ACHILLES TENDON RUPTURE (SURGICAL REPAIR) REHABILITATION PROTOCOL

Phase 1 Acute Inflammatory (Postoperative): 0-6 Weeks Therapeutic Objectives: o Minimize Pain o Control Swelling o Begin Range of Motion Exercises Therapeutic Exercise: o Active Range of Motion Flexion and extension of the toes in a supine position: 25 x 3 sets, 3 times daily Plantar Flexion of the ankle and dorsiflexion to neutral in a supine position: 30 x 2 sets, 3 times daily Extension of the knee in a sitting position (hold for 2 seconds): 10 x 3 sets, 3 times daily Flexion of the knee in a prone position: 10 x 3 sets, 3 times daily Extension of the hip in a prone position (hold for 2 seconds): 10 x 3 sets, 3 times daily Therapeutic Modalities: o Non-Thermal Ultrasound Used to: Aid the inflammation response so that healing can occur Increase the phagocytic activity of the macrophages Increase protein synthesis as well as tissue regeneration Parameters Pulsed, 3 MHz, 0.5 W/cm2, 5 minutes o Ice application before and after each rehabilitation session to help with pain reduction so that exercise can occur Evaluation Procedures and Criteria used for Functional Progression (Short Term Goals) o The patient will demonstrate full range of motion in the toes, knee and hip by 3 weeks. o The patient will demonstrate the ability to bear full weight in a double legged stance without pain by 6 weeks.

Phase 2 Healing and Strength (Exercise and Range of Motion) Part 1: 6-9 Weeks o Therapeutic Objectives: Improve ankle strength and flexibility Begin regaining cardiorespiratory endurance losses

o Therapeutic Exercises: Ankle flexion and extension exercises with light manual resistance: 30 x 3 sets, 3 times daily Ankle supination and pronation active exercises: 30 x 3 sets, 3 times daily Standing on the toes and heels alternately: 30 x 3 sets, 3 times daily Ankle extension exercises against a light resistance theraband: 20 x 3 sets, 3 times daily Ankle stretching exercises to flexion with the help of a theraband: 30 seconds x 5 sets, 3 times daily Stretching exercises for the toes and ankle against the hand in a sitting position: 30 seconds x 5 sets, 3 times daily Single Leg Balance: 30 seconds x 5 sets, 3 times daily Treadmill Walking: 15 minutes daily o Therapeutic Modalities: Cross Friction Massage (5 minutes) Performed to help realignment of collagen fibers and break down scar tissue This will be done before thermal ultrasound, and therapeutic exercise Thermal Ultrasound (performed before therapeutic exercise): Used to: o Increase extensibility of collagen fibers o Increase metabolism o Increase blood flow to that area o Decrease pain perception Parameters: o Continuous, 3 MHz, 1.0 W/cm2, 10 minutes Ice application after each rehabilitation session to help with pain reduction o Evaluation Procedures and Criteria used for Functional Progression (Short Term Goals) The patient will demonstrate improvements on the BESS test (without balance pad use) throughout part 1 of phase 2. The patient will demonstrate the ability of walking without a limp on the treadmill for 15 minutes by the end of part 1 of phase 2. Part 2: 9-12 Weeks o Therapeutic Objectives: Improve coordination and skill

 Improve ankle strength and flexibility Maintaining/improving cardiorespiratory endurance gains o Therapeutic Exercises: Bilateral heel raising (progress to single leg heel raising): 20 x 5 sets, 3 times daily Theraband exercises (progress from light to moderate to heavy resistance) Ankle extension 20 x 5 sets, 3 times daily Ankle flexion 20 x 5 sets, 3 times daily Ankle inversion 20 x 5 sets, 3 times daily Ankle eversion 20 x 5 sets, 3 times daily Stretching of the calf musculature weight bearing on a slant board (progress to a higher angle of inclination) Single leg balance with the knee in somewhat flexion: 30 seconds x 5 sets, 3 times daily Treadmill walking: 30 minutes daily o Therapeutic Modalities: Cross Friction Massage (5 minutes) Performed to help realignment of collagen fibers and break down scar tissue This will be done before thermal ultrasound, and therapeutic exercise Thermal Ultrasound (performed before therapeutic exercise): Used to: o Increase extensibility of collagen fibers o Increase metabolism o Increase blood flow to that area o Decrease pain perception Parameters: o Continuous, 3 MHz, 1.0 W/cm2, 10 minutes Ice application after each rehabilitation session to help with pain reduction o Evaluation Procedures and Criteria used for Functional Progression (Short Term Goals) The patient will demonstrate the ability to perform 20 reps x 5 sets of single leg heel raise without pain by 12 weeks. The patient will demonstrate the full active and passive ankle range of motion, as compared bilaterally without pain by 12 weeks.

Phase 3 Sport Specific (Functional Rehabilitation): 12-24 Weeks Therapeutic Objectives: o Improve coordination and skill o Improve ankle strength and flexibility o Maintaining/improving cardiorespiratory endurance Therapeutic Exercise: o Lunges in each of the three planes of motion: 20 x 3 sets, 3 times daily o Lateral step ups: 20 x 3 sets, 3 times daily o Jogging: start at 10 minutes daily: progress 2 minutes longer each session up to 30 minutes Once reached 30 minutes of jogging repeat progression with running o Four square hopping Front to back, side to side, diagonal Focusing on keeping feet together and speed 3 sets of 10 hops in each of the three directions o Theraband or slant board assisted stretching: 30 second hold x 5 sets, 3 times daily Therapeutic Modalities: o Ice after each session to help with the reduction of pain Completion of Long Term Goals (see Long Term Goals (Criteria for Return to Play)

Phase 4 Maintenance: >24 weeks Therapeutic Objectives: o Maintaining long-term goal completion and stretching Therapeutic Modalities: o Ice as needed after physical activity

Long Term Goals (Criteria for Return to Play) The patient will demonstrate full AROM of the involved ankle as compared to uninvolved side by the end of phase 3. The patient will demonstrate isokinetic strength of the ankle plantar flexors at 90-95 percent of the uninvolved side by the end of phase 3. The patient will demonstrate 90-95 percent of the number of heel raises throughout the full ROM in a 30-second period as compared to the uninvolved side by the end of phase 3.

The patient will demonstrate the ability to walk, jog and run without an observable limp and successful completion of a sport-related functional progression without any Achilles tendon irritation by the end of phase 3.