Case Study

1. Recovering from Achilles Tendon Repair in an Outpatient Rehab Facility: A Case Study
Kristen White
Clemson University
Objective: To describe a patient’s progression through physical therapy treatment following an
Achilles tendon repair.
Background: The patient suffered an injury to his Achilles tendon while playing pickle ball. He
then had his Achilles tendon repaired and was referred to physical therapy by his physician.
Intervention: The patient has been participating in physical therapy sessions 2-3 times per week
for 14 weeks. The treatment involves manual therapy to include instrument assisted soft tissue
mobilization (IASTM), progressive therapeutic exercises, proprioception activities, modalities,
Neuromuscular Reeducation, and a home exercise program. The treatment is focused on
improving tolerance for and safety with all weight bearing activities of daily living.
Conclusion: The treatment methods used have proven to be effective, as the patient has
responded very well to therapy. He has been able to make great progress toward his goals of
increasing range of motion in his right ankle, increasing his ability to walk and climb stairs
without pain, and ultimately being able to return to pickle ball and golf. His Foot and Ankle
Ability Measure (FAAM) and self reported level of function have improved as well. He is
continuing treatment sessions at Excel in order to bring him the highest level of healing and
functioning possible.
INTRODUCTION:
The Achilles tendon is the largest and strongest tendon in the body. It links the calf
muscles to the heel bone and produces the majority of the force that pushes the ball of the foot
down during walking or running2
. Achilles tendon ruptures most commonly occur in middle-
aged men and often occur when pushing off of the foot and while playing a sport like basketball
or tennis. People will usually report feeling a “shot” in the back of the calf and then having sharp
pain. This injury is debilitating and can cause immense pain1
. Regaining Achilles tendon
function after an injury is critical for walking. The goal of an Achilles tendon repair is to
reconnect the calf muscles with the heel bone to restore push-off strength. The most common
method of repair is an open repair. This starts with an incision made on the back of the lower leg
starting just above the heel bone. After the surgeon finds the two ends of the ruptured tendon,
these ends are sewn together with sutures. Then the incision is closed. Physical therapy is
typically started six weeks after surgery when the patient is allowed full weight bearing out of
the cast or boot and is aimed at restoring ankle range of motion. Patients are usually able to
return to full activity by six months after surgery, but it may be over a year before a patient
achieves full recovery2
. The following case study describes a patient’s progression through
physical therapy at an outpatient rehabilitation clinic following an Achilles tendon repair.
BACKGROUND:
The patient is a 78-year-old white male who suffered an Achilles tendon injury on his
right foot while playing pickle ball on June 3, 2016. His Achilles tendon repair surgery was on
June 29, 2016. His medical doctor released him from wearing his boot on August 11, 2016 and

2. he has not used the boot since. Following surgery, he complained of pain in his right ankle and
joints of the right foot, as well as swelling. He reported occasional discomfort when walking and
had a difficult time going down stairs. Most of his pain came during the day. The patient was not
currently taking any medications for his right Achilles. He reported a right plantaris tear 1.5
years ago. His past medical history included lower back surgery in 1974 and a right rotator cuff
repair in 2009. He had no limitation in function prior to his injury. He played pickle ball three
times per week and golf twice per week. His main goal for therapy is being able to return to
pickle ball and golf.
EVALUATION:
The patient was initially evaluated by the physical therapist on August 16, 2016. The
patient reported pain at the time of the evaluation to be 1-2/10. The patient reported pain at
maximum to be 3/10 over the last week. Pain is reported on a 0-10 scale where 0 is no pain and
10 is the maximum pain possible. Bilateral hip and knee range of motion were found to be within
functional limits. Ankle Active Assistive Range of Motion (AAROM) was then assessed. See
Table 1 for Range of Motion (ROM) measurements at initial evaluation. Strength was then
assessed using an ankle Manual Muscle Test (MMT). See Table 2 for strength measurements at
initial evaluation. His neurological functioning was noted to be intact light touch without
deviations noted. Upon observing the patient, the therapist noticed mild edema in the right ankle.
His ankle circumference was 29 cm on the right and 27 cm on the left. The incision was closed
and there was no redness or warmth noted. While observing his gait, his push off was absent on
the right side. He was able to hold a single leg balance for 15+ seconds on the left and 5 seconds
on the right. There was no focal Tender to Palpation (TTP). His (FAAM) was 48/84 and his self
reported level of functioning was 60%. His functional limitations and objective deficits included
limited tolerance for walking and descending stairs and all weight bearing on uneven surfaces
and recreational/fitness activities. He presented with limited right ankle ROM, right ankle
weakness, limited right single leg stability, and pain. The therapist reported that he would benefit
from physical therapy in order to address these deficits and improve tolerance for and safety with
all weight bearing activities of daily living. The therapist determined the following goals for
therapy:
Short-term goals (1-2 weeks):
• The patient will be independent with a home exercise program to improve right
ankle mobility and strength.
Long-term goals (4 weeks):
• The patient will present with increased ROM in his right ankle to a level of equal
with the left to increase tolerance for descending stairs and walking on uneven
ground.
• The patient will present with pain in his right ankle to a level of 0/10 to increase
tolerance for all weight bearing activities and return to recreation and fitness
activities.
• The patient will present with increased PF strength in his right ankle to a level of
4/5 and inversion to 4+/5 to increase tolerance for walking and all weight bearing
activities of daily living.
The therapist prognosis of rehabilitation potential was excellent.

3. Table 1: ROM
Initial Right Initial Left
Ankle Inversion 25 deg 39 deg
Ankle Eversion 10 deg 26 deg
Ankle Plantarflexion 20 deg 22 deg
Ankle Dorsiflexion/Knee Flex 5 deg of PF 5 deg
Table 2: Strength
Initial Right Initial Left
Ankle Dorsiflexion 5/5 5/5
Ankle Plantarflexion 2+/5 5/5
Ankle Inversion 4/5 5/5
Ankle Eversion 4+/5 5/5
INTERVENTION:
Physical therapy treatment began including one-hour therapy sessions 2-3 times per
week. The typical duration of therapy for an injury of this type is 12-18 weeks. This patient has
been in therapy for 14 weeks and is still being treated today. The treatment plan includes
modalities, manual therapy, therapeutic exercises, Neuromuscular Reeducation, and a home
exercise program.
The first therapy session included manual therapy techniques with joint and soft tissue
mobilization (STM). This included STM on the Achilles, retroedema STM and dorsiflexion (DF)
stretching. It included therapeutic exercises for foot and ankle, including a Gastroc stretch
standing, a Heel Raise Double Leg Stance, Resisted Inversion/Eversion, and a Soleus stretch.
The patient was given a home exercise plan. In his second treatment session, manual therapy and
therapeutic exercises were again used. Some therapeutic exercises were added including a warm
up on the Scifit machine, Ankle Circles, the Shuttle machine, Towel Crunch, and Weight Shifts
Ground. The session ended with a cold pack on the right elevated Achilles. The patient tolerated
his first full treatment session well without pain noted. He fatigued quickly with ankle
strengthening and displayed significant ankle motor control deficits on all planes.
The second week of therapy, the patient continued therapeutic exercises for the foot and
ankle adding balance and proprioception exercises including a Step Down, eccentric heel raises,
and Tilt Board and Wobble Board circles on the Shuttle. He is also now doing Weight Shifts
using a foam roll. He tolerated progression of the exercises well, being most limited by fatigue.
The patient was unable to step down from a four-inch step without a weight shift and right lower
extremity compensations. Manual therapy progressed to Instrument Assisted Soft Tissue
Mobilization (IASTM) for the Achilles and stretching all planes. A few days later, a half
kneeling DF stretch was added to therapeutic exercises. He presented with increasing weight
bearing right ankle DF, but was still limited in his ability to descend a four-inch step without
compensating at the hip. He was reported to be progressing with PF strength.
The third week of therapy the patient started warming up on the Elliptical machine at
level two for six minutes. He started noticing that his ankle had more motion when he walked.
The Shuttle machine resistance was increased and standing inversion/eversion was added. He
was very challenged with the progression of the Shuttle resistance, but tolerated sessions without
pain. He was reported to be gradually progressing with functional DF strength. The physical

4. therapist planned to start incorporating treadmill walking at his next visit with an emphasis on
pushing off.
The fourth week of therapy the patient’s Foot and Ankle Ability Measure (FAAM) was
reassessed. It increased to 64/84 and his self reported level of function increased to 65%. His
functional DF range of motion was measured to be 9 degrees. The patient displayed a decreased
left weight shift with the step down from a four-inch step. He was reported to be progressing
well with his right ankle strength.
At the fifth week of therapy, he progressed to standing single leg heel raises. Walking on
the treadmill at two miles per hour was also added. A single leg ball toss, walking and cone taps
were added as well. The patient was able to perform single leg heel raises on his right foot with
moderate upper extremity support. With bilateral upper extremity support on the treadmill, the
patient displayed a good push off on his right foot at terminal stance. However, this decreased
toward the end of five minutes due to fatigue. At the next session, a marble pick up was added
along with toe and heel walking. The step down height was also increased to eight inches. The
patient was able to descend a six-inch step without compensation. He was reported as able to toe
walk with relative knee flexion, but was unable to maintain knee extension with toe walking on
the right foot. He was assessed to benefit from continuing PF strengthening and single leg
stability therapeutic exercises.
On September 21, 2016, during the sixth week of therapy, the physical therapist
performed a Re-Evaluation. The total number of visits to date was 15. The treatment rendered
included manual therapy to his right ankle and Achilles to decrease irritation and discomfort and
progressive therapeutic exercises to increase right ankle ROM, strength, and single leg stability.
The patient reported pain at the time of re-evaluation to be 0/10 and 3-4/10 at maximum in the
last week. The patient reported feeling great overall and being better able to climb stairs. He
reported discomfort around his incision when he wears shoes and when he has to walk long
distances. At this point, both his ROM and strength had increased a significant amount.
Objective improvements since the beginning of therapy included an FAAM increasing from
48/84 to 69/84 and self reported level of function increasing from 60% to 80%. The patient
continued to present with functional deficits to include a limited tolerance for prolonged walking
on uneven ground and without shoes due to pain and discomfort. He presented with significantly
improved right ankle ROM and strength. However, deficits remained compared to his left side.
The physical therapist reported that he would benefit from continued physical therapy in order to
address the remaining DF ROM deficits, PF weakness, and relative right ankle instability. He
met his short-term goal for independence with his home exercise program. He had partially met
his long-term goal for ROM and strength. He was reported to be progressing well toward his
long-term goal for pain. The treatment plan was noted to continue with the same treatment
approach as started at the initial evaluation with an emphasis on functional DF ROM, PF
strength, and ankle stability. The estimated remaining treatment time was twice per week for
four weeks.
The seventh week of therapy, plyometrics were added. He tolerated the addition of these
shuttle jumps well with improving eccentric PF control.
The ninth week of therapy, the patient returned to playing golf and said that it went well,
but still felt a little unstable. The physical therapist added a double leg landing when jumping
down from a two-inch step.
On October 20, 2016, the physical therapist re-evaluated the patient again. The total
number of visits to date was 22. The patient reported pain at the time of re-evaluation to be 0/10

5. and 3/10 at maximum in the past week. The patient reported that he was getting stronger but still
had a hard time walking barefoot, walking up his inclined driveway, and walking up stairs. Both
his ROM and strength measurements have continued to increase over time. See Table 3 for
updated ROM measurements compared to those taken at initial evaluation. See Table 4 for
updated strength measurements compared to those taken at initial evaluation. His self reported
level of function had increased to 85%. He presented with significantly improved right ankle
ROM and strength, however mild deficits remained compared to the left side. The therapist
decided that he would benefit from continued physical therapy in order to address the remaining
PF weakness and right ankle dynamic instability. Continued treatment would include once or
twice per week for 4-6 weeks with progression to an independent home exercise program. The
treatment plan would continue with the same treatment approach as noted in the initial evaluation
with an emphasis on functional DF ROM, PF strength, and ankle stability. In addition, five point
hops were added to therapeutic exercises.
The twelfth week of therapy, cold packs were no longer being used. The therapist added
toe yoga for three minutes and eccentric heel raises to the treatment plan. The patient displayed
limited foot intrinsic coordination.
Table 3: ROM
Initial Right Current Right Initial Left Current Left
Ankle Inversion 25 deg 35 deg 39 deg
Ankle Eversion 10 deg 22 deg 26 deg
Ankle PF 20 deg 20 deg 22 deg
Ankle DF/Knee
Flex
5 deg of PF 9 deg; 16 deg in
WB
5 deg 20 deg in WB
Ankle DF/Knee
Ext
6 deg
Table 4: Strength
Initial Right Current Right Initial Left
Ankle DF 5/5 5/5 5/5
Ankle PF 2+/5 4-/5 5/5
Ankle Inversion 4/5 4+/5 5/5
Ankle Eversion 4+/5 4+/5 5/5
OUTCOME:
The patient has not been discharged yet, but is continuing to progress toward his goals.
He has responded very well to therapy. His FAAM improved from 48/84 at initial evaluation to
66/84. His self reported level of function has improved from 60% at initial evaluation to 85%. He
met his short-term goal of being independent with his home exercise program to improve
mobility and strength. He has partially met his long-term goal for ROM and strength and is
progressing well toward his long-term goal for pain. He will continue to benefit from progression
of foot and ankle strengthening and continued dynamic stability exercises to improve his walking
on uneven ground and up and down inclines.
DISCUSSION:

6.
Instrument assisted soft tissue mobilization (IASTM) has been used throughout the
patient’s entire treatment process. Soft tissue mobilization (STM) is a form of manual physical
therapy where a physical therapist uses hands on techniques on the muscles, ligaments, and
fascia with the goal of breaking adhesions7
. Graston instrument assisted soft tissue mobilization
is a specialized technique where the clinician uses stainless steel instruments to contact the tissue
instead of the hands. The treatment effect is more substantial because the instruments have the
potential to break up larger amounts of dysfunctional tissue in one session than is possible with
the unaided hand3
. Adhesions are the body’s attempt to heal a soft tissue injury with a long
inflammation process, resulting in long strands of collagenous scar tissue. These new tissues pull
against one another, forming trigger points of pain. Goals of IASTM include break down of
adhesions, improving ROM, lengthening muscles and tendons, reducing swelling and edema,
decreasing pain, and restoring functionality7
. Graston Technique (GT) has been the leading
modality in IASTM. GT enables clinicians to effectively address scar tissue and fascial
restrictions and maintain optimal ROM through comprehensive training and education. GT is
clinically proven to achieve faster and better outcomes for Achilles Tendonitis. The effectiveness
of GT is founded in research conducted by GT trained clinicians at Ball Memorial Hospital at
Ball State University in Muncie, Indiana. They found that controlled micro-trauma induced
through GT increased the amount of fibroblasts to the treated area. The amount of inflammation
to the scar tissue helps initiate healing. The tissue structure is then rearranged and damaged
tissue is replaced by new tissue. Other clinical studies show that GT achieves better outcomes
when compared to traditional therapies, and resolving injuries that fail to respond to other
therapies6
.
Eccentric training was used in the patient’s plan of treatment. The faculty of Medicine
and Health Sciences in the Department of Rehabilitation Sciences and Physiotherapy at Ghent
University in Belgium conducted a study that investigated whether eccentric training affects the
mechanical properties of the plantar flexor’s muscle tendon tissue properties. They found that the
dorsiflexion range of motion was significantly increased only in the eccentric training group. The
eccentric heel drop program also resulted in a significant decrease of the passive resistive torque
of the plantar flexors. The study provided evidence that an eccentric training program results in
changes to some mechanical properties of the plantar flexor muscles and therefore can be
effective in the rehabilitation of patients with Achilles tendonopathy5
.
Proprioceptive exercises were used in the patient’s treatment program in order to improve
ankle stability. Proprioception is defined as “the reception of stimuli produced within the
organism,” whereas balance is defined as “physical equilibrium”. Proprioception is a neurologic
process, which encompasses both peripheral nervous system receptors and central nervous
system integration to produce an awareness of one’s surroundings. Proprioceptive deficits occur
after prolonged immobilization or swelling that limits movement. A study by Payne et al. found
a direct relationship between ankle proprioceptive deficits and ankle injuries. These studies show
the importance of proprioceptive training after injury. Numerous studies have shown that
proprioceptive training can improve dynamic balance4
.
CONCLUSION:
This case study described the progression of an Achilles tendon repair patient through
physical therapy treatment. Through the use of manual therapy, therapeutic exercises, modalities,

7. and Neuromuscular Reeducation, the patient has been able to make great progress toward his
goals of increasing ROM in his right ankle, increasing his ability to walk and climb stairs
without pain, and ultimately being able to return to pickle ball and golf. This case study further
supports findings that physical therapy can greatly benefit patients who have recently undergone
an Achilles tendon repair.
REFERENCES:
1. "Achilles Tendon Injury." The Stone Clinic. N.p., 10 May 2016. Web. 16 Nov. 2016.
<http://www.stoneclinic.com/achilles-tendon>.
2. "Achilles Tendon Rupture Surgery." FootCareMD. American Orthopaedic Foot & Ankle
Society, 2016. Web. 16 Nov. 2016.
<http://www.aofas.org/footcaremd/treatments/Pages/Achilles-Tendon-Rupture-
Surgery.aspx>.
3. DeLuccio, Justine. "Instrument Assisted Soft Tissue Mobilization Utilizing Graston
Technique ® : A Physical Therapist’s Perspective." Orthopaedic Practice 18 (n.d.): 32-
34. Web. 16 Nov. 2016.
4. Hanney, William J. "Proprioceptive Training for Ankle Instability." Strength and
Conditioning 22.5 (2000): 63-68. Research Gate. National Strength & Conditioning
Association. Web. 16 Nov. 2016.
5. NN, Mahieu, McNair P, Cools A, D'Haen C, Vandermeulen K, and Witvrouw E. "Effect
of Eccentric Training on the Plantar Flexor Muscle-tendon Tissue Properties." Medicine
and Science in Sports and Exercise (2008): n. pag. American College of Sports Medicine.
Web. 16 Nov. 2016.
6. "Research Supports GT." Graston Technique. Graston Technique, LLC, 2016. Web. 16
Nov. 2016. <http://www.grastontechnique.com/research>.
7. "Soft Tissue Mobilization." Soft Tissue Mobilization - Baylor Scott & White Health.
Baylor Scott & White Health, 2016. Web. 16 Nov. 2016. <http://www.sw.org/physical-
medicine-rehabilitation/soft-tissue-mobilization>.