Major progress - read this guys

Greeting from London….naturally it’s raining :)

It’s only been a few days since my last post but I wanted to get this post in asap having read the comment from iasablan and ty620 who are both on a similar timeline to me.

It’s quite a lengthy post this, but worth it, this will shave weeks off your recovery.

I saw my surgeon on Saturday who is very experienced in ATRs and is involved in all sorts of studies on the matter and he talked me through a study which compared the results of loads of trials on the subject of post surgery treatment.

The full report is available here but you’ll have to buy it ($35), http://www.sciencedirect.com/science/article/pii/S0020138314003155

My surgeon gave me a copy so ask your surgeon. It’s a long read but well worth it.  I summarise like this:

There have been lots of trials over the years that compare different types of treatment for ATRs.  This study from 2014 put together all of those trials to try to come up with a definitive approach that led to a faster return to pre-rupture activity but also keep re-rupture rates low.

So the trials covered groups that took the more ‘traditional’ approach of NWB for 2-3 weeks in a cast, then PWB for 4-6 weeks in the boot, then FWB followed by the usual physio etc.  The sort of approach you’ll read a lot about throughout this website. Throughout those 6 weeks there is absolutely no movement of the ankle, referred to in the report as non-mobilization.

Groups in other trials studies were treated with a far more aggressive approach. FWB immediately……yep, straight away from surgery, FWB.   I can’t quite imagine what that would feel like but that’s what they did.  Still in the cast for 2 weeks, still the boot after that, but no crutches.  FWB straight away…..madness right?  These people were fixed in plantar flexion (toes pointing down) in the cast for 2 weeks but allowed mobilization after that.  They could have up to 30 degrees of dorsi flexion (pulling your toes up) whilst having the boot on/off.  After 6 weeks the boot came off.

Well the results are incredible….I’m quoting here:

“ALL trials found mobilization to be superior as it shortens time to return to work and sports significantly”

“This combination (FWB with mobilization) was most beneficial. Patients showed significantly higher satisfaction, less use of rehabilitation resources, earlier return to pre-injury activities and further demonstrated significantly increased calf muscle strength, reduced atrophy and tendon elongation

No study found an increased re-rupture rate for the more progressive treatment.”

At the end of the document it gives a recovery protocol.  I don’t know about you guys, but the protocol I was given by my physiotherapist was 6 pages long, full of all sorts of information I felt I didn’t need.  This protocol from this study is just a few lines long and is split into 3 categories: ROM (Range of Motion) and ORTHESIS (that’s the posh name for the boot) and WEIGHT BEARING

ROM:
Week 0-2      None
Week 3-6      work up to 30 degress DF/PF
Week 7           Free movement

ORTHESIS
Week 0-2      Fixed in a cast, PF
Week 3-6      Occasionally off, work up to 30 degress DF/PF
Week 7          Off

WEIGHT BEARING
Full weight bearing throughout

So, how does this play into my own recovery, I am currently 4 days into week 5.  My surgeon made it clear to me the best advise is to listen to your body.  If you go FWB, be prepared to take it easy to begin with, don’t just start walking everywhere thinking you can get back to normal everyday activities.  I am FWB, ditched the crutches as soon I came out of seeing him.  However, I am not going mad.  Round the house is easy enough, and if it hurts I can sit down for a few minutes.  No trips round the supermarket just yet.

In my experience, the only part that actually hurts and bothers me is the actual wound site rather than the tendon itself.  I am getting zero pain from actually inside my leg, it’s all on the surface.

JUST TO BE CLEAR….when you are FWB you should always be doing it IN the boot.  I have not had the all-clear to put my foot on the floor without my boot yet.  I expect that to happen in the last week of August, my surgery +7 weeks.  At that stage I’m going to put shoes on and get around the house.  Something backless, Crocs maybe, so as to not rub on the scar.

The more I read about this aggressive, accelerated approach, the more I am convinced it’s the right way.

Speak to your surgeon but I would advise getting FWB as soon as you can. As long as you listen to your body and rest when it hurts, get on your feet, get weight through it.  Walking in a boot is tricky, I’m not very good at it yet, but it feels great to be getting around without crutches. The other benefits are I’m using my legs properly so muscle atrophy should stop, my hips/shoulders/hamstring/hands aren’t aching from all the crutch work.  The only bit that is sore is the ball of my foot, those wedges are hard, but if this shaves weeks off my recovery I can live with a sore foot.

Sorry for the long post but I hope this helps,

Andy

15 Responses to “Major progress - read this guys”

  1. Greetings to you Andy from sunny Southern California,

    I appreciate the information you just shared. Thank you for the time and effort you put into researching this stuff.

    Today being the start of Week 2 of post-op, I’m going nuts from the inactivity. Needless to say, I’m anxious to get back to normal, but not at the expense of a setback.

    I’m willing to share this with my ortho guy next Tuesday to see what he thinks. But I’m up for the challenge.

    Thanks again, Andy.

  2. Just to clarify, you have indicated up to 30 degree plantar flexion (pulling toes up). Pulling toes up is dorsi flexion. 30 degrees dorsi flexion would be difficult to achieve in a healthy tendon and impossible for a recently ruptured AT. Some people could read this to think they can push the tendon to this level which I feel could be harmful. There is no mention whether the ROM is active or passive and that will have considerable bearing. Passive ROM is dangerous in the early stages. I do agree with other aspects regarding early weight bearing and mobilization within this time frame.

  3. oh yes good spot, I was typing without reviewing, have changed it to dorsi, thanks :)

    Naturally movement would be AROM but as I said speak it all through with your surgeon and/or physio first.

    From the sofa, leg raised.

    Andy

  4. Hey Andy this is great news and I totally appreciate your long post!
    I have been FWB since week 3 when I got my staples removed and cast off. My surgeon put me in my boot and said FWB and wean myself off the crutches. I ditched my crutches by week 4.

    I go see my surgeon again next Monday which is week 7. I will keep you in the loop.

    So my scar actually hurts to. I was wondering what should my scar look like at week5. As my surgeon said I can not immerse my foot in water. I am only able to shower which mean I have Terrible dry skin.

    Hey Andy was anything said about what type of ROM and massaging the scar?

  5. Everyone’s case is probably different as well as recovery protocols/results.
    Mine was super conservative - 6 weeks complete immobilization in the hard cast with No weight bearing.

    Went straight from hard cast into FWB in the shoes and no crutches same day cast came off.

    My tendon was so rigid it was stuck in negative 6 degrees of plantar flexion. Every step was a huge amount of pain.

    Apparently my doctor made a choice to sacrifice initial ROM for strength of repair. (At least according to him on the choice of protocol). He also told me that walking is the best therapy. And that after a surgery and 6 weeks in the cast unless I fall off the stairs I will not rerupture tendon again.

    Recovery is 6-12 month process and 3-4 month down the road initial treatment protocol is not as important as being persistent and keeping an eye on the ball.

  6. Since mine wasn’t ATR but rather surgical cutting of the achilles to remove a bone spur my recovery is a bit different. I totally believe that the sooner you are FWB the less rehab you’ll need due to muscle atrophy. That is my biggest issue now - getting the strength and flexibility back in the calf/achilles. My doc had me doing ROM at 3 weeks which worked great for me. And, up until recently, I was seeing regular improvement in all aspects on a weekly basis. The improvement has slowed down a bit now - but hopefully with a change of running shoes and a slight tweak in my exercise pattern I’ll see more improvement.

  7. Thanks for the long post Andy. Confirms everything I’ve been told about early movement. I do my exercises daily and have been so happy to add in cardio now with rowing, biking (both with only one leg strapped in) and pull buoy swimming! Those are all in my protocol after 2weeks. I’ve also found yoga a huge help to keep my ROM going and stretch out some of those compensating aches.

    Happy healing!

  8. Just to explain for those unsure about ROM. Active ROM is only what you can do with your own muscles. No outside assistance. Initially it will be moving your foot around and I have always told people to write the alphabet with their foot while the leg from ankle up is fully supported. Passive ROM comes later and involves theraband or a therapist manipulating your foot. Walking in shoes will also give the same effect. Everybody has the potential to heal the same but there will be some variance depending on method of treatment. I am not sure what Zoomie’s doctor meant but if it means keeping the foot locked up NWB for longer to gain a stronger repair then studies have shown this is not the case. It is in fact the opposite but it was conventional thinking for a long time. Zoomie is correct about the length of time to fully heal and those following a modern protocol will return to some kind of normal activity a little quicker and those on a more conservative treatment will catch up so after 12 months all are about the same. If you are happy with your treatment then there is no need to worry. Many people will worry about their ROM and I would suggest from experience that it will come back in time with normal activity. Do not push it early as this can undo the repair before it has enough strength to manage the stress. The risk of healing long will be increased by early passive ROM.

  9. @sargegirl - Am I right to understand that you are rowing and on a static bike just two seeks post surgery? That’s amazing, I’m very jealous.
    I have physio next Wednesday but I’ll be nearly 6 weeks by then, hopefully given the all clear to do the same.

  10. @Stuart.
    We all should get to the finish line about the same. In 12 month we all will be back to normal activities and difference in strength between 2 legs will be academical.

    Regarding the journey to the finish line - I was questioning super conservative protocol in the beginning but looking back at it I can’t say that I am disappointed with the choice of my doctor.

    I could walk 2 miles in flip flops by week 8. (2 weeks after taking cast off).
    By week 10 my limp was almost not noticeable.
    I started jogging at Week 15 on the flat asphalt around my neighborhood. Its been exactly 2 weeks since I’ve started jogging (end of week 16) - the progress has been steady - jogging 3/4 of the mile under 6 minutes. Tomorrow will try to do 1 mile keeping it under 8 minutes.

    There is no pain or swelling after jogging. I am usually out of breath or my calf is tired but tendon is holding up (just as it should according to my doc).

    I believe the most important aspect of recovery progress is what you do when your cast or boot comes off. And who is helping you with this. I was very fortunate to find a very highly experienced sports injuries rehabilitation specialist who helped a lot.

  11. @zoomie at what week did you start therapy?
    Your progress is very impressive!!!!

    I’m at week 6 with boot on. I’m very afraid to put weight on my foot without the boot. I do start therapy the end of my week 7.

  12. @ty620.
    Hard cast came off at exactly 6 weeks to the day. This rehabilitation specialist came along by pure chance (in conversation with a common acquaintance ). I started rehabilitation with him 3 days later. He was careful initially - it was only deep tissue massages and passive ROM in the beginning.
    His massages were magical. The immediate effect was incredible - the effect didn’t last long but each time it reverted to a slightly better condition than before.

    I remember after PT session #2 - just 5 days since cast came off - I came home and my wife even made a video of me walking because I practically did not limp.
    Next morning of course the tendon was back to its usual self and I would be limping for few more weeks.

  13. I’m non surgery route. My protocol was NWB for two weeks then move,move, move! As an avid runner…I have just been so excited to sweat. I’m progressing gradually though…aerobic activity now 30min every other day and no pressure on the aircast.

  14. Looks like you guys are really active posting so I wanted to jump in. I ruptured my Achilles and had surgery March 21, 2017, stitches out and walking flat in boot on March 31, 2017. Doc had me walking without a boot on April 28, 2017. 3 more months have passed and progress is still steady.I guess I’m about week 17 or 18 and my life is back to normal. I’m 63 so normal is a lot different for me but I’m cutting firewood, built a deck and doing everything I want without a problem. I can go up and down stairs, even on my toes, but still can’t lift my weight on the toes of that foot. Doesn’t hurt, I just can’t do it. No swelling or pain but my darn heel is still pretty numb, probably from walking on it rather than on my toes.

  15. Andy:
    So what I’m about to write supports 100% what these people found. I am a 53 year old former college athlete. I have lifted, run and continue crossfit workouts mixed with biking and swimming my entire life. I am 6ft 203 lbs with 15% body fat. I provide these stats/intro so any reader can compare their condition and read with cautionary perspective based on my response to a radical functional rehab and weight bearing program I entered after my full rupture of the left leg Achilles (it snap and there was approx a 2-3 cm gap/indent) The swelling and immediate pain and loss of function was frightening in the first hour. I have had injurys prior including a third degree AC joint shoulder blowout with fractured clavicle — pain was nowhere close to this. It snapped as I was stepping off a curb and sounded like a wallop/gunshot. I immediately filled 5 gallon bucket with ice water and froze it and was able to get an appt next am with ortho. He said it’s a total tear. I asked if surgery was better for outcome and he said no better to go with conservative 1st. We was dead on right (for me) they casted it with a 30 deg toe down flexion for 2 weeks. Here is where Andys study/research post was exactly correct (again or me). They told me to stay off it for 2 weeks and take off work, after which Inwould be booted and start the whole PT thing. This is was happened: 2 days after cast a friend Inwork out with told me about the active rehab they do with injurys suffered by his team in the SEALS- I listened to him because these people are the cutting edge in return to work from injurys. We proceeded to modify my cast cutting off the front around the toes to allow movement and their flexion as well as cutting out a part under the pad/front of foot. This was done so that I could walk on the cast. 4mm neoprene was cut to fit to allow a 1inch size piece to be inserted between the toes/foot and edge of cast in front so that it would not rub. I began walking on this as best I could. There was pain but nothing bad. This allowed the calf muscle to fire and rush blood into that area. I mixed this with use crutches about half the time. I I did this for the next two weeks. I also did passive active calf squeezes with my fingers inserted inside of the top of the cast so I could feel the calf tensing . This allowed me to exercise the lower leg the entire time cast was on. When they cut the cast off two weeks later there was no atrophy. However the ankle and foot required swollen. I did some icing and then also within a day or two began to do very light stretching bending the knee forward. And I mean lite. My injury occurred on June 20, 2017. I did not use a boot but rather created a 4 mm neoprene ace wrap and securely wrapped my ankle and foot. I left this on day and night except when I iced it. I had someone to work with me and therefore did not engage PT. What I did to you was each day at different times during the day was to begin stretching as well as pressing the foot out to build strength. This was done using rubber exercise tubing as well as pressing against fixed objects. entire time I was walking but mostly heel walking with increasing light pressure and weight shifting to the front of the foot. I am now two months and six days from injury. I am able to walk completely without pain or hobble. I am able to stand on that foot for many minutes (I did buy and use an AirRex foam block to practice this) i’m still using it is it’s great. I am also now able to run for about 100 yards very softly. There is some light swelling. And at the end of the day there is some pain but very little. I believe that getting on this foot so quickly but you’re being careful just had a dramatic effect on recovery. I would say this: you need to be damn careful in the very beginning but you’ve done slowly and the weight bearing begins early I have seen the results.

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