Rupture to Run: Post-Achilles Tendon Repair

Golden State Warriors forward Gui Santos and guard Gary Payton II vie for a loose ball with Utah Jazz center Kyle Filipowski during the first quarter at Chase Center. Mandatory Credit: D. Ross Cameron-Imagn Images

The Achilles tendon (AT) is the largest, strongest, and most powerful spring in the human body, primarily functioning to provide a tendinous connection for the soleus and gastrocnemius muscles to the calcaneus. It endures tremendous loads, particularly during eccentric calf contractions, with forces reaching up to 15 times body weight during activities like gymnastics landings⁽¹⁾. Rupture of the AT is a traumatic injury requiring significant force and often results in lasting functional deficits, regardless of the treatment approach⁽¹⁾. In recent years, there has been an increase in AT ruptures, particularly in explosive sports such as basketball, football, and gymnastics, with a notable prevalence among athletes aged 20-39, particularly males⁽²⁾.

“In recent years, there has been an increase in AT ruptures…”

Clinicians categorize treatment for acute AT rupture into surgical and non-surgical management. Furthermore, they generally prefer surgical repair for elite athletes due to superior outcomes in reducing re-rupture rates and restoring plantar flexor strength. Open repair remains the gold standard due to its strength and early mobilization benefits⁽³⁾. Minimally invasive options, like the SpeedBridge™ technique, aim to combine the benefits of open and percutaneous repairs, though concerns about calcaneus pain from suture anchors persist⁽¹⁾. Although less common in elite sports, non-operative management offers comparable outcomes when practitioners initiate early functional rehabilitation⁽²⁾.

Rehabilitation Stages

Surgical site protection phase (0-2 weeks): Rehabilitation post-Achilles tendon repair involves several phases tailored to specific recovery goals. In the immediate post-operative phase (0-2 weeks), the primary focus is managing pain, controlling swelling, and protecting the surgical site (see table 1). This period involves immobilization, often in a CAM boot with heel wedges, to promote wound healing and minimize stress on the repair⁽¹⁾. Clinicians can initiate proximal and core strengthening exercises during this phase, emphasizing maintaining proximal muscle strength while avoiding excessive sweating near the wound to reduce infection risk⁽¹⁾.

“Several factors influence rehabilitation success and RTS timelines.”

Table 1: Achilles tendon repair management(1)

Controlled mobilization phase (2-6 weeks): The primary goal during this phase is to accommodate ambulating in the boot and provide controlled tension to the repair while avoiding tendon elongation. Accelerated weight bearing protocols typically progress from partial to full weight bearing by 4-6 weeks. Clinicians must educate patients about load progression and manage walking volumes to prevent tendon overload⁽¹⁾. Furthermore, they can assess passive tension with the patient positioned in prone, knee bent to 90°, and hip in a neutral position to ensure the tendon is not overstressed(1). Following progress to FWB in the CAM boot, the surgeon must provide clearance to initiate gait training in an athletic shoe with heel lifts, which fosters the gradual return to normal walking. 

The intermediate rehabilitation phase (6-12 weeks): This phase focuses on improving ankle dorsiflexion ROM without excessive elongation stress and normalizing gait mechanics. Exercises progress from double-leg to single-leg heel raises, with continued use of blood flow restriction therapy (BFRT) to preserve muscle strength (see figure 1). A key milestone during this phase is achieving a double-leg calf raise through full ROM⁽¹⁾. Clinicians must monitor resting dorsiflexion tension to avoid excessive elongation⁽¹⁾.