Achilles Rupture Rehab Told Through the Heel Raise

Walking, climbing stairs, running, jumping, changing direction, almost everything we ask of the Achilles tendon involves one fundamental action: raising the heel off the ground. In other words, you can think of Achilles rehab as one long progression of the single-leg heel raise (SLHR).

This blog, informed by expert Dr Karin Grävare Silbernagel’s Practical, focuses on that ever-so-important action, and how to re-train it in your Achilles rupture patients.

If you want to see exactly how an expert rehabs mid-late stage Achilles ruptures, watch Karin’s full Practical HERE. With Practicals, you can be a fly on the wall and see exactly how top experts assess and treat specific conditions – so you can become a better clinician, faster. Learn more HERE.

The seated heel raise

There’s no avoiding it: initial Achilles rehab can be quite dull.

That’s why it’s important to keep patients doing everything their Achilles allows them to do. The Achilles-specific rehab itself is relatively simple at this stage, so I won’t spend too much time on it.

A big part of their rehab while you’re keeping them in neutral is working on seated calf raises. Once a patient can perform 20 seated single-leg heel raises with 50% of their body weight, this criterion has high sensitivity and specificity for identifying those who can perform a standing single-leg heel raise.

The standing heel raise

Around 3-4 months after injury or surgery, it’s time to see whether the patient can perform a standing SLHR.

For many patients, this is harder than expected.

A successful heel raise is defined as lifting the heel at least 2cm from a neutral position. Many patients simply can’t achieve that initially, even if they feel like they’re pushing as hard as possible.

If that’s the case, it isn’t necessarily time to push on regardless. Instead, continue building calf capacity. Karin also demonstrates how she uses Neuromuscular Electrical Stimulation (NMES) in standing to maximise calf activation when patients still can’t generate enough force to achieve that first heel raise.

Once patients can clear the 2 cm threshold, they’re ready for formal testing of heel raise endurance and height.

Watch Karin demonstrate how to do a proper, repeatable SLHR test in this clip from her Practical:

Then make the heel raise stronger

As patients move into the gym, the goal isn’t simply to perform more heel raises. It’s to expose the Achilles to heavier loads and different positions that prepare it for real life and sport.

Karin demonstrates several ways to achieve this, including: kettlebell SLHR, leg press heel raises and seated bent-knee calf raises.

One particularly useful exercise is her isometric push-off.

Rather than performing a traditional heel raise, the patient holds a push-off position with the heel elevated and drives force through the forefoot into a fixed surface. It’s an excellent way to build strength in the position where many patients still feel weakest, while also bridging the gap towards more dynamic activities like sled pushes.

An important takeaway from Karin’s Practical is not to avoid training through the patient’s available range simply because they can’t reach the same heel height as the uninjured side. Work through the range they have!

The heel raise gets faster (i.e. jumping and hopping)

Okay fair enough, a SLHR is only one element of jumping but it’s an important one.

Karin demonstrates a battery of jumping tests that patients can perform around the six-month mark. These heavily load the Achilles and provide a good indication of whether the patient is ready to return to sport. Watch her demonstrate some of them in this video from her Practical:

How should a patient be progressing?

Timelines are always going to depend on the person, but the research provides some good reference points.

In terms of the SLHR test, when comparing to the uninjured side, at 3 months only 50% of patients can do the test, at 6 months they may be able to achieve 70% of the heel raise height and 85-90% of the repetitions achieved on the uninjured side, and at 1 year they should achieve closer to 80% of the height of the uninjured side.

Patients are usually within 80–90% of the uninjured side at six months for all jumping tests except the drop countermovement jump, which typically reaches only 60–70%. Karin explains this is often due to fear. So not only is the drop countermovement jump a great test but also a great exercise to help patients regain confidence.

Wrapping up

No matter which way you look at it, Achilles rehab is always going to involve a lot of heel raises, but that doesn’t mean it has to be boring.

You should be helping the patient prepare for all kinds of speeds and positions, all specific to their goals and needs.

If you’d like to see exactly how Karin manages mid- to late-stage Achilles rupture rehabilitation, watch Karin’s full Practical here.