Functional Rehabilitation after Achilles Tendon Rupture

Abstract

Optimal treatment of an acute Achilles tendon rupture remains controversial. There’s but a clear tendency that either treated conservatively or operatively, patients should start as soon as possible with early functional rehabilitation. It should include an early range of motion exercises and controlled weightbearing protocol with the support of crutches. Softcast brace is a simple, effective, removable, individually adapted, and well-tolerated orthosis, that can be easily made, if necessary, replaced or changed, and safely used during the healing process and if necessary, in the further rehabilitation period. Proposed rehabilitation protocol with the use of a softcast brace can be used either in conservatively or operatively treated patients, with comparable results in terms of complication rate (re-ruptures, thromboembolic events, sural neuritis) and long-term clinical (ROM, length of tendon) and functional results (return to pre-injured activities).

1. Introduction

Controversy regarding the optimal treatment of an acute complete Achilles tendon rupture (ATR) remains despite great interest and several articles in the last decades. Treatment can be broadly classified into conservative management with cast immobilization or functional bracing [1, 2, 3, 4, 5, 6] and operative management with open repair (with or without augmentation) [1, 2, 3, 5, 6, 7], or minimally invasive procedures with closed percutaneous repair [8, 9, 10, 11], or semi-open techniques [12, 13, 14, 15], with possible ultrasonography guidance [16, 17], or endoscopic control [18, 19, 20]. There are several postoperative rehabilitation protocols—traditionally, nonweightbearing, bellow knee cast immobilization is generally recommended for 6 to 8 weeks [1, 2, 6], that has changed in the last decades in mainly functional accelerated rehabilitation with functional bracing (including early ankle motion exercises and weightbearing) for the same period [2, 3, 4, 5, 13, 16, 21, 22, 23, 24].

Meta-analyses and quantitative reviews of the literature regarding the management of ATRs have shown that open-operative treatment was associated with a lower risk of re-rupture (pooled rate in the literature range from 1.4 to 5% [25, 26, 27, 28, 29, 30, 31, 32, 33, 34]) than nonoperative management (pooled rate of re-rupture in the literature range from 2.4 to 13% [25, 26, 27, 29, 30, 31, 32, 33, 34, 35]. Systematic review and meta-analysis of 10 randomized controlled trials involving 944 patients and 19 observational studies, including 14,918 patients showed a significant reduction in re-ruptures after operative treatment (2.3%) compared with nonoperative treatment (3.9%) (risk difference 1.6%; risk ratio 0.43, 95% confidence interval 0.31 to 0.60; p < 0.001; I² = 22%), but with significantly higher complication rate in operative than nonoperative treatment (4.9 vs. 1.6%; risk difference 3.3%; risk ratio 2.76, 1.84 to 4.13; p < 0.001; I² = 45%) [36]. The risk of complications could be possibly diminished by percutaneous repair (pooled rate of 26.1% in the open group vs. pooled rate of 8.3% in the percutaneous group) [30].

The concept of early dynamic functional rehabilitation has dramatically changed the results in a term of re-rupture rate, particularly in conservative treatment of ATR [4, 23, 37]. Meta-analysis of 10 randomized trials in 418 surgically treated patients and in 408 patients who underwent nonsurgical treatment showed that if functional rehabilitation with early range of motion (ROM) was employed, re-rupture rates were equal for surgical and nonsurgical patients (risk difference = 1.7%, p = 0.45), [37]. If such early ROM was not employed, the absolute risk reduction achieved by surgery was 8.8% (p = 0.001 in favor of surgery) [37]. Similar findings were also found in the largest systematic review and meta-analysis, with no statistically significant difference in re-rupture rate between operative and nonoperative treatment in studies that used accelerated functional rehabilitation (risk ratio 0.60, 0.26 to 1.37; p = 0.23; I² = 0%) [36]. The beneficial impact of early dynamic functional rehabilitation has been proven only by both, early weightbearing and ankle motion exercises [38].

2. Functional rehabilitation after Achilles tendon rupture

2.1 Immobilization and orthoses

According to the literature, there are several options available for functional treatment after ATR. Generally, they can be divided into different, mainly individually (custom) made splints, (semi)casts or orthoses from cast or different plastic materials and various special shoes, boots, or walkers (Figures 1 and 2) and prefabricated braces and orthoses, manufactured by different medical companies.

Figure 1.

Walker.

Figure 2.

Heel support.

As functional rehabilitation should consist of early weightbearing and range of motion (ROM) exercises, there are various solutions proposed for that among previously listed types of immobilization. In rigid types of semi-casts, at least two different casts should be made—first in the plantar flexion of foot for about 25 to 30 degrees and after 3 weeks in the neutral position. In the last decades, plantar flexion is recommended to be changed every second week— every time for about 10 degrees, so at the end of a period of 6-weeks of immobilization, a neutral position of the foot could be achieved, with gradually increased tension to the injured AT, what seems to bring a beneficial effect to the strength and therefore to lower re-rupture rate [23, 37, 39, 40]. In orthoses, made from softcast or soft-plastic materials, reduction of the plantar flexion of the foot to a neutral position can be gradually achieved with the softening of the orthosis with the increased weightbearing and thus providing all the time the increase of the tension to the injured AT, with the same possibly beneficial effect of reducing the re-rupture rate [39].

In various special shoes, boots, or walkers’ plantar flexion can be achieved with the added special heel lifts that can be diminished every week by 0.5 cm or every 2 weeks for 1 cm (Figure 2). Some of these special boots or walkers have a hinge at the level of tibiotalar joint, which can be locked in a desired position or can restrict plantar flexion at the beginning from 30 to 50 degrees and then gradually every week more, toward 0 to 50 degrees (Figure 3). With the addition of heel lift, early controlled weightbearing can be achieved, too.

Figure 3.

Walker with the locking mechanism.

2.2 Softcast functional orthosis

Simple, but effective and individually adjusted orthosis is presented on Figures 4–6. It can be used in conservative as well as in operative treatment, whether in an open or minimally invasive way. Generally, it’s applied with the foot at 25 degrees PF. Long stockinette (3 M, St. Paul, MN) (Figure 4) is dorsally covered with the splint, made of several (5) folded layers of Softcast (3 M, St. Paul, MN) (Figure 5). The splint is fixed with a folded stockinette or a simple (additional) bandage, which enables patients to perform PF and prevents dorsiflexion (DF) (Figure 6).

Figure 4.

Softcast functional orthosis—Preparation with stockinette).

Figure 5.

Softcast functional orthosis–folding stockinette.

Figure 6.

ROM exercises—Plantar flexion in orthosis.

2.3 Rehabilitation protocol

Patients are immediately allowed to walk with crutches in a toe-touch technique. In the next 2 to 3 days, they can carefully increase weightbearing (WB) to 5 kg and then every week for an additional 5 kg, reaching so 15 kg of weightbearing within first 3 weeks (about 25% of body-weight (BW)). They should be immediately encouraged also to perform ROM exercises, as much as their immobilization allows (Figure 6).

After a week, patients are allowed to take off and on brace during the day and to perform careful PF and DF between 25 and 50 degrees in a seating position (in water without orthosis). The useful tip should be recommended to the patients, to perform ROM exercises and weightbearing only until the pain is felt.

After 2 weeks, patients should be encouraged to continue with increasing weightbearing for 5 kg every week, continuously with gradation until pain is felt.

After 4 week, they can start with weightbearing as much as tolerated and if they have no pain, they can start to walk even without crutches but should be very cautious if walking on a wet or slippery floor. Softcast (functional) immobilization routinely softens with weightbearing, so there is no need to exchange this type of immobilization to achieve a neutral position of the foot. On the other hand, this is also a way of controlling patients about weightbearing.

Bilateral seated ROM exercises, with a progressive increase of dorsiflexion and force (pain) controlled pushing knee by hands (ankle down until pain is felt), should be encouraged according to the protocol in Table 1 to reach a neutral position of the foot within 6 weeks (Figures 6 and 7).

After 6 weeks, immobilization can be removed, and patients should start with the rehabilitation protocol (learned and controlled by physiotherapists). They may walk without crutches, with progressively increasing weightbearing (till tolerable pain). ROM exercises with increasing DF above the neutral position should also be performed carefully—it’s recommended till 8 weeks in the sitting position and if possible, in the water.

Special attention should be given to incorrect gait patterns. Generally, no additional heel pad or cushion is recommended. Patients should be encouraged to perform as much as possible exercises in the whirlpool, where full weightbearing is allowed.

Careful stretching exercises and controlled squats with a lifted heel could be started after 8 weeks with careful increasing of the load (until pain is felt). Full active dorsiflexion is expected to be reached after 4 months. Raising on toes or heels with the operated leg only is generally allowed 12 weeks after the operation. Sports activities should be carefully started and individually adjusted after 3 months, with recommended full loading 6 months after the operation. Steps in rehabilitation are summarized in Table 1.

Proposed early dynamic functional rehabilitation with softcast orthosis can be successfully implemented with conservative as well as other open, semi-open, or closed percutaneous methods, too, as there are no contraindications for this type of treatment.

Long-term results with the use of proposed early dynamic functional rehabilitation, together with the closed percutaneous repair under local anesthesia, can be compared to other methods of ATR in terms of complication rate (re-ruptures, thromboembolic events, sural neuritis, etc.) and long term clinical (ROM, length of tendon) and functional results (strength and return to pre-injured activities) [16, 39].

2.4 Functional rehabilitation program (never exceed pain)

0 to 1 week
Immobilization, Plantar flexion 25°	Crutches, Toe-touch/5 kg weightbearing (WB)	Gait control
1 to 2 weeks
Immobilization, Plantar flexion 20°	Crutches, 5–10 kg WB, bathing	Seated ROM exercises
2 to 3 weeks
Immobilization, Plantar flexion 15°	Crutches, 10–15 kg WB (20%BW)	Seated/pushing exercises
3 to 4 weeks
Immobilization, Plantar flexion 10°	Crutches, 15–20 kg WB (30%BW)	Seated/pushing exercises
4 to 5 weeks
Immobilization, Plantar flexion 5°	Crutches*, 20–25 kg WB (40%BW)(as tolerated)	Seated/pushing exercises
5 to 6 weeks
Immobilization, Plantar flexion 0°	Crutches*, 25–30 kg WB (50%BW)(as tolerated)	Seated/pushing exercises
6 to 8 weeks – starting with physiotherapy
No immobilization, Dorsiflexion+5°	No crutches, walking with weightbearing	Careful swimming
Control swelling (Ultrasonography, laser, negative pressure…), massage; Gait control / no limping, careful weightbearing on slippery surfaces; Pain controlled strength and endurance exercises (cycling, walking on treadmill, hydrotherapy)
8 to 10 weeks
Active dorsiflexion +10°	Walking with normal weightbearing	Bilateral raising on toes
Graduated resistance exercises (pain controlled) (skipping with leaning on hands, (light) cycling, treadmill…); Careful stretching, friction massage…; Proprioception exercises (controlled), NO jumping, sprinting, sudden loading, etc.
10 to 12 weeks
Active dorsiflexion +15°	Walking with full weightbearing	Gradual raising with OP leg
Progress of resistance exercises (pain controlled), (careful start—light sports activities, warming/stretching…)
12 to 16 weeks
Active dorsiflexion +20°	Fast walking, careful jogging, running	Raising on toes with OP leg
Pain controlled progress of resistance and endurance exercises, sports activities, eccentric exercises (retrain strength, power, dynamic weightbearing exercises…)(individually adapted according to progress)
After 16 weeks
Gradual return to sports activities—individually adapted—if no pain, increasing activities like running, jumping, sprinting, sudden loading, etc.
After 6 months
Generally, return to all sports activities (take care about tendinopathy /warming, stretching, strengthening)

Table 1.

Rehabilitation protocol in steps.

Figure 7.

Pushing knee in a seated position—Increasing dorsiflexion of ankle.

3. Discussion

Restoration of the length and tension of the ruptured AT with the return to preinjury activities with as less complications as possible should be the goals of the treatment of ATR. As in complete ATR, there always come to retraction of the triceps muscle. Consequently, a gap (elongated tendon) remains between torn ends, which heals in conservative treatment with fibrous tissue [16, 39]. Due to biomechanical characteristics of the musculotendinous complex, elongation of less than 0.5 cm seems not to affect AT function in basic daily activities but might be important in high-caliber athletes [16, 39, 41, 42, 43]. Open surgical repair enables restoration of the original length, together with tendon augmentation, but poses a higher risk for complications [5, 7, 16]. Percutaneous repair, particularly semi-open with the possible control of the length (Achillon® system (Integra Life Sciences Corporation, Plainsboro, NJ), PARS™ system (Arthrex, Naples, FL), Achilles midsubstance Speed Bridge repair variation (Arthrex, Naples, FL) [12, 13, 14, 15] or closed percutaneous repair with ultrasonographical control [10, 16, 17, 39], seems to bridge the gap, particularly with reducing the overall number of complications.

The results of studies support a beneficial effect of early functional rehabilitation with all types of ATR treatment. Wu et al. found in their systematic review and network meta-analysis of 2060 patients in 29 randomized controlled trials 7.41% of overall complication rates in the group of open surgery and accelerated rehabilitation in comparison to 8.47% in the group of minimally invasive surgery and accelerated rehabilitation, 12.09% in nonsurgery group and accelerated rehabilitation and 13.97% in nonsurgery group and early immobilization [44].

It has to be stressed that weightbearing and early ROM exercises before the healing of an ATR could have some detrimental effects, too. Eliasson et al. found in their study that ruptured AT elongates for 6 months after surgical repair regardless of early or late weightbearing in combination with ankle mobilization [45]. Kangas et al. and Mortensen et al. also showed separation of the tendon ends during the postoperative period and Lee et al. and Clanton et al. warned in their studies about gapping in cycling loading, which might cause tendon elongation [22, 46, 47, 48]. Weakness of plantar flexion strength, together with a deficit in heel-rise test in patients with ATR could therefore be explained with tendon elongation [49, 50].

Strength of the tendon repair with the resistance to elongation during loading could possibly have an impact on the final results, so generally with any type of operative treatment, the strongest repair should be considered [39].

Probably the simplest way to achieve the goals of accelerated rehabilitation (early weightbearing with early ROM exercises), could be the adjustment of all activities to the proportion of pain. Proposed kg of weightbearing in weekly intervals should probably serve only as a sort of general recommendation, which should be individually adjusted (according to body weight), as it has no sense to compare 5 kg of weightbearing in 100 kg body-weight man, with a lady of 50 kg body-weight.

Functional treatment with early ankle motion and early weightbearing might have an impact on the negative effect of immobilization and thus risk for deep venous thrombosis (DVT) and venous thromboembolism (VTE) [39]. There is but no clear consensus about the incidence of VTE and prophylaxis in patients after ATR and it seems that patient-specific risk factors for VTE should be assessed individually [51, 52, 53, 54]. The American College of Chest Physicians’ (ACCP) review recommends against chemical prophylaxis in lower leg injuries requiring immobilization [53]. Functional treatment and early ankle motion could support this decision easier.

4. Conclusion

Controversy regarding optimal treatment after ATR remains. There’s but clear tendency that either treated conservatively or operatively, patients should start as soon as possible with early functional rehabilitation.

Softcast brace is a simple, cheap, effective, removable, individually adapted, and well-tolerated orthosis, that can be easily made and safely used, together with the use of crutches, during the healing and rehabilitation process of the ruptured AT.

Long-term results support the choice of the proposed functional method for the patients with acute, complete ATR as the method that brings promising end functional results, with a low rate of complications.