Typical Patient. Clinical Guidelines AAOS: Tx of Achilles Tendon Rupture. Key to Rehab

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1 Typical Patient Melanie McNeal, PT Male Middle aged Active in recreational sports Weekend warrior Key to Rehab Strengthen healing tendon while maintaining integrity of repair Tendon lengthening -if rehab method does not provide adequate restriction of mvt during early phases Tendon re-rupture occurs when too much load is applied through the tendon before it is healed. Clinical Guidelines AAOS: Tx of Achilles Tendon Rupture Chiodo et al, 2010 Moderate recommendations: Early (2 wks or before) protected post-op WB Use of protective/orthotic device that allows mobilization by 2-4 wks post-op(no consensus on which devices to be used, how much PF should be maintained in the device, and how long it should be worn) Research: Sx vs Conservative Jones Open et al, surgical 2012 repair 4.4% re-rupture rate vs 10.6% in non surgical group Highest rate of re=rupture was in those managed without surgery and placed in cast Surgery results in more complications than conservative mngmt including wound infection, altered sensation, and adhesions PARS repair offers no reduction in re-rupture rate but did have fewer post-op infections Research: Short term Outcomes (Olsson et al 2014) Higher functional outcomes in patients that can perform SL heel raise at 12 weeks postop Only 49% of patients could perform at 12 wks Predictors of decreased function: Increasing age Higher BMI Higher pre-injury physical activity level

2 Research: Endurance Deficits Calf muscle endurance deficits anywhere from 12-48% at 1 year post injury (Don et al 2007) Deficits in repetitions and distance travelled when performing SL calf raises following ATR at 6 and 12 months (Silbernagel et al, 2010) Major functional deficits exists at 2 years following rupture (Olsson et al 2011) Impaired calf muscle endurance at 1 yr post ATR (Bostick et al, 2010) Resting pain at 3 mo, male, decreased ability to perform SL calf raises at 6 mo : delayed recovery at 1 yr Possible explanation: increased tendon length causing suboptimal length-tension relationship at musculotendinous junction Research: Altered Running Mechanics (Silbernagel et al, 2012) 23 y/o F, rec athlete; running analysis, ATR 4 wks later 1 yr postop c/o only minor limitations and resumed N running routine BUT differences seen uni vs I: Decreased heel rise test: 12 rep difference, 5cm difference in ht Decreased peak PF torque: isometric and isokinetic Increased DF ROM: 5 deg difference Resting PF position: 11 deg vs 21 deg Increased tendon length as shown on US: 20.6 vs 16.5 cm Running analysis post-op: increased DF, eversion and abduction were seen at postop analysis vs preop Attributed to limited power in PF (results in increased mvt/decresaed stability in other planes) and and lengthened tendon Resulted in: increased loads on knee and post tib Research: Elite athletes Parekh et al, % professional football players unable to return to sport following ATR Of those who did, greater than50% reduction in power ratings compared to pre-injury Research: Predicting Outcomes Return to Activity postop ATR (Saxena et al, 2011): Casted for 2 wks postop then boot worn only 4 wks RTA determined by Ability to perform 5x25 SL calf raises Calf circumference equal to 5mm or less difference side to side measured 10cm distal tib tub Ankle DF and PF ROM within 5 deg of nonop ankle For acute ATR: RTA was anywhere from wks postop Better clinical outcomes are reached when less tendon elongation occurs (Kangas et al, 2007) Research: Outcome Measures The Achilles tendon Total Rupture Score is valid, reliable, and sensitive self reported outcome measure in patients following tx for ATR (Nilsson-Helander 2007, Kearney 2012) 10 questions Score from 0 (major limitations/symptoms) to 10 (No limitations/symptoms) Victorian Institute of Sport Assessment Achilles questionnaire (VISA-A): valid and reliable to measure severity of Achilles tendinopathy (Robinson et al, 2001) Questions remain There is no consensus regarding protocol following surgery in terms of: How soon can safely initiate WB postop? What is safe ROM postop to prevent stretching repair? How long should protect weight bearing? What is the correct/optimal protective orthotic? What is proper amount of functional loading? When can safely initiate SL calf raises What size and how long should heel lift be used when out of boot or should one be used at all What functional objective measures should be attained to safely initiate jogging/jumping/rta??

3 Inform your patients: Immediately postop: stress importance of not stretching out repair Do not walk flat footed Do not pull foot up into DF If stretch out repair, will NEVER get strength back and will NEVER be able to return to desired level of function Worse thing patient can do is keep foot immobilized Higher incidence of DVT and re-ruptures and increased atrophy Better to be stiff when allowed to ambulate in N shoe than to be too loose: can always increase ROM; can never tighten stretched out repair Compression sock helps decrease effusion Tendon will never be same size as other side Purchase gel inserts and stack on top of each other when transition to shoe and wear on both sides Up to 6 months post-op not uncommon to have some numbness, minor aches and pains, not feel Normal Protocol for Kevin Varner, MD Postoperatively pt is NWB in splint for days PT is initiated when splint is removed Pt is placed in walking boot and allowed WBAT when splint is removed If not using Vacoped boot, while have lift in boot maintaining equinus Boot is worn 6-8 wks depending on sex (Females 6 wks bcs can wear wedge shoes) Pt transitioned to regular shoe with 2-3cm heel insert which will be worn for approximately 1 month Various boot types Changing degree of PF VACOPED Description: A self-adjusting vacuum cushion conforms to the patient's anatomy and in conjunction with a rigid lattice frame provides castlike stabilization Can simply remove the sole and/or replace it Can change PF ROM in 5 degree increments Can set fixed ROM or allow specific range (i.e., 30-15deg) Traditional Aircast WB REHAB: PHASE ONE IN BOOT

4 PHASE ONE EXERCISES REHAB: 6/8-12 WKS Scar mobilization Active inversion/eversion Biofeedback PF Seated marble pick up avoid heel contact Progression allowed if pain free: Bridge on balls of feet: B to marching Seated calf raises limited range Phase Two Exercises AlterG ROM: Post talar glides and subtalar distraction to increase DF as needed Active DF with TB Gait training: in shoes Weight shifting Single leg balance Tandem walking: floor to unstable surface Cone walking: forward and side step Alter G Phase Two Exercises cont d Phase Two Exercises cont d Strength: Single leg bridge on balls of feet B calf raises Calf raises on leg press with knee ext and flexion Seated calf raise machine Step ups: increase height and alter surface Squats to chair Bridge on swiss ball SL dead lifts Sidestep with theraband around ankles Proprioception Single leg Balance: floor, eyes open/closed, Airex, BOSU both sides TB 4 way kicks progress to cable column, change surface Tandem walk: floor to airex; on balls of feet Plyotoss: vary surface

5 Return to Function Exercises Return to function exercises Dynamic warmup High knees, backpedal, shuffles, grapevine, tapioca Quick feet Jump rope Box jumps SL hop for distance, triple hop for distance, timed lateral cone hop Figure 8 run