*WK 1: Op or Non-Op That is the question… (Jun 8th - 16th, 2016)
June 16, 2016 by agnesatr
Well, what a week it has been! I think everyone that had something new and major happen to their body knows what I mean. The worst part for me during week 1 was the stress of the decision whether to operate or go with the non-operative route.
Thursday and Friday after my Wednesday night rupture were interesting to say the least. I found out that crutches are VERY limiting. You cannot carry anything!!! That means you hobble to whatever place you are at and you do things there if you need to use hands. Kitchen counters help as you can slide things to different parts of the kitchen and hop on one leg around. This is very limiting though…. I will write up few tips on using crutches that worked for me and also some equipment recommendations for first few weeks soon.
So, my first 2 days were basically spent in bed with my leg elevated. Eating had to happen at the kitchen counter, since I was not able to move anything while on crutches. Hubby’s help in the evenings was well needed and appreciated after all the hopping around during the day. I felt so tired not knowing what I did to be so tired!
On Saturday I finally received iWalk 2.0 - a pretty awesome invention I now call My Leg! I cried happy tears when I put it on and could walk and use my arms. I felt like a free person again! 
I cannot believe I was excited to do the dishes… Something…
FIRST STEPS IN IWALK2.0 WHILE EATING FRUIT!!!
I’M WALKING (sort of)!
Now, that I figured out how to move, there was a bigger issue on hand: the decision of surgery or not.
I saw a first orthopedic doctor on Friday (2 days post rupture). Doc#1 examined me, did Thompson test and confirmed ATR. She explained surgical and non-surgical options with the standard answers that active, healthy people usually get surgery. Surgery has its risks. Non-surgical option was also available, if I wanted, but that re-rupture rates are higher with it. My husband did a little research on ATR by then and asked about the latest studies on non-surgical treatments and their success rates. She acknowledged these, but stated that these are not conclusive yet to be a standard. We then saw a surgeon that works with Doc#1 and he confirmed everything Doc#1 said. I was not pushed by them to go one way or the other. They basically laid down all the facts and said to take couple of days to think about it and let them know what we choose. They spent a lot of time with us, answered all the questions we had and said that we cannot make a wrong choice. Both options can be applied successfully. Doc#1 changed my cast for a boot with a 20 degree toe decline. I felt so much more comfortable in it than in the cast. I was allowed to remove the boot for the shower and icing only. I was ordered to be non weigh bearing (NWB).
MY BOOT AFTER CAST REMOVAL (20 DEGREES TOES DECLINE)
We spent the next 3 days researching everything we could find on surgical and non surgical options. We read a lot of medical studies, websites and blogs. I joined ATR facebook group and got some good perspectives there too. AchillesBlog.com was so helpful as well with all the resources! I think I will provide a separate tab on my blog for resources I used, since there are so many. My head was spinning from all the information. At the end of it I saw quite a few success stories with non-surgical approach in athletic persons that I was very interested in that option.
We had a Tuesday appointment (6 days post rupture) with a second orthopedic surgeon, recommended to us by Emergency Room. We were hoping that something gets clarified in our heads during that visit. Well, we were wrong… Doc#2 was not interested in anything other than surgery with 6 weeks of no movement and a very conservative PT. I asked about early weight bearing and non-surgical studies that show success and he dismissed these. According to Doc#2 there is consensus in medical community that active young people get surgery. I asked what did he think about the risks of the surgery and he dismissed them saying that I should not worry about that if he does the surgery. Well, we felt pretty informed after our research and I knew that what Doc#2 was saying was not wholly representing the facts out there. The risks of surgery are real and the studies are real as well. I knew in my heart right then that this is not a doctor for me, as we were not even able to have an educated conversation with him. I am sure he is a great surgeon and has a high success rate, but I did not like the approach of “my way or a highway”. Doc#2 did spend quite a lot of time with us, we did not feel rushed, but all the conversations were about the surgery he performed and questions about any other approach were shut down. Doc#2 basically stated if I want non-op, or different post surgery protocol, to go somewhere else. He scheduled us for a surgery 3 days from then, just in case and said to call and cancel if we change our mind.
Third opinion. We got a recommendations from my husband’s work contact about another orthopedic doctor. We were trying to get an appointment with him for a week and finally managed it for Thursday (8 days post rupture). When we saw Doc#3, we felt at ease immediately. He seemed informed in different treatment strategies around the world, did not dismiss anything and himself stated facts from the latest studies. We felt like we could exchange information we read and get his opinions on them. Doc#3 stated that they had surgeon from New Zealand in the past and he was treating athletes in non-operative way, because that was the direction he knew from New Zealand. He stated that if I was back in Europe than I would probably not have a surgery with my case, but even that depended on a country. He also admitted that in the USA the current approach is still to cut if you are healthy and active. On the other hand he confirmed that the new studies show that there is similar recovery rate with non-operative treatment for active persons. Doc#3 treated athletes this way as well in the past. Ok, we finally felt like we met a doctor that knew both sides. I asked about recommendation on imaging for non-op (something I read in one of the no-op studies). He stated he can do an ultrasound right now regardless of our the choice. Before I knew it, I was on my belly and my hubby was seeing my rupture on the screen. It confirmed full rupture with minimal gap and all looked good for healing either way. I was comforted by it. Doc#3 also looked at my foot’s natural bend and stated that maybe bigger angle of the boot was needed. I confirmed that current boot angle feels like it pushes my toes up a bit. My boot was reset to about 35 degrees (somewhere between 30 and 45 degrees - hard to read). Basically the doc asked the person adjusting to align the angle with my foot’s natural hanging angle.
35 DEGREE PLANTAR FLEXION - FIRST 2 WEEKS OF TREATMENT (WEEK 2/3 POST RUPTURE)
At the end of the visit we spoke about the treatment protocol and I was told that in the next 4 weeks the angle of my toes pointing down is the most important. In the non-surgical treatment connective tissue will need to grow to connect the ends of the tendon. The downward toes angle is there for the ruptured parts to be as close to each other as possible, thus preventing creation of too much connective tissue. More connective tissue = weaker tendon and possibly too long tendon after healing. I was also told not to take off my boot at all except for spot cleaning my foot and changing the sock. I was instructed to not take the boot off for the shower, but just use bag over my boot. This made sense to me, as during the previous week, I felt the most vulnerable during the shower with my foot hanging and in risk of being injured further. Remember, that if you do not have surgery, any movement of toes up risks rupturing whatever healed already.
We were so happy after the visit. I immediately cancelled the scheduled surgery and appointments with Doc#2. I felt like the stress of last week drained all my energy I was supposed to use for healing! I was not stressing about the surgery itself - if I was told I need one, I would do it immediately, no problem. What was keeping me awake at night was the decision about the best approach for me and my case. If the latest studies show that there is not much difference in recovery with the non-operative approach for athletic people, I just do not see the need to risk the complications from surgery. I have it in my head that if I re-rupture, I will probably decide to go for surgery then, but I decided to worry about it only if I have to. For now, I am fully concentrating on the non-op approach.
I have appointment with Doc#3 in 2 weeks. I am supposed to be NWB for 2 weeks and to elevate my foot as much as possible. Btw, Doc#3 was also the only one who knew about iWalk 2.0, which made me see that even in this aspect he was aware of the latest things available out there.
So here it is, the beginning of my non-operative journey to recovery!
My advise to all new ATR patients would be to not be afraid of seeing multiple doctors and getting few opinions. There is no one right way that fits all, because every person and injury is different. What matters is to do solid research to know YOUR options and not only the options that the particular physician practices. Choose a doctor and treatment track YOU are comfortable with. It’s not easy. I do not know about other medical fields, but unfortunately ATR medical community does not have a unified view on treatment plan. What one doctor practices and swears by, another will not think about and will even criticize. I found it strange and confusing, but I am glad my decision is made and I feel good about it!
Now, back to healing that leg!
HERE IS MY VLOG FROM WEEK 1:
Excellent post. I get a little tired of repeating the same things about non-op treatment so now I should just send them to you. The most important thing is for the tendon ends to touch. A 5mm gap is enough for a clinical failure which means less push off strength. The advantage of surgery is the tendon ends are assured of touching but there are many complications apart from an ugly scar which can rub on your shoes later. The USA is probably driven to surgery because it pays better through the insurance companies. England struggles as it is government funded and they want to save money so non-op is preferred but the doctors there are still not together on treatment even with conclusive studies done by the Exceter team. The New Zealand doctor you mentioned was most likely Twaddle and his studies, although small, were good. Taking your leg out of the boot before 3 weeks did not seem very logical to me so now I would consider your treatment start date would be from Doc 3 visit. Putting a tab with your references is a good idea. I did it on my page as well (xplora). I found it helpful to understand how tendons heal as it put in perspective the rehab process. You could also be the twin sister of one of my closest friends who lives near Sydney, Aus.
Thank you Stuart. Yes, it is sad that things like insurance and money dictate treatments recommended by drs. I understand patients making these choices based on their financial situations, but ethically doctors should not be recommending treatments based on costs… The good thing is that both, op and non-op, approaches are successful.
I am glad you gave me your blog’s id. I read through it today. I see you went with op approach and recovered nicely. Congrats on it! We should ask Dennis to make comment names to be links to our blogs. Would be easier than to just visit a site of a person commenting. I will check out your resources tab and might add a link to it in my future resources link.
And yay - I have an Australian twin!
Agnes - I was given the same lines at the hospital about fit and active have surgery. Non surgical has a higher re-rupture etc. It was a difficult time for me. We had been due to move to were we live now and begin the building process when one of my closest friends died so we a stayed behind for the funeral and then the injury on the weekend before the funeral. If I knew what I know now then it would have been easy but even in Aus the doctors like to cut. Government pays if you go to the hosptial but most have private insurance and can choose your doctor. Fortunately our hosptial doctors are also the same as the private but they usually get their registrar to do the job for training. The non-op approach is not for everyone with this injury. If the tendon retracts too far then good approximation is not likely. Some tendons have degenerated significantly and require a tendon transfer. The best way to check this is ultra sound and then MRI. There have been some re-ruptures which are actually new ruptures in a different spot going non-op.
As things turn out I am pretty happy I ruptured when I did and not after I had moved into a tent. Winters here are also difficult and we would have been pushing to get some habitable dwelling built before the cold/wet set in.
Your boot is pretty good and you can buy heel inserts (wedges) which stick to the inside of the boot. This will enable you to maintain a foot angle and reduce the boot angle to make weight bearing and walking easier. Nothing needs to happen until you are ready to weight bear and most PT’s will be able to help you with the adjustment to get the angle right.
Sounds like a good approach. You are much better educated than I was at this point (I got surgery, which healed up well in the long run). Happy healing!
Great post, and great approach. I look forward to hearing good news of your progress!
Stuart - interesting info about Australia’s system. I still find it crazy (but unfortunately not surprising) that treatment recommendation can be based on the $$$! Thanks on the tips about using this boot and wedges. Will be speaking to my doc this week about it. Also, that’s interesting about re-ruptures, but in a different place… I guess that’s due to overall tendon’s collagen level decrease, or tight tendon…
oscillot - Glad to hear you healed well! Thank you.
Evan - Thank you. You inspired me to do my research on non-op! I am really glad it worked out so well for you and that you shared your journey!
My orthopaedic surgeon did not offer surgery even as an option. He said they stopped doing surgery here two years ago as Non surgery method has been proven to be just as effective treatment and the stats are showing re-reuptures to be minimal/same as with surgery. I checked into his credentials and he gets a 4.5 rating. Really hope we have chosen the right method. I am hoping to get back on the tennis courts on day again!
Ps I live in Toronto, Canada.
Sharlene - as I said in the previous comment, you can definitely get back to tennis with good rehab. Just make sure that the physical therapist is familiar with non-op rehab protocol and does not introduce stretching too soon. One thing that is still different between operative and non-operative patients is the risk of healing long. Once you heal long you will not have push off power and that would make playing tennis difficult. And yes, according to the latest studies if early weight bearing and early mobilization is included in non-op rehab, the re-rupture rates are almost the same for op and non-op patients! The key is appropriate and solid rehab.
Also being cautious during these first few months is essential! It is easy to do something silly and re-rupture regardless of surgical or non-surgical treatment! Ps-I just came back from a week long trip to Toronto. Love going there.
I’m just reading your response now Agnes!! I didn’t get a notification so I figured you were done with this ATR stuff! I’m in week 5 now and took a wedge out - getting there slowly but surely. I’ve read of so many reruptures after the boot is off its scary! I’m a very active 57 year old so I will have to hold back and slow down for the next 9 months I think! You definitely have youth on your side too which helps! Some people talk about strapping - I don’t think you have done this?
I will be continuing to follow your super blogs as I plod along!
Ps. Glad you enjoyed Toronto!
Also Agnes, could you provide a bit more detail on your reference to “healing long” ? I’m starting physio next week and want to be fully informed! Thanks so much!!
Hope you are progressing well Sharlene! Ya, I also do not get notifications for comments in spite of the setting being set for it, so often do not see comments until I come back to the blog to check it. Slowing down is definitely something one needs to do and also be patient. I am sure not many of us are very patient, so that part is hard.
I did not have strapping done. My PT only used KT tape on me once I got out of the boot and into shoes. It was not for the protection from re-rupture though. My physical therapist kept emphasizing that the tape was only to serve as a reminder not to stretch that foot too much while walking and to take smaller steps. If I was to do anything silly with my foot, KT tape would not protect the tendon.
As far as healing long, if one develops too much scar tissue between the healing tendon ends (non-op), or one stretches too early or too much too early (op and non-op), or one has an accident during the initial weeks and pushes too much body weight on the injured foot (op or non-op) - then the tendon will be too long (longer than before rupture) and one will not have the same push off power afterwards. That means that jumps will be a problem, running will be a problem and there will be lack of strength in the leg. This is something to look for in non-operative cases especially, but I have seen few ppl after operation healing long as well… My PT’s approach to preventing it was to start my dedicated stretching late - week 19th of my recovery. He made me do some aggressive strength training from the beginning, but without stretching my calf. The physical therapy for operative and non-operative patients differ in this respect in the initial weeks as the op patients have sutures and the non-op patient have only scar tissue holding the tendon together.
Good luck with your PT!
Wow! Thanks for you story. I had surgery on my right atr. I went to a different a doctor this time for my left. He said surgery might not be necessary. My last doctor basically said surgery was only option. My current orthopedist said current studies show benefits from both. After my mri, if it’s a complete tear, I’ll consider surgery. If it’s a partial, I think I’ll go non-surgical.
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