Postoperative ankle flexion, knee flexion 30 long leg plaster fixation;
After 3 weeks, it was replaced with high-heeled short-leg plaster and quadriceps femoris was exercised regularly.
After 6-8 weeks, take off the plaster and exercise the ankle joint function; Protection and healing period (1~6 weeks)
The first stage of rehabilitation after operation is very important for protecting the repaired achilles tendon, controlling exudation and pain, reducing scar formation and improving joint mobility. The degree of postoperative load bearing and the type of brace are determined by the doctor. The degree of load-bearing ranges from not excessive load-bearing when wearing the left brace to partial load-bearing until the patient can bear it to the maximum. You need to bear the weight under protection within 2~8 weeks after operation. With the development of surgery and rehabilitation technology, the common method at present is to let patients put on a kind of fixed boots with a roulette wheel and observe part of the load under the protection of crutches.
Early joint movement and protected weight bearing are the most important contents in the first stage after operation. Because weight bearing and joint activity can promote the healing and strength increase of achilles tendon, it can prevent the negative effects brought by braking (such as muscle atrophy, joint stiffness, degenerative arthritis, adhesion formation and deep vein thrombosis).
Under the guidance of patients, many active joint activities should be done every day, including ankle dorsiflexion, plantarflexion, varus and valgus. When knee flexion is 90, active ankle flexion should be limited to 0 (neutral position). Passive joint movement and stretching should be avoided to protect the healing achilles tendon from excessive stretching or fracture.
When the patient begins to bear part of it completely, fixed bicycle exercise can be introduced at this time. When pedaling a bicycle, the patient should be told to use the back (or heel) of the foot to carry it, not the front foot. Massage scar and slight joint activity can promote healing and prevent joint adhesion and stiffness.
Cold therapy and raising the affected limb can control the pain and edema. The patient should be told to try to raise the patient as high as possible all day to avoid keeping a heavy posture for a long time. Patients can also be advised to ice several times with ice packs for 20 minutes each time.
Progressive resistance training scheme should be adopted in the practice of near hip and knee joint. Patients with limited load can adopt open-chain exercise and isotonic exercise.
Matters needing attention
Poor healing and infection after achilles tendon repair are the most common complications. Therefore, it is very important for rehabilitation doctors and patients to check the incision frequently in the first stage after operation. Once you find that the incision is not healed well or infected, you should inform the doctor immediately.
Patient exudation is also one of the common complications. Patients should be warned to bear weight reasonably, raise the affected limb (limit the time to keep the weight position), take the initiative to carry out joint activities and ice several times a day. Early joint activity (6~ 12 weeks)
In the second stage, the degree of load-bearing has changed obviously, the joint activity has increased, and the muscle strength has increased. Patients should first put on braces under the protection of crutches to complete the complete load-bearing of the affected limb, and then get rid of crutches and wear shoes to carry the load. In the process of converting the foot brace into a shoe, you can put a heel pad in the shoe (generally bending the ankle and sole by 20 ~ 30). With the increase of joint mobility, the height of heel pad will decrease. When the patient's gait returns to normal, the heel pad can be dispensed with. A prerequisite for walking with a normal gait.
If the surgical incision heals well. Gait can be practiced on the underwater treadmill system, which can reduce the load of the affected limb. Water can lose weight by 60%~75% when walking sideways on the chest and 40%~50% when walking sideways on the waist.
Practice active range of motion indefinitely, but avoid passive joint movement. Normal walking can promote the recovery of functional range of activities. Although it is best to restore normal joint mobility at this stage, drafting is not desirable.
At this stage, you can start a mild eversion isometric muscle strength exercise, and later you can practice with rubber bands. Patients can increase muscle strength by drawing letters with their ankles on a multi-axis device. When you get enough range of motion, you can start practicing the two main muscles of leg plantarflexion (gastrocnemius and soleus). Six weeks after operation, you can start to practice plantar flexion resistance movement with 90 knees bent. By the eighth week, you can start the plantar flexion resistance movement of the knee joint in the straight position.
At this stage, you can also use the knee extension pedal device and leg flexion equipment to practice plantarflexion. At this time, the fixed bicycle movement should use the front foot to carry the load, and gradually increase a lot.
Walking backwards on the treadmill can strengthen the control ability of centrifugal sole flexion. These patients usually find it more comfortable to walk backwards because it can reduce the need for a slight start. You can also introduce the practice of going up the steps, and the height of the steps can be gradually increased (250px, 375px, 500px).
Early training of neuromuscular and joint range of motion is best carried out on biomechanical ankle-plate system (BAPS). At first, it was a sitting exercise, and then it gradually transitioned to a standing exercise. In addition, carrying out bilateral lower limb weight-bearing exercises on the balance control system or the isometric flat system can also promote the recovery of proprioception, neuromuscular and balance. With the recovery of strength and balance, the movement mode has also changed from double lower limbs to unilateral lower limbs. If necessary, scar massage, physical therapy and slight joint mobilization should be continued.
Matters needing attention
Achilles tendinitis (or pain) is a common complication in the second stage. Patients usually increase their activity after taking off crutches or stopping wearing fixed boots with wheels, but at this time, the healed achilles tendon is not strong enough to bear the increased activity, so the achilles tendon will naturally have pain and inflammation. Therefore, it is necessary to inform patients of the limits of activities of daily living (ADL), correct their wrong behaviors, and make them move within the painless range. Similarly, if the rehabilitation plan is designed to make the joint range of motion and strength exercise progress too fast, it will also cause achilles tendon pain and inflammation. Rehabilitation doctors must comprehensively consider patients' complaints and objective measurement results when perfecting rehabilitation programs, and emphasize compliance with family training plans. Early muscle strength exercise (week 12~20)
When the patient reaches the second stage of rehabilitation standards, he can enter the next stage of rehabilitation. The goal is to restore the range of motion of the ankle joint, restore the plantar flexion muscle strength to normal, and improve the balance ability and neuromuscular control ability.
Normal plantar flexion muscle strength means that patients have the ability to lift their heels 10 times with one foot. Of course, the patient must first complete the lift heel of both feet on the plane without fear, and then gradually return to normal according to the process in the table below.
When the above actions can be done well and there is no fear, you can start to complete higher-intensity strength and endurance training through some equipment (such as training ladders and climbing ladders in turn).
When going up and down the steps, the height of the steps should be gradually increased (250px, 375px, 500px). The difficulty of balance training is gradually increasing, including single-leg load bearing and multi-directional support plane (spring pad, vibrating plate, foam roller, etc. ) and interference training.
Isokinetic exercise can further enhance the strength and endurance of muscles around the ankle joint. Constant velocity movement is to exert appropriate resistance on the basis of fixed speed. Therefore, a certain speed can be set in advance, so that the ankle joint can resist the maximum dynamic resistance under the condition of full range of activities.
Once the patient achieves normal gait, full range of passive joint movements and normal muscle strength, he can run in water without a chest. The weight of achilles tendon can be reduced by using the buoyancy characteristics of underwater treadmill system.
The patient's therapeutic exercise program at home should be constantly adjusted according to the re-evaluation results.
Use NeuroCom or Biodex balance system to evaluate the balance and compare it with the healthy side. By the end of this stage, it is best to reach the same balance level as the healthy side.
Matters needing attention
Because joint mobility and/or muscle strength are still abnormal, patients should always be encouraged to insist on corrective exercise. The most common complications at this stage are muscle soreness and tendinitis caused by the patient's private increase in activity. Patients may increase their activity under the condition of insufficient lower limb strength, and rehabilitation doctors must continue to emphasize the problem of limited activity to patients. If patients go to the gym for rehabilitation training, they must follow the treatment plan and cannot increase the amount privately. Late muscle strength exercise (20~28 weeks)
With the normalization of calf muscle strength and the improvement of exercise level, the recovery of patients reached a slightly higher level of dynamic exercise. The treatment strategy is mainly to prepare for the safe recovery of patients/athletes' individualized exercise level.
Twenty weeks after operation, the plantar flexor, dorsal flexor, varus and valgus muscles of ankle joint should be evaluated at the same speed. Compared with the measurement of unarmed muscle strength with equal length, isokinetic evaluation has more accurate results for dynamic muscle strength. Isokinetic assessment can provide objective indicators and repeatable data for doctors, and can monitor patients' status. Through the objective data obtained, it can be clear whether the calf muscle strength and endurance return to normal. If the data of the affected lower limb reaches 75% of that of the healthy side, and the affected limb has completed 10 times of one-leg heel lifting, you can start running training on the treadmill. The forward running practice on the treadmill should emphasize short distance, low to medium speed and the degree of patient's subjective painless.
At this stage, we should continue to strengthen the isokinetic exercise of ankle dorsiflexion, plantarflexion, varus and valgus muscle strength and endurance.
Progressive resistance exercises and flexibility exercises should be continued within the tolerable range, and sensitivity exercises based on individual exercise level should be added to the rehabilitation plan. Running and physical exercise should be carried out on a straight board at first, and then gradually increase the difficulty and requirements, such as striding, interweaving, splaying, acceleration and deceleration training, etc. You can also apply resistance through the moving belt to further increase the difficulty.
As mentioned in the third stage, balance training is still very important. However, the interference training at this time should be combined with the challenge of ankle muscle strength and control ability. Interference exercises can include spring pads, oscillating plates, foam rollers, etc.
At this stage, you can start a mild functional reciprocating movement, and increase muscle strength by periodically stretching the achilles tendon. During exercise, patients are required to have all-round joint movements, good flexibility and normal muscle strength. More importantly, complete the action painlessly and without fear. The reciprocating motion to enhance the bouncing function can be practiced from both sides. For example, jumping with both feet and jumping with both feet on the box can reduce the impact. With the progress of rehabilitation, more difficult training methods can be gradually adopted, such as bilateral jump and quadrant jump.
The patient's family therapy training plan should be adjusted in time according to the re-evaluation results and functional level.
Matters needing attention
Because patients still have functional defects, they need constant encouragement to adhere to a reasonable amount of activity. Rehabilitation doctors must emphasize the principle of painless when introducing treadmill running exercise and flexibility exercise. Many patients/athletes will be so enthusiastic when they resume the running training stage that they will continue to practice when they feel unwell. Rehabilitation personnel must closely observe the signs of weakness and fatigue of patients and make appropriate adjustments to running exercises. The correct running practice is to start from a short distance at a low speed and gradually transition to a medium/long distance at a normal speed. Moreover, it is suggested that patients insist on practicing plantar flexion muscle strength to make it fully recover, and at the same time, it will reduce the risk brought by overuse. The amount of running practice should be kept to a minimum, and cross-training methods (swimming and cycling) should be adopted to avoid re-injury and inflammation of achilles tendon. Full physical recovery (28th week ~ 1 year)
According to patients' different requirements for exercise level and physical condition, the final stage of rehabilitation can be from 28 weeks after operation to 1 year after operation. At this stage, any defects in muscle strength and flexibility should be made up. In order to meet the demand for function in sports, this stage should make full use of sports special exercises and more advanced functional reciprocating movements and flexibility exercises to achieve this goal.
In order to reach the normal level of muscle endurance required by exercise, we should continue to carry out isokinetic training. Functional reciprocating motion is upgraded to one-legged motion at this stage, such as one-legged jump, one-legged jump on both sides, quadrant jump and so on. When the patient is ready to resume full-scale physical exercise, functional assessment, such as vertical jump assessment, can be used to clarify the functional state of the patient in dynamic exercise. Vertical jump evaluation is an effective method to measure muscle strength, and it can also measure the limit of lower limb functional movement. It requires the function of the affected limb to reach 85% of the healthy side, and it can only be resumed with the permission of the doctor.
Matters needing attention
Patients must pay attention to whether they have sufficient muscle strength, joint mobility and flexibility before participating in high-level sports, such as functional reciprocating sports and special sports training. Patients should be able to complete low-level exercise without fear before transitioning to more difficult exercise until they finally resume exercise. The method used for functional evaluation should be able to reproduce the special requirements of competitive sports, so as to ensure that patients can safely resume full-scale sports. The selected functional test items should be able to reproduce the athletes' special sports requirements to ensure their safe return to the whole event.