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Non-operative treatment of Achilles tendon ruptures

Phase I: weeks 0-2

GOALS:

  • Protect tendon
  • Control pain

PRECAUTIONS & MANAGEMENT

  • Plaster cast with ankle plantar-flexed to approx. 20°
  • Non-weight-bearing with crutches

Phase IIA: weeks 2-4

GOALS:

  • Protect tendon
  • Regain ankle range of movement
  • Manage swelling

PRECAUTIONS

  • Avoid moving ankle beyond plantargrade dorsiflexion when performing any exercise.
  • Use camboot with a 2-4cm heel lift. Tubigrip to be worn under camboot to help control swelling.
  • Protective weight-bearing with crutches and camboot:
    • Week 2-3: 25% weight-bearing
    • Week 3-4 : 50% weight-bearing
  • Emphasise patient must use pain as a guideline; if increased pain, decrease activity and/or weight-bearing level.

MANAGEMENT

  • Active DF and DR ROM to neutral, inversion/eversion below plantargrade.
  • Static calf contraction in camboot.
  • Modalities to control swelling.
  • Knee/hip exercises with no ankle movement.
    E.g. Knee extension in sitting, prone hip extension, SLR.
  • NWB fitness/cardio
    E.g. Exercise bike with one leg

Phase IIB: weeks 4-6

GOALS:

  • Protect tendon
  • Regain ankle range of movement
  • Progressively increase weight-bearing in camboot

PRECAUTIONS

  •  Continue protective weight-bearing with crutches and camboot:
    • Week 4-5: 75% weight-bearing
    • Week 5-6 : 100% weight-bearing
  • Avoid moving ankle beyond plantargrade when performing any exercise, but can do co-contraction exercises and move through range.
    E.g. sliding heel along ground, but not past plantargrade dorsiflexion)

MANAGEMENT

  • Continue Phase IIA management
  • Emphasise patient doing non-weight-bearing cardio activities as tolerated.

Phase III: weeks 6-8

GOALS:

  • Protect tendon
  • Continue to regain ankle range of movement
  • Begin light Achilles lengthening/strengthening

PRECAUTIONS

  • Avoid moving ankle beyond plantargrade when performing any exercise.
  • Weight-bearing as tolerated in camboot.
  • Gradually remove heel lift over 2-3/7:
    E.g. If patient as 2 x 2cm lifts, take one out at a time

MANAGEMENT

  • Continue with modalities for swelling as required.
  • Active assisted DF stretching to plantargrade – slowly and initially with a belt in sitting , doing knee straight and knee bent
  • Graduated resistance exercises (open and closed kinetic chain as well as functional activities). Start with theraband exercises
  • Gait re-training ( as now 100% WB in camboot)
  • Cardio to now include WBAT exercises eg bike
  • Hydrotherapy

Phase IV: weeks 8-12

GOALS

  • Wean camboot (usually over 2-5 days) – can drive once 100% weightbearing and no camboot
  • Increase anti-gravity calf strength
  • Continue to progress ROM and proprioception exercises.

PRECAUTIONS:

  • Begin pain free gentle stretching into dorsiflexion beyond plantargrade – no forceful stretch
  • Do not allow ankle to go past neutral position during strengthening
  • Wear ankle brace to provide added stability once camboot removed, if required for patient confidence.
  • Tendon remains vulnerable to sudden loading of the Achilles (eg
    tripping etc) so ensure patient is diligent with ADL’s/exercises to
    avoid re-rupture.

MANAGEMENT:

  • Wean camboot as above- patient may need to return to crutches/SPS as required during the weaning process.
  • Add exercises such as stationary bike, elliptical, walking on treadmill as patient tolerates.
  • Add wobble board activities- progress from seated to supported standing to standing as tolerated.
  • Add double heel raises and progress to single heel raises when tolerated. Ensure the ankle does not go past plantargrade position into dorsiflexion.
  • Continue to progress strength/proprioception/ROM exercises as tolerated.

Phase V: weeks 16+

MANAGEMENT:

  • Increase dynamic WB exercise, included plyometric training sport specific retraining.
  • Can now introduce full range of motion in strengthening i.e. can go into dorsiflexion beyond plantargrade.
  • Return to normal sporting activities at 6 months.