An achilles tendon injury is relatively common injury with options for conservative (non-operative) or operative management. It will involve a period of graded immobilisation in the early weeks and subsequently an extended period of rehab commonly extending beyond 9 months to regain higher level function and strength.

In the long term it is normal to have some strength deficits or weakness and some patients may not return to their previous level of function.

Here I wanted to detail the rehab of a patient I have been working with since last year, considerations I made and how we assessed progress and return to sport testing.

Our initial appointment consisted of goal setting and the expectations for recovery and the role each of us would play. The initial assessment looked at how he was walking, ability to use the calf in isolation, measures of calf strength and outlining the rehab plan moving forwards. Given their other interests we look at strength throughout the leg as it is important to consider deconditioning across the whole body following a period of immobilisation.

Rehab then consisted of walking retraining and use of the calf through a step, and lots and lots and lots of practice, with frequent prompts and cues initially, decreasing in frequency and a more consistent patter was achieved. This is a common issue after immobilisation in the boot even though a patient is able to fully weight bear and is important to prevent elongation of the tendon as this will compromise its functional capacity in the long term, ie it will not be able to generate force effectively through a good range of motion. Strength training involved heel raises with front foot on a step - the aiming being to encourage a drive straight up. Commonly patients will try to drive the knee forwards and drag the heel up rather than actively pushing the foot into the floor. We loaded with isometric holds and loading through range. We integrated the rest of the lower limbs with carefully perform squats and rear lunge with careful observation of avoiding dorsiflexion through us of heel wedges.

At the next appointment we continued the theme of isometric calf work combined with roll outs on a foam roller, a penguin walk for isometric calf loading in plantar flexion as he was now able to hold body weight on one leg with a neutral ankle. Previous exercises we progressed from bodyweight to extra loading

Subsequent sessions involved integration of some plyometric work with partial body weight aiming to encourage ankle and tendon stiffness along with training landing mechanics and tolerance. This then progresses to a small box jump to focus on force generation. This opens the door to combined jumps with increasing force and distance. Alongside was a program of extensive plyometrics to progress tendon tolerance and stiffness, There was a small complaint of a sense of tendon stiffness in the mornings and after a period of immobilisation - signs of a low level tendinopathy which if managed carefully are not problematic and are a sign of adaptation within the tendon to increasing demands at the upper limit of its capacity.

To increase tendon and muscle demand further progress was made with heavy isometric holds on a step. Testing strength at the 8 month stage revealed 

He had regained 85% of strength of the opposite leg and was able to progress to heel raises through range with a focus on the drive up and force generation.

In the latter stages we introduced graded change of direction work with a focus on how he completed the push off step, important as this is when a lot of achilles injuries occur, This return to sport was key as it allowed him to see the goal was in sight.

Final testing of lower limb symmetry involved hop testing and agility tests. These revealed a limb symmetry of 95%. The final session outlined the need for a graded exposure to play at 100 intensity build up over a period of 3-4 weeks.

All in all a successful return to sport at the 13 month point. Key considerations from the rehab journey include exercise selection and loading, monitoring for symptoms response and responding accordingly. Understand of the use of plyometrics and getting the right entry point and how they can be progressed in terms of intensive or extensive. Functional testing is key - shows high level performance and confidence of the patient to commit to using the injured limb.