171. Achilles tendon ruptures: Rehab & recovery with Prof. Peter Malliaras

Your patient is running, playing sport, or jumping or lunging forward - an activity with fast eccentric or concentric activity in dorsiflexion,and suddenly they feel like they've been kicked in the back of the leg.

They might hear a snap and have difficulty weightbearing, walking and pushing off.

What's your likely diagnosis?

You picked it - an Achilles tendon (AT) rupture.

AT ruptures are a devastating injury that can drastically impact a patient's ability to walk, run, or return to sport.

Despite their frequency, there's a lot of uncertainty among clinicians, patients, and even surgeons around how to best assess, treat, and rehabilitate Achilles tendon ruptures.

Patients are often fearful of doing the wrong thing and re-rupturing the tendon.

Therapists often follow a non-surgical protocol of putting people in a boot, but are unsure how to progress, how fast to progress and what to do during and after they're in the boot.

An even bigger problem than AT re-rupture is the very common issue of an elongated tendon where patients have long-term difficulty with calf weakness and inefficiency, walking long distances, hopping, jumping, and returning to sport.

In this podcast, David Pope (APA Titled Musculoskeletal and Sports & Exercise Physiotherapist) is joined by Prof. Peter Malliaras (Specialist Physiotherapist FACP, clinician and researcher with a PhD in tendinopathy) to explore the latest evidence, clinical insights, and rehab strategies for Achilles tendon ruptures.

Peter draws on his extensive clinical experience, recent research, and the development of a specialist Achilles rupture service at OrthoSport Victoria to help guide your decision-making and treatment approach.

In this podcast, you'll discover:

• The mechanism of injury and clinical presentation of Achilles tendon ruptures.
• Key diagnostic tests and how to avoid missed or delayed diagnoses.
• Common pitfalls that lead to tendon elongation—and how to prevent them.
• When to recommend surgical vs non-surgical management.
• A new, innovative approach to strengthening the Achilles tendon while the patient is in the boot.
• How to safely begin loading the Achilles in the early phase of rehab.
• Strategies to protect against tendon elongation during and after boot use.
• Whether we should be stretching or trying to improve dorsiflexion.
• Objective strength criteria to guide progression through rehab stages.
• Return-to-walking and return-to-sport timeframes—and how to individualise them.
• What to do when patients present late or have already developed elongation.
• Complications to watch for post-injury or post-surgery.
• How to help patients navigate the psychological and motivational challenges of recovery.

Listen to this episode to gain clarity on Achilles tendon rupture assessment and rehab, and develop a structured, evidence-based approach you can apply immediately in your clinical practice.

Timeline

00:06:23 Problems Physios and patients face with AT ruptures?

00:09:29 Subjective - How to identify a likely AT

00:12:03 Who gets an AT rupture?

00:18:45 Why do AT's rupture?

00:20:06 Misdiagnosis

00:24:14 Surgical or non-surgical management?

00:30:25 Elongation - Improve dorsiflexion or make the AT stiffer?

00:36:53 Safe loading in the boot & progressions

00:42:49 When to start exercising in the boot

00:46:08 Elongation - why is it a problem?

00:54:00 Bent or straight knee calf exercises?

00:59:55 RTP - How long does it take?

01:03:32 Surgical vs non-surgical timeframes

01:04:25 Assessment and diagnosis of AT ruptures

01:08:40 Initial management of an AT rupture

01:11:26 Education - What to tell patients

01:12:54 Imaging

01:14:57 Delayed presentation - How to manage

01:16:10 Red flags & complications

01:19:10 Walking - How to guide patients as they come out of the boot

01:21:27 Exercise progressions after the boot

01:23:48 Key takehome messages

Get free access to the "Tricky tendons" infographic series

Unlock the secrets of successful tendinopathy assessment and treatment with this free infographic series for therapists.

Links associated with this episode:

• Prof Peter Malliaras at OrthoSport Victoria
• Prof Peter Malliaras
• Online courses with Prof Peter Malliaras
• Tendinopathy podcast with Prof Peter Malliaras
• Summary handout
• Adductor related groin pain rehab with Andrew Wallis
• FAI assessment and treatment with Dr Adam Weir
• Accelerated conservative management of medial knee injuries with Chris Morgan
• Improve your musculoskeletal and sports injury assessment & treatment results with a free trial Clinical Edge membership
• Click here to register and receive immediate access to the Tricky tendons infographic series
• Free Achilles tendinopathy video series with Tom Goom
• David Pope at Clinical Edge
• Download and subscribe to the podcast on iTunes
• Download the podcast in Overcast
• Listen to the podcast on Spotify
• Dr Lachlan Giles
• David Pope on Twitter
• David Pope & why I started Clinical Edge
• Review the podcast on iTunes
• Infographics by Clinical Edge

Research associated with this podcast

• Barfod, K. W., Hansen, M. S., Sandholdt, H., Boesen, A., Hölmich, P., Troelsen, A., & Kristensen, M. T. (2022). The Copenhagen Achilles length measurement performed at time of acute Achilles tendon rupture is correlated to tendon elongation after 1 year. The Journal of Foot and Ankle Surgery, 61(5), 1098-1102.
• Barfod, K. W., Overgård, A. B., Hansen, M. S., Haddouchi, I. E., Toft, M., & Hölmich, P. (2023). Effect of the Copenhagen Achilles Rupture Treatment Algorithm (CARTA) on Calf Muscle Volume and Tendon Elongation After Acute Achilles Tendon Rupture: A Predefined Secondary Analysis of the First 60 Patients in a Randomized Controlled Trial. Orthopaedic Journal of Sports Medicine, 11(11), 23259671231211282.
• Hansen, M. S., Vestermark, M. T., Hölmich, P., Kristensen, M. T., & Barfod, K. W. (2020). Individualized treatment for acute Achilles tendon rupture based on the Copenhagen Achilles Rupture Treatment Algorithm (CARTA): a study protocol for a multicenter randomized controlled trial. Trials, 21, 1-14.
• Hansen, M. S. (2022). Achilles tendon rupture: Tendon elongation, gait dynamics, and individualized treatment(Doctoral dissertation, School of Health and Medical Sciences, University of Copenhagen).
• Hansen, M. S., Bencke, J., Kristensen, M. T., Kallemose, T., Hölmich, P., & Barfod, K. W. (2023). Achilles tendon gait dynamics after rupture: A three-armed randomized controlled trial comparing an individualized treatment algorithm vs. operative or non-operative treatment. Foot and Ankle Surgery, 29(2), 143-150.
• Willits, K., Amendola, A., Bryant, D., Mohtadi, N. G., Giffin, J. R., Fowler, P., ... & Kirkley, A. (2010). Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation. JBJS, 92(17), 2767-2775.