Gems for rehabilitation - Clinical Ideas for the Physiotherapist
Periodisation in Rehab, Achilles Rupture Phases 1-2

Appropriate rehabilitation following an Achilles tendon rupture no matter if surgically, conservative or functionally managed needs a clear structured rehabilitation programme to allow for optimal results.  Perseverance by both patient and physiotherapist is essential as the literature reports many patients never return to pre injury function due to their lack of strength. Appropriate strength training often takes up to a year!

Those of us with exercise science knowledge typically would use a clear periodisation plan (Macrocycle) to break up a year’s training into phases (Mesocycles). This allows for periods of overload and then appropriate rest. It also clearly outlines training goals for each phase, which is important for all patients.

Athletes are accustomed to a periodised training plan when preparing for their sporting events. Outlining such a plan with rehabilitation assists in setting short term realistic goals along their (and all patients) rehabilitation journey. I always review this plan during the initial rehabilitation phase, and I believe that this is essential to gain all patients buy in.

The initial periodisation phase is that of non-weight bearing while their lower limb is immobilised. The key elements are firstly to maintain other muscle mass and fitness and is only limited by the therapist’s ability to provide a range of exercises while non weight bearing. It is also critical to build rapport with the athlete and assist in providing emotional support.

At the later stage of this cycle I also commence specific intrinsic foot muscle reactivation when the foot is still immobilised in preparation for weight bearing.

The second phase of a periodised plan following an Achilles tendon rupture is the progression to normalisation of weight bearing.  This is critical to achieve with all everyday tasks. Traditionally I have simply used dual scales for this but with technology advances currently I use a dual force plate system with real time feedback for the patient.

I use this initially with the patient viewing their weight bearing status in quiet stand, sit to stand and then calf raise tasks. With each activity once the athlete has achieved this task utilising biofeedback, I then complete the tasks blinded.  Accurate biofeedback at this phase can also be used to prescribe and measure training loads, repetitions and fatigue in the transition to full weight bearing.

This task seems so simple but is often missed with patients continuing to offload their weightbearing with activities of daily living for a prolonged period of time. Hence not fully stimulating the necessary neuromuscular adaptation needed for optimal progressions of strength training and later periodised phases.