Surgical Considerations - Achilles Repair Flashcards
What is the MOI of an Achilles Rupture?
What may patients report with this injury?
Forceful activation of Gastroc/Soleus during sudden acceleration and deceleration, such as landing or jumping
Patients will report that they felt like they got kicked in the back of the leg
What are the Characteristics of an Achilles Rupture?
- Typically ruptures 3 to 4cm proximal to calcaneal insertion
- Males 3x more than females
Other factors associated with rupture:
- Diabetes, smoking, reinjury use of quinolone antibiotics and/or sterioid injection in the tendon
On Clinical Examination, the presence of what 3 findings are high suggestive of a compete Achilles Rupture?
- Abnormal Thompson Squeeze Test (ankle does not PF)
- Decreased ankle resting tension in prone with the knee at 90° flexion. Normal resting tension is approximatley 20-30° PF
- Palpable defect of Achilles Tendon
What are the Indications for Surgery?
- Acute, complete rupture of the Achilles tendon
- The individual wanting to return to high demand activity
- Chronic complete rupture in which end-to-end opposition cannot be achieved by conservative means
What are the Different Techniques for Achilles Repair?
- Open Primary Repair (Most Common)
- Percutaneous Primary Repair
- Mini Open Primary Repair
- Delayed Repair/Reconstruction
What are the Characteristics of the Open Primary Repair Surgery?
- 10 cm posteromedial incision (this is made to visualize both ends of achilles tendon)
- Tendon ends are sutured together (allow it to heal back together; if necessary, the repair may be augmented with a graft tissue to increase the strength of the repair)
- Ankle is positioned in Slight PF or Neutral during the repair
- Patients are typically put in a soft cast for about 2 weeks and then put in a hinge cam walking boot that keeps the ankle immobilize in 20° of PF, this can later be adjusted as they progress
What are the characteristics of the Pericutaneous Primary repair?
- The tendon ends are located and sutured back together through several small puncture wounds that are made along the medial and lateral aspects of the achilles tendon or through several small transverse incisions made directly over the tenson
- This is associated with a lower overall complication rate but increased risk of sural nerve injury
What are the characteristics of the Mini-Open Primary Repair?
- This uses a shorter skin incision than an open approach (~ 5cm)
- The tendon end is identified, sutured, and anchored to a boney drill hole for repair
Post-Achilles Repair, what should the Subjective Exam focus on?
Gathering information about their specific surgery
- Red/Yellow Flag screening (Intake docs and OM)
- Understanding full-scope of the surgery (What are the restrictions from the surgeon)
- Will they be working or going to school while rehabbing?
- Will they be doing any other training while rehabbing?
- What level of activity do they need to get back to?
(What sport or activity do they participate in?)
What are the structure(s) affected by surgery?
Primary, secondary, tertiary
Primary: Tendon
Secondary: Bone
Tertiary: Surrounding tissues disrupted by surgery to access the primary tissues
What are potential complications from surgery?
- Disruption of the Sural Nerve that can cause sensation issues at the lateral border of the foot
- Considerable pain, stiffness, weakness and kinesiophobia
The Clinicians ability to educate the patient on the procedure and why thery are feeling these symptoms is very important. This will help set the expectation of decreased activity during the first phase of rehab to avoid risk of re-injury
Post-Achilles Repair, What does the Physical Examination entail?
- Integumentary Exam
- Ankle ROM
- Muscle Performance Testing
- Palpation
May also include a neurological exam if they report any sensation changes along the lateral border of their foot
Post-Achilles Repair, with the Physical Examination, when should an Integumentary Exam take place and what is expected?
- Before and after treament
- We expect to find redness, erythema and maybe eccymosis around incision.
- Signs to look out for are signs of necrosis, excessive tenderness or edema, increased heat and drainage, which indicated infection and/or delayed healing
The most common complication from surgery is infection and/or wound complications
Post-Achilles Repair, with the Physical Examination, what is done during Ankle ROM?
We expect limited motion in all motions
- Tested to patients tolerance to get baseline measurements
- Active motion ONLY
Care should be taken when assessing DF AROM, and surgeons protocals should be followed
Post-Achilles Repair, with the Physical Examination, what takes place during Muscle Performance Testing?
- Gastroc/Soleus activation
This may or may not be appropriate depending on surgeons protocol, if tested we expect decresed activation
Post-Achilles Repair, with the Physical Examination, What is expected during palpation?
- TTP of gastroc/soleus, achilles tendon, surgical incision
What is the Prognosis for an Achilles Repair?
This will vary based on:
- Natural History (The bodys ability to heal its self over time)
- Primary tissue healing times (Tendon, quality of tissue and repair)
- Age
- Social determinants of health (SDOH)
For improved outomes, rehab may last as long as 8-12 months in order to return the patient to a higher level of activity or sport
What are the Phases of Rehab for Achilles Repair?
- Patients will typically begin formal PT 3-4 weeks post-op, which is in phase 1.
- However older individuals may not start therapy until 6 to 8 weeks post-op to allow more time for healing
With the 1st phase of rehab what is the rehab focus?
- Phase 1 the primary pain mechanism is nociception from trauma from surgery (Acute SOH). This phase aims to protect the surgical procedure, control pain and swelling, slowly increase ankle ROM, increase gastroc/soleus activation and improve tolerance to weight bearing
With the 2nd phase of rehab what is the rehab focus?
- Phase 2 is also nocicption pain mechanism, however there less severity and irritability allow for more activity and rehab (Subacute SOH). This phase aims to increase gastroc/soleus strength, increase tolerance to activity, improve balance and proprioception and normalize gait pattern
With the 3rd phase of rehab what is the rehab focus?
- Phase 3, patient should not have any pain symptoms (remodeling stage of healing). This phase aims to continue to strengthen the gastroc/soleus, glutes and core, improve balance and coordination, pt may be able to progress to light jogging around week 16 and should perform pre-running exercise to prepare impact loading
With the 4th phase of rehab what is the rehab focus?
Phase 4 is the return to sport phase, but due to the typical time frame of 9 to 12 months to return to full participation, this phase will be several months in duration. This phase includes running, jumping, agility, cutting and sport-specific drills to prepare them to returnj them to participation safely
With Phase 1, What are the Precautions, Goals, and Interventions?
Treatment approach is to control pain, modulate post-op symptoms and slowly increase ROM
Precautions
- Prevent stretching of achilles tendon
- Weight bearing restriction per surgeon
Goals
- AROM DF to 0°
- Initiate weight bearing in walking boot
Interventions
- Manual Therapy (Soft-tissue massage)
- Exercises:
-AROM DF/PF
-Isometrics of the foot and ankle
- Education of use of crutches and wearing the walking boot
With Post-Op Achilles Repair, what is the Critera to Progress from Phase 1 to Phase 2?
- Minimal pain and swelling
- Ability to weight bear
- Progressing DF ROM
With Phase 2, What are the Precautions, Goals, and Interventions?
Precautions
- Avoid activities that increase pain or swelling
- Avoid over-stretching or achilles tendon
Goals
- AROM DF to 5°
- Normalize gait pattern by week 12
Interventions
- Manual Therapy (Soft-tissue massage, Joint Mobilizations)
- Exercises (for gastroc/soleus):
-Double limb strength exercises
-Double and single limb balance exercise
-Gait training
{Additional exercises targeting the glutes, hamstrings, quads and core should be incorporated}
- Education on avoiding over stretching the achilles during activity out of the boot
With Post-Op Achilles Repair, what is the Critera to Progress from Phase 2 to Phase 3?
- No pain or swelling
- Ankle DF ROM at leat 5°
- Good Gastroc/Soleus strength
With Phase 3, What are the Precautions, Goals, and Interventions?
Precautions
- Avoid activities that increase pain or swelling
- Avoid over-stretching or achilles tendon
Goals
- Full ankle ROM
- Initiate jogging
- Progressive LE strengthening
Interventions
- Manual Therapy: As needed
- Exercises:
-Progressive Gastroc/Soleus strengthening
-Hip, Glute and Core strengthening
-Balance training in single limb
- Education on avoiding higher-load exercises such as running and jumping
With Post-Op Achilles Repair, what is the Critera to Progress from Phase 3 to Phase 4?
- No pain or swelling with jogging
- Normal gait pattern
- Able to perform 20 single leg heel raises
With Phase 4, What are the Precautions, Goals, and Interventions?
Precautions
- Slowly progress strengthening, running, agility, and plyometrics to avoid overuse
- Caution with overstretching achilles tendon and agility and plyometrics
Goals
- Return to running
- Symmetrical strengthening and balance
- Progress towards full return to sport or activity
Interventions
- Manual Therapy: As needed
- Exercises:
-Gastroc/Soleus strengthening - Focus on Eccentric
-Progressive strengthening of LE and core
-Appropriate and jumping exercises as appropriate
- Education of full return to sport is typically 12 months
With Post-Op Achilles Repair, what is the Critera to Progress from Phase 4 to Return to Sport?
- Symmetrical Gastroc/Soleus strength
- Good mechanics with jumping, landing and cutting
- No Kinesiophobia
