Most Achilles Protocols Ignore the One Thing That Actually Predicts Recovery

Now, before you get up in arms, let me preface this article by saying this isn't true of ALL protocols. However, the majority of patients I've seen typically fall into one of two categories:

1. They were instructed to wait 8 weeks after surgery before beginning physical therapy, to protect the tendon at all costs, and to remain non-weight bearing for far too long.

   
   

2. They were told to just try and walk with the boot and do some heel raises, and they'd be fine.

   
   

That's it.

These patients often feel frustrated or confused by the lack of instructions, and truthfully, I can't blame them. When I see these patients for the first time, the overwhelming majority of them are overly conservative, protective, and straight up afraid of putting more weight on their operative leg!

Here's the issue with that approach: most people recovering from an Achilles rupture are getting stuck in this old-school mentality of "protect it at all costs."

Rest it.

Don't load it.

Keep it immobilized as long as possible.

This strategy often leads to weaker tendons, longer recovery times, and higher reinjury rates. The research is clear: tendons NEED load to heal properly and need to be protected from elongation.

So, how do we do this, even after acute trauma?

Let me walk you through the protocol that is backed by evidence.

For an easy-to-follow PDF version, click the button below!

Achilles Rupture Rehab Protocol.pdf

Download PDF • 254KB

Protocol Principles

• Early Mobilization: Begin graded mobilization within two weeks post-rupture.

• Avoid Tendon Elongation: No passive dorsiflexion stretching until week 12.

• Progressive Loading: Step-wise progression of external load to promote healing.

• Criterion-Based Progression: Advance based on function and performance, not just time.

• Patient Education: Understanding of basic load principles, exercise modification, pain-response system, and general progression of exercises.

  
  

These first three principles are fairly standard in most Achilles rehab protocols. But the last two (criterion-based progression and patient education) are just as important, and they're the pieces that get skipped over most often.

Here's the issue with the majority of PT protocols, most, are built around a calendar. Week 4, do this. Week 8, do that. But healing isn't that predictable.

Two people with the exact same repair, done by the exact same surgeon, can be in completely different places at week 6. One might be ready to progress, the other might need more time. A strictly time-based protocol treats everyone the same regardless of how their tissue is actually responding, which means some people get pushed too fast and others get held back longer than they need to be.

Criterion-based progression fixes this by using objective markers: swelling, range of motion, strength, heel raise test, number of successful repetitions, etc to decide when it's actually time to move to the next phase, rather than just because the calander says so.

Patient education matters for a similar reason. If you don't understand why you're avoiding passive dorsiflexion, or why load needs to increase gradually, you're far more likely to either push too hard out of impatience or hold back too much out of fear.

Understanding the basic principles of how tendons adapt to load, what "good" pain versus "bad" pain feels like, and why progression looks the way it does, puts you in a position to actually participate in your own recovery instead of just following instructions blindly.

Ok, now lets get into the good stuff.

Weeks 0-2 [Protection and Initial Healing]

The goal during this phase is to protect the surgical or injured site, manage pain and swelling, and begin low-level strengthening for the calf and hip. During this time, the tendon is still fragile, so we avoid stretching it, especially into dorsiflexion, to prevent elongation, the most common cause of long-term weakness.

A quick but important nuance: not everyone follows the same immobilization approach in these first two weeks, and it depends entirely on your surgeon's protocol.

• If you're in a hard, non-removable cast: you're typically kept strictly non-weight bearing during this window. Follow your surgeon's instructions here. This approach prioritizes incision protection and initial healing, and weight bearing usually begins once you're transitioned into a removable boot around week 2.

  
  

• If you're placed directly into a removable walking boot at surgery: some surgeons allow early, protected weight bearing starting as early as week 1 — often beginning with toe-touch or partial weight bearing on crutches within the boot, then progressing from there. If this is your situation, you can likely begin the gradual weight-bearing progression described in the next section earlier than someone coming out of a hard cast.

  
  

Either way, defer to your surgeon's specific instructions on weight bearing status during this phase: the tissue-healing timeline and stability of the repair (open vs. percutaneous vs. augmented) factor into which approach they choose. What stays consistent regardless of which route you're on is the restriction on dorsiflexion stretching and passive ankle motion.

Swelling management is a priority early on: elevate the leg above heart level when resting, and use ice or compression as tolerated around the boot. Gentle ankle pumps within the boot's fixed range (not removing the boot to force motion) can help circulation without stressing the repair.

Strengthening at this stage stays well away from the ankle itself. Focus on:

• Hip abduction, extension, and clamshells (side-lying or standing, light resistance) to prevent the deconditioning that comes with reduced activity.

• Isometric quad sets and straight leg raises to maintain thigh strength while non-weight bearing.

• Core and upper body work as tolerated, since this phase is largely about not losing ground elsewhere while the tendon heals.

  
  

Weeks 2-8 [Early Mobility and Progressive Weight Bearing]

According to a 2024 study in the International Journal of Sports Physical Therapy, early functional rehabilitation, including controlled loading in a walking boot, is associated with improved tendon healing, reduced rerupture rates, and quicker return to activity compared to prolonged immobilization (Marrone et al., 2024).

The first six to eight weeks of recovery focus on protecting the healing tendon while gently reintroducing movement and load.

Consistent walking in a protective boot is highly encouraged.

A separate randomized trial found that an accelerated loading approach led to significantly higher general health and wellness outcome scores at 6 months, though longer-term tendon-specific scores were similar between groups (Aufwerber et al., 2020).

As you continue to gradually increase weight-bearing, listen to your body during this process, but also aim to rely less on crutches. Begin with light toe-touch or 25% weight and increase daily as tolerated. I use two crutches and take smaller steps at first — it feels awkward in the beginning, but it gets easier quickly. From there, I gradually progress to 50%, then 75%, then down to one crutch, and eventually full weight bearing.

I start removing heel lifts around weeks 3–4, with the goal of reaching neutral dorsiflexion by weeks 6–8.

If using a boot with degree fixation, a typical progression looks like:

• 0–4 weeks: 30° of plantarflexion

• 4–6 weeks: 15° of plantarflexion

• 6–8 weeks: Transition to 0° (neutral)

Precautions	WBAT with two crutches (25%-100%) Avoid passive dorsiflexion stretching Signs for infection/DVT
Goals	Prevent muscle atrophy Manage pain and inflammation Decrease Plantar Flexion in boot from 30 degrees to 0 degrees
Exercises	Ankle/Foot Strengthening o   Toe curls o   Ankle TheraBand exercises above neutral o   Plantar flexion isometrics o   Incline seated heel raises Proximal Gluteal/Hip Strength o   Single Leg Glute bridges o   Standing hip abduction o   Hamstring curls Knee Strengthening o   Knee extensions o   Sit to Stands
Frequency	Perfom 1x daily; 2-3 sets of 12-15 reps

Weeks 8-12 [Progressive Strengthening]

During this stage, the tendon is stronger and capable of handling controlled loading, which helps stimulate remodeling and restore lower limb strength. The key focus now is progressive strengthening while continuing to protect the repair. Avoid any passive stretching into dorsiflexion until week 12 to prevent undue stress on the healing tissue.

As you regain confidence in your gait, begin to reintroduce walking mechanics, emphasizing a smooth heel-to-toe pattern. Retrograde (backward) walking can be a valuable exercise at this point as it encourages gentle loading of the Achilles without excessive strain. To perform this, hold on to a table or counter with the hand opposite of your affected leg. Slowly take a step backwards (leading with your affected foot), keeping your steps short and controlled. Focus on a smooth roll through your foot, from toe to heel, to encourage eccentric control of the calf.

You can also practice exercises that break down the gait cycle.

• Start lateral-to-lateral sway to improve stability and foot control: shift your weight side-to-side between feet, maintaining equal loading and steady ankle alignment.

• Add assisted push-off drills by holding onto a wall or counter for balance, rise onto your toes to mimic the final phase of walking, then lower slowly. This helps retrain calf activation for forward propulsion.

Strength work should progress gradually. Start with seated or supported heel raises, then transition to standing double-leg heel raises, adjusting the load by shifting more weight toward the recovering leg as tolerated.

Milestones

By this stage, progression through heel raises should be based on performance, not just time. Before advancing from bilateral to single-leg work, a useful objective benchmark is being able to perform 3 sets of 20-25 controlled bilateral heel raises through full available range on flat ground.

Another major milestone is to be able to perform a seated single leg heel raise with at least 50 % of your bodyweight.

Once you have reached these two goals, hopefully by week 12, it's time to start standing single leg heel raises.

Precautions	Highest risk of re-rupture and tendon elongation/rupture Avoid active dorsiflexion past neutral until week 8 Avoid passive stretching into dorsiflexion until week 12
Goals	Transition into normal shoes Improve walking mechanics Perform 20-25 reps of bilateral heel raises Perform seated single leg heel raise (50% of bodyweight)
Exercises	Progressive Strengthening Leg Press Squats/Sit to Stands Leg curls Leg extensions Seated heel raises (Work up to 50% of body weight) (Ankle mechanics to neutral) Standing heel raises Bilateral with UE support and slowly progressing equal weight bearing w/o support   Gait Activities Lateral to Lateral Sway Anterior Posterior Rockbacks Assisted Push-Off Retrograde Walking Balance/Proprioception o   NBOS o   Semi Tandem o   Tandem Stance o   SL Stance o   Standing on foam
Frequency	Perform 2-3x a week Heel Raises Daily

Weeks 12-24+ [Plyometrics Introduction and Return to Running]

As tendon integrity improves, the body becomes ready for more dynamic challenges. This phase transitions from basic loading to higher-level movements like lunges, single-leg training, and progressing heel raises off a step (past neutral dorsiflexion). Plyometrics are introduced to improve the tendons’ ability to store and release energy, preparing the body for return to sport and running.

This is an exciting milestone but it must be approached with patience, discipline, and methodical progression to protect the healing tendon.

Running places approximately 6–8 times your body weight of force through the Achilles tendon with each step. Considering that even walking can transmit 1.5-3 times body weight, it’s clear that reintroducing running too early or too aggressively can easily overload the tendon before it has regained full tensile strength.

Begin with a 4:1 walk-to-run ratio, such as four minutes of walking followed by one minute of light jogging, repeated for 20–30 minutes. The following week, progress to a 2:1 ratio, then to 1:1 as comfort and tolerance improve. This slow ramp-up allows the tendon to adapt to higher loads while maintaining good running mechanics and minimizing compensations.

To monitor your strength progression, I recommend performing tests such as the single-leg heel rise test. To perform:

• Stand on one leg.

• Measure the distance you can raise your heel from the floor.

• Compare the height to the non-injured side.

  
  

Ideally, you want to be within 2 cm of difference. Another test is to perform as many consecutive single-leg heel raises on a 10-degree incline. The goal is to be within 90% repetitions compared to the non-injured side.

Milestones:

1. Perform 20+ repetitions of single leg heel raises with at least 90% height symmetry compared to non injured leg

2. Full range active and passive dorsiflexion

3. Ability to perform repetitive low grade rebounding calf raises and jogging in place with no adverse symptoms.

Precautions	Graded progression with plyometrics with sub maximal effort
Goals	Initiate progression to running Heel-rise test 90% of uninvolved side or < 2 cm SL heel raise full bodyweight (20+ reps)
Exercises	Progressive Strengthening o   Lunges (FWD/Lateral) o   Squats o   Step ups o   DL eccentric heel raises o   SL heel raises o   DL heel raises (full range dorsiflexion) Balance/Proprioception o   SL RDL o   Step downs o   Toe Walking o   SL squats with TRX o   Wobble board activities Plyometrics o   Hopping in place o   DL jumping o   Rebounding heel raises o   Jog in place
Frequency	Perform 2-3x a week Heel Raises Daily

6-12+ Months [Return to Sport]

This final stage focuses on rebuilding athletic capacity and efficiency through progressive sport-specific drills. Your tendon is structurally healed but still requires ongoing remodeling. Graded exposure to energy transfers and jumping ensures your body adapts safely to high loads and impact. Continued daily heel raises reinforce calf endurance and tendon stiffness is still important here.

True agility exercises to return to sport require three main components: speed, change of direction, and reactionary cueing. While returning to sport drills, the body needs more time to recover compared to standard rehabilitation. For this reason, it’s recommended to keep sessions at 1-2x a week and then gradually build the intensity over time.

Precautions	Gentle full range of dorsiflexion Graded exposure to running
Goals	Heavy loaded and slow resistance calf training (2-3x a week) Progression to higher level plyometrics Agility and speed training
Exercises	Progressive Strengthening o   Bulgarian Split Squats o   Heavy Loaded Slow Squats o   Eccentric heel raises Balance/Proprioception o   SL RDL o   Standing clam shells o   Pistol Squats Plyometrics o   Snap Downs o   Forward & Lateral Jumping o   Double leg hopping o   Single leg hopping o   CMJ o   Depth Jumps o   Drop Jumps Agility o   Side shuffle o   Ladder drills o   Cross over steps o   Cone drills o   Low box lateral cuts o   Change of pace/direction with reactionary cues
Frequency	Perform heavy calf work 2-3x a week

References

Aufwerber, S., Heijne, A., Edman, G., Silbernagel, K. G., & Ackermann, P. W. (2020). Does Early Functional Mobilization Affect Long-Term Outcomes After an Achilles Tendon Rupture? A Randomized Clinical Trial. Orthopaedic journal of sports medicine, 8(3), 2325967120906522. https://doi.org/10.1177/2325967120906522

Marrone, W., Andrews, R., Reynolds, A., Vignona, P., Patel, S., & O'Malley, M. (2024). Rehabilitation and Return to Sports after Achilles Tendon Repair. International journal of sports physical therapy, 19(9), 1152–1165. https://doi.org/10.26603/001c.122643

Aujla, R. S., Patel, S., Jones, A., & Bhatia, M. (2019). Non-operative functional treatment for acute Achilles tendon ruptures: The Leicester Achilles Management Protocol (LAMP). Injury, 50(4), 995–999. https://doi.org/10.1016/j.injury.2019.03.007

Disclaimer

The content on this website, including blog posts, downloadable materials, digital products, and any communication provided through email or social media, is intended for educational and informational purposes only. It is not a substitute for medical advice, diagnosis, or treatment from a licensed healthcare provider.

Purchasing or reading any content from PhysioVenture does not create a physical therapist–patient relationship. If you are experiencing pain, injury, or health concerns, you should consult with a licensed physical therapist, physician, or qualified healthcare provider in your local area.

While Dr. Martin Gonzalez, PT, DPT, is a licensed physical therapist, services provided through this website do not constitute physical therapy services as defined by state practice acts.

Always consult your own healthcare provider before starting any exercise, rehabilitation, or wellness program. Use of this website and its content is at your own risk. In case of a medical emergency, please call 911 or your local emergency services immediately.