What is early loading?
Early rehabilitation refers to protocols that allow for weightbearing and sometimes other exercise types on the injured side within the first 2 weeks post injury. This early weightbearing must take place in a boot designed for purpose. One such boot, the Vacoped boot by Oped is a popular choice and is well researched as a safe option. This is the boot I am wearaing in the picture below.
Early weightbearing protocols are different from traditional rehabilitation protocols where weightbearing and additional exercise is not initiated for several weeks post-injury.
Fig. 1 – The Vacoped Boot
Early loading benefits
The proposed benefit of early weightbearing is improved healing of the tendon. During the first 6 weeks or so of healing after an achilles tendon rupture (or after any injury for that matter), the body is laying down new collagen fibers among other things. In principle, stimulating the tendon with tensile load via early weightbearing (inside a boot for safety of course) can stimulate the production of these fibers and also encourage their laying down in an organised orientation that is stronger and more functional than would be the case without loading.
The main risk of early loading is rerupture of the tendon. A lot of research has gone into the safety of early loading protocols and the consensus now is that they are safe with rerupture rates similar to traditional rehab protocols.
The duration of time in the protective boot varies. Some protocols call for 11 weeks of protected activity in the boot and others call for weaning off the boot starting as early as 6 weeks. There is good evidence that 8 weeks can deliver earlier independence without compromising safety or functional outcomes in the long term.
Return to sports though?
There is no getting around the challenge of full return to sport post achilles tendon rupture. People do return to sport, one recent review of this topic for example reported that 80 percent of non-elite athletes -that’s us incase you are wondering :)- return to participation in their sport, but the timelines are long. Research suggests that typical time for return to sport in the general population is about 6 months, maybe a little less for non contact sport and a little more for contact sport.
Because of the risk of re-rupture, taking time to let the tendon properly remodel and muscle to fully strengthen is very important. Consider that professional athletes might take a year or more to return to sport I think that it’s only fair that we give ourselves the same grace period for our return to a competitive environment. Taking an extra month or two to train in the safe confines of the gym certainly won’t hurt and may reduce the risk of re-injury.
A thought on the general risk of sport
All sport involves an element of risk. As I often say, “active people get injuries”. Indeed the achilles tendon as an example is the most commonly injured tendon and is typically injured by middle aged men participating in sport. However, the overall benefit to health of regular exercise is profound and documented by a small mountain of evidence. My philosophy is that this benefit of exercise across multiple health domains is worth the cost of musculoskeletal injury, even significant injury as in the case of achilles tendon tear. I say that as the patient of such injuries as well as in my physiotherapist role.
I don’t wish injury on anyone. But by the same token, when injuries do occur I wish everyone a satisfying rehab experience that leads to a speedy and safe return to meaningful participation in exercise.
Further reading (if you really want to impress your friends).
Aujla, R., Kumar, A., & Bhatia, M. (2016). Non-surgical treatment of Achilles rupture: does duration in functional weight bearing orthosis matter?. Foot and Ankle Surgery, 22(4), 254-258.
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.
Coopmans, L., Aliaga, J. A., Metsemakers, W. J., Sermon, A., Misselyn, D., Nijs, S., & Hoekstra, H. (2022). Accelerated rehabilitation in non-operative management of acute Achilles tendon ruptures: a systematic review and meta-analysis. The Journal of Foot and Ankle Surgery, 61(1), 157-162.
D’Onofrio, G., Kirschner, J., Prather, H., Goldman, D., & Rozanski, A. (2023). Musculoskeletal exercise: Its role in promoting health and longevity. Progress in Cardiovascular Diseases, 77, 25-36.
LaPrade, C. M., Chona, D. V., Cinque, M. E., Freehill, M. T., McAdams, T. R., Abrams, G. D., … & Safran, M. R. (2022). Return-to-play and performance after operative treatment of Achilles tendon rupture in elite male athletes: a scoping review. British Journal of Sports Medicine, 56(9), 515-520.
Tarantino, D., Palermi, S., Sirico, F., & Corrado, B. (2020). Achilles tendon rupture: mechanisms of injury, principles of rehabilitation and return to play. Journal of functional morphology and kinesiology, 5(4), 95.
Valkering, Kars P., et al. “Functional weight-bearing mobilization after Achilles tendon rupture enhances early healing response: a single-blinded randomized controlled trial.” Knee Surgery, Sports Traumatology, Arthroscopy 25 (2017): 1807-1816.
