Achilles Repair and Rehabilitation
The goal of treatment is to have an Achilles and calf that functions as best as possible, allowing full activity and sport.
The Achilles tendon is exceptionally strong and, as yet, we don’t know why it ruptures. It often happens during the simplest activities and you and any spectators may have heard it snap. Patients often say it feels as though they were hit from behind.
When the tendon ruptures, It is very much like a rope snapping with two frayed ends. The tendon heals with scar tissue and it’s very important that they are as close together as possible. They should then heal with the optimum tension giving the muscle maximum power once recovered. If the tendon ends gap then this leaves the muscle lax and weaker.
Naturally, because the Achilles is so strong, it takes a long to time to heal fully. It will take several months to be functioning well and over a year to heal fully. Research has shown that a tendon heals best if it is carefully moved in a protected environment – therefore Physiotherapy is an essential part of this and you will get to know your physio well!
Preparation for Surgery
You should have received a letter detailing the codes and costs for the surgery and giving instructions on where to go and at what time. Please check these details carefully as you will be liable for any costs not covered by your insurers.
You will need to be nil-by-mouth – No food for 6 hours before surgery. Clear fluids can be taken for up to 2 hours before the operation.
Before or on admission to hospital a nasal swab will be taken to screen for MRSA. There is a small chance this is positive. If so your operation will be moved to the end of the list or rarely to another day to prevent cross infection.
The surgery is normally a daycase procedure, performed under a general anaesthetic with local anaesthetic after for additional pain relief. It is not normally a particularly painful operation and most patients report minimal pain.
The Achilles is repaired using a minimally invasive (MI) or keyhole technique. This is performed through a 1-2cm transverse incision over the rupture site. The keyhole surgery causes minimal trauma to the Achilles sheath and skin and so has the lowest risks. It also allows rapid healing with benefits in early rehabilitation. The surgery is performed with strong permanent sutures passed using MI methods. Even though the incision is small, the tendon repair can be assessed and visualised to ensure that the best tension and repair has been achieved.
At the end of the surgery, the leg is immobilised in a plastercast with a soft bandage at the front or “backslab”, to allow for any swelling. You will be discharged in this, on crutches non-weight bearing (NWB). The cast will be changed at 10-14 days to a protective boot for 8-10 weeks.
Risks of Surgery
It is important to be aware of the risks of surgery. The vast majority of patients have no problems, but complications can happen and we do our best to minimise these risks.
Approx 1% risk. Usually this is a small infection of the skin that can be treated with oral antibiotics. Very rarely, a deep infection occurs requiring further surgery and this will compromise the final outcome.
Risk 1%. The sural nerve is a sensory that supplies sensation to the skin of the side of the foot and heel. It can be temporarily or permanently damaged. Usually no further treatment is needed. Rarely the nerve will be painful requiring further surgery.
Risk 2-3%. This is usually due to a slip or fall.
Risk 2-5%. You will be given an oral anticoagulant to protect against this. If it does occur, this is treated with oral anticoagulants for 3 months.
Immediately after surgery
You will be referred to a physiotherapist who will advise on walking while keeping weight off the ankle using crutches. You will be sent home only when you are comfortable.
Pain relief and take home medications
You will be given high doses of prescription painkillers to take home. Use these for the first 2-3 days and reassess.
There is a small risk of blood clots “DVT’s” with Achilles surgery and you will be prescribed a blood thinner for 2 weeks.
Initially you will be Non WB for 2 weeks then partially WB in a protective boot, with Full WB at the 4 week stage.
Using crutches can be difficult even for the able-bodied. There are some useful aids that can be bought or hired.
- The knee rover is a scooter with brakes that takes the weight of the leg. www.kneerover.com
- The iWalk is a ‘peg-leg’ – it requires good balance. www.peglegs.co.uk
Physiotherapy should start at 2-3 weeks. Your rehabilitation is based on a structured rehabilitation programme over the next 6 months, gradually increasing the flexibility and strength of the tendon / muscle. This will start with very gentle mobilisation and massage, progressing over several weeks through the stages to full calf power with explosive plyometric exercises.
The rehabilitation schedule is below.
If there are any concerns during this period please ask your physio to get in touch with me.
Washing and Bathing
It’s important to keep the plaster cast totally dry – the nurses will show you how to do this with a waterproof cover. Once the plaster is removed you can shower as normal if the wound is healed, but gently dab it dry.
The bathroom is where most re-ruptures occur – ideally sit on a plastic seat in the shower and dry off in there. If there is no shower, take great care getting in and out of the bath – use a non-slip mat.
When can I start to drive again?
The DVLA states that it’s the responsibility of the driver to ensure they are always in control of the vehicle. You can drive once fully weightbearing and out of immobilisation – minimum 8 weeks. If it’s a left sided Achilles rupture and an automatic car, you can drive after 2 weeks. It remains your responsibility to drive safely and you should also check with your vehicle insurer to confirm you are covered.
WEEKS 0-2 Mobilisation: Non Weight Bearing on Crutches
This period focuses on reducing swelling and achieving good wound healing. Excessive swelling causes the wound to heal slowly and increases the risk of infection.
Elevation of the Ankle above the height of the hips is essential for the first week, 45mins / hour day and night. Effectively, you will need to be house bound and reclining through the day. After one week this can be reduced to 30mins / hour
Review in clinic at 10-14 days and change to the Vacoped Achilles Boot.
WEEKS 2-4 Mobilisation: Partial Weight Bearing in Vacoped Boot
Partial WB of 50% of body weight allowed – test how this feels like on a bathroom scales.
CHANGE TO VACOPED ACHILLES
- locked in full plantarflexion.
- wear 24 hrs a day.
- can take off when sitting.
- ↑ df range by 1 notch per week (5 per week)
PHYSIOTHERAPY STARTS - NO DORSIFLEXION STRETCHES AT ANY STAGE
- Soft tissue massage
- Gentle Active
- Work on Achilles gliding
WEEKS 4-8 Mobilisation : Fully Weight Bearing in Vacoped boot
- remove walker at night.
- ↑ dorsiflexion by 1 notch per week.
- discard crutches when able
- zero position at 8 weeks – change to flat sole
- Active Plantarflexion with Theraband
- Compex muscle stimulation if available
- Seated heel raises
- Full PF, inversion and eversion
- At 6 weeks start light NWB aerobic exercises - e.g. cycling (push with heel, not toes)
WEEKS 8-12 Mobilisation: Vacoped to Shoes with heel raise
- discard vacoped at +10’
- change to flat shoe with 1cm heel raise for 4 weeks
- Proprioception/balance work
- Gait re-education
- Ecc/Con loading (bilat to single. Emphasise ecc phase)
- Single stairs
- Progress to upslope and downslope.
WEEKS 12-16 NORMAL SHOES
- Progressive exercises
- Full NWB work eg Xtrainer / Bike
- Progress to Jogging then fast acc. & deceleration.
- Directional running / cutting
- Pylometrics. e.g. toe bouncing upwards / forwards /directional
Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis
This meta-analysis shows that operative treatment of Achilles tendon ruptures reduces the risk of re-rupture compared with nonoperative treatment. However, re-rupture rates are low and differences between treatment groups are small (risk difference 1.6%). Operative treatment results in a higher risk of other complications (risk difference 3.3%). The final decision on the management of acute Achilles tendon ruptures should be based on patient specific factors and shared decision making. This review emphasises the potential benefits of adding high quality observational studies in meta-analyses for the evaluation of objective outcome measures after surgical treatment.