Achilles Tendon Repair

Chapter 38 Achilles Tendon Repair



Robert A. Maschi, PT, DPT, CSCS, Heather M. Cloutman, PT, MSPT, CSCS, Nicole Fritz, PT, DPT


The incidence of Achilles tendon rupture is increasing in Western society where lifestyles are sedentary and interest in athletic activities has increased. Acute ruptures are commonly associated with white-collar professional men in the third or fourth decades of life who are involved in recreational athletics. The majority of injuries occur during racquet or ball sports, which involve acceleration/deceleration mechanisms, sprint starts and jumping. Traumatic injury is another common cause of acute Achilles tendon rupture, including falling from a height, falling down stairs, or slipping into a hole.


Operative repair of an Achilles tendon rupture combined with early rehabilitation enables the patient to return to preinjury functional level, achieve normal ankle range of motion (ROM), and decrease the risk of rerupture. The Hospital for Special Surgery (HSS) Achilles tendon repair rehabilitation guideline is presented.



Surgical Overview



• Open repair of the Achilles tendon is accomplished by exposing the tendon via an incision on the posterior aspect of the leg.

• The paratenon is opened and the tendon ends are juxtaposed and sutured together. Many different suture techniques can be used, and these vary among surgeons.

• If the tendon ends are frayed where the Achilles has ruptured often a circumferential suture is used as well. The repair can be reinforced with the plantaris tendon grafts.

• The paratenon is closed and then the skin is closed and covered with a sterile dressing.

• A plantar splint is placed at this time to prevent dorsiflexion, which could disrupt the repair. Some surgeons prefer to use a cast or an anterior splint.

• A Cam walker boot can also be used after sutures are removed in 10 to 14 days, which allows for examination of the wound and early mobilization.

• Meticulous soft tissue handling and closure of the paratenon are key elements of the procedure.


Rehabilitation Overview



• The rehabilitation program following Achilles tendon repair begins 2 to 6 weeks postoperatively.

• Special attention must be given by the rehabilitation specialist to protect the repair. For example, it is imperative that passive heel cord stretching is avoided until at least 12 weeks postoperatively. In addition, weight-bearing should be progressed incrementally and guided by communication with the surgeon.

• The clinician must consider the four phases of tendon healing (inflammation, proliferation, remodeling, and maturation) throughout the progression of the postoperative rehabilitation program.

• The tendon is weakest during the first 6 weeks of healing (inflammation and proliferation phases) and then slowly increases in strength over the next 6 weeks to 12 months (remodeling and maturation phases).

• The patient is progressed via criteria-based functional progression.


Postoperative Phase I: Protection and Healing (Weeks 1 to 6)



GOALS



• Protect repair

• Control edema and pain

• Minimize scar formation

• Improve ROM of dorsiflexion to neutral (0 degrees)

• Increase proximal lower extremity musculature 5/5 in all planes

• Progressive weight-bearing–surgeon directed

• Independence in home exercise program


PRECAUTIONS



• Avoid passive heal cord stretching

• Limit active dorsiflexion ROM to neutral (0 degrees) with knee flexed at 90 degrees

• Avoid heat application

• Avoid prolonged dependent position


TREATMENT STRATEGIES



• Progress weight-bearing status in the Cam boot with crutches or cane-surgeon directed

• AROM dorsiflexion/plantar flexion/inversion/eversion

• Scar massage

• Joint mobilizations

• Proximal musculature strengthening

• Modalities

• Cryotherapy


CRITERIA FOR ADVANCEMENT



• Pain and edema controlled

• Weight-bearing status-surgeon directed

• ROM dorsiflexion to neutral (0 degrees)

• Proximal lower extremity muscle strength 5/5


Postoperative Phase II: Early Mobilization (Weeks 6 to 12)



GOALS



• Normalize gait

• Restore full functional ROM necessary for normal gait (15-degree dorsiflexion) and for ascending stairs (25 degrees)

• Normalize dorsiflexion, inversion, and eversion ankle strength 5/5


PRECAUTIONS



• Avoid pain with therapeutic exercise and functional activities
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Jun 22, 2016 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Achilles Tendon Repair

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