3 Principles for Achilles Ruptures–An Elite Gymnast Case Study

6 min read. Posted in Ankle
Written by Noah Mandel info

Achilles tendon ruptures are one of the most serious injuries a person can experience due to the long-standing deficits that accompany them. While they can be life or career-altering, a well-executed rehabilitation plan can play a major role in helping someone bounce back. While every patient’s rehab may look a little different, there are some guiding principles we can apply to any case in order to help our patients recover to the best of their ability.

In this blog post, we’ll explore three key principles for rehab following an Achilles rupture. These lessons are taken from Scott Greenberg’s Case Study on an elite gymnast who ruptured her Achilles tendon during Olympic trial warm-ups and went on to have her Achilles repaired. While not every patient is an Olympic-calibre athlete, this Case highlights considerations which can be applied to any Achilles rupture case.

If you’d like to see exactly how expert physio Scott Greenberg treated a real patient with Achilles rupture, check out his full Case Study HERE. With Case Studies you can step inside the minds of experts and apply their strategies to get better results with your patients. Learn more here.

 

Principle #1: Protection

One of the most crucial aspects of treating an Achilles rupture is the principle of protection soon after the injury. Specifically, we want to promote successful surgical wound healing for our Achilles repair patients and prevent excessive tendon elongation for all patients, whether managed surgically or conservatively.

The first priority after an Achilles repair is to have the wound close successfully without succumbing to any infection. Firstly, as physios, we need to ensure that there is nothing in our management plan that may compromise wound healing, such as excessive dorsiflexion during manual therapy treatments or exercise. Educating the patient on proper wound care is essential as an infection can delay the healing process and lead to further complications. Always ensure you are maintaining a sterile environment and the patient is following the prescribed post-surgery care protocol.

Aside from wound healing, another priority is to avoid excessive dorsiflexion in the early stages, as this can result in Achilles tendon elongation. An elongated Achilles tendon can have decreased elastic capabilities, leading to deficits in strength and explosiveness in the long-term. Thus, it is vital that throughout Achilles rupture rehab that we don’t rush to restore dorsiflexion range of motion. This is why Achilles rupture protocols will often have patients begin with a fixed position of plantarflexion, which gradually progresses into a more dorsiflexed position over the course of multiple weeks.

There may be a pressure to return the athlete back to sport as soon as possible in competitive settings. However, rushing through the protective phase can end up causing a delay in the rehab process due to complications. Here is Scott emphasising the importance of a successful protective phase in this snippet from his Case Study – even in the case of his patient needing to return back to sport as soon as possible:

 

Principle #2: Regaining strength

Regaining strength is one of the most challenging and vital parts of recovering from an Achilles tendon rupture. Muscle atrophy in the calf and surrounding areas begins almost immediately after the injury, and rebuilding plantarflexion strength and lower limb capacity should be a feature of any Achilles rupture management plan. However, we cannot start with a body weight calf raise! The tendon is too compromised early on, and most protocols will have a period of non-weight bearing. So, once it is safe, start with simple active range of motion and progress to using a resistance band.

As healing progresses from the early to middle stages, the rehab focus should shift from open-kinetic chain movements to weight-bearing activities and functional movements like standing calf raises and squats. Both physiotherapists and patients may feel nervous about beginning closed-chain exercises and progressing them. These video demonstrations from Scott’s Case Study provide some insights into how we can progress or regress closed-chain exercises:

 

Principle #3: Individualisation

No two patients are the same, and successful recovery from an Achilles rupture is ultimately determined by whether someone successfully and safely meets their long-term goals. For this gymnast, regaining elite-level performance is necessary, but that may not be as essential for someone whose goal is to get back to hiking.

Individualisation means we help patients build confidence, capacity, and capability in tasks that align with their long-term goals. How do we make sure we are doing this? We choose relevant subjective and objective measures to track progress.

For most Achilles rupture patients, limitations in dorsiflexion range of motion and plantarflexion force production will be the main barriers to achieving their goals. So, it makes sense to track these as objective outcomes in some fashion for most patients. For some, simply looking at the symmetry between limbs in their knee-to-wall test or in the amount of calf raises they can do may be adequate.

However, for the gymnast, detailed analysis of dynamometry and force plate measures can be useful for evaluating her readiness for high-impact routines. In the below video from his Case Study, Scott explains why simply looking at symmetry, in this case, in force production during a jump, is not adequate for this gymnast:

Someone with different long-term goals—such as hiking—probably does not need to have their jump height measured. Instead, they might benefit more from objective measures related to walking tolerance, endurance, and balance rather than jump metrics. For example, tracking improvements in walking distances or incline tolerance can provide meaningful feedback for a hiker.

Scott chose to use the Achilles Tendon Rupture Score (ATRS) to evaluate his patient’s functional recovery. Here are her results at 4 months:

image

As you can see, there are questions in the ATRS that refer to running, jumping, and hard physical labour. This is a questionnaire that may be quite useful for our athletes, but not so much for our more sedentary patients. Perhaps a different tool, like the Foot and Ankle Ability Measure (FAAM) could be more relevant for this population.

Ultimately, tailoring the plan ensures that every exercise, test, and milestone serves a purpose, empowering individuals to return to the activities that matter most to them. Whether it’s landing a complex gymnastics routine or completing a challenging hike, rehabilitation should pave the way to achieving personal goals.

 

Wrapping up

Achilles tendon ruptures can present unique challenges, requiring a balance between protecting the healing tendon, rebuilding strength, and tailoring the rehabilitation process to each patient’s goals. Scott Greenberg’s Case Study provides invaluable insights into how to navigate these complexities with evidence-based strategies.

By emphasising protection, progressive strength training, and individualised care, we can help patients—from elite athletes to weekend hikers—return to the activities they value most. Dive into the Case Study to gain a deeper understanding of how these principles can guide your approach and elevate your practice in managing Achilles ruptures – watch the full Case Study HERE.

👩‍⚕️ Looking to sharpen your clinical reasoning?

🙌 Our Case Studies service is here to help!

🎥 Watch case study presentations that reveal how top clinicians treat real patients…

🏆 And apply their strategies to get better results with yours!

 

preview image

Don’t forget to share this blog!

Leave a comment

If you have a question, suggestion or a link to some related research, share below!

You must be logged in to post or like a comment.

Elevate Your Physio Knowledge Every Month!

Get free blogs, infographics, research reviews, podcasts & more.

By entering your email, you agree to receive emails from Physio Network who will send emails according to their privacy policy.