What is the recommended rehabilitation protocol post-operative tendon repair?

Rehabilitation Protocol Post-Operative Tendon Repair

Begin early protected mobilization within 2-4 weeks post-operatively with controlled range of motion exercises, combined with early weight-bearing (within 2 weeks) when applicable, as this approach accelerates functional recovery without compromising tendon integrity or increasing rerupture risk.

Immediate Post-Operative Phase (0-2 Weeks)

Weight-Bearing and Protection

• Initiate protected weight-bearing within 2 weeks of surgery for lower extremity tendon repairs (particularly Achilles), as this significantly reduces return-to-activity time during the first 6 months without affecting long-term outcomes 1, 2
• Use a protective device that limits dorsiflexion to prevent excessive strain on the repair 1, 3, 4
• For Achilles repairs specifically, immobilize in maximum plantar flexion initially, transitioning to a walking boot that restricts dorsiflexion 4, 5

Early Exercise Initiation

• Begin isometric exercises immediately including static quadriceps contractions and straight leg raises during the first 2 postoperative weeks, which accelerates range of motion recovery without compromising stability 1
• For upper extremity repairs, initiate early passive-active motion protocols with 40-80 cycles of partial-range active flexion per session, performed 4-6 times daily 6

Critical Pitfall: Patient compliance is essential—documented reruptures occur with non-compliance to protective devices and premature unprotected weight-bearing 1, 2

Early Mobilization Phase (2-4 Weeks)

Range of Motion Progression

• Transition to active mobilization using a protective device by 2-4 weeks post-operatively 1, 3
• Early mobilization improves knee flexion and extension range of motion without compromising joint laxity, regardless of graft type 1
• For extensor tendon repairs (zones V-VI), early active mobilization protocols provide superior outcomes compared to immobilization 7

Strengthening Introduction

• Begin closed kinetic chain exercises such as leg press at 3 weeks, which improves subjective knee function and functional outcomes 1
• For upper extremity repairs, progress from partial-range to fuller range active flexion gradually during weeks 2-3 6

Progressive Strengthening Phase (3-6 Weeks)

Exercise Advancement

• Initiate eccentric strengthening exercises at 3 weeks using progressive resistance, which results in greater strength gains, better daily activity levels, and greater muscle hypertrophy compared to delayed initiation at 12 weeks 1
• Add open kinetic chain exercises at 4 weeks for lower extremity repairs, starting with seated knee extension from 90° to 45° of flexion, though monitor for anterior knee pain 1
• Both open and closed kinetic chain exercises are recommended for optimal strength recovery, though open chain may induce more anterior knee pain 1

Functional Milestones

• Patients should achieve normal gait pattern without limp by 6-8 weeks 2
• Protective devices are typically discontinued by 6-8 weeks, transitioning to regular shoes 2

Important Consideration: Hamstring grafts may be more vulnerable to early open kinetic chain exercises compared to bone-patellar tendon grafts—monitor closely and adjust accordingly 1

Advanced Rehabilitation Phase (6-12 Weeks)

Progressive Loading

• By 9 weeks post-repair, patients should be fully weight-bearing without protective devices, actively working on progressive range of motion and structured strengthening 2
• Continue eccentric training protocols as they demonstrate persistent beneficial effects at 1 year without affecting laxity, pain, or swelling 1

Return to Function

• Most patients return to sedentary work by 9 weeks, while physical labor may require additional time 2
• Begin light sport-specific activities with progression toward full return between 3-6 months 1, 2, 3

Return to Sport Timeline (3-6 Months)

Activity Progression

• Plan for return to sports between 3-6 months post-surgery for surgically treated tendon repairs 1, 2, 3
• Low-impact activities typically begin around 10-12 weeks 2
• Full sports participation is generally safe at 4-6 months depending on sport demands and functional testing 2

Long-Term Outcomes

• By 12 months, functional outcomes are similar regardless of early versus delayed mobilization protocols, though early protocols allow faster recovery in the first 6 months 1, 2
• Early functional rehabilitation with full weight-bearing after quadriceps tendon repair is safe and does not lead to inferior outcomes or increased complication rates 8

Evidence Quality Note: While the American Academy of Orthopaedic Surgeons guidelines provide moderate-strength recommendations for early mobilization and weight-bearing, they acknowledge weak evidence for specific physical therapy protocols, emphasizing the need for clinical judgment in supervised rehabilitation 1