Typical Patient
Melanie McNeal, PT
[email protected]
Key to Rehab
Strengthen healing tendon while maintaining
integrity of repair
Tendon lengthening - if rehab method does not
provide adequate restriction of mvt during early
phases
Tendon re-rupture occurs when too much load is
applied through the tendon before it is healed.
Research: Sx vs
Conservative
Open surgical repair 4.4% re-rupture rate vs
10.6% in non surgical group
Highest rate of re=rupture was in those
managed without surgery and placed in
cast
Surgery results in more complications than
conservative mngmt including wound
infection, altered sensation, and adhesions
PARS repair offers no reduction in re-rupture
rate but did have fewer post-op infections
Jones et al, 2012
Male
Middle aged
Active in recreational sports
Weekend warrior
Clinical Guidelines AAOS:
Tx of Achilles Tendon
Rupture
Chiodo et al, 2010
Moderate recommendations:
Early (2 wks or before) protected post-op WB
Use of protective/orthotic device that allows
mobilization by 2-4 wks post-op(no consensus on
which devices to be used, how much PF should be
maintained in the device, and how long it should
be worn)
Research: Short term
Outcomes
(Olsson et al 2014)
Higher functional outcomes in patients that
can perform SL heel raise at 12 weeks postop
Only 49% of patients could perform at 12 wks
Predictors of decreased function:
Increasing age
Higher BMI
Higher pre-injury physical activity level
Research: Endurance
Deficits
Calf muscle endurance deficits anywhere from 12-
48% at 1 year post injury (Don et al 2007)
Deficits in repetitions and distance travelled when
performing SL calf raises following ATR at 6 and 12
months (Silbernagel et al, 2010)
Major functional deficits exists at 2 years following
rupture (Olsson et al 2011)
Impaired calf muscle endurance at 1 yr post ATR
(Bostick et al, 2010)
Resting pain at 3 mo, male, decreased ability to perform SL
calf raises at 6 mo : delayed recovery at 1 yr
Possible explanation: increased tendon length causing
suboptimal length-tension relationship at
musculotendinous junction
Research: Elite athletes
Research: Altered Running
Mechanics (Silbernagel et al, 2012)
23 y/o F, rec athlete; running analysis, ATR 4 wks later
1 yr postop c/o only minor limitations and resumed N
running routine BUT differences seen unI vs I:
Decreased heel rise test: 12 rep difference, 5cm difference
in ht
Decreased peak PF torque: isometric and isokinetic
Increased DF ROM: 5 deg difference
Resting PF position: 11 deg vs 21 deg
Increased tendon length as shown on US: 20.6 vs 16.5 cm
Running analysis post-op: increased DF, eversion and
abduction were seen at postop analysis vs preop
Attributed to limited power in PF (results in increased
mvt/decresaed stability in other planes) and and lengthened
tendon
Resulted in: increased loads on knee and post tib
Research: Predicting Outcomes
Parekh et al, 2009
Return to Activity postop ATR (Saxena et al,
2011):
32% professional football players unable to
return to sport following ATR
Of those who did, greater than50% reduction
in power ratings compared to pre-injury
Casted for 2 wks postop then boot worn only 4 wks
RTA determined by
Ability to perform 5x25 SL calf raises
Calf circumference equal to 5mm or less difference side
to side measured 10cm distal tib tub
Ankle DF and PF ROM within 5 deg of nonop ankle
For acute ATR: RTA was anywhere from 12-26 wks
postop
Better clinical outcomes are reached when less
tendon elongation occurs (Kangas et al, 2007)
Research: Outcome Measures
The Achilles tendon Total Rupture Score is valid,
reliable, and sensitive self reported outcome
measure in patients following tx for ATR
(Nilsson-Helander 2007, Kearney 2012)
10 questions
Score from 0 (major limitations/symptoms) to 10 (No
limitations/symptoms)
Victorian Institute of Sport Assessment –
Achilles questionnaire (VISA-A): valid and
reliable to measure severity of Achilles
tendinopathy (Robinson et al, 2001)
Questions remain…
There is no consensus regarding protocol
following surgery in terms of:
How soon can safely initiate WB postop?
What is safe ROM postop to prevent stretching repair?
How long should protect weight bearing?
What is the correct/optimal protective orthotic?
What is proper amount of functional loading?
When can safely initiate SL calf raises
What size and how long should heel lift be used when
out of boot or should one be used at all
What functional objective measures should be
attained to safely initiate jogging/jumping/RTA??
Inform your patients:
Immediately postop: stress importance of not stretching out
repair
Do not walk flat footed
Do not pull foot up into DF
If stretch out repair, will NEVER get strength back and will NEVER be
able to return to desired level of function
Worse thing patient can do is keep foot immobilized
Higher incidence of DVT and re-ruptures and increased atrophy
Better to be stiff when allowed to ambulate in N shoe than to be
too loose: can always increase ROM; can never tighten stretched
out repair
Compression sock helps decrease effusion
Tendon will never be same size as other side
Purchase gel inserts and stack on top of each other when
transition to shoe and wear on both sides
Up to 6 months post-op not uncommon to have some numbness,
minor aches and pains, not feel “Normal”
Various boot types
VACOPED
Protocol for Kevin Varner,
MD
Postoperatively pt is NWB in splint for 10-14 days
PT is initiated when splint is removed
Pt is placed in walking boot and allowed WBAT
when splint is removed
If not using Vacoped boot, while have lift in boot
maintaining equinus
Boot is worn 6-8 wks depending on sex (Females
6 wks bcs can wear wedge shoes)
Pt transitioned to regular shoe with 2-3cm heel
insert which will be worn for approximately 1
month
Changing degree of PF
Description:
A self-adjusting vacuum
cushion conforms to the
patient's anatomy and in
conjunction with a rigid
lattice frame provides castlike stabilization
Can simply remove the sole
and/or replace it
Can change PF ROM in 5
degree increments
Can set fixed ROM or allow
specific range (i.e., 30-15deg)
Traditional Aircast WB
REHAB: PHASE ONE IN BOOT
PHASE ONE EXERCISES
REHAB: 6/8-12 WKS
Scar mobilization
Active inversion/eversion
Biofeedback PF
Seated marble pick up avoid heel contact
Progression allowed if pain free:
Bridge on balls of feet: B to marching
Seated calf raises limited range
Phase Two Exercises
AlterG
ROM:
Post talar glides and subtalar distraction to
increase DF as needed
Active DF with TB
Gait training: in shoes
Weight shifting
Single leg balance
Tandem walking: floor to unstable surface
Cone walking: forward and side step
Alter G
Phase Two Exercises cont’d
Phase Two Exercises cont’d
Strength:
Proprioception
Single leg bridge on balls of feet
B calf raises
Calf raises on leg press with knee ext and flexion
Seated calf raise machine
Step ups: increase height and alter surface
Squats to chair
Bridge on swiss ball
SL dead lifts
Sidestep with theraband around ankles
Single leg Balance: floor, eyes open/closed, Airex,
BOSU – both sides
TB 4 way kicks progress to cable column, change
surface
Tandem walk: floor to airex; on balls of feet
Plyotoss: vary surface
Return to Function
Exercises
Return to function
exercises
Dynamic warmup
High knees, backpedal, shuffles, grapevine,
tapioca
Quick feet
Jump rope
Box jumps
SL hop for distance, triple hop for distance,
timed lateral cone hop
Figure 8 run