Dr. Strasser Achilles Tendon Repair Protocol

The typical Achilles tendon rupture occurs in the mid-substance of the Achilles tendon. This is generally in the weekend warrior, recreational athlete, in his late 20’s to early 40’s. However, it does occur less commonly in the high-level competitive athlete. The optimum treatment for complete Achilles tendon ruptures remains controversial. The following guidelines are for a surgical repair, not non-operative treatment of acute Achilles tendon ruptures. The acute repair consists of using suture material to re-approximate the ends of the tendon and restore appropriate length-tension relationships of the gastroc soleus complex. This could be with a traditional open approach or could be a Minimally Invasive Technique (MIS). 

Due to variation in surgical techniques several time frames may be adjusted. Check with your individual surgeons’ guidelines.

This protocol can also be used for chronic repairs. The protocol may be modified to accommodate additional healing of the tendon and possible tendon transfers. 

First Postoperative Visit:

1. The patient’s wound is evaluated and the sutures should not be removed unless the wound is completely dry and healed.

2. Once the sutures are removed the patient can then follow-up with the protocol dictated be the physician in his operative report. Either a cast or a walking boot will be placed on the patient in the equinus position until the 4-week follow-up.

Second Postoperative Visit:

6 Weeks postop:

1. Cast/Boot removed and wound re-evaluated.

2. Instruct in gentle A/AROM not to exceed neutral Dorsiflexion.

3. Placed in a walking boot and may begin PWB when neutral Dorsiflexion is achieved.

4. Referral to Physical Therapy (2-4 weeks s/p)

5. Follow-up physician visit is at 12 weeks s/p reconstruction if referred to Physical Therapy. If referred to an outside physical therapy center follow up visit is at 8 weeks and 12 weeks. The Physical Therapist is to monitor the patient for any complications and refer back to physician earlier if required. 

Physical Therapy: (to begin between 3-4 weeks for acute repair and 5-6 weeks for a chronic repair)

1. Discuss tissue quality and strength of the repair with the physician. Discuss combination procedures and modifications to the protocol.   

2. “General” tissue healing times:

* Immobilization to protect the repair, 4 weeks s/p

* A/AROM: 4 weeks s/p, based on pain, swelling, and tissue quality of repair.

* AROM: 4-6 weeks s/p, based on pain, swelling, and tissue quality of repair.

* Resistive ROM: 8-10 weeks s/p, based on pain, swelling, and tissue quality of repair.

* Progress as tolerated: 10-12 weeks s/p, based on pain, swelling, and tissue quality of repair.

PHASE 1:

Weeks 0-3 Postop:

Goals:

* Promote skin healing

* Minimize swelling and pain

* Protect repaired tendon

* Postop protocol:

* Sutures typically removed 2-3 weeks after surgery and transitioned to postop boot in plantarflexion

o In the setting of a chronic repair with tendon transfer, immobilization will likely occur until 4 weeks postop. PT will begin between 5-6 weeks after surgery.

* Prescription for PT given to begin after splint removal 

PHASE 2:

3-6 Weeks Post-Op:

Goals: 

* Complete protection of repair.

* Look to have neutral dorsiflexion between 6-8 weeks post-op.

* Progressive edema reduction, pain control, desensitization and scar mobility.

1. Progress from PWB to FWB with crutches/cane by 6-8 weeks based on pain, swelling and tissue quality of repair.

2. Short leg brace/orthosis worn during FWB ambulation.

3. Limit active dorsiflexion ROM to neutral with knee flexed to 90 for first four weeks.

4. No passive stretching into dorsiflexion until 8 weeks s/p.

5. Bicycle; light resistance, with brace on until 8 weeks s/p, then progress as appropriate.

6. Proximal musculature PRE's as tolerated, no closed chain Dorsiflexion past neutral until 8 weeks s/p.

7. Modalities for edema reduction, pain control, desensitization and scar mobility.

PHASE 3

6-10 Weeks Post-op:

Goals: 

* Restoration of normal walking gait

* Elimination of edema, pain, normalize sensitivity and normalize scar mobility.

* Improved 4-Quadrant ROM

1. Static balance progression and proprioceptive training (6 weeks).

2. Bicycle, increase resistance as tolerated (8 weeks).

3. Inversion and eversion isometrics.

4. Low resistance isotonics, through a pain-free ROM.

5. Gentle passive dorsiflexion beginning at 8 weeks.

6. Modalities PRN.

7. 6 to 8 weeks D/C brace and initiate heel lift in regular shoe, as per Dr.’s recommendations.

8. Dynamic balance progression and proprioceptive training (8-10weeks) based on pain, swelling and tissue quality of repair.

PHASE 4

10-14 Weeks Post-op:

Goals: 

* Improve strength.

* Restore normal A/PROM.

* Increase intensity of Cardio activity

1. Progressive plantar and dorsiflexion PRE's as tolerated, emphasize plantar flexion eccentrics.

2. Inversion/eversion PRE's as tolerated.

3. Plantar and Dorsiflexion Isokinetics as appropriate.

4. Continue proximal musculature PRE’s.

5. Reassess entire LE Biomechanics identifying areas that would increase long-term stress to the reconstruction.

6. Begin double limb heel raise (week 12)

7. Progression to walk/jog program (12 weeks) if appropriate strength and function. (Minimum 15-20 single leg toe raises)

PHASE 5:

14-24 Weeks Post-op:

Goals:

* As Above

* Continue lower extremity strength training

* Add agility and sport specific activity

Progressive return to athletic activities (16 weeks): if all above goals are achieved.

1. Continue functional closed chain rehabilitation.

2. Advanced proprioceptive retraining, Fitter, BAPS, Plyoback, Agility drills, etc.

3. Continue full LE PRE's.

4. Progressive running program. Isokinetic testing.

5. Sports Performance and Speed and Agility Drills/Testing.

PHASE 6:

24-52 Weeks Postop:

Goals:

* As above

* Sport Specific Activity

* Prevent Injury – 

Progressive back to Sports Specific Activity:

· Motion should be pain free and symmetric

· Equal strength between both limbs

· Symmetry of gait with running, jumping, cutting and pivoting

· Monitor for symmetric ROM with sport specific activities as the athlete fatigues

After Return to Sport:

· Total body strengthening exercise

· Single leg (for both limbs) eccentric Achilles training