Surgical management post-achilles rupture
In the last blog we discussed achilles ruptures and conservative management
. As mentioned in the last post, we have seen an up-tick in achilles ruptures presenting to us lately. We suspect this is linked to a return to team sport and explosive loading of the achilles post covid. Running, jogging and walking don’t load the achilles in the same way as jumping, landing and explosive acceleration. As such, a return to team and court sports can be a shock to the system. Today we will discuss surgical management post- achilles tendon surgical repair. Refer to the previous Achilles management blog for the early management advice.
Achilles tendon surgical repair verses conservative management
There are many factors to consider regarding achilles surgery vs conservative non-surgical repair. It is a decision that should be made with as much information as possible, involving discussions with your physio, your surgeon and your GP. As a rule of thumb, surgical achilles repair is often preferred for younger athletes. This is especially so in those who have a desire to return to sport. This is even more so if the sport requires explosive speed and acceleration.
Achilles surgery rehab at the Movement Centre
If you present to Movement Centre Randwick with a torn or suspected torn achilles, we will advise you to consult with a surgeon as soon as possible. Regardless of the path taken, consultation with a surgeon is generally necessary to ensure all possible options are considered and analysed for best management. We have surgeons locally that we have worked with who we are happy to recommend. And we are always happy to ask around for further recommendations so our patients can get timely and convenient care. Most surgeons recommend early presentation for assessment – generally within the first week or so post-injury. In that time, the patient should be completely non-weight bearing – using crutches for mobilising.
- The surgeons we recommend are generally happy to see patients without a GP referral. The need for expediency often makes seeing a GP prior to the surgeon difficult.
- At the consultation with the surgeon, they will confirm the presence of an achilles rupture, and discuss with you the pros and cons of achilles surgery.
- The achilles repair surgery involves sewing together the two ends of the achilles. The ease of this depends on the type of the tear, the quality of the tissue, and the degree of retraction of the torn ends.
Post-op the patient is usually placed in a plaster cast for 2 weeks and instructed to not bear any weight through the foot during this period. The foot is placed in a plantar flexed position for this initial period to allow the achilles to commence healing without too much stretch or strain.
Post-op the surgeon will provide you with pain relief. Patients will usually also be provided with some blood thinning medication to prevent clotting in the calf during the period of immobility.
- 2 weeks onwards – initial recovery
After 2 weeks the cast is removed, and the patient is put in a boot. This is usually a very specialised boot provided by the surgeon. The boot controls the angle of the ankle, and allows for small adjustments to be made throughout the recovery. Crutches are often still necessary for the first few weeks in the boot. Weight bearing is gradually progressed to reintroduce load through the achilles. During the time in the boot, the physiotherapist will often commence some very gentle strength work. There is usually no stretching of the calf / achilles during this phase of the rehabilitation. This is due to a desire to protect the repair site, but also a desire to prevent excessive loosening of the achilles. There is a concern that too much stretching here may impact explosiveness further down the line.
- Out of the boot
The patient can often come out of the boot between 6-8 weeks post achilles surgery, and commence a very slow and graded walking program. We usually try to monitor steps, minutes on feet, and exercise repetitions for the overall loading in the first few weeks.
Initial walking can be quite stiff, and feel a bit weak with pushing off the toes. We work with you to adjust your stride, often with a focus on shorter strides to allow a normalised heel-toe pattern. It is important at this stage to be patient. The new achilles needs time to adjust to the loads being put through it. At this stage in the rehab, controlled and graded strengthening and walking load is the priority.
As strength progresses, the physio can add more and more challenging exercises to the routine. There is always an eye on the overall loading to ensure that there isn’t too big a step up in the requirements of the achilles.
High-end achilles rehab and return to sport after achilles tendon surgical repair
By the 3 month mark post-op, the achilles is generally feeling back to normal for most daily activities. This creates a challenge for recovery, as it is when many [patients become complacement with their rehabilitation. We often hear stories of patients who get back to normal life at the 3 month mark post-op, and having decided to sit out the upcoming season, they ease off the rehab, thinking that time will provide the rest of the recovery. It is from the 3-6 month mark that much of the most important work needs to take place.
Depending on the surgeons specific advice, light jogging can generally commence from around 4 months. As well as time, this is also dependent on good healing and graded strengthening work, so the true time for commencement of jogging will often vary.
After the commencement of jogging, progression to more sport specific work after achilles surgery is a slow and gradual process. The new tendon material takes time to remodel, and develop strength along the lines in which it has been appropriately loaded. Introduction of acceleration, plyometric and shock absorption type exercises are done very slowly. It is through this period where some of the most lasting and durable improvements can be made. Regular and increasingly spaced out appointments with your physio are necessary through this stage. This allows for objective measures to be taken to track progress, and adjustments made to the load to ensure healthy recovery.
Movement Centre physiotherapists here to help
If you have questions about achilles repair, or achilles surgery, or if you are undergoing achilles rehab
now, please don’t hesitate to consult our team at Movement Centre at Randwick. We love making sure our patients get all the right information and treatment. Our goal is to provide each of our patients with the most individually tailored approach to their health care. We have the skillset and environment to make sure that each of out patients gets back to doing what they love.
Please remember that all of the information above is used as a rough outline. Every single achilles repair and achilles surgery is different, just as every patient is different. We encourage all going through the process to be diligent and patient with the process.