Achilles rehab after surgery: Exercises, targets, and recovery time

In this article, we provide the outline for what a typical rehab plan after Achilles tendon surgery should look like according to the latest research, what targets you should aim for in each stage, and how long you can expect recovery to take. Please remember that we’re all different, and everyone’s programme should be tailored to their unique circumstances. If you need more help with an Achilles injury, you're welcome to consult one of our team via video call.

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The terms tendinitis, tendonitis, tendinosis, and tendinopathy mean the same thing for all practical purposes, and we use these interchangeably in our articles.

In this article:

1. Restrictive vs. progressive rehab programmes

2. Do NOT overstretch!

3. Progression criteria

4. Example of a post-surgery Achilles rupture rehabilitation programme

5. Return to running and sport

6. Recovery time

7. How we can help

We've also made a video about this:

You can find advice about how to diagnose complete Achilles tears and the pros and cons of conservative vs. surgical Achilles rupture treatment here.

Restrictive vs. progressive rehab programmes

The rehab programme outlined in this article is a progressive one, as it allows for early weight bearing and ankle mobilisation exercises, from the third week, when the patient is still in an orthopaedic boot.

More traditional rehab programmes are quite restrictive and often only allow patients to start placing weight on their injured side after six or eight weeks.

Early (from week three) weightbearing in a boot may improve your recovery after Achilles surgery.

A recent review of the literature that analysed the results of 20 randomised controlled trials involving 1,007 patients found that those who followed a more progressive Achilles rehab programme tended to have fewer and less severe re-ruptures and complications afterwards.

There is also limited evidence that a progressive programme may allow earlier return to sport and work. More research is needed before we can say that this is definitely the case.

Please note, your surgeon may have very specific reasons relating to your specific case for not wanting you to start early weightbearing. Always follow their guidance.

Do NOT overstretch!

It is normal for your Achilles tendon and ankle to feel very stiff for the first 12 weeks after surgery. I often see patients and clinicians become obsessed with stretching the tendon out by doing strong stretches and holding them for a long time. Please don’t do this.

There is convincing evidence that ruptured Achilles tendons tend to heal in a lengthened position (even after surgery) and that this affects how your calf muscles and Achilles tendon function. In cases where the Achilles tendon has lengthened excessively, people are often not able to push off properly when they walk, go up and down stairs, run, and jump.

So, researchers did a study where they tested the rehab outcomes of two groups of patients. One group followed the traditional approach that included Achilles stretches (dorsiflexion, where your toes move towards you shin) from eight weeks post op onwards, and the second group kept the Achilles tendon in an unstretched position (plantar flexion, where your toes point down) for the first 12 weeks, and only then started with dorsiflexion stretches (past neutral) and eccentric exercises.

When they evaluated the patients 12 months after surgery, the second group had better outcomes.

Does this mean that the delayed stretching and dorsiflexion protocol is definitely the best? No, we don’t have enough evidence yet. But it does make a convincing case for not focusing too heavily on regaining full dorsiflexion range of motion in the first 12 weeks after surgery. This advice is also echoed in a recent consensus statement.

Progression criteria

When a body part is injured, it lacks the strength, endurance, and control to handle your regular daily and sporting activities. You can restore this by following a structured rehab programme.

Rehab programmes usually start with low-load exercises that don’t require much control and then carefully progress by increasing the load and complexity. Progression criteria are goals that patients are meant to reach before it is safe for them to move on to the next level.

These goals are not to be achieved as quickly as possible; you need to ensure that you regain the full strength and function in each stage before moving on to the next. If you rush your rehab, you risk re-injury.

The progression criteria for all injury rehab programmes consist of:

• Time-based criteria – Our bodies require a set number of days or weeks to repair and rebuild something, and you can’t hurry this along. This is why some exercises or activities should only be started after a certain number of weeks.

• Function-based criteria – You usually need to demonstrate a certain amount of movement, strength, endurance, balance, weight bearing, and so on before you can safely move on to the next level of exercise or activity.

When deciding whether you’re ready to move on to the next stage of your rehab, your physio will check whether enough time has passed and whether you’ve achieved all the functional goals of the current stage.

Example of a post-surgery Achilles rupture rehabilitation programme

Below is an outline of what an Achilles tendon rupture repair rehab programme might look like if you combine all the elements that the research has found to be beneficial. The most noteworthy elements include:

• Early weightbearing in a boot with your ankle in plantar flexion.

• Early mobilisation of the foot and ankle (but not into dorsiflexion).

• Delaying dorsiflexion stretches until 12 weeks after surgery.

• Delaying full weight eccentric-only exercises until 12 weeks after surgery.

Please note that surgeons may have very good reasons for prescribing different programmes. This is only one example, and it may not be right for you. You should always follow the instructions of your physio or doctor.

First 2 to 3 weeks after surgery

Your leg will be placed in a cast for the first few weeks.

Cast

Expect your foot to be in a below-the-knee cast with your toes pointing down into plantar flexion at a 30° angle.

Walking advice

In most cases, you’ll be provided with crutches and asked not to place any weight on your foot.

Ankle and foot exercises

None.

Rest of the body

You can do any leg or core exercises that don’t place pressure on your cast or injured foot.

Examples of core exercises:

• Sit-ups

• Russian twist

• Push-ups supported on knees

• Side plank supported on knees.

Examples of leg exercises:

• Side leg lift

• Leg curls in standing (standing on the uninjured leg)

• Knee extension (the weight of the boot can be useful here)

• Hip extension prone or on hands and knees.

3 weeks after surgery

Boot

Your cast will be removed, and you’ll likely be placed in an orthopaedic boot with heel wedges (2 inches or 5 cm thick) to keep your foot at a 30° angle. Some boots, like the VACOped, has a hinge system that allows you to adjust the angle without having to use wedges.

Walking advice

You should wear your boot whenever you’re upright and moving around. In most cases you’ll be allowed to place your full weight (or as much as you can without pain) on your foot while wearing the boot and using crutches for stability.

Top tip: Use an Evenup shoe leveller and a running shoe with a thick sole on your uninjured foot when you walk. Otherwise, you will find that the sole of the Achilles boot is really thick and causes you to walk unevenly, even when you wear a thick-soled shoe like a running shoe.

Ankle and foot exercises

You can usually remove your boot and do ankle range of motion exercises, making sure your ankle does not bend up past 0° dorsiflexion.

The neutral position represents 0° dorsiflexion.

Exercises include (see video for demo):

1. Free active inversion and eversion movements while keeping the foot pointed down into plantar flexion.

2. Free active plantar flexion and dorsiflexion up to 0° dorsiflexion (neutral) or less if you start to feel a pull in your Achilles tendon.

Stay below neutral dorsiflexion range

3. Isometric eversion, inversion, and dorsiflexion can be useful to help maintain your strength. This is when you gentle push against resistance but you don't actually move your foot. Hold the contraction for about 10sec and do 10 repetitions into each direction up to 3 times a day.

4. Foot arch exercises to keep your smaller foot muscles strong and engaged. Gathering a towel with your toes can work well.

Have your foot further forward from the chair to avoid getting dorsiflexion in the ankle.

NB: Avoid all dorsiflexion stretches.

Rest of the body

Continue leg and/or core exercises that don’t place pressure on your boot or injured foot. You may be allowed to cycle with the heel of your boot on the pedal.

4 to 6 weeks after Achilles tendon surgery

Boot and walking

Your foot angle will likely be reduced to about 15° plantar flexion or having a wedge of about 1 inch or 2.5 cm under your heel. Always wear the boot when you’re standing or walking.

Exercises

These usually remain as before, with the addition of doing heel raises while sitting down. If your ankle and Achilles are stiff, start with your feet further forward to avoid stretching the tendon. Do not go past 0° dorsiflexion (see video for demo).

6 weeks after Achilles tendon surgery

Boot and walking

Your heel wedges will likely be further reduced to half an inch, or 1 cm, while you continue weightbearing in your boot.

Exercises

You can usually start strengthening your ankle into all directions using an exercise band (still no dorsiflexion past neutral). Concentrate on slow and controlled contractions - see video for demo. (Get your exercise bands here.)

Plantar flexion using resistance band - do not pull back past neutral dorsiflexion.

Dorsiflexion against resistance - do not pull up past neutral.

Eversion against resistance

Inversion against resistance

Week 7 post surgery

Boot and walking

This may be your last week in the boot! The heel wedge is usually reduced to a quarter inch, or 0.5 cm.

Exercise

Continue with the same exercises. If you find them too easy, you can increase the resistance of the exercise bands.

8 to 12 weeks after Achilles tendon surgery

Boot and walking

It’s time to transition to wearing regular shoes with your quarter inch or 0.5 cm heel wedge. However, choose a shoe that has at least a 10 mm heel-to-toe drop, so that your heel is still lifted around 1.5 cm in total. Stable running shoes, like Asics (get them here), are often most comfortable.

You'll likely be asked to use a heel raise insert in your shoe.

Try to use a normal walking pattern, landing with your heel first and rolling over your foot to push off with your toes. This will take some time to achieve, and you may find a stick or crutch helpful in the beginning to help you balance.

Get used to equal weight

When you first come out of the boot, it will feel really strange to place weight on your leg that has been operated on. You will have to retrain your brain and get used to what it feels like to place equal weight on your legs. So, the first exercise is to make sure that, whenever you stand, your weight is evenly distributed.

Calf and Achilles strength while standing

You can usually start doing standing heel raises, supported on both feet, while wearing your shoes and heel lifts. Progress them as follows (see video for demo):

• First, get comfortable doing 10 repetitions, slow up and slow down, with 75% of your bodyweight on the uninjured leg and only 25% on the operated one, 5 times a day (these can be spread out, but if you’re doing them in one go, rest at least 60 seconds between sets).

• Once that is easy, gradually increase the reps until you can easily do 5 x 25 reps in a day.

• Then, aim to place a bit more weight on your operated side, and build up to doing 5 x 25 reps with 50% of your bodyweight (so, equal weight on both legs).

• Finally, shift more weight over to your operated side (about 75%) and build up to doing 5 x 25 repetitions.

Please note: These repetition goals are what I would typically prescribe for an active person who does sports. If you are less active or perhaps quite unfit, your goals will likely be much lower.

Calf and Achilles strength while sitting

Doing seated calf raises with a light weight placed on your thighs is another excellent way to build strength. Make sure to lift through the full range of plantar flexion and concentrate on lowering down slowly (see video for demo).

Balance

You can usually practice tandem stance or single-leg balance, but place one hand against a wall for extra stability.

3 to 6 months after Achilles tendon surgery

What exercises you do and rehab targets you aim to achieve during this phase will be determined by your end goal. The rehab plan for someone who just wants to get back to walking will look very different from that of someone who wants to get back to running or jumping sports.

Walking

You should now be able to transition gradually to walking in regular shoes without heel lifts. It is best to start by taking the heel lifts out for a few hours per day.

Swimming pool

Being in water reduces your weight, and it can be a great way to practice walking and placing weight on your injured leg. This should not replace the exercises you do out of the pool.

Walking in a swimming pool can help you to relearn a normal walking pattern after Achilles surgery.

Calf and Achilles strength while standing

You can usually now start with eccentric calf drops, where you lift up on both feet and lower yourself down slowly on just one (see video for demo). Gradually increase the number of repetitions. Aim to get to 3 x 15 repetitions with very good control and form.

Eccentric calf drop exercises done over a step strengthens the Achilles tendon while also improving dorsiflexion range of motion.

Top tip: It's usually best to start by doing your calf drops and raises at floor level, but once you feel confident with the movement, you can move to doing them over the side of a step. This will then also act as an active stretch to help you regain your full dorsiflexion range of motion.

Then, you can usually transition to doing single-leg heel raises (going up and down on one leg). Again, aim to achieve 3 sets of 15.

Single leg heel or calf raises done over a step.

Then, add extra weight. Start with light weights, and if your goal is to get back to running and jumping sports, it often works well to build up to weight that equals about 20% of your bodyweight. This can take 12 weeks or longer to achieve, so don’t try and rush it. (Here are some hand weights on Amazon - I find it works best to place them in a backpack on your back, so that your hands are free to help you balance.)

Placing the weights in a backpack leaves your hands free to help support you.

Calf and Achilles strength while sitting

Doing weighted calf raises in sitting can also be useful, as it targets the lower portions of the calf muscles more. You can do them by placing a weight on your thigh or using the seated calf raise machine in the gym. You can also do these over the edge of a small step or a book to help regain dorsiflexion (see video for demo).

If you're doing these at home, it can become difficult to increase the weight safely past a certain amount. If this is the case, these can be progressed to doing calf raises while standing with your knees bent. These do create quite a strong stretch in the Achilles, so it may be best to only start these once you've regained some of your dorsiflexion range of motion. Your physio will be able to guide you one this.

Achilles and calf stretches

It is important to regain the full range of motion in your ankle, including dorsiflexion.

However, we know from the research that an elongated Achilles tendon doesn’t work that well (see here) and that overstretching should be avoided.

So, doing active stretches and using eccentric exercises to stretch your Achilles and regain full range of dorsiflexion may be more beneficial than doing lots of strong passive stretching.

Why are active stretches and eccentric movements preferred? Active stretches strengthen the tendon and calf while it lengthens them, whereas passive stretches only lengthen them.

A good way of stretching your tendon is to do your calf raise exercises over the side of a step. You don’t have to be afraid of passive stretches, as long as you don’t force them or hold them for very long periods (30 seconds is usually OK).

Both active and passive Achilles and calf stretches can be used to regain dorsiflexion range of motion.

Plyometric exercises

If you want to get back to playing a sport that involves jumping or running, you have to include plyometric exercises (hops and jumps) in the later stages of your rehab. These exercises develop your calf and Achilles tendon’s ability to produce strong, forceful contractions. You should first build good single-leg calf strength before adding these to your plan. Your physio will let you know when you’re strong enough to start with these.

Plyometric exercises develop the explosive strength and function of the calf-Achilles complex.

Rest of the body

Your body will be a bit out of kilter when your leg comes out of the boot. The uninjured leg will likely feel a bit overworked from carrying most of your weight, while your leg that has been operated on will be generally weaker. This is why it is important to also include exercises to strengthen your glutes, hamstrings, and quad muscles.

If your uninjured leg feels tired and sore, do less on that side and allow the injured side to catch up.

Balance exercises

Balancing exercises are great for regaining control after an injury. Start with simple balancing exercises (like standing on one leg) and progress them by adding in movement or unstable surfaces like balance boards.

Return to running and sport

The best way to introduce running is to alternate between short periods of running and walking. This helps to strengthen your calf and Achilles tendon without pushing them to exhaustion.

It is usually safe to start a run-walk programme once you:

• Have at least 20° of dorsiflexion (or 90% of what you other leg can do) and almost full plantar flexion range.

• Can do single-leg heel raises with extra weight over the side of a step (your physio will be able to set targets specific to you).

• Have completed a plyometric programme without problems.

• Can walk for 30 minutes at a brisk pace with a normal gait.

If you want to play a sport that involves quick changes of direction and pace, such as football, tennis, or basketball, your programme should also include drills for those elements during this phase.

If your sport requires quick changes of direction, these drills should form part of the final rehab stage.

Achilles tendon surgery recovery time

The typical time for return to sports is about six months. This is for initial sports participation, not high-intensity sport or competition.

Is your recovery taking longer? Don’t worry – we are all different, and several factors can influence recovery time, including age, genetics, and medication. If you’ve worried about your progress, it may be time to ask for a review with your doctor or physio.

How we can help

Need more help with your Achilles injury? You’re welcome to consult one of the team at TMA online via video call for an assessment of your injury and a tailored treatment plan.

We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Treat My Achilles we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here.

About the Author

Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Master's Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate.

References:

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