 

 
 
Rehabilitation Protocol for Achilles Rupture Repair 
 
This protocol is intended to guide clinicians through the post-operative course for Achilles tendon repair. This protocol is 
time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs 
of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes 
contained within this guideline may vary based on surgeon’s preference, additional procedures performed, and/or 
complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with 
the referring surgeon. 
 
The interventions included within this protocol are not intended to be an inclusive list. Therapeutic interventions should 
be included and modified based on the progress of the patient and under the discretion of the clinician.  
 
Considerations for the Post-operative Achilles tendon repair program 
Many different factors influence the post-operative Achilles tendon rehabilitation outcomes, including type and location 
of the Achilles tear and repair. Consider taking a more conservative approach to range of motion, weight bearing, and 
rehab progression with tendon augmentation, re-rupture after non-surgical management, revision, chronic tendinosis, 
and co-morbidities, for example, obesity, older age, and steroid use. It is recommended that clinicians collaborate 
closely with the referring physician regarding intra-operative findings and satisfaction with the strength of the repair. 
 
If the patient develops a fever, unresolving numbness/tingling, excessive drainage from the incision, uncontrolled pain 
or any other symptoms you have concerns about, the referring physician should be contacted. 
 
PHASE I: IMMEDIATE POST-OP (0-3 WEEKS AFTER SURGERY) 
Rehabilitation 
Goals 
- Protect repair 
- Maintain strength of hip, knee and core 
- Manage swelling 
Weight Bearing 
Walking 
- Non-weight bearing (NWB) on crutches in splint and/or Achilles boot. 
Intervention 
Range of motion/Mobility (in boot/splint) 
- Supine passive hamstring stretch 
 
Strengthening (in boot/splint) 
- Quad sets 
- Straight leg raise 
- Abdominal bracing 
- Hip abduction  
- Side-lying hip external rotation-clamshell 
- Prone hip extension 
- Prone hamstring curls 
Criteria to 
Progress 
- Pain < 5/10 
 
 
PHASE II: INTERMEDIATE POST-OP (4-6 WEEKS AFTER SURGERY) 
Rehabilitation 
Goals 
- Continue to protect repair 
- Avoid over-elongation of the Achilles 
 

 
 - Reduce pain, minimize swelling 
- Improve scar mobility once incision is healed 
- Restore ankle plantar flexion, inversion, and eversion 
- Dorsiflexion to neutral 
- Normalize gait as much as possible while in boot by utilizing a Shoe Leveler for the uninvolved 
side to prevent secondary musculoskeletal complaints. 
Weight Bearing 
Walking (**Weight-bearing, wedge use/weaning, and boot types may vary by surgeon/practice.) 
- Week 4:  Begin partial progressive weight-bearing on crutches in an Achilles boot with 3 
wedges (~1” in height each).  Suggest gradually progress weight-bearing by 25% of body weight 
per week as tolerated until Full Weight-bearing (FWB) through the surgical side without pain. 
- Week 5:  Wean one heel wedge leaving 2 wedges remaining in Achilles Boot. 
- Week 6:  Wean 2nd heel wedge, leaving 1 wedge remaining in Achilles Boot. 
Additional 
Intervention 
*Continue with 
Phase I 
interventions 
Range of motion/Mobility 
- Initiate ankle passive range of motion (PROM), active assisted range of motion (AAROM) and 
active range of motion (AROM) - DO NOT dorsiflex (DF) ankle past 0 degrees 
- Ankle pumps (do not DF ankle beyond neutral/0 degrees) 
- Ankle circles (do not DF ankle beyond neutral/0 degrees) 
- Ankle inversion 
- Ankle eversion 
- Seated heel-slides for ankle DF ROM (not past 0 degrees) 
- If stiff from immobilization, initiate great toe DF and PF stretching (by patient or therapist) – Do 
not exceed neutral (0 degrees) DF when performing this stretch. 
- Foot and ankle joint mobilizations: per therapist discretion 
- Modify hand placement to avoid pressure on healing incision 
- May begin gentle scar mobilization once incision is healed - NO instrument assisted soft tissue 
mobilization (IASTM) directly on tendon until at least 16 weeks post-op.   
 
Cardio 
- Upper body ergometer 
 
Strengthening 
- Continue proximal lower extremity strengthening as in Phase I 
- Lumbopelvic Strengthening:  planks (in Achilles Boot) 
- Once able sit with foot flat on the floor with ankle close to neutral DF: 
- Seated heel raises 
- Seated arch doming 
- Exercises for foot intrinsic muscles to minimize atrophy while in boot 
 
Proprioception 
- Joint position re-training 
Criteria to 
Progress 
- Pain < 3/10 
- Minimal swelling (recommend water displacement volumetry or circumference measures such 
as Figure 8) 
- Full ROM PF, eversion, inversion 
- DF to neutral 
- Optimal gait in Achilles Boot with 1 wedge, crutches and Shoe Leveler on uninvolved side 
 
PHASE III: LATE POST-OP (7-8 WEEKS AFTER SURGERY) 
Rehabilitation 
Goals 
- Continue to protect repair 
- Avoid over-elongation of the Achilles.  No overt stretching of the Achilles. 
- Normalize gait in Achilles Boot without wedges using a Shoe Leveler for the uninvolved side. 
- Restore full range of motion including DF 
- Safely progress strengthening 
- Promote proper movement patterns 
- Avoid post exercise pain/swelling 
 

 
 - FWB in boot without wedges, without crutches, with good tolerance and normalized gait pattern 
by week 8 
Weight Bearing 
Walking 
- Week 7:  Remove final heel wedge from Achilles Boot.  
- WBAT/FWB with one crutch/no crutches as needed for normalized gait pattern in 
Achilles Boot without wedges, with Shoe Leveler on the uninvolved side (remove 
one layer of the Shoe Leveler) 
- Week 8:  FWB in Achilles Boot (no wedges) with Shoe Leveler on uninvolved without crutches 
Additional 
Intervention 
*Continue with 
Phase I-II 
Interventions as 
indicated. 
Range of motion/Mobility 
- Continue seated heel-slides for DF ROM to tolerance – DF ROM no longer restricted but 
continue to gently progress. 
- Continue toe stretching as needed 
- Gentle stretching of proximal muscle groups as indicated: (Examples: standing quad stretch, 
standing hamstrings stretch, kneeling hip flexor stretch, piriformis stretch)  
- Ankle/foot mobilizations (talocrural, subtalar, midfoot, MTPs) as indicated 
- No overt stretching of the calf in NWB or weight-bearing.  NWB stretches such as calf towel 
stretch should only be implemented if DF ROM progression is delayed 
 
Cardio 
- Stationary bicycle  (in Achilles boot) 
 
Strengthening 
- 4 way ankle with resistance band 
- Lumbopelvic strengthening: bridges on physioball, bridge on physioball with roll-in, bridge on 
physioball alternating 
- Gym equipment: hip abductor and adductor machine, hip extension machine, roman chair 
- Progress intensity (strength) and duration (endurance) of exercises 
Criteria to 
Progress 
- No swelling/pain after exercise 
- Normal gait in Achilles boot without wedges or need for crutches 
- ROM equal to contralateral side 
- Joint position sense symmetrical (<5 degree margin of error) 
 
PHASE IV: TRANSITIONAL (9-10 WEEKS AFTER SURGERY) 
Rehabilitation 
Goals 
- Maintain full ROM 
- Normalize gait in supportive sneaker with 1 cm heel lift 
- Avoid over-elongation of the Achilles 
- Safely progress strengthening 
- Promote proper movement patterns 
- Avoid post exercise pain/swelling 
Weight Bearing 
Walking 
- Transition to sneaker with 1 cm heel lift (FWB) 
Additional 
Intervention 
*Continue with 
Phase I-III 
interventions as 
indicated. 
Range of motion/Mobility 
- Ankle/foot mobilizations (talocrural, subtalar, midfoot, MTPs) as indicated 
- Continue Seated ankle heel-slides for DF.  Progress to standing ankle dorsiflexion stretch on 
step. 
 
Cardio 
- Stationary bike, flutter kick swimming/pool jogging (only if incision fully healed) 
 
Strengthening 
- Begin Standing calf raise progression: (based on tolerance/performance and will extend into the 
later phases) 
-  Bilateral standing heel raises (25% body weight thru involved leg) 
-  Bilateral standing heel raises (50% equal weight through both legs) 
-  Bilateral standing heel raises (75% body weight thru the involved leg) 
 

 
 - Knee Exercises for additional exercises and descriptions 
- Gym equipment: seated hamstring curl machine and hamstring curl machine, leg press machine 
 
Balance/proprioception 
- Double limb standing balance utilizing uneven surface (wobble board) 
- Single limb balance - progress to uneven surface including perturbation training 
Criteria to 
Progress 
- No swelling/pain after exercise 
- Normal gait in supportive sneaker with 1 cm heel lift 
 
PHASE V: TRANSITIONAL (11-12 WEEKS AFTER SURGERY) 
Rehabilitation 
Goals 
- Maintain full ROM 
- Normalize gait in supportive sneakers without heel-lift 
- Avoid over-elongation of the Achilles 
- Safely progress strengthening 
- Promote proper movement patterns 
- Avoid post exercise pain/swelling 
Weight Bearing 
Walking 
- Wean heel-lift from sneaker.  Normalize gait pattern. 
Additional 
Intervention 
*Continue with 
Phase I-IV 
interventions as 
indicated. 
 
- Continue to progress with interventions for ROM, cardio, strengthening, balance and 
proprioception from previous phases as indicated. 
Criteria to 
Progress 
- No swelling/pain after exercise 
- Full ROM during standing bilateral concentric calf raise with equal weight bearing through both 
legs 
- Normal gait in supportive sneakers 
 
PHASE VI: ADVANCED POST-OP (3-6 MONTHS AFTER SURGERY) 
Rehabilitation 
Goals 
- Safely progress strengthening 
- Promote proper movement patterns 
- Avoid post exercise pain/swelling 
- Avoid over-elongation of the Achilles 
- Good tolerance with progression to plyometrics and agility training 
Additional 
Intervention 
*Continue with 
Phase II-V 
interventions as 
indicated. 
Range of motion/Mobility 
- Continue Standing ankle DF mobilization on step 
- If indicated, may initiate gentle IASTM directly to the tendon beginning at 16 weeks. 
 
Cardio 
- Elliptical, stair climber 
 
Strengthening 
- If able to perform bilateral standing heel raises with 75% of body weight through the full range 
of involved limb, progress to eccentric calf raises (bilateral raises, unilateral lowering on 
involved) on level surface followed by progression to unilateral heel raises.   
- Seated calf machine or wall sit with bilateral calf raises 
- **The following exercises are to focus on proper pelvis and lower extremity control with emphasis 
on good proximal stability: 
- Hip hike 
- Forward lunges: Begin leading with injured leg only then progress to leading with 
uninjured leg. 
- Lateral lunges 
- Bilateral squats progressing to single leg progression (below) 
 

 
 - Single leg progression: partial weight bearing single leg press, slide board lunges: retro 
and lateral, step ups and step ups with march, lateral step-ups, step downs, single leg 
squats, single leg wall slides 
 
Plyometrics  
- Initiate Beginner Level plyometrics: 
- Once able to perform 3 sets of 15 of bilateral standing heel-raises with equal weight 
bearing progress to rebounding heel raises bilateral stance.   
- Once able to perform 3 sets of 15 unilateral heel raises progress to rebounding 
unilateral heel raises. 
- Once able to demonstrate good performance/tolerance with rebounding heel raises 
then initiate hopping in place bilateral stance.  Progress as able to unilateral hopping in 
place. 
Criteria to 
Progress 
- No swelling/pain after exercise 
- Standing Heel Rise test > 90% of uninvolved 
- No swelling/pain with 30 minutes of fast-paced walking 
- Good tolerance and performance of Beginner Level plyometrics 
- Achilles Tendon Rupture Score (ATRS) 
- Psych Readiness to Return to Sport (PRRS) 
 
PHASE VII: EARLY to UNRESTRICTED RETURN TO SPORT (6+ MONTHS AFTER SURGERY) 
Rehabilitation 
Goals 
- Continue strengthening and proprioceptive exercises 
- Safely initiate sport specific training program 
- Symmetrical performance with sport specific drills 
- Safely progress to full sport 
Additional 
Intervention 
*Continue with 
Phase III-VI 
interventions as 
indicated. 
Range of motion/Mobility 
- May initiate gentle standing gastroc stretch and soleus stretch as indicated at 6 months post-op 
 
Running 
- Interval walk/jog program (Phase 1 of the Return to Running Program) 
- Return to Running Program (Phase 2) 
 
Plyometrics and Agility  
- Criteria to progress to the Agility and Plyometrics Program: 
- Good tolerance/performance of Beginner Level Plyometrics in Phase VI above  
- Completion of Phase 1 Return to Running Program (walk/jog intervals) with good 
tolerance. 
Criteria to 
Discharge 
- Clearance from MD and ALL milestone criteria below have been met. 
- Completion of both phases of the Return to Running Program without pain/swelling. 
- Functional Assessment 
- Lower Extremity Functional Tests should be ≥90% compared to contralateral side for 
unilateral tests.   
   Contact 
Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol 
Revised 8/2021  
 
 
References: 
 
1. 
Baxter JR, Corrigan P, et al.  Exercise Progression to Incrementally Load the Achilles Tendon.   Medicine & Science in Sports & Exercise. 2020. 53(1): 
124-130. 
 
2. 
Groetelaers PTGC, Janssen L, et al. Functional treatment or case immobilization after minimally invasive repair of an acute achilles tendon rupture: 
prospective, randomized trial. Foot & Ankle International. 2014. 35(8): 771-778. 
 
3. 
Mandelbaum BR, Silvers HJ, Watanabe DS, et al. Effectiveness of a Neuromuscular and Proprioceptive Training Program in Preventing Anterior 
Cruciate Ligament Injuries in Female Athletes: 2-year follow-up. Am J Sports Med. 2005;33:1003-1010.  
4. 
McCormack R, Bovard J. Early functional rehabilitation or cast immobilization for the postoperative management of acute achilles tendon rupture? 
A systematic review and meta-analysis of randomized controlled trials. Br J Sports Med. 2015. 49:1329-1335. 
 

 
 5. 
MGH Orthopedics Foot and Ankle Service. Physical Therapy Guidelines for Achilles Rupture Repair. 
https://www.massgeneral.org/assets/MGH/pdf/orthopaedics/foot-ankle/PT-guidelines-achilles-rupture-repair.pdf 
 
6. 
Silbernagel KG, Nilsson-Helander K, et al. A new measurement of heel-rise endurance with the ability to detect functional deficits in patients with 
Achilles tendon rupture. Knee Surg Sports Traumatol Arthrosc. 2010. 18:258-264. 
 
7. 
Wang KC, Cotter EJ, et al. Rehabilitation and return to play following achilles tendon repair. Operative Techniques in Sports Medicine. 2017. 25:214-
219. 
 
8. 
Zellers JA, Carmont MR, et al. Return to play post-Achilles tendon rupture: a systematic review and meta-analysis of rate and measures of return to 
play. Br J Sports Med. 2016. 50:1325-1332. 
 
 
 
 
 
 

 
 Functional Assessment 
 
Patient Name:    
 
 
 
 
 
MRN:    
 
 
Date of Surgery:   
 
 
 
 
 
Surgeon:   
 
 
 
 
 
 
Concomitant Injuries/Procedures:   
 
 
 
 
 
 
                                 
Ready to jog? 
 
 
YES 
 
NO 
Ready to return to sport? YES 
 
NO 
Recommendations:   
 
 
 
 
 
 
 
 
 
 
  
Examiner:   
 
 
 
 
 
 
 
 
Range of motion is recorded in X-0-X format: for example, if a patient has 6 degrees of hyperextension and 135 degrees 
of flexion, ROM would read: 6-0-135.  If the patient does not achieve hyperextension, and is lacking full extension by 5 
degrees, the ROM would simply read: 5-135.   
 
Pain is recorded as an average value over the past 2 weeks, from 0-10.  0 is absolutely no pain, and 10 is the worst pain 
ever experienced. 
 
Standing Heel Rise test is performed starting on a box with a 10 degree incline. Patient performs as many single leg heel 
raises as possible to a 30 beat per minute metronome. The test is terminated if the patient leans or pushes down on the 
table surface they are using to balance, the knee flexes, the plantar-flexion range of motion decreases by more than 50% 
of the starting range of motion, or the patient cannot keep up with the metronome/fatigues. 
 
Hop testing is performed per standardized testing guidelines.  The average of 3 trials is recorded to the nearest 
centimeter for each limb. 
 
 
 
Operative Limb 
Non-operative 
Limb 
Limb Symmetry 
Index 
Range of motion (X-0-X) 
 
 
- 
Pain (0-10) 
 
 
- 
Standing Heel Rise test 
 
 
 
Hop Testing 
 
Single-leg Hop for Distance 
 
 
 
Triple Hop for Distance 
 
 
 
Crossover Hop for Distance 
 
 
 
Vertical Jump 
 
 
 
Y-Balance Test 
 
 
 
Calculated 1 RM (single leg press) 
 
 
 
Psych. Readiness to Return to Sport (PRRS) 
 
 

 
 Return to Running Program 
 
This program is designed as a guide for clinicians and patients through a progressive return-to-run program. Patients 
should demonstrate > 80% on the Functional Assessment prior to initiating this program (after a knee ligament or 
meniscus repair). Specific recommendations should be based on the needs of the individual and should consider clinical 
decision making. If you have questions, contact the referring physician.  
 
PHASE I: WARM UP WALK 15 MINUTES, COOL DOWN WALK 10 MINUTES 
Day 
1 
2 
3 
4 
5 
6 
7 
Week 1 
W5/J1x5 
 
W5/J1x5 
 
W4/J2x5 
 
W4/J2x5 
Week 2 
 
W3/J3x5 
 
W3/J3x5 
 
W2/J4x5 
 
Week 3 
W2/J4x5 
 
W1/J5x5 
 
W1/J5x5 
 
Return 
to Run  
Key: W=walk, J=jog 
**Only progress if there is no pain or swelling during or after the run 
 
PHASE II: WARM UP WALK 15 MINUTES, COOL DOWN WALK 10 MINUTES 
Week 
Sunday 
Monday 
Tuesday 
Wednesday 
Thursday 
Friday 
Saturday 
1 
20 min 
 
20 min 
 
20 min 
 
25 min 
2 
 
25 min 
 
25 min 
 
30 min 
 
3 
30 min 
 
30 min 
 
35 min 
 
35 min 
4 
 
35 min 
 
40 min 
 
40 min 
 
5 
40 min 
 
45 min 
 
45 min 
 
45 min 
6 
 
50 min 
 
50 min 
 
50 min 
 
7 
55 min 
 
55 min 
 
55 min 
 
60 min 
8 
 
60 min 
 
60 min 
 
 
 
Recommendations 
- Runs should occur on softer surfaces during Phase I 
- Non-impact activity on off days 
- Goal is to increase mileage and then increase pace; avoid increasing two variables at once 
- 10% rule:  no more than 10% increase in mileage per week 
 
 
 

 
 Agility and Plyometric Program 
 
This program is designed as a guide for clinicians and patients through a progressive series of agility and plyometric 
exercises to promote successful return to sport and reduce injury risk. Patients should demonstrate > 80% on the 
Functional Assessment prior to initiating this program. Specific intervention should be based on the needs of the 
individual and should consider clinical decision making. If you have questions, contact the referring physician.  
 
PHASE I: ANTERIOR PROGRESSION 
Rehabilitation 
Goals 
- Safely recondition the knee 
- Provide a logical sequence of progressive drills for pre-sports conditioning 
Agility 
- Forward run 
- Backward run 
- Forward lean in to a run 
- Forward run with 3-step deceleration 
- Figure 8 run 
- Circle run 
- Ladder  
Plyometrics 
- Shuttle press: Double leg
alternating leg
single leg jumps 
- Double leg:  
- Jumps on to a box
 jump off of a box
 jumps on/off box 
- Forward jumps, forward jump to broad jump 
- Tuck jumps 
- Backward/forward hops over line/cone 
- Single leg (these exercises are challenging and should be considered for more advanced 
athletes): 
- Progressive single leg jump tasks 
- Bounding run 
- Scissor jumps 
- Backward/forward hops over line/cone 
Criteria to 
Progress 
- No increase in pain or swelling 
- Pain-free during loading activities 
- Demonstrates proper movement patterns 
 
PHASE II: LATERAL PROGRESSION 
Rehabilitation 
Goals 
- Safely recondition the knee 
- Provide a logical sequence of progressive drills for the Level 1 sport athlete 
Agility 
*Continue with 
Phase I 
interventions 
 
- Side shuffle 
- Carioca 
- Crossover steps 
- Shuttle run 
- Zig-zag run 
- Ladder 
Plyometrics 
*Continue with 
Phase I 
interventions 
- Double leg:  
- Lateral jumps over line/cone 
- Lateral tuck jumps over cone 
- Single leg(these exercises are challenging and should be considered for more advanced 
athletes): 
- Lateral jumps over line/cone 
- Lateral jumps with sport cord 
Criteria to 
Progress 
- No increase in pain or swelling 
- Pain-free during loading activities 
- Demonstrates proper movement patterns 
 
 
PHASE III: MULTI-PLANAR PROGRESSION 
Rehabilitation 
Goals 
- Challenge the Level 1 sport athlete in preparation for final clearance for return to sport 
Agility  
*Continue with 
Phase I-II 
interventions 
- Box drill 
- Star drill 
- Side shuffle with hurdles 
Plyometrics 
*Continue with 
Phase I-II 
interventions 
- Box jumps with quick change of direction 
- 90 and 180 degree jumps  
Criteria to 
Progress 
- Clearance from MD 
- Functional Assessment 
- ≥90% contralateral side 
- Achilles Tendon Rupture Score (ATRS) 
- Psych Readiness to Return to Sport (PRRS) 
 
 
 
