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Pilates for Rehabilitation of Achilles Tendon Rupture
Six Months Post Injury
Susan Kirkpatrick-Laird
28th August 2015
Course Year – 2013/2014
Brisbane, Queensland, Australia
1
Abstract
The purpose of this paper is to outline a BASI Pilates program for an active adult sportswoman
six months after undergoing surgical treatment to repair a complete rupture of her left achilles
tendon.
At age 42 the client recommenced playing netball once a week and during the third game of
netball her left achilles tendon completely ruptured.
Initially non-surgical treatment was advised, however two weeks post injury, after consultation
with another Orthopaedic Surgeon, keyhole surgery was undertaken to reconnect the ends of
the ruptured tendon. The lower left leg was then set in a back slab plaster cast and two weeks
post operation transitioned to a range of motion walking boot.
The client’s six month post injury rehabilitation program was managed by the surgeon and a
sports physiotherapist, who both hold the critical information and relevant in depth training
and experience to manage the client’s condition.
This paper focuses on the BASI Pilates aspect of the rehabilitation process onwards from six
months post injury, when the client was able to return to the Pilates studio.
2
Contents
Abstract ......................................................................................................................................................... 1
Anatomical Description ................................................................................................................................. 3
Case Study ..................................................................................................................................................... 4
Conditioning Program ................................................................................................................................. 10
Conclusion ................................................................................................................................................... 17
References .................................................................................................................................................. 18
3
Anatomical Description
Achilles Tendon (Tendo Calcaneus)
Tendo Calcaneus is often referred to as Achilles tendon after the mythical Greek warrior who
was vulnerable only in the heel. (Moore 1992)
The achilles tendon is a large tendon at the back of the ankle. The tendon is an extension of the
calf muscles (gastrocnemius and soleus) running down the back of the lower leg attaching to
the heel bone (calcaneus). The achilles tendon connects the leg muscles to the foot and gives
the ability to push off during walking and running.
Figure 1
Figure 2
4
Case Study
Name: Susan Age: 42
Sporting History: The client has been actively involved in sports all her life and during her
younger years competed in tennis, netball, cricket, soccer, swimming and long distance
running.
In her twenties the client began competing as an individual in triathlons with a disciplined
training regime which she continued with for ten years when her interests turned primarily to
road cycling, mountain biking and swimming. She also began Yoga and Pilates to enhance and
complement her sporting activities, incorporating these two modalities into her weekly training
schedule.
Her professional business career involved a corporate office environment with mainly a
sedentary working life. Prior to sustaining the achilles tendon injury she had not sustained any
major sporting injuries, apart from the breakage of both her hands at age 39 as a result of a
road cycling accident, from which she fully recovered.
In summary, the client is a fit active sports woman. At age 42 the client began playing netball on
a weekly basis and it was during the third game of netball that her left achilles tendon
completely ruptured. She collapsed to the ground and was unable to stand and bear weight on
her left leg.
5
Subsequently she was transported to hospital and the diagnosis of achilles tendon rupture was
confirmed via the appropriate medical procedural tests. Initial medical advice was to allow the
tendon to heal without surgical intervention. Two weeks post injury, after seeking a second
medical opinion from an Orthopaedic surgeon specialising in achilles tendons, a gap of 2 ½
inches between the ends of the tendon was discovered. It was advised a much better outcome
would be achievable through surgery and subsequently keyhole surgery was undertaken.
The client rested directly after sustaining the injury allowing her body to recover and
regenerate from injury and surgery. Post surgery the client’s energy levels fluctuated as a result
of the injury trauma and adapting to the use of crutches in her daily life. As the client is
naturally fit and physically capable, she quickly became confident moving safely with forearm
crutches after guidance from sports physiotherapist. A range of motion walking boot was worn
by the client on the injured leg from week two to week twelve post surgery. The boot provided
protection for the healing leg and facilitated gradual controlled incremental increases in range
of motion.
Post surgery care, managed by the surgeon and sports physiotherapist, included scar and
swelling management, massage, elevation of leg and overall rest. Initially the focus on exercise
and body maintenance was on stretching major muscle groups whilst seated, lying supine or
prone. Once energy began to return after recovery from surgery, core work and joint stability
exercises were undertaken to help retain muscle strength, especially for hip stabilisation and
balance.
6
During the nine weeks following surgery the client’s rehabilitation was closely monitored by
both the surgeon and sports physiotherapist. The surgeon advised it would be possible to
rehabilitate an achilles tendon rupture of this nature to 90% of its original condition in twelve
months. Determined to achieve the best possible outcome and return to sporting activities
(excluding netball) the client fully participated in her rehabilitation process and followed the
rehabilitation regime very closely and with caution.
Along with bi-weekly visits to the sports physiotherapist for treatment and the take home
exercises prescribed, the client incorporated her own series of stretches and exercises. These
included exercises learned from the many years experience as a sportsperson, Pilates and Yoga
student. All exercises were checked by and agreed to with the sports physiotherapist.
Client incorporated ball and theraband as assists into her home exercises which included the
gluteals side lying series, side lifts, back extension, hamstring stretches, catch stretch, rolling,
spine stretch, pole series exercises (pole replaced with theraband). All exercises were carried
out slowly, controlled and mindfully.
It was noted the left calf muscles naturally began to atrophy. Rehabilitation focused on working
towards full weight bearing on left leg. To rebuild fitness levels, client returned to swimming
once scar healed (excluding pushing off wall).
7
At the nine week point the surgeon was satisfied with the progress and was no longer involved
in the rehabilitation process, however client continued with bi-weekly visits to sports
physiotherapist.
At this nine week point crutches were no longer required, however the client continued with
the range of motion walking boot until week twelve. Once range of motion walking boot was no
longer required, heel raise inserts were placed in the left shoe and gradually decreased in angle
until no longer required.
As a result of being on crutches for nine weeks, it was observed that the client’s gait had
become imbalanced even though the client was able to maintain stability in the pelvic region
with her strong core muscles. Sports physiotherapist instruction was provided to retrain the
gait cycle, incorporating the heel and toe strike. Exercises on both the ball and heels of the feet
were encouraged to assist with retraining alignment of the feet as the feet are the foundation
for the body when upright. Foot alignment was monitored closely.
Return to basic Pilates exercises began with the use of a reformer located at physiotherapist’s
clinic. Focus is to gradually build strength - particularly in upper leg and gluteal muscles.
Exercises specific to hip abduction, adduction, extension and flexion were undertaken regularly,
both in clinic and at home with the assist of a theraband. Pelvic curls were introduced. Exercises
to improve the client’s proprioception and balance were prescribed by the sports
physiotherapist.
8
In addition to re-introducing Pilates exercises on reformer, client re-commenced cycling on a
stationary bike with minimal resistance along with walking on treadmill with hands supported.
Improvement in walking was observed along with the client’s ability to ascend and descend
stair cases one at a time. At this point the client’s balance and proprioception had improved as
a result of following the program set by the sports physiotherapist.
Until the six month time period was reached, the client continued with bi-weekly visits to the
sports physiotherapist to measure and monitor range of motion; massage left leg.; work on
gradual increase in range of motion of left foot and ankle (inversion and eversion, pointing and
flexing).
Due to the nature and severity of the injury, along with the client’s desire to return fully to her
sporting activities (excluding ball), returning to the Pilates studio for group classes (which
effectively has less one-on-one focus) was not appropriate until such time as the sports
physiotherapist was satisfied with the progress.
At three months post injury the client was able to incorporate basic Pilates exercises using the
reformer located in the treating sports physiotherapist’s clinic under their close supervision.
At the six month mark the client was able to return to group classes at the Pilates studio, fully
equipped with reformer, mats and assists. Weekly sports physiotherapy visits continued for
9
twelve months post injury. Sports physiotherapist verified suitability of Pilates exercises
undertaken in the Pilates studio. One hour Pilates classes were undertaken on a weekly basis.
As client is experienced in Pilates exercises, it was unnecessary to start at basic education in
regards to the pelvic floor and core muscles.
The client’s goal through Pilates exercises is to regain a more centered alignment and balance
between the left and right legs, along with general all over body maintenance. The following
program may initially appear less complex than some, however to achieve the desired outcome
meticulous execution of all exercises is of paramount importance to enable the client to regain
her desired level of proficiency in her sporting activities (mainly road cycling and mountain
biking).
10
Conditioning Program
Twelve week BASI Pilates conditioning program
Commencing six months post injury
Reformer Equipment
Weeks 1 – 4
Exercises initially commenced with light resistance and a small number of repetitions to ensure
client’s body not overloaded prematurely and risking a setback in rehabilitation or re-injuring
achilles tendon. All exercises were undertaken by the client with awareness, precision and
control. Exercises will reintroduce underused muscles re-activate, lengthen and strengthen to
full range of motion.
Limitations - limited flexibility of the ankle joint, stiffness of the ankle joint and pain still present
when pressure applied to the back of the left achilles tendon, mainly whist sitting on heels or
squatting deeply.
The overall desired result during this period is to set a solid foundation to then increase the
resistance and number of repetitions for each exercise, progressively overloading the range of
exercises over the course of the next four week period. Specifically the goal is for the exercises
to assist improvement in the client’s gait cycle and overall general level of musculoskeletal
fitness.
11
Weeks 5 – 8
Additional and alternative exercises introduced to provide an increment in physical challenge
and to ensure client did not become bored with exercises.
The desired result during this period is to build strength and stamina to support the client’s
endeavors to recommence longer distance cycling and walking.
Single leg hip work is also incorporated to afford an opportunity for the injured leg to work
autonomously.
Client has been able to recommence cycling, working up to a period of two hours, once a week.
Weeks 9 - 12
The desired result during this period is to re-introduce the client to more advanced Pilates
movements to offer a sense of achievement in the rehabilitation process. Full range of motion
for the injured leg to similar angles compared with the client’s right leg has been achieved. At
the completion of the twelve week period the client still experienced some discomfort from
time to time in the left achilles tendon. Often during exercises it was observed that the area
around the inside of the left ankle would sweat, indicating the parasympathetic nervous system
was still healing from the injury. Client has continued with monthly massage on her leg and also
self massage at home. Standing for long periods of time has become more tolerable.
12
BASI BLOCK SYSTEM REPERTOIRE
WARM UP Intermediate warm up exercises are incorporated into each session to fulfill the BASI
block system. The warm up is designed to bring the client’s awareness into the room, focusing
on the connection within their whole body.
FOOT WORK is to address the hamstring and quadriceps muscles whilst also building strength in
the hip, knee and ankle joints which is imperative to rebuilding an efficient gait cycle. These
have been especially beneficial towards rebuilding strength in the injured leg.
ABDOMINAL WORK exercises are an extension on what the client has been able to practice at
home on the mat and are for overall general fitness.
HIP WORK addresses the hip adductors, building strength and stretching. Hip work will assist
greatly in the client regaining their strength for cycling and walking.
SPINAL ARTICULATION – Bottom lift and bottom lift with extension assists with maintaining
correct foot alignment, assisting the client to rediscover the ankle knee hip connection and feel
the line of force that exists between and through these three areas.
STRETCHES – The standing lunge will assist with hamstring and hip flexor stretch.
13
FULL BODY INTEGRATION Fundamental/Intermediate - Initially Up Stretch 1 exercise is
incorporated allowing a greater angle of the ankle, working towards Elephant stretch, which
places a stronger stretch on the calf muscles and achilles tendon.
ARM WORK is designed to maintain strength in shoulders and arms.
FULL BODY INTEGRATION Advanced/Master - Balance control front requires trunk stabilisation
and to maintain plantar flexion of the feet, challenging the client and also focusing stabilising
the ankle joints.
LEG WORK The leg work chosen in the program focuses on the gluteus medius muscle, which is
crucial to support efficiency in walking and cycling.
LATERAL FLEXION/ROTATION The mermaid exercise provides the body with an overall stretch
and opening of each side of the body.
BACK EXTENSION The exercises chosen support strengthening the back muscles.
14
Twelve week conditioning program commencing six months post injury
Weeks 1 - 4
number of repetitions exercise resistance
Warm Up
2 roll down n/a
5 roll up n/a
5 spine twist supine n/a
5 to 8 double leg stretch n/a
5 to 8 single leg stretch n/a
5 to 8 criss cross n/a
Foot Work
6 parallel heels light
6 parallel toes light
4 to 6 V position toes light
4 to 6 open V heels light
4 to 6 open V toes light
4 to 6 calf raises light
6 single leg heel light
6 single leg toes light
Ab Work 8 hundred prep light
6 to 8 coordination light
Hip Work
4 frog light
4 circles up light
4 circles down light
4 openings light
Spinal Articulation
2 bottom lift medium
2 bottom lift with extension medium
Stretches 1 standing lunge light
FBI F/I 3 Up Stretch 1 light
3 elephant light
Arm Work 6 arms supine series light
FBI A/M 2 balance control front light
Leg Work 4 to 6 single leg skating light
Lateral Flex/Rotation
4 mermaid light
Back Extension
6 breaststroke prep light
Finish 2 roll downs n/a
15
Twelve week conditioning program commencing six months post injury
Weeks 5 - 8
number of repetitions exercise resistance
Warm Up
2 roll down n/a
6 roll up n/a
6 spine twist supine n/a
8 double leg stretch n/a
8 single leg stretch n/a
8 criss cross n/a
Foot Work
6 parallel heels medium
6 parallel toes medium
6 V position toes medium
6 open V heels medium
6 open V toes medium
6 calf raises medium
6 single leg heel medium
6 single leg toes medium
Ab Work 6 double leg abdominals legs in straps light
6 double leg with rotation abdominals legs in straps light
Hip Work
6 frog light
6 frog single leg light
6 circles up light
6 circles down light
Spinal Articulation
4 bottom lift medium
2 bottom lift with extension medium
Stretches 2 kneeling lunge light
FBI F/I 5 Up Stretch 1 light
5 Elephant light
Arm Work 6 arms supine series light
FBI A/M 5 balance control front light
Leg Work 6 to 8 single leg skating light
Lateral Flex/Rotation
6 mermaid light
Back Extension
6 breaststroke light
Finish 2 roll downs n/a
16
Twelve week conditioning program commencing six months post injury
Weeks 9 - 12
number of repetitions exercise resistance
Warm Up
2 roll down n/a
6 roll up n/a
6 spine twist supine n/a
8 double leg stretch n/a
8 single leg stretch n/a
8 criss cross n/a
Foot Work
8 parallel heels medium
8 parallel toes medium
6 to 8 V position toes medium
6 to 8 open V heels medium
6 to 8 open V toes medium
6 to 8 calf raises medium
8 single leg heel medium
8 single leg toes medium
Ab Work
6 round back - short box series n/a
6 flat back - short box series n/a
6 tilt - short box series n/a
Hip Work
6 frog light
6 frog single leg light
6 circles up light
6 circles down light
Spinal Articulation
6 short spine light
6 long spine light
Stretches 2 full lunge light
FBI F/I 4 down stretch light
4 long stretch light
Arm Work 6 arms kneeling series light
FBI A/M 5 balance front control light
Leg Work 8 single leg skating light
Lateral Flex/Rotation
6 mermaid light
Back Extension
4 each pulling straps 1 and 2 light
Finish 2 roll downs n/a
17
Conclusion
The client’s overall health and physical condition prior to injury, and her commitment to
recovery greatly contributed to the successful rehabilitation of the ruptured tendon. The high
level of communication between the surgeon, sports physiotherapist and client positively
contributed to the successful rehabilitation.
An achilles tendon rupture is unique in nature. There is a plethora of information available and
varying opinions as to which course of action to take in terms of surgical or non-surgical
treatment. It is best to seek the advice from a surgeon who is experienced and specialises in an
injury of this nature.
The BASI Pilates exercises with reformer were re-introduced with a gradual approach six
months post injury, progressively overloading the client’s musculoskeletal system. Special
attention was given to the exercises involving the hips, legs, ankles and feet, of which the BASI
Pilates repertoire covers a comprehensive range of needs for these areas.
Client has satisfactorily returned to her sporting activities and continues to undertake Pilates
classes on an ongoing basis.
18
References
Books
Moore, Keith L. Clinically Oriented Anatomy 3rd Edition. Williams & Wilkins 1992.
Isacowitz, Rael. Auxiliary Movement Analysis Workbook. Body Arts and Science International
200-2013.
Isacowitz, Rael. Mat Movement Analysis Workbook, Body Arts and Science International 2000-
2012.
Isacowitz, Rael. Reformer Analysis Workbook, Body Arts and Science International 2000-2012.
Websites
“Achilles Tendon Injuries”. Sports Medicine Australia.
http://sma.org.au/resources-advice/injury-fact-sheets/achilles-tendon-injuries/
Other
Figure 1
https://www.google.com.au/search?hl=en&site=imghp&tbm=isch&source=hp&biw=1366&bih=631&q=achilles+tendon&oq=achilles+tendon&g
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Figure 2
https://www.google.com.au/search?hl=en&site=imghp&tbm=isch&source=hp&biw=1366&bih=631&q=achilles+tendon&oq=achilles+tendon&g
s_l=img.3..0l10.821.3033.0.3267.15.9.0.1.1.0.316.1037.2-
3j1.4.0....0...1ac.1.64.img..10.5.1039.Qb96Q72JzkM#hl=en&tbm=isch&q=achilles+tendon+rupture&imgrc=iszqt6Fkc8Kz3M%3A
