Achilles tendon repair

Description

The Achilles tendon connects the calf muscle to the calcaneus (heel bone) and is one of the body’s most important tendons. The main function of the Achilles tendon is plantar flexion of the foot. Common pathologies include: tendinopathy tear or rupture. Examples of Rupture Damage Mechanisms These include: strong plantar flexion of the ankle in a fall (eg, knee extension during jumping) or arresting the fall with the foot during a fall [1]. Clinically they show increased gaps palpable on palpation passive dorsiflexion lack of heel elevation and Thompson positivity test [1]. Achilles tendon ruptures can be treated conservatively with a plaster cast or with Achilles tendon repair surgery.

For more detailed information on Achilles tendon ruptures, visit this page.

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Conservative vs Surgical Intervention

There is much debate in the literature regarding the management of Achilles tendon ruptures and there are two options, conservative or surgical. Numerous studies have shown that re-rupture rates are higher when treated nonoperatively. recent research shows Rerupture rates are equal or increased compared to surgical intervention [3] [4]. However, many go on to receive surgical repairs, and physiotherapists will continue to see them in their clinics for post-operative rehabilitation.

Visit the Achilles tendon rupture page for information on conservative treatment.

Pre-op

General edema-reducing interventions (rest, ice, compression, elevation) should be used prior to surgery. Surgery is best done within a week of the rupture.

Surgery Description

Many techniques exist for this procedure, including transverse medial and longitudinal incisions. Place the ankle in a neutral position and suture the severed ends of the tendon together. The surgeon will then view the ankle through its full range of motion to see the integrity of the ankle repair. Casts are often used with the surgical technique that determines how long the cast remains [5]. Many surgeons are now focusing on early weight bearing and passive movement to improve tendon healing. A new minimally invasive technique involves utilizing the peroneal brevis muscle through two routes Quasi-midline incision. This technique has been reported to preserve skin integrity at the sites most prone to rupture in open reconstruction with a vertical incision. [6] Another study suggested percutaneous repair for recreational athletes and patients concerned with cosmetic and open repairs High-quality athletes who can’t afford any chance of another breakup. [7]

Post-Op

Early mobilization after Achilles tendon repair has been reported to facilitate postoperative recovery and improve tendon vascularity. Despite growing support for accelerated rehabilitation systems, there is still no consensus on the most desirable options. Protocols were developed by Brumann et al. [8] and Braunstein et al. [9].

See the following clinic protocols:

• Fowler Kennedy
• Indiana Total Therapy
• Ballart orthopaedics 

Dutton [5] described three stages of rehabilitation after Achilles tendon repair.

Phase I

Phase I typically lasts three weeks.

Goals of this phase are as follows:

• Control edema and protect the repair site
• Minimizes adverse effects of scar adhesion and fixation
• Progression to full weight bearing as tolerated/indicated
• Pain 5/10 or less Strength 4/5 All lower body muscles except plantar flexors

Phase I interventions include:

• Modalities for pain and oedema
• Week 3 Increased Stretching of Gastrocnemius/Soleus Muscles of Large Lower Body Muscle Groups
• AROM: plantar and dorsiflexion 3×5; 3 times a day; add varus and valgus at week 2
• Foot/Ankle Isometrics Week 2; Band Practice Week 3
• Lower body proprioceptive training; gait training
• Upper extremity cardiovascular exercise
• Joint mobilization and soft tissue work as shown

Phase II

The second stage usually begins 4-6 weeks after surgery.

Goals for this phase are as follows:

• Normalized gait pattern
• Full ankle ROM
• 5/5 lower extremity strength
• Return to full ADL ability
• Pain reported to be <2/10
• Equivalent to proprioceptive responses on the non-operated side

Phase II interventions include:

• Ankle flexibility at various knee angles
• Progressive Closed Kinetic Chain Lower Limb Strengthening
• Cardiovascular progression
• Proprioceptive training on various surfaces
• Manual resistance exercises and joint mobilization as shown

Phase III

Phase III usually begins 6-15 weeks after surgery.

Goals for this phase are as follows:

• Initiate running program
• Improve balance and coordination
• Increase velocity of activity
• Return to sport

Phase III interventions include:

• Progressive ankle and lower body strengthening
• Agility exercises
• Double heel raise/lower progresses to single leg heel raise at various speeds

A recent systematic review by Brumann and colleagues (2014) [10] identified an updated rehabilitation protocol for Achilles tendon repair. They summarized their findings with the following guidelines;

Week 0 – 2

• Nil ankle RoM
• Orthosis fixed at 30° of PF
• Progress to full weight bearing (FWB)

Week 3 – 6

• FWB
• Active ankle RoM 0-30°
• Orthotics limited to plantar (0° DF) to 30° PF

Week 7+

• Full ROM
• Nil orthosis