RECOVER NOW
BOOK A DISCOVERY VISIT

3 Pillars of Achilles Tendon Rupture Early-Stage Management

Seamus McFadden

Introduction:


The Achilles tendon is the strongest and thickest tendon in the body. Tendons are connective tissues that consist of multiple bundles of dense parallel collagen fibers, that connect our muscles to our bones. The function of tendons is to transmit force from our muscles to the bones to produce joint movement. Tendons are designed to handle high tensile loads, however, whether due to overuse, or other factors (such as age or genetics), tendons can become degenerative, leading to loss of function/strength, or even rupture1.


When a tendon rupture occurs, such as an Achilles tendon rupture, tendons can either be restored surgically, or conservatively (through casting). Tendon healing goes through 3 phases, just like all other soft tissues in the body.


Phase 1 – Inflammatory phase (First 48 hours): This is where we see increased blood flow, and an influx of inflammatory cells such as platelets, macrophages, monocytes, etc., all of which recruit formation of new blood cells (angiogenesis), fibroblasts, and intrinsic tenocytes2.


Phase 2 – Proliferative Phase (Day 7 – Day 21): The previously mentioned fibroblasts are responsible for laying down new collagen and re-attaching the ends of the tendon. The collagen is laid down as fast as possible and is both immature, and disorganized (type 3 collagen), meaning it is not aligned along the lines of force, and therefore weak and unable to handle much load3. This collagen web is referred to as a callus. The disorganized structure and overall strength of the tendon is why you will be non-weightbearing for a period after an Achilles rupture.


Phase 3 – Remodeling Phase (Day 21 – 12 months +): The remodeling phase is where the immature and disorganized collagen, is converted into mature, and organized collagen (type 1 collagen). These fibers are laid down along the lines of applied stress, so it is crucial to initiate optimal loading in this stage of healing.


With that said, lets explore the 3 fundamental pillars of early-stage Achilles tendon rupture (ATR) rehabilitation. At The Lab – Rehab and Performance, this is what we refer to as the Recover phase of our 3R continuum, the phase where we focus on recovery of tissue integrity, normal activation, and functional ability. Subscribe to our blog to learn more about our process for maximizing patient success.

  1. Minimize Tendon Lengthening

Whether you had your Achilles tendon rupture managed conservatively (casting), or surgically, a primary concern and predictive factor of recovery is tendon elongation. This is a process that will occur in all Achilles tendons after a rupture and cannot be completely avoided, but it is imperative that you adopt strategies to minimize the amount of elongation. This is important because deficits in strength, power, and heel rise height are strongly correlated with increased tendon elongation4. Tendon lengthening occurs mostly within the first 3 months but can occur up to 6 months post injury5.


The question then becomes, how can I limit tendon elongation? As discussed above, tissue loading is an important part of the remodeling phase of tendon healing. As more research emerges on the early management of Achilles Ruptures, there is a growing body of evidence that indicates early mobilization is superior in both the short and long term when it comes to patient’s functional outcomes6. Not only does early mobilization improve outcomes, but it also limits the amount of elongation7. This follows what we know about tissue healing and how loading is an important part of the remodeling phase where tendon strength and stiffness are developed. Following a period of immobilization (2-3 weeks), people recovering from ATR will begin a gradual progression towards full weight-bearing as instructed by their surgeon. Once this process begins, you should start exercises that engage the muscles of your calf (triceps surae, including the gastrocnemius and soleus) and gently load the Achilles tendon. An example of a safe exercise initially is low-intensity, end-range isometrics. Consult a Physiotherapist to ensure that any exercises you perform do not compromise your tendon healing, and to develop a plan of care that addresses your individual needs, and goals.

2. Early Loading

Initiating early loading has 3 major benefits for patients in the early stages of management for an Achilles tendon rupture. First is to optimize tendon healing by facilitating the formation of a stronger callus. As discussed in the stages of tendon healing above, loading is an essential part of optimal healing for tendons as it promotes stronger collagen to be laid down in a more organized pattern, which increases the strength of the tendon, and reduces the risk of re-rupture.

Any exercises that load your Achilles tendon prescribed in early-stage rehabilitation should be done with a focus on regaining the ability to contract the triceps surae, in particular, activation of the medial head of your gastrocnemius. Research indicates that neuromechanical activation of the calf complex remains altered 3.5 years post rupture8, early-stage activation-based exercises can help normalize muscle function for the calf complex, or at the very least, optimize the adaptations required to overcome tendon lengthening. Tactile cueing and feedback during isometric calf exercises are a great way to ensure you are activating the gastrocnemius muscle, and not compensating with the surrounding musculature of the foot and ankle.

The third, and likely most important reason to initiate loading early is to optimize tendon healing and minimize tendon elongation. A Registered Physiotherapist will be able to prescribe safe and effective exercises to ensure optimal healing without risking excessive tendon elongation.

Below is a graphic summarizing these points from Physio Network.

3. Regain Normal Walking Gait

When we look at outcomes overall following an Achilles rupture, there is a good return to sport rate with 80% of patients being able to return to their sport and activities10.   

Despite this, a lot of research reports that significant deficits in strength, power, as well as gait patterns (i.e. running and jumping) persist up to at least 4 years and likely for the rest of the patient’s life9. It is also known that a patient’s function regained in the first 3 months is a good predictor of outcomes at 1 year10. This data demonstrates is the importance of effective early-stage Physiotherapy treatment. Restoring normal gait is a pre-requisite for returning to running of any kind, and vital for return to performance. There may be some minor changes to an individual’s gait following Achilles tendon rupture depending on the amount of tendon elongation as a longer tendon will increase dorsiflexion range of motion and decrease plantar flexion work during the gait cycle. However, in order to return to sport, individuals/athletes must regain normal biomechanics at the foot and ankle including, but not limited to, heel to toe foot strike, supination to pronation, push-off through the big toe, when walking. This training can begin even when in your walking boot. Focusing on a heel to toe pattern and pushing off using your calf muscle will help prime you for gait re-training once you have been cleared for walking out of your boot by your surgeon.  

Progression Criteria:

Early-stage management is typically considered the first 12 weeks of recovery. However, as technology and Physiotherapy progress, we are moving away from arbitrary time-based criteria, towards objective strength, mobility, and functional criteria. Research has shown that only 49% of patients regain the ability to perform a single leg heel rise at 12 weeks11. The same study also found a negative correlation between kinesiophobia and the ability to perform a SL heel rise at 12 weeks11. As discussed, early strength and functional outcomes are a strong predictor of successful return to sport/activity in the late stages of Achilles tendon rupture management.

At The Lab – Rehab and Performance, we use objective criteria like the SL heel rise test, SL balance (measured using the VALD force plates), gait, and the Tampa Scale of Kinesiophobia to help gauge when our patients are ready to progress to mid-stage, where we initiate heavier loading for the Achilles tendon and start prepping for Return to Sport.

Recovering from an Achilles tendon rupture? Book with one of our Physiotherapists today to get on the fast track to resurgence.

References:

  1. Kaya, M., Karahan, N., & Yılmaz, B. (2019). Tendon Structure and Classification. IntechOpen. doi: 10.5772/intechopen.84622
  2. Killian, M. L., Cavinatto, L., Galatz, L. M., & Thomopoulos, S. (2012). The role of mechanobiology in tendon healing. Journal of shoulder and elbow surgery, 21(2), 228-237.
  3. Chartier C, ElHawary H, Baradaran A, Vorstenbosch J, Xu L, Efanov JI. Tendon: Principles of Healing and Repair. Semin Plast Surg. 2021 Aug;35(3):211-215. doi: 10.1055/s-0041-1731632. Epub 2021 Jul 15. PMID: 34526870; PMCID: PMC8432990.Hoeffner R, Svensson RB, Bjerregaard N, Kjær M, Magnusson SP. Persistent Deficits after an Achilles Tendon Rupture: A Narrative Review. Transl Sports Med. 2022 Jul 16;2022:7445398. doi: 10.1155/2022/7445398. PMID: 38655161; PMCID: PMC11022787.
  4. Larsson, E., Helander, K.N., Falkheden Henning, L. et al. Achilles tendon resting angle is able to detect deficits after an Achilles tendon rupture, but it is not a surrogate for direct measurements of tendon elongation, function or symptoms. Knee Surg Sports Traumatol Arthrosc 30, 4250–4257 (2022). https://doi.org/10.1007/s00167-022-07142-9
  5. Braunstein, Mareen, et al. “Development of an accelerated functional rehabilitation protocol following minimal invasive Achilles tendon repair.” Knee Surgery, Sports Traumatology, Arthroscopy 26 (2018): 846-853.
  6. Kangas J, Pajala A, Ohtonen P, Leppilahti J. Achilles Tendon Elongation after Rupture Repair: A Randomized Comparison of 2 Postoperative Regimens. The American Journal of Sports Medicine. 2007;35(1):59-64. doi:10.1177/0363546506293255
  7. Wenning, M., Mauch, M., Heitner, A. et al. Neuromechanical activation of triceps surae muscle remains altered at 3.5 years following open surgical repair of acute Achilles tendon rupture. Knee Surg Sports Traumatol Arthrosc 29, 2517–2527 (2021). https://doi.org/10.1007/s00167-021-06512-z
  8. Heikkinen, Juuso MD; Lantto, Iikka MD, PhD; Piilonen, Juuso MS; Flinkkilä, Tapio MD, PhD; Ohtonen, Pasi MSc; Siira, Pertti PT; Laine, Vesa MSc; Niinimäki, Jaakko MD, PhD; Prof; Pajala, Ari MD, PhD; Leppilahti, Juhana MD, PhD; Prof. Tendon Length, Calf Muscle Atrophy, and Strength Deficit After Acute Achilles Tendon Rupture: Long-Term Follow-up of Patients in a Previous Study. The Journal of Bone and Joint Surgery 99(18):p 1509-1515, September 20, 2017. | DOI: 10.2106/JBJS.16.01491
  9. Zellers, J. A., Carmont, M. R., & Silbernagel, K. G. (2016). Return to play post-Achilles tendon rupture: a systematic review and meta-analysis of rate and measures of return to play. British journal of sports medicine, 50(21), 1325-1332.
  10. Hansen MS, Christensen M, Budolfsen T, Østergaard TF, Kallemose T, Troelsen A, Barfod KW. Achilles tendon Total Rupture Score at 3 months can predict patients’ ability to return to sport 1 year after injury. Knee Surg Sports Traumatol Arthrosc. 2016 Apr;24(4):1365-71. doi: 10.1007/s00167-015-3974-0. Epub 2016 Jan 5. PMID: 26733273.
  11. Olsson N, Karlsson J, Eriksson BI, Brorsson A, Lundberg M, Silbernagel KG. Ability to perform a single heel-rise is significantly related to patient-reported outcome after Achilles tendon rupture. Scand J Med Sci Sports. 2014 Feb;24(1):152-8. doi: 10.1111/j.1600-0838.2012.01497.x. Epub 2012 Jun 21. PMID: 22716232.

SIGN UP

Get Practical Recovery and Performance Pearls, as well as updates on future events

Join our bi-weekly ‘Recover, Rebuild, Resurge E-Journal’ Dispatch.

Check your inbox. We’ll email you a confirmation.