Case Study: Achilles Repair

There are too many abstract discussions in the performance space these days about how to train and rehabilitate athletes. These circular arguments usually yield nothing substantive or actionable because providers spend too much time defending their ideology and trying to articulate why they are in the right instead of just being transparent and “showing their portfolio”. As an example, investors should demand that financial advisers share their own portfolios instead of pontificating about macroeconomic theory. Words matter but what people do when they have skin in the game reveals more about them than their explanatory justifications for said actions.  The point of these case studies is not to suggest that what we did in any of these situations is particularly good. If we’re being honest, we don’t always have robust outcome measures to suggest that what we do really “works”. More often than not, we default to the eye test. We coach and own our decisions. The intent here, therefore, is to be completely transparent about what we did when an athlete’s time, money, and readiness was at stake in hopes that other providers share their experiences and contribute to a more genuine collective conversation. 

Background

32 year old male executive/entrepreneur status post L achilles repair 6 years ago. Patient is pain free and not limited during activities of daily living but states that he never regained his strength after the surgery which manifests itself while playing pickup basketball. Basketball is the patient’s primary form of exercise and he hasn’t felt comfortable driving to the basket since the surgery and instead settles for shooting from the perimeter. Patient generally doesn’t enjoy gym-based exercises but is willing to do whatever is required to regain his explosiveness and confidence for basketball.

Constraints

• Time: Patient is willing to devote 6 days/week (6 hours total) to rehab
• Logistics: Patient has a “basic gym” (think hotel gym) in his office
• Financial: No factor but our interaction was limited to a single session for other reasons
• Interpersonal Factors: Patient had never completed a structured strength training routine and thus preferred exercises that required minimal supervision to execute safely. Otherwise, patient was eager to partake in any routine that would help him achieve his goals.

Evaluation Findings

• This was a virtual session so the evaluation revolved primary around the subjective history and watching the patient perform various progressions/regressions of the exercises below until an appropriate routine was in place.

Plan of Care

Warm Up (Daily):

1) Couch Stretch, 90s/side

2) Inch Worm, 2 sets of 40/side, each heel touches ground 40x

3) Lateral Lunge Windmill, 10-12/side

Strength (3x/week):

A1) Low Box Shuffle, 3 sets of 10s, gradually progress speed and intent

B1) Bound and Stick, 2 sets of 6-8/side, emphasis is on sticking the landing

C1) Swiss Ball Leg Curl, 3 sets of 6-15 reps (whatever you can do with good form), start with 2 legged version and progress to single leg over time

C2) Single Leg Squats (Rounded Back Version), 3 sets of good form/side

D1) Quad Nordics, 2 sets of good form

D2) Push-Ups, 3 sets of good form (max 15 reps), gradually progress hand position closer to floor over time

E1) Bear Rollout, 2 sets of good form

E2) Single Leg Calf Raise, 3 sets of 8-15/side, take 3s to lower yourself to bottom position, can start with bodyweight and increase weight over time, ensure full contraction in top position and pause there for 1-2s

Running/Conditioning (1x/week per session)

1A) A Run, start with 3 sets of 8-10s with maximal intent every minute on the minute (so 50-52s rest). For your first session do 3 sets of 6 with 3 mins rest between sets (18 total repeats). Over time work up to 3 sets of 12 with 3 mins rest. In week one start with 3 sets of 6 and add an additional repetition to the set each week so 3 sets of 7 in week 2, etc. Increase amplitude and intent over time. Start conservatively.

1B) Incline Treadmill Walk, 20-30 mins, treadmill at max incline, wear a backpack with 15-20lbs and work at a pace that feels moderately difficult while breathing through nose

1C) Calf Iso Bent Knee, 3 sets working up to 60s over time, start with weaker leg and let that dictate time for stronger leg

1D) Calf Iso Hold Straight Knee, same protocol as bent knee

2A) Jump Rope, every minute on the minute for 15 mins, start with 20s on/40s off, work up to 45s on/15s off over time

2B) Alternating Step Ups, 15-20 mins, start with bodyweight and work up to 15-20lb backpack, fully extend leg in top position, use box that keeps knee and hip angle around 90 degrees

2C and D) Repeat Calf Iso series

3A) Repeat A Run protocol from earlier in the week

3B) Backward Elliptical (hands free), 20 mins, replace with other low impact cardio machine of choice if no elliptical

3C and D) Repeat Calf Iso series