Why I Tell My Patients to IGNORE Standard Protocols

Understanding the Common Misconceptions in Achilles Rehabilitation

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

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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: Active participation in the rehabilitation process.

  
  

As I approach two weeks after surgery, I promote weight bearing immediately. Gradually starting with light toe-touch or 25% weight bearing. Begin with two crutches and take smaller steps. It may feel very awkward initially, but it will become easier over time. You can then slowly progress to 50%, 75%, one crutch, and eventually full weight bearing. Start taking out heel lifts after week 3-4 and aim to be at neutral dorsiflexion by week 6-8.

If using a boot with a degree fixation, then aim for 30 degrees of plantar flexion from 0-4 weeks, 15 degrees of plantar flexion from weeks 4-6, and then transition to 0 degrees from weeks 6-8.

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

Weeks 0-8 [Controlled Mobilization]

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. An accelerated approach to loading the Achilles has been shown to lead to better health and vitality (Aufwerber, S et al, 2020).

Gradually increase weight-bearing while using the boot to reduce muscle atrophy. Listen to your body during this process, but also aim to rely less on crutches. Begin with light toe-touch or 25% weight and gradually increase daily as tolerated. We can also start taking out the heel lifts of the boot each week, after four weeks. If using a boot with a degree fixation, then aim for 30 degrees of plantar flexion from 0-4 weeks. 15 degrees of plantar flexion from weeks 4-6. Then, transition to 0 degrees from weeks 6-8. 

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—a common cause of long-term weakness.

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   S/L hip abduction o   SLR o   Side plank
Frequency	Perfom 1x daily

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.

By week 12, the goal is to perform bilateral heel raises on a flat surface with equal weight bearing, showing improved strength and symmetry in both legs. Controlled, consistent progression during this phase lays the foundation for safe single-leg loading in the next stage.

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 Prevent Re-rupture Improve walking Improve calf strength Overcome fear
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 [Late Rehabilitation Phase]

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.

Precautions	Graded progression with plyometrics with sub maximal effort
Goals	Progression to running Heel-rise test 90% of uninvolved side or < 2 cm SL heel raise 50% of bodyweight (15-20 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 running and jumping ensures your body adapts safely to high loads and impact. Continued daily heel raises reinforce calf endurance and tendon stiffness—both critical for preventing reinjury.

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	Progression to running Introduction to plyometrics
Exercises	Progressive Strengthening o   Bulgarian Split Squats o   Squats o   Eccentric heel raises Balance/Proprioception o   SL RDL o   Standing clam shells o   Pistol Squats Plyometrics o   CMJ o   Lateral Jumping o   Single leg hopping o   Forward o   Lateral 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 2-3x a week Heel Raises Daily

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

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