A plantar splint is worn postoperatively to prevent dorsiflexion of the foot to avoid re-breaking of the repaired tissue. Some prefer to use a tubular cast or anterior splint. A postoperative long-leg cast is often used for three weeks, with the knee flexed at 60° or straightened and the ankle plantarflexed at 20° to 30°. After three weeks, a short-leg cast is used for immobilization.
After the wound is removed in 10-14 days, the affected limb can wear a fixed boot with a gurney to allow for wound inspection and early joint movement.
Rehabilitation overview
Rehabilitation begins 2 to 6 weeks after surgery
Normal ankle mobility must be understood prior to rehabilitation
Post-operative rehabilitation after Achilles tendon rupture repair is divided into the following phases.
I. First postoperative phase: protection and healing period (week 1 to 6)
Objectives
Protect the repaired Achilles tendon
Control edema and pain
Reduce scar formation
Improve dorsiflexion mobility to neutral position (0°)
Increase proximal lower extremity muscle strength in all groups to grade 5/5
Progressive weight-bearing under medical supervision
Independent completion of home training program
Precautions
Avoid passive stretching of the Achilles tendon
Active ankle dorsiflexion in 90° of knee flexion should be limited to a neutral position (0°)
Avoid heat application
Avoid prolonged hyperextension
Therapeutic measures
Progressive weight-bearing in a gurneyed stationary boot when using an axillary cane or walking stick under medical supervision
Active ankle dorsiflexion/plantarflexion/inversion/extrusion
Massage of the scar (gentle lateral massage of the Achilles tendon after 3 weeks)
Joint release
Proximal muscle strength exercises (knee flexion/extension and quadriceps strength exercises)
Physical therapy (ultrasound, extracorporeal shock wave)
Cold therapy
Advancement criteria
Pain and edema are under control
Weight-bearing under medical supervision
Ankle dorsiflexion in neutral position (0 °)
Proximal muscle strength of lower extremity reaches grade 5/5
Second stage of postoperative period: early joint movement (6th to 12th week)
Objective
Restore normal gait
To restore sufficient functional joint mobility to meet the requirements of normal gait (15° ankle dorsiflexion) and step-up (25° ankle dorsiflexion)
Restore ankle dorsiflexion, inversion and valgus strength to normal 5/5
Precautions
Avoid pain during therapeutic exercises and functional activities (Achilles tendinitis)
Avoid passive stretching of the Achilles tendon
Therapeutic measures
Weight bearing to full weight bearing gait practice with protection and pain free abduction
Underwater bicycle system for gait practice
In-shoe heel pad to help restore normal gait (approximately 3 cm, gradually lowered)
Active ankle dorsiflexion/plantarflexion/inversion/eversion exercises
Proprioceptive training
6 weeks postoperatively: progressive resistance ankle plantarflexion/dorsiflexion exercises in 90° knee flexion
Isometric/isotonic exercises; ankle inversion/eversion
Plantarflexion exercises with leg flexion device and foot pedal device in knee extension position
8 weeks postoperatively: progressive resistance ankle plantarflexion/dorsiflexion exercises at 0° knee extension
Bicycle exercise (heel force – forefoot weight bearing – progressive increase)
Lettering on a multi-axis device on foot
Reverse bicycle walking
Physical therapy
Scar massage
Step forward exercises (10cm, 15cm, 20cm)
Advancement criteria
Normal gait
Adequate passive ankle dorsiflexion angle (20 ° )
Ankle dorsiflexion, inversion, and valgus muscle strength up to unassisted muscle strength assessment level 5/5
Third postoperative stage: early muscle strength exercises (week 12-20)
Objective
To restore full range of active joint mobility
Achieve normal ankle plantarflexion strength of 5/5 (ability to lift heel 10 times on one foot)
Restoration of normal balance (assessed by NeuroCcom or Biodex balance system)
Restoration of pain-free functional movement
Ability to step down
Precautions
Avoid pain during therapeutic exercises and functional activities (pain-free principle)
Avoid high loads on the Achilles tendon (i.e. excessive dorsiflexion of the ankle or jumping under the entire body weight)
Therapeutic measures
Isotonic/isometric inversion/external rotation exercises
Stationary bike, training ladder, Versa climbing exercises
Proprioceptive training: proprioceptive plate/BAPS/foam roller/spring mat/NeroCom
Strengthening ankle plantarflexion progressive resistance exercises (emphasizing centrifugal movement)
Sub-polar specific motor skills exercises
Progressive proprioceptive exercise program
Underwater bicycle system running exercises
Lower extremity proximal muscle strength exercises (progressive resistance exercises)
Isometric project exercises (strengthening muscle strength and endurance around the ankle joint)
Flexibility exercises required in activities
Forward step exercises (10cm, 15cm, 2cm)
Advancement criteria
Perform activities of daily living without fear
Normal flexibility
Adequate muscle strength as demonstrated by the ability to lift the heel 10 times on one foot
Reciprocal step-down exercises
Symmetrical lower limb balance ability
Fourth postoperative stage: late muscle strength exercises (20th to 28th week)
Objective
To be able to complete forward running activities on the bicycle comfortably
Achieve 75% of the average peak torque measured at isometric speed
To be able to meet the maximum muscle strength and flexibility required for activities of daily living
Return to unrestricted functional activities
To be able to perform higher levels of physical activity without fear
Precautions
Avoid pain and fear during activity
Avoid running and sports activities until sufficient strength and flexibility are achieved
Therapeutic measures
Start forward running exercises on the bicycle
Isometric evaluation and training
Continue lower extremity strength and flexibility exercises
Interference with lower advanced proprioceptive training
Mild functional reciprocal movements (jumping exercises on both feet)
Continued strengthening of plantarflexion progressive resistance exercises (emphasis on centrifugal movements)
Submaximal physical skill practice
Continued bicycle, training ladder, Versa climbing exercises
Continued strengthening of proximal lower extremity muscle strength exercises (progressive resistance exercises)
Advancement criteria
Pain-free running ability
Isokinetic determination of average peak torque of 75%
Normal flexibility
Normal muscle strength (all muscle strengths of the ankle joint are 5/5)
Sports-specific exercises without fear
V. Fifth postoperative stage: full recovery of sports skills (week 28 to 1 year)
Objective
Play sports without fear
To be able to meet the maximum muscle strength and flexibility required for individual sports activities
Vertical jumping assessment of the affected limb up to 85% of the healthy side
Isometric strength assessment of the affected limb up to 85% of the healthy side (plantarflexion/dorsiflexion/inversion/extrusion)
Precautions
Avoid pain during therapeutic, functional and sporting activities
Avoid all sports until adequate muscle strength and flexibility are achieved
Therapeutic measures
More advanced functional training and flexibility exercises
Functional reciprocal movements
Sport-specific exercises