Achilles ruptures - striking a chord of fear for any athlete or weekend warrior, these injuries are slow to rehabilitate and take a big investment in strength and in looking after them the right way. Having recently been approached for a second opinion on a couple of Achilles rehabs that have not gone to plan, and having seen a number of these injuries from immediately post injury working in the Emergency Department, through to early rehab and ultimately back to playing professional level sport, I wanted to provide some information for those of you faced with this challenge. I also want to dispel a couple of myths, and show that there is light at the end of the (long) tunnel!
If you've ruptured your Achilles, you'll be faced with two options - conservative management (i.e. no surgery) or surgical management. It might seem strange that you could recover from an Achilles rupture without surgery, but there is an increasing amount of evidence that non-surgical management can result in good outcomes, similar to those who have surgery. However there are several individual factors that influence the prognosis here (age, sex, sport, level, goals) and as such it is important to get an opinion from an orthopaedic surgeon as to what may be a better decision for you.
Surgery for Achilles rupture involves, in a very blunt way of putting it, suturing (stitching) up the margins of the tendon, bringing the injured ends of the tendon together and bundling the tendon up like a Christmas ham (apologies to the orthopods out there for the crude description!). The tendon is then brought into a shortened position - with the foot and ankle pointing down - to allow healing of the tendon. Nonsurgical management often sees you placed in an equinus cast (foot pointing down) for 2 weeks followed by a bracing regime in a boot.
Surgery or not, the next 6-10 weeks is spent in a cast or boot, commencing with the foot in the plantarflexed position (foot down) to keep the free ends of the tendon together and give them a chance to heal. You gradually progress your range of motion towards neutral (ankle at 90degrees) over this time period. Depending on your specialist's preference the amount of weight you can put down, and the extent to which you are allowed to load the tendon, is highly variable. And this is where the interesting part begins (and where I think, for some people, it goes wrong).
The more recent evidence is consistent with a theme that seems to echo across the body - when patients start to load (strengthen, move) healing tissues earlier, provided you do it in the right ranges and at the right intensity, patients get good outcomes without additional risks. See a couple of links HERE (great recent review paper by Aujla et al) and HERE for examples of what current research is showing us. So as a physiotherapist, I like the idea of encouraging gentle, sensible loading of the Achilles from an early point - if we can start basic strengthening exercises such as isometric holds in an inner range (shortened) position of the tendon from about 4 weeks post injury or surgery, I believe we are encouraging tissue healing and strengthening. I've managed a rehab for a professional rugby union prop who started his strength program at the four week mark, even though he was in the boot at other times, who went on to have a really successful return to rugby the next season.
One of the most common things we see after an Achilles repair is the tendon losing its 'stiffness'. This might sound like a good thing, but it isn't. A tendon's job is to transfer force, to be a stiff spring, and almost without fail the tendon lacks the same tension after a rupture - regardless of whether or not you have surgery. Therefore, the primary goal of rehab should be to maximise this tendon spring, and below is what I consider critical in avoiding a tendon that is too lengthened, or lacks strength:
- protection early on. This means following the specialist's advice very closely in regards to slowly increasing the range of motion (stretch) you expose the tendon to. This is done with the use of a boot that can be gradually altered from a position of plantar flexion to neutral over 6-8 weeks.
- AVOID STRETCHING IT in the early stages! I can't say this loudly enough. Often the first thing patients get told as they are coming out of the boot is to start stretching it. Terrible idea, for the reasons I've stated earlier about the spring function. You should be guided by your physiotherapist and specialist as to when and to what extent you should mobilise (stretch) your Achilles.
- early loading of the tendon. STRENGTH OVER STRETCH. The evidence is pretty clear - our tendons (and muscles, and bones, and cartilage, and just about anything else for that matter) need to be loaded if the collagen fibres (the base building block of our tendons) are going to heal in a well aligned manner. This is what will determine the outcome of your rehab. If you were to go through rehab without strengthening the tendon, you would end up with weak, poorly aligned collagen through the tendon, and a poor outcome as the result. Strengthening should start with the ankle in a plantarflexed (foot down) position, to make sure the tendon heals with a degree of stiffness. GET ADVICE on this program - Dr Google is not an appropriate source of information.
- work on your mechanics. When you come out of the boot you won't know how to walk properly. You'll need to retrain your gait pattern, rebuild lower body strength and proprioception (balance) and gradually build up your walking distances and exposure. Just because your specialist says you can take your boot off doesn't mean you'll be ready to throw it away - usually it takes a couple of weeks to wean out of the boot.
As you move past the first month or two out of the boot, you will need to progress into more challenging exercises. If you're coming back to some sort of demanding sport or task, you'll need ongoing advice about how to progressively strengthen your tendon. You'll need patience - improvement is slow and it takes a very long time to get back a decent amount of calf bulk, strength and power - and it usually is never quite as good as before the injury. HOWEVER - provided you follow a good program, you've got a good chance of getting back to running, sport, and getting on with your day to day life without this being a problem!
If you've had an Achilles rupture, it is a tough injury and I wish you all the best in your recovery. Hopefully this gives you some guidance on what to expect and how to approach your rehab, and a physio clinic that you know will look after your Achilles rehab in the best possible way!
Ben Mather | APA Musculoskeletal Physiotherapist
Stack St Physio | Fremantle WA