Achilles Tendon Presented By Jared Romero Haley Bryson

Achilles Tendon Presented By: Jared Romero, Haley Bryson, & Justin Valdez

Overview of Injury • Thickest tendon in the body. 1, 2 • Connects gastrocnemius, soleus, and plantaris to the calcaneus. 1 • Commonly injured by sudden plantarflexion or dorsiflexion of ankle. 2

Risk Factors • Athletes, runners, basketball players. Older adults in high demand sports. 1 -15 • ~40 Years of Age 1, 3 -5, 7, 15 • Fluoroquinolone Antiobiotics and Direct Steroid Injections into the tendon. 3 • Previous Achilles Tendon injury.

Surgical Procedure • 2 Types of surgery to repair a torn Achilles. 4 -6 1) Open Surgery: Large, single incision. 7 2) Percutaneous Surgery: surgeon makes several small incisions rather than one large one. 8, 9

Rehabilitation: Phase 1 • Surgery to 4 weeks after surgery. • Precautions: o Avoid long periods of dependent positioning of the foot. 11 o Avoid excessive walking and standing § Rehab appointments are 1 -2 x per week § At end of phase 1: Goal is to have pain-free active dorsiflexion to 0 degrees.

Phase 1: Weeks 1 -4 • ROM Exercises o Foot stabilized o Active ROM exercises for toes, knee, and hip. o Elevate Leg • Stretching of the hamstrings, gastrocnemius, soleus and quad. • Straight Leg Lifts • Hip Abduction • Strengthening Isometric quad contractions Isometric knee extensions w/ ball

Phase 1: Cardiovascular Endurance • Stationary Cycle o With brace on, ride a stationary bike for 15 -20 minutes a session if patient is able to without any pain. • Upper Body Ergometer o Continue to work on conditioning through the rehab process. 15 -20 min a session.

Phase II Rehab: 4 -8 weeks • Goals o Begin weight bearing 11, encouraging normalized gait through all steps. 1 -3, 11, 12, 16 -18 o Increase ROM between 5° of dorsiflexion to 40° of plantar flexion 1 -3, 11, 12, 16 -18 o Maintain Upper and Lower body strength, using exercises from phase I. 1 -3, 11, 12, 16 -18 • Precautions o Slowly wean from the use of the boot 11 o Avoid over stretching the repair 1 -3, 11, 12, 16 -18 o Activities that have a high impact should be avoided o PROM should be gentle, do not push too far 1 -3, 11, 12, 16 -18 Rehab appointments are daily with an ATC; outpatient clinic is 12 x/week. 16 -18

Phase II Rehab: 4 -8 weeks • Treatment o If needed use of Grade I and II joint mobilizations at the talocrural joint, both anterior and posterior. o Use applicable modalities o Maintaining previous training levels 16 -18 • Stretching/ ROM o PROM at the foot and ankle o AROM dorsiflexion to 0° o Once patient is partial weight bearing they may begin using a BAPS board while sitting to increase AROM. 11 16 -18 1 -3, 11, 12, 16 -18

Phase II Rehab: 4 -8 Weeks • Strengthening o Continue to strengthen all other areas of the body o 4 -6 weeks isometric ankle exercises in all directions o 6 -8 weeks add light resistance bands at the ankle in all directions 16 -18 11, 12, 16 -18 • Cardiovascular Endurance/ Gait o As the patient becomes partial weight bearing begin walking in the pool. 12 • Goal: normalized gait • Once gait is normalized, power walking can be added for 30 mins per session. o Continue to use UBE and add the stationary bike o Work on proper gait technique, out of the water. 12 1 -3, 11, 12, 16 -18 1 -3,

Phase II Rehab: 4 -8 weeks • Proprioception o Begin single leg stance on uninjured leg o Double leg standing with eyes closed when FWB permitted o Tandem stance on floor 16 -18

Phase III: 8 -12 Weeks • Goals o AROM between 15° of dorsiflexion and full plantar flexion 16 -18 o Single leg heel raise with good control for 10 seconds 16 -18 o Decrease pain with functional movements 16 -18 o Full weight bearing 16 -18 o Increase strength and endurance 16 -18 • Precautions o Limit forceful impact activities until approx. 12 weeks. 1 -3, 11, 12, 16 -18 o Avoid activities where over compensation may occur 1 -3, 11, 12, 16 -18 Rehab appointments are daily with ATC; 1 x/ week outpatient setting 16 -18

Phase III: 8 -12 Weeks • Stretching/ ROM o Use foam pad to increase ROM and stretch (proprioception) o Use grade III and IV posterior joint mobilizations as needed to increase mobility for dorsiflexion. o Dorsiflexion door stretch (strength) • Strengthening o Continue the use of tubing in all directions, increase reps at first then increase resistance o Begin doing bilateral heel raises; start unilateral around 10 weeks o Standing squats w/ ball o Lunges & Reverse Lunges 1 -3, 11, 12, 16 -18 1 -3, 11, 12, 16 -18

Phase III: 8 -12 weeks • Cardiovascular Training: o Continue to use the stationary bike/ power walking in the pool (week 8) • 30 minute warm up per session o Progress to: • Elliptical (week 9) • Rowing (week 10) • Power walking on the treadmill or jogging in the pool (week 11) • Jogging may start at week 12. 16 -18

Phase III: 8 -12 weeks • Proprioception o Tandem Stance o Balance board o Bosu ball tandem stance o Progress to single leg once single leg raise can be done: • Single leg stance on bosu ball • Single leg stance on half foam roller 16 -18

Phase 4: 12 weeks to completion of Rehab • Goals: o o o Jogging without pain for 2 miles. Maintain regained ROM Functional and sport specific movements with no pain. Plyometrics without pain. Return to play with no pain. • Precautions: o Ease into more impacted movements. o Progress only when pain is absent. o Avoid overcompensation.

• Stretching/ROM Phase IV o Full ROM should be present prior to this phase o Maintain ROM with slant board work in Phase III each day prior to phase IV work. • Strengthening o Patient will progress from heel raises by adding ankle weights to increase resistance. o Continue with lunges but add weight as necessary

• Plyometrics Phase IV o Once able to complete weighted heel raises progress to double leg hops. o Progress to single leg hops. o Progress to lateral double leg hops. o Progress to lateral single leg hops. • Cardiovascular Endurance o Patient must be able to jog on a flat surface for up to 2 miles with no pain in order to progress to next level of running drills. o Weeks 12 -14: strict jogging. o Weeks 14 - finish: Sprinting will be added.

• Speed Phase IV o Body weight sprints of short yardage is required o build up to maximal effort by rehabs end o Sprints should be between 10 and 30 yards • Power o Power will be regained by taking simple movements such as the squat or a single leg skip and making it explosive o Squat jumps o Power skips • Agility o Figure 8 cone drills

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