Physiotherapy for Achilies Tendon Ruptured

Tendon Ruptures
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ACHILLES TENDON RUPTURE

What is the Achilles Tendon?

Tendon = band of tissue that connects a muscle to a bone.

Achilles tendon

a.k.a the "heel cord, 

a strong band of elastic connective tissue that runs down at the back of the lower leg

the Achilles tendon is formed from the gastrocnemius, soleus, and plantar muscles of the calf and is attached to the calcaneous (heel-bone).

largest and strongest tendon in the body.

What is an Achilles Tendon Rupture?

Partial :partly torn but still joined to the calf muscle.

Complete :completely torn so that the connection between the calf muscles and the ankle bone is lost.

Mechanism of injury : occurs when the tendon is stretched beyond its capacity such as :

• forceful jumping or pivoting
• sudden accelerations of running
• falling or tripping.
• forceful push off with the foot
• suddenly forced into an upward pointing position
• deep cut at the back of the ankle

The Achilles tendon is weak due to :

• Corticosteroid medication (prednisolone) - mainly if it is used as long-term treatment rather than a short course.
• Corticosteroid injection near the Achilles tendon.
• Older age (60 years onwards).
• Certain rare medical conditions such as Cushing's syndrome, where the body makes too much of its own corticosteroid hormones.
• 'Tendonitis' (inflammation) of the Achilles tendon.
• Other medical conditions : rheumatoid arthritis, gout and SLE (lupus).
• Certain antibiotics (quinolone).
• The risk  actually very low, and mainly applies if you are also taking corticosteroid medication or are over age 60.  

Risk factors :

Typically, middle-aged people participating in sports in their spare time.

Less commonly, illness or medications, such as steroids or certain antibiotics, may weaken the tendon and contribute to ruptures

 

Signs and Symptoms

•  Sudden sharp pain (which feels like a kick or a stab) in the back of the ankle or calf – usually settles quickly and often subsiding into a dull ache.
• A popping or snapping sensation.
• Swelling on the back of the leg between the heel and the calf.
• Difficulty walking (especially upstairs or uphill).  
• Difficulty rising up on the toes.
• Flat footed walk - can walk and bear weight, but cannot push of the ground properly on the side where the tendon is ruptured
• May feel a gap just above the back of the heel in complete tear. However, if there is bruising then the swelling may disguise the gap.

TREATMENTS

Early action that should be taken - the "R.I.C.E." method

1. Rest. Stay off the injured foot and ankle, since walking can cause pain or further damage.
2. Ice. Apply a bag of ice covered with a thin towel to reduce swelling and pain. Do not put ice directly against the skin.
3. Compression. Wrap the foot and ankle in an elastic bandage to prevent further swelling.
4. Elevation. Keep the leg elevated to reduce the swelling. It should be even with or slightly above heart level.

Decision of Rx are based on the

• severity of the rupture
• the patient’s health status
• activity level (active VS less active)‏
• individual preference and circumstances.
• Types of Rx :
• Non-Surgery
• Surgery

Both options will involve having a plaster cast or brace (orthosis) for about 8 weeks, to protect the tendon while it heals.

 The plaster or brace is positioned so that the foot is pointing slightly downwards, which takes the strain off the tendon.Traditionally, patients were given crutches to keep weight off the leg during the first few weeks of treatment.

       Now there is a trend towards 'early mobilization' involves fitting a plaster or brace which you can walk on more convenient because do not need to use crutches. Physiotherapy is often provided as well.

Non-Surgery
-a.k.a 'conservative treatment’.

-the tendon heal naturally, resting it in a brace or plaster cast.

-Generally associated with a higher rate of re-rupture

Selected for

• minor ruptures
• Older or less active patients
• those with medical conditions that prevent them from undergoing surgery

Involves use of

• Cast
• walking boot
• brace

Fx : to restrict motion and allow the torn tendon to heal.

A surgical repair can then be done later, if the tendon :

does not heal on its own and re-rupture.

Surgery
recommended for

• younger people
• those doing sports.
• delay in starting treatment.

Offers important potential benefits such as :

• Decreasing the likelihood of re-rupturing the Achilles tendon,
• Often increases the patient’s push-off strength and improves muscle function and movement of the ankle.

Various surgical techniques are available :

• type of surgery called ‘percutaneous’ -  uses smaller cuts than the traditional operation. It  reduce the risk of getting a wound infection.
• sews together the torn ends of the Achilles tendon
• may also use another tendon
• a tendon graft to help with the repair.

The surgeon will :

• select the procedure best suited to the patient.
• determine when the patient can weight bearing.
•  Following surgery, the foot and ankle are initially immobilized in a cast or walking boot.
•  after surgery, a brace seems to be better than a plaster cast in terms of faster recovery and return to normal activities, a lower complication rate and patient preferences. 

Complications such as :

• incision-healing difficulties - the tendon may scar or become shorter
• re-rupture of the tendon
• nerve pain
• wound infection
• reduced sensation near the operation site

PHYSIOTHERAPY MANAGEMENTS

ACHILLES TENDON REPAIR
REHABILITATION PROTOCOL

PHASE I (0-8 WEEKS)

WEIGHT BEARING –

i.  (0-4 weeks) :Heel toe touchdown weight bearing in post-op splint.

ii. (4-8 weeks) : As tolerated with crutches & cam walker.

BRACE –

i.  (0-2 weeks) : Worn at all times.

ii. (2-4 weeks) : Locked at 20 ° of plantarflexion – worn at all times except for exercise & hygiene.

iii.(4-8 weeks) : Worn during weight bearing activities.

ROM –

i.  (0-2 weeks) :NO physical therapy & motion

ii. (2-6 weeks) : Limit active dorsiflexion to 90° with knee flexed at 90°

iii.(6-8 weeks) : ROM to tolerance

THERAPEUTIC EXS -

i.  (0-2 weeks) : NO physical therapy & motion

ii. (2-8 weeks) : Inversion/eversion ROM, stationary bike with brace on, knee/hip strengthening, joints mobilizations – NO passive heel cord strecthing

PHASE II (8-12 WEEKS)

WEIGHT BEARING – As tolerated with crutches – discontinue crutch use when gait is normalized

BRACE – None

ROM – gain full & pain free

THERAPEUTIC EXS – Begin light dorsi/plantarflexion exs with knee flexed, inversion/eversion isometrics, cont. with bicycle & knee/hip strengthening

PHASE III (12 WEEKS - 5 MONTHS)

WEIGHT BEARING – Full with normalized gait pattern

BRACE – None

ROM – Full & pain-free

THERAPEUTIC EXS – Progress Phase II activities, begin inversion/eversion isotonics, aggressive dorsi/plantarflexion resisitive exs with emphasis on plantar eccentrics

Besides that, generally what we can do….

• Help reduce swelling and pain though application of :
• Electrotherapy such as ultrasound
• compression bandaging
• Passive exs – to increse ROM
• AROM - avoid pain when exercising
• active free exs : plantarflexion, dorsiflexion, pronation, supination, inversion and eversion
• Mobilising exs :
• Ankle Circles : Sit on the floor or in a chair. Remove shoes and socks. Moving only your ankle, draw circles. Repeat 10 to 20 times.
• Drawing The Alphabet: Sit on the floor or in a chair. Remove shoes and socks. Moving only your ankle, draw the alphabet on the floor. Do the entire alphabet once.

Stretching exercises :

Gastrocnemius

Soleus

Strengthening exercises :

Hip :SLR, hip pattern

knee : SQE, IRQ

Ankle : Resistive Tubing Exercises (Theraband)‏

                : Toe Raises

                : Walking on Heels

                : Toe Scrunch:

-Place a towel on the floor near your chair.

-Sit down, placing the toes of one foot on  the towel.

-Use your toes to scrunch up the cloth.    

Keep your heels flat on the floor.

Repeat 10 to 20 times

: Wobble Board

Postural challenge - partner challenges a person's stability while he or she is standing on one leg, gently touching the person in one direction and then the other.

Mini Trampoline Exercises -Stand on a mini trampoline with one foot. Work up to two minutes without falling, then switch to the other ankle.

Progression to :

hop and stop

throw ball

fig 8's

running

Instruct on use of crutches if needed

• NWBC
• PWBC
• Strap the ankle to make walking easier.
• Functional actvt e.g. ambulation,step up & down, running, jumping

Pt education :

• keep ball of foot supported when long sitting to avoid your ligament healing in a lengthened position. 

For sports

Advise on when to return to sport.

Start with warm-up exercises.

Recommend ankle braces

Corticosteroid medication (prednisolone)‏

Should be used carefully and the dose should be reduced if possible. But note that there are many conditions where corticosteroid medication is important or lifesaving.

Quinolone antibiotics

Should be used carefully in people over 60 or who are taking steroids. 

wallahuallam... 

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