Second ATR, first non-surgical cure


Written on January 19, 2010 – 11:40 pm | by normofthenorth

I tore my right AT 8 years ago playing competitive volleyball. At the time, everybody still thought that surgery led to better outcomes, so I had the surgery. It was a constant fight with my surgeon to get quicker mobilization, physio, & weight-bearing, but he was “conservative”. I was his first AT patient ever to use a hinged boot, instead of a bunch of casts.

I was back playing competitive volleyball around 11 months post-op, and have been comfy and confident with that leg ever since. The tendon is a little bit shorter than it was (less flexion), and the ankle often snaps/clicks when I do a calf-raise, but it’s otherwise great, and those two things are both “small stuff”.

This past Dec. 8 I tore the left one, same sport, same move. (Ironically, though I’m the oldest guy on the volleyball court and I was 8 years ago, I’ve since switched from 6-on-6 volleyball to 4-on-4 volleyball, so I can get a better workout!)

I went to the chief surgeon of the local pro football team (Toronto Argonauts, in the CFL), looking for another operation. He told me he stopped doing the surgery 4 months earlier, based on the latest study that shows that surgery brings no benefits with more complications. (He also knows the authors, and he’s discussed it all with them.)

My Dad brought me up to always doubt a carpenter who recommended wood, but always trust one who recommends AGAINST using wood. So I looked over the protocol (and later, the reports and stats), and got slapped into an AirCast boot 2 days after the rupture, Dec. 10.

I’m following the same protocol as the recent study done at Univ. of Western Ontario. 2cm heel lift, 2 wks non-weight-bearing, 2 weeks “protected” WB, then WB as tolerated.

Details on the study & the protocol are at http://clinicaltrials.gov/ct2/show/NCT00284648 and http://www.medscape.com/viewarticle/588904. [Sorry, I can't get the "link" function or even the "ul" function to work right!]

I’ve switched from crutches to a cane, and now I’m forgetting where I put the cane, alternating between semi-normal walking and doing a left-foot-forward “gimp walk”.

In a couple of days (6 wks) I remove the heel lift. Two more weeks (8 wks) and the protocol says “wean off boot”.

I’m still wearing it 24/7, though I’ve started showering without it. I’ve also started wearing a high (”Exec length”) sock on my injured side. It’s WAY more comfy not having my skin plastered against the foam! I thought I’d be very nervous putting the sock on, but it wasn’t too bad.

This site is a great resource, and it does have links to a number of modern studies and meta-studies that show the advantages of the non-surgical option. Yet the structure and tone of the site still seems locked into the world of my first ATR, when “everybody knew” that surgery was better for athletes. I don’t get it. As the Medscape article from AAOS 2009 says,

“There is a lot of bias, especially in the United States, toward surgical treatment of Achilles tendon ruptures,” said lead researcher Kevin Willits, MD, from the Fowler Kennedy Sport Medicine Clinic at the University of Western Ontario, in London. “For some people, it’s almost like a religion — they believe that surgery should be the standard of care. But studies on both methods of treatment have actually been conflicting and equivocal,” he said.

Meaning no disrespect or ingratitude, but is this site an example of that “religion”?

So far, my second (non-surgical) rehab has been quicker, more convenient, and less painful than my first (surgical). It’s too soon to know how successful the “cure” will end up being, but so far, that ankle and foot feel stronger and sounder and better every day. My AT “failed” the Thompson test last week — i.e., my foot jumped when the physio squeezed my calf — so there’s some sort of AT re-established there, which is good.

My schedule — God Willing! — includes skiing a week in mid-April, racing small sailboats (Albacores) starting on May 7, and returning to competitive 4-on-4 volleyball in the Fall (or maybe a bit sooner).

So far, my progress (e.g. to full weight-bearing) seems to be matching the patients in the study. We’ll see.

The part that mystifies me the most is how the length of the tendon can possibly end up short enough this way. My calf is still in a bit of a knot after 5.5 weeks. On the other hand, the non-surgical patients ended up with the same strength and the same ROM as the surgical ones, so it seems to work out somehow, at least on average. For me, too, I hope!!

Post-script: I should have mentioned that I also paid for (and got) 3 injections of Platelet-Rich Plasma = PRP. A brand-new peer-reviewed study (the first careful one) showed it had no benefit for Achilles Tendinopathy sufferers. My physio thinks it might still do some good for us ATR sufferers, but maybe it’s a waste. Cdn$1200 and 3 extra trips (on crutches!) and it hurt like hell, too!

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  1. 21 Responses to “Second ATR, first non-surgical cure”

  2. By doug53 on Jan 20, 2010 | Reply

    Hi Norm,

    Perhaps nonoperative treatment of ATRs will someday become the norm. A couple of thoughts about this study, though:

    One issue is what statisticians call beta error. In this case, the beta error issue would be if this study is big enough to show a difference in a rare problem like rerupture. For (an extreme) example, nobody would be convinced by a study with three people in each group, with no reruptures, and a claim that both methods were therefore equivalent. Is this study big enough to show, say, that the rerupture rate in one group is actually twice that of the other? I’m not enough of a statistician to answer that question with confidence, but my hunch is it may not be.

    The other issue that always comes up when two treatments are being compared is whether or not both approaches are being done as well as possible. Their rehab for the nonsurgical group may be appropriately aggressive, (and a rerupture rate of about 4% is reasonably low), but their use of an identical rehab program for the surgical group may be a problem.

    As regulars at this site well know, I’m a big believer in postsurgical rehab that is much more aggressive than what is usually done. In particular, many postop rehabs are no more aggressive than nonsurgical rehabs, as in this study, and that is likely a waste of the strength given to the tendon by the surgical repair. For one example, I was able to hold my body weight up on my injured foot’s toes and walk truly normally when the surgical patients in this study were just getting out of their boots. Even if the eventual results are the same, a faster return to health is an advantage.

    Despite my quibbles, this study could indeed lead to a change the general approach to ATRs. Their nonsurgical rerupture rate was pretty low, and eventual overall recovery (of calf strength in particular, a big problem if the tendon heals too long) is apparently good, (knowing only what is on the Medscape site). If speed of recovery is not an issue, nonsurgical treatment could be the way to go.

    In your particular case, if your current nonsurgical rehab is quicker than your prior surgical rehab, I think that likely means your first rehab was slower than it needed to be.

    I hope your great progress continues,

    Doug

  3. By 2ndtimer on Jan 20, 2010 | Reply

    Hi Normofthenorth,
    So you are doing your own study… sorry to hear you have to go through it a second time.
    I was not able to find the results of this study on the link you gave. Can you point me to it?
    My experience was not so good with conservative treatment - but ATR is a very complex issue. Keep us posted on your progress.
    Btw there was a blogger here see: http://achillesblog.com/mazmouza/ who participated in one of these studies.
    Lots of bloggers from the UK are going through the conservative treatment these days, too.
    Wish you speedy recovery.

  4. By 2ndtimer on Jan 20, 2010 | Reply

    I found the results of this study finally.
    Thanks.
    So it all boils down to rehab?
    “Dr. Willits attributed the low rate of complications seen in the study — in both surgery and nonsurgery groups — to the aggressive rehabilitation program.”
    I wonder why then I was kept in the cast/boot for 11 weeks both times…

  5. By normofthenorth on Jan 20, 2010 | Reply

    Thanks for the thoughtful comment, Doug, and all good points.
    I think you’re right that my first rehab was slower than it needed to be, and I strongly thought so at the time — except for ONE DAY:
    On the first day when I could walk normally in bare feet (around 4 months post-op), my physio paraded me up and down the Univ. of Toronto Sports Medicine Clinic (barefoot) because I was a Huge Success Story. Unfortunately, when we returned to her Physio table and started doing stuff, she finished by asking me to do one-legged calf raises on my repaired (right) side.

    I told her that I wasn’t ready for one-legged calf raises, because there was no way that I could do 8 of them. (I was raised to consider 8-12 reps a reasonable range for strength exercises.) She responded by telling me to “Just do as many as you can.” Foolishly, I agreed, and grunted out 3 or 4, maybe 5 — and I couldn’t walk normally in bare feet again for another MONTH! I also experienced my first real pain in the whole experience starting a few hours later, right at the back of my heel, where I’d obviously over-strained something — probably not the torn/repaired part of my AT, either, but just a part of the chain that was weak or atrophied from disuse.

    So while I’m definitely on your side on the rapid-return thing (and I’m thinking of jumping into a hinged boot any second now, though my physio is advising against it), there’s definitely such a thing as “too much too soon” as well. Scylla and Charybdis both! This time around, I won’t be doing any of that “as many as I can” stuff until I’m good and ready!

    Finally, while your point about missing big ratios in tiny numbers (like re-ruptures) may be correct, it also may be irrelevant. At some point, the re-rupture rate/risk becomes small enough that it fades as a consideration in the total equation, compared to all the other factors. They studied something like 175 torn tendons, and the re-rupture rate/risk was very low, zero to a first approximation. If a study 10 times as big found similar numbers but statistically significantly different ones, would that rationally change anybody’s choice of surgery vs. non? I’d think probably not — unless of course mine was the one re-rupture in 100! ;-)

    Also, don’t forget that there are a lot of “good” reasons for re-ruptures — somebody loses their balance while unprotected, falls on the stairs or on ice, or otherwise pulls hard on a healing AT, etc. With events like that, I’m not sure it matters much whether you had surgery or not, because it’s definitely possible to re-tear either kind in the early days/weeks. I’ve never heard much in the way of anecdotal elaboration around the re-ruptures (though there are a few in the AT blogs), but I bet they’d tell a tale!

  6. By normofthenorth on Jan 20, 2010 | Reply

    2ndtimer, you and me both, at least my first time! Even in 2001/2, the evidence was there to show benefits of early mobilization of torn ATs (and lots of other body parts!), which was why I was such a Rotten Patient for my orthopedic surgeon! And now the evidence is even stronger.
    Interestingly, the preliminary design of the UWO study (first link near the top) shows a much more aggressive rehab protocol than they eventually followed (2nd link). I’m following the second one, though I’m wondering if I could go faster.
    And doug53 may well be right that the optimal post-op protocol can be faster (after a week of moaning and groaning!) than the optimal non-op protocol, because of the physical strength of the sutures, the fact that the two torn ends are already together, etc., etc.
    We’re definitely still learning what’s best, but the old way — surgical or non-surgical — is definitely not it!

  7. By normofthenorth on Jan 20, 2010 | Reply

    Mazmouza’s experience is sad and scary for somebody who’s basically following the same protocol he followed. So far so good for me — and I hope not to trap my good foot in a barber chair, too! (Yikes!)

  8. By doug53 on Jan 20, 2010 | Reply

    Norm,

    You’re absolutely right, 2, 4, or 6% rate of rerupture isn’t that big a difference, especially when you consider that troublesome wound infections, which can be at least as bad, probably make up the difference, anyway.

    In general, experiments are best when only one thing differs between the two groups. I imagine that basic principle guided the design of the study you are in. If surgery allows faster rehab, however, that may not be the fairest design. I guess that’s my main point.

    I was pretty gung ho with sutures holding things together. (I was a Rotten Patient, too. I just didn’t tell my doc what I was up to until it was “too late.”) I wouldn’t be so quick to dismiss my doc’s advice with nonsurgical treatment. For what it’s worth, I suspect you are already pushing about as fast as is safely possible without surgery.

    2ndtimer, I really do think the rehab makes all the difference, hence my railing against casts for weeks after surgery. I don’t think I’m some fast-healing freak of nature. I suspect many people could rehab as fast and as comfortably as I did after surgery.

    Also as I’ve commented before, rupturing the tendon “cures” the tendinosis that made the tendon weak; so once you’ve busted both of them (and successfully rehabbed), you may be good for life. I wonder if the *elasticity* of the tendon, which stores energy and therefore helps with jumping, ever fully recovers, though.

    Best wishes,

    Doug

  9. By normofthenorth on Jan 20, 2010 | Reply

    Yes, Doug, I fully agree with your “main point”. Perhaps some day we’ll get a randomized study that compares the results of “best” protocols for surgical and non-surgical patients. If so, it probably does make sense that the non-surgical patients will spend a bit extra time in the boot. (Frankly, I’m shocked at how quickly this rehab is moving, without stitches.)

    Just for picky accuracy (my specialty!): Neither Mazmouza nor I are/were actually in the Univ. W. Ontario study. Mazmouza was apparently seen/treated by the chief investigator in that study, and the surgeon who slapped me into the boot consulted with the authors, and I’m following the same protocol as the study.
    The UWO study is now complete, as I understand it. The results were delivered at AAOS 2009, though I don’t think they’ve actually been published yet in a proper journal.

  10. By doug53 on Jan 20, 2010 | Reply

    Senility is surely to blame for my faux pas.

  11. By 2ndtimer on Jan 20, 2010 | Reply

    My 2nd surgeon’s regular routine after surgery is 1 month cast, and one month boot (starting PT while in boot). But as I was a re-rupture, he kept me in the boot an extra 2 weeks. So I guess normally he is pretty aggressive in rehab.
    Funny you mention the episode with the heel raises on one leg: I re-ruptured the day after I was made to try it…

  12. By ultidad on Jan 20, 2010 | Reply

    Isn’t there a quote along the lines of “there are two kinds of statisticians: liars and damn liars”?
    I agree that the “religion” of this blogsite favors operative treatment. I also believe that it is human nature to vigorously defend the treatment that we received, whether it was assigned to us or chosen by us. I tried looking at the Group Marathon Tracker to get a quick estimate of the surgical:non-surgical ratio, but a surgery date was listed for everyone - even you, Norm! It is my sense, tho, that the majority of bloggers here have had surgery. Now, does this population (contributors to achillesblog) adequately represent the population of ATR sufferers as a whole, or is there some selection bias happening such that people who have had surgery gravitate towards this site while those who have not had surgery either go elsewhere or do not join blogs at all?
    On the surface, it seems that it should be an easy question to answer: surgery vs non. However, this site shows that the question is much more complex given that variables such as age, level of fitness, injury circumstances, time from injury to treatment and rehab protocols are not controlled for.
    My two cents’ worth. Ron

  13. By maryk on Jan 20, 2010 | Reply

    Ultidad, you are so right! Since I have already HAD surgery, I refuse to countenance any notion that maybe I didn’t have to have it! ha! But seriously, bottom line the study I read said that (contrary to long-held assertions) the re-rupture rate is not higher among the conservatively treated. BUT also that the long-term outcomes for both groups in terms of both function and quality of life are similar, and quite good. So let us all limp boldly into our future, with no regrets! :)

  14. By normofthenorth on Jan 20, 2010 | Reply

    Folks, I’ve got that same tendency to justify AT surgery, because I had it myself!! Moreover, the results were just fine, and I was spiking the ball from well above the net ~11 months later, with solid confidence in that AT. If I’m not lucky, I could do a lot worse this time, as too many bloggers here have (surgical and non).

    The website rules here require a “date of surgery” and the instructions say that you should fill it in with your date of immobilization if you don’t get surgery — so everybody’s got a date of surgery! That’s one of the things I meant when I wrote that

    “the structure and tone of the site still seems locked into the world of my first ATR, when “everybody knew” that surgery was better for athletes”.

    Ultidad, I think the quote is “There are liars, damned liars, and statisticians.” But my fave quote on the subject is “Figures don’t lie, but liars figure!”
    Meanwhile, the UWO study seems remarkably careful, with the subjects split into the surgical and non-surgical groups randomly.
    I’m guessing that there are lots of US residents on this site, and US residents seem to get rushed under the knife after they tear an AT. Canadians did, too, until partway through this past year, but it’s changing fast. (BTW, I was born and raised in the USA.)
    I will be curious to see if the new evidence affects the practice for elite and professional athletes. I think it already has in Ontario, probably including Toronto’s pro hockey, football, and basketball teams — though I have no real evidence other than the statement of my surgeon, who’s the chief surgeon for Toronto’s pro football team. And the head of that same clinic (Sports Medicine Specialists) was quite recently the chief physician for the Maple Leafs hockey team. . .
    But if one or two sports superstars tear an AT and decide to go with the boot instead of the scalpel, it will probably shake up the practice — especially in the US — more than all the randomized control studies in the world.
    Mind you, if Doug53’s super-fast experience is replicable with surgery but not without, there will still be major pressure on top athletes to get the sutures and save a few weeks off the field/court/ice, even if the results after 11 months are exactly the same, not counting surgical complications. Now I think it’s mostly “everybody knows” and “Eminence Based Medicine” that’s sustaining the surgery.
    (Heck, there were DECADES when doctors forced ulcer sufferers to change jobs and diet etc., when we now know that ulcers are caused by a bacterium!)

  15. By ultidad on Jan 21, 2010 | Reply

    “Eminence” Based Medicine - I love it. One of the best (and longest-lasting) aspects of my residency program was that we were encouraged to question everything. One of our most knowledgeable and well-read professors was constantly challenging us to say, “show me the data”. Ever since, I have always bristled at “well, that’s the way we do things here”. Also, when talking to my patients’ parents, I readily tell them when things that I do or suggest are based on my opinion/experience vs. published data. Unfortunately, in my field of pediatric anesthesia, there are some questions that can never be answered due to the impossibility of doing the appropriate studies.

  16. By doug53 on Jan 22, 2010 | Reply

    Ultidad,

    Check out

    bmj.com/cgi/pdf_extract/319/7225/1618

    one of the best articles in all of the medical literature. I never could locate reference number 6, though.

    Doug

  17. By ultidad on Jan 22, 2010 | Reply

    Doug- thanks for the laugh, I needed it. I would add one more category: Malignancy Based Medicine, Marker: rate of student and resident attrition, Measuring device: student and resident directory, Unit of Measure: body count.

    Norm- thanks for letting us take your post off on a tangent.

  18. By normofthenorth on Jan 22, 2010 | Reply

    Don’t thank me, I’ve enjoyed it. I’m guessing that my first exposure (a day or two ago) to that cute phrase (from the BMJ article) came from Doug, so it’s all his fault, anyway! ;o)

    BTW, I find the version of that (great) article at http://www.bmj.com/cgi/content/full/319/7225/1618 much easier to read than the one in Doug’s link.

  19. By normofthenorth on Jan 22, 2010 | Reply

    I’ve posted my recent developments in a new post. I hope that doesn’t mess up the thread of comments. . .

  20. By sheepskin10 on Feb 14, 2014 | Reply

    Norm…i am four months today healing from non op and i just reruptured. What now….i am back in vacocast elevated. Surgery this time?????

  21. By sheepskin10 on Feb 14, 2014 | Reply

    I was so close

  22. By normofthenorth on Feb 14, 2014 | Reply

    So sorry to hear that, Sheepskin10! Did you do something violent to it, or what?

    We’ve had a few reruptures here (post-op and post-non-op) who’ve gone non-op the second time, but the vast majority (here and elsewhere) opt for surgery. I probably would too, if only to have the psychological reassurance that somebody’s laid eyes on my tendon and DONE something “hands-on” to repair it. There’s no evidence on the subject, so it’s impossible to base a decision on scientific data. Of course, if you end up with a nasty non-closing wound (God Forbid!) or the like, you’ll be kicking yourself, but no treatment comes with a guarantee.

    There’s also no scientific way to bias the decision in your favor — e.g., to choose surgery if your gap is large but not if it’s small — because that logical correlation and a few others have been shot down by the evidence we do have. The only logical correlation I can think of that’s still standing is this: If your reruptured leg is mega-swollen, with lots of inflammation, that may well mean that your prospects for a NON-op cure are better than average. The logic is simply that the inflammatory response is what does the natural repairing — and also what does the post-op healing, after surgery creates mega-inflammation. (Many people imagine that it’s the skillful stitching that does the post-op magic, but I suspect it’s really all the slicing. We’ll never test that, because we can’t slice somebody up without stitching them back together. . .)

    There’s a blog page here that’s all about re-ruptures, for you to read and also to add to. And you should start your own page — directions on the Main Page, starting with an email. And Good Luck! Anybody who’s reruptured deserves some!

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