorable results with protocols of early motion after Achilles tendon repairs. Mandelbaum et al33 treated 29 athletes with Achilles tendon rupture using Krackow repair and began range-of-motion exercises 72 hours after surgery, using a posterior splint for 2 weeks. Ambu-lation was started in a hinged orthosis at 2 weeks. The orthosis was discontinued at 6 weeks and full weight bearing allowed. Progressive resistance exercises were also initiated. There were no reruptures. Isokinetic strength testing revealed a 2.9% deficit at 6 months and no deficit at 12 months. All patients returned to preinjury activity levels at a mean of 4 months.

More recently, authors have proposed early range of motion exercises and early weight bearing with a functional orthosis after surgical Achilles tendon repair. Speck and Klaue34 proposed early mobilization with early full weight bearing after surgical repair of Achilles tendon ruptures. This was instituted to allow the tendon to experience tension during healing. Tension improves strength and orientation of collagen fibers as well as vascularity. Twenty patients were treated with a Kessler-type suture repair and plantigrade splint for 24 hours. The postoperative program included 6 weeks of full weight bearing in a removable walker. There were no reruptures. All patients reached their preinjury activity level and showed no statistically significant difference in isokinetic strength.

Aoki et al35 reported early active motion and weight bearing after cross-stitch Achilles tendon repair in 22 patients. Twenty of the tendons (91%) healed without rerupture. Patients returned to full sports activity in 13.1 weeks. MRI studies were obtained at 4, 6, 8, 12, 16, and 20 weeks. Excellent healing was seen on the MRI at an average of 12.6 weeks. Akizuki et al36 defined the relative stress on the Achilles tendon during weight bearing with immobilization in varying degrees of plantarflexion. They examined electromyographic activity during ambulation in 10 subjects in normal walking, immobilization with a walker boot in neutral plantarflexion, walker boot with a half-inch heel lift, and a walker boot with a 1-inch heel. They concluded that the stress of the Achilles tendon is determined by the degree of plantarflexion and that a 1-inch heel lift sufficiently minimized plantarflexion activity.

Maffulli et al37 did a comparative longitudinal study to determine the effects of early weight bearing and ankle mobilization after repair of Achilles tendon rupture. One group, at 2 weeks, was mobilized with weight bearing as tolerated in the plantigrade position. An anterior below-the-knee slab was secured to the leg with Velcro straps, and patients were instructed by the physical therapist to perform concentric exercises against manual resistance and mobilization within the limits of the anterior slab. The anterior slab was discontinued at 6 weeks. The second group was initially casted in the equinus position and was non-weight bearing for 4 weeks. The patients were casted in the neutral position at 4 weeks and made weight bearing as tolerated. There were no differences found in isometric strength or thickness of the tendon. These results suggest that it is not deleterious to start early weight bearing and ankle mobilization after open repair of Achilles tendon ruptures.

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