Guest blog by Heidi Mills BSc (Hons) GSR – a Graduate Sports Rehabilitator who writes for www.sportsinjuryclinic.net.
The achilles tendon is the thick tendon which can be felt at the back of the ankle. It attaches the two main calf muscles (Gastrocnemius and Soleus) to the heel bone and transmits the forces they produce to the foot. It is a vital structure for all activities which involve pointing the foot down or rising up onto the tip toes, including walking, running, and jumping.
The achilles tendon can be ruptured either partially or fully. In this article, we’ll address the full tear.
Ruptures occur most commonly in men between the ages of 30 and 50. The achilles can rupture from a relatively insignificant movement and often causes a very loud pop or bang noise when it tears which can be quite alarming.
Whilst levels of pain are variable and often full ruptures are less painful than a partial tear, the most noticeable symptom is a lack of function and difficulty walking. A gap can often be felt where the tendon should be and firmly squeezing the calf muscles results in no ankle movement.
Treatment Options
After an achilles tendon rupture there are two options for treatment: Surgical repair or conservative treatment without surgery. There are numerous reasons why an individual may choose to undergo surgery or to steer clear of it. Here are the most pertinent factors when it comes to making that decision:
- Activity levels – A highly active individual is more likely to go for surgical repair than someone more sedentary.
- Re-rupture risk – Surgery has a 10% lower risk of re-rupture than conservative treatment.
- Risks – Surgery carries risks of infections, adhesions and disturbed skin sensitivities.
- Timescales – Return to jogging within 4 months following surgical repairs; Return to jogging after non-surgical treatment may not be for 6-9 months.
Post Surgery Rehabilitation
The exact protocol following achilles repair varies slightly depending on your surgeon’s preferences. But generally the ankle is immobilized in a cast using crutches to prevent weight bearing for the first two weeks following surgery.
After this period the cast is replaced by a removable boot or brace which allows the patient to perform exercises and begin partial weight bearing. The boot or brace will usually have a small (1”) heel raise to reduce the stretch on the healing tendon. This is used for a period of around 6 weeks, after which time the patient can remove the brace and gradually introduce full weight bearing.
Ankle exercises can begin after just two weeks of immobilization. Initially these are mobility exercises to regain full movement of the ankle. Strengthening and proprioceptive exercises can begin at 6 weeks post surgery.
Rehabilitation without Surgery
When the conservative route is taken, the ankle is again placed in a cast, using crutches to avoid weight bearing for around 8 weeks. During this time the cast may be changed to a boot or brace which allows partial weight bearing. Initially the ankle is immobilized in a plantarflexed position (foot pointing downwards) to shorten the tendon and allow the two ends to knit back together. Over time the position of the ankle is moved further into dorsiflexion to start to stretch the tendon back to its normal position.
Ankle exercises usually start a little later during the conservative protocol, as the ankle needs to be immobilized for longer to allow the tendon to heal itself. The progression of rehabilitation tends to also be slower to reduce the risk of re-rupture, hence the recovery period being considerably longer.
Exercises
Time periods of when exercises can begin and how rapidly they can progress may be different between surgical and conservative treatment methods. But regardless of the treatment method, the same exercises can be used.
Here are some examples of recommended exercises to regain full movement, strength, and balance of the ankle following an achilles rupture.
- Mobility. Gentle ankle mobility exercises can begin with ankle pumping (plantarflexion and dorsiflexion) and then ankle circles. These should be performed several times a day and start with small movements and progressing to larger movements as the ankle warms up. Stretching exercises for the calf muscles and achilles tendon can be performed, although should be performed with care and only once ankle circles and pumps are comfortable. Start sitting on the floor with the legs out straight holding a towel looped under the sole of the foot to pull the foot up towards you.
- Strengthening. Strengthening of the calf muscles and achilles tendon should start with isometric contractions which may also be known as static contractions. The patient attempts to push the foot down against resistance provided by a therapist, friend, or static object such as the floor or a wall. There is no movement at the ankle during these exercises, but the calf muscles contract as the patient pushes. Calf strengthening can be progressed before full weight bearing is permitted using resistance bands to provide resistance as the patient moves through the full range of plantarflexion. Seated heel raises are also ideal at this stage. Once full weight bearing is allowed, calf raises can be performed, first bilaterally (on two legs), adding small handheld weights to increase difficulty, and then progressing to unilateral (single leg) raises.
- Balance (Proprioception). After such an injury, the sense of balance and positioning at the ankle (known as proprioception) is diminished. This sense can be retrained using simple exercises, once full weight bearing is permitted. Start with a simple single leg balance, holding for as long as possible. Ensure there is something close by that can be grabbed if balance is lost. This exercise can be progressed by adding arm movements or small knee bends. Wobble boards, cushions or rocker boards are also ideal pieces of equipment for improving Proprioception.
- Functional Exercises and Return to Sport. Once daily activities are comfortable and full movement has been regained, the focus can shift to more functional and sports based exercises. These tend to be more dynamic and mimic movements that are required to perform occupational or sporting activities. Examples include lunges, jumping, bounding, and hopping. Pieces of equipment such as agility ladders and mini hurdles are ideal for training sessions, to get the ankle used to performing these movements again, before returning to sport for real!
