Private healthcare - what a difference!
If you read the previous post about my trip to the NHS fracture clinic you’ll know that I wasted the best part of a day waiting for availability of people and equipment. Here’s the difference between free and private healthcare:
It had now been exactly a week since my ATR and I was desperately keen to figure out what I was going to do and start on the long road to recovery. The next step in this process was to see a foot and ankle specialist at a Nuffield hospital.
5 minutes past my appointment time my name was called and I made my way to the specialists office.
Prior to the appointment I had emailed the specialist with details of my working life, activity levels and that I hoped to return to pre-injury levels of fitness. With this information the specialist made his recommendation and I was booked in for surgery the following day.
My recovery was planned to be as follows:
2 weeks post surgery - Remove cast, check wound and re-cast
3 weeks post surgery - Remove cast. Position foot to half equinus position
6 weeks post surgery - Remove cast, fit Aircast boot and begin physio
Not much to be said about the surgery. I went to sleep on my front with my leg in a cast and woke up about 1.5 hours later sat up in a bed with a new cast on my leg and feeling suitably confused.
The specialist stopped by to tell me that the surgery went well and I was then wheeled back to my room where I was given a cup of tea, a sandwich and told that I wasn’t to get up for any reason.
A “block” had been put in my leg so I had zero pain and had no feeling on the underside of my toes.
After an uneventful night I was sent home with some paracetamol and ibuprofen for the pain that would be coming once the block wore off.
I was going to post this in the other thread so I’ll post it here instead…
achillesblog.com/cecilia/protocols
Many, many more recent studies have debunked the non-op higher re-rerupture rate position
I elected to have surgery the first time, but not after the partial re-tear at week 4.
Age and such plays into it but a case can be made for either approach based on science.
I think for those looking to return a more, much more, demanding level of activity (pro athletes, extreme sports people, mountain climbers, etc) surgery seems to still be the desired protocol for the level of activity.
I think that really ought to determine the protocol (caveat being age issues, anesthesia allergies, and all those outliers) not a fear of re-rupture in and of it self.
for you, surgery was/is a perfectly fine choice and congrats on moving ahead with private care, piece of mind and speed of information are important.
Thanks for taking the time to share Eric.
I’m still not really sure what’s going on as I was relying on the specialist knowing what he’s doing but 6 weeks in plaster post op is starting to sound like a very long time.
I’m back to the specialist on Tuesday so will discuss the possibility of getting into a boot a bit earlier.
At what stage did you move from a cast and into a boot?
I’ve seen protocols in which post surgery you are moved from a cast to a boot anywhere between 2 weeks and up to 12. I’ve seen some strange protocols with no boots and right into two shoes. I’ve seen walking casts instead of a boot…I don’t think you doc is way off, maybe just not up to date, or he may be up to date but is going with what has always worked for him??? You’d have to ask him to justify.
However, I’d say off the cuff that the average is 2 - 8 weeks in a cast. I was in my boot at 3 weeks, and am now at 14 weeks.
It’s your choice, but I think it’s pretty safe to move into a boot between 2 - 4 weeks. Longer than that seems unnecessary and though it won’t hurt you it will make rehab more difficult due to all the issues that can arise from prolonged immobility, not to mention your quality of life. The boot stage isn’t pretty, but compared to the cast stage it’s heaven!
Also, many of the 2 weeks cast then boot protocols call for PT to start immediately with sitting ROM moments. I didn’t start until 6 weeks. I’d like to emphasize that in the end WE ALL HEAL!
I’d advise not getting too caught up in the debates because it can drive you crazy. Use your own common sense. You are obviously smart, and able to take care of yourself and make sound decisions regarding your body…because in the end we all walk again. After the first few months we’re all in two shoes doing our PT.
Best of luck to you.
I was in a boot at 2 weeks post op. They checked the incision and it was good enough to shower with nothing covering it and I was to begin WB shortly after.
Lots of variables though, as Donna said. One week here, one week there that’s fine really.
Once you start getting into a handful of weeks and it’s not the norm or at least not backed by any recent science PLUS your particular situation then I get a little nervous about whether your doc could be making adjustments to improve your quality of life a bit (getting into a boot is one I feel).
Just ask for his reasoning is all, discuss the recent study groups with him. I’ve found that the PT has been much more helpful for me than the OS regarding ongoing management.
Unless there’s a specific individual reason, meaning your specific situation/injury, you’re getting into territory where I would question the rationale for being in a cast so long.
I got my boot yesterday and the incline to 90 degrees to get in the boot was uncomfortable but I’m glad I got my stitches out. Putting ice directly on the injury is also a plus for me because I feel like I’m really trying to reduce the swelling. I still have calf soreness but the Dr. told me that calf flexing and light WB are the cause and it will eventually get better. 12 days since surgery and progress is all I can ask for.
I was originally told 1 week splint, 2 weeks cast, 3 weeks boot then PT. This morning I had my first followup appointment (a week day out from surgery) and the doctor is now saying 4-6 weeks in a cast then 2 weeks in a boot. This is not due to anything with my recovery thus far - in fact he said it looked extremely good. It’s really frustrating to me that they told me something different before. I guess the doc who gave me the 1/2/3 protocol is a first year resident and apparently didn’t know what he was talking about. He also mentioned a boot with a wedge that would be taken out each week to change the angle. When I mentioned this to the doc today, he went so far as to say they don’t even have boots like that which they use (they use the cast to change angle), and apologized that I was given misinformation. On one hand I completely agree with Donna’s wisdom to not worry too much about trying to control things and it will all work out fine, but on the other hand it’s frustrating to me that the protocol seems to be somewhat arbitrary and based on the particular whims of the doctor. I do realize that long term I’ll likely heal the same either way, but it feels frustrating to have no control over the details. I mentioned to the doc today about how there are some protocols that call for earlier motion and weight bearing that I read about, and he sort of brushed it off and indicated that the stuff I was reading was more than likely for partial tears, or different cases, etc. It’s frustrating for me because in truth, he’s absolutely right - I am not a medical doctor, and I can spend a full week researching stuff online and still not be even remotely as knowledgeable when it comes to making these kinds of decisions as someone who has studied medicine and the foot for 8 years plus however many years of experience (this guy is actually a 3rd yr resident and was the ‘1st assist’ for the op, but I assume his protocol is based upon the experienced head surgeon who I didn’t see today). I guess at the end of the day, for me it comes down to the fact that I’m basically stuck with VA health care, for better or worse. If I had been on my wife’s insurance, I likely could have gotten a clearer idea of what the rehab protocol would be, and if I felt so inclined, gotten a second opinion elsewhere.
Does anyone know if the early protocol has anything to do with the way the tendon was repaired? In my op report it said they used a ‘krackow suture using 2-0 FiberWire’. Then they also applied a midsubstance suture using ‘3-0 Vicryl’, and an ‘Acell graft was placed around the tendon and sutured in place’. Whatever the heck that all means. ugh - this lack of control is frustrating. When I fix up my bike or buy new parts, I’m able to research and know exactly what I’m getting, and do it myself so I know what is going on. This is about a billion times more important yet I have to rely upon the judgement of people I barely met.
Skelonas, you’ve done a good job of summing up everything I was going to say in response to the comments. I also liked the bike parts analogy!
It sounds very much as though we will be following the same protocol following surgery except that once my cast finally comes off I will be getting a boot although not sure about the heel wedges.
When the cast finally comes off (hopefully at week 6) the physio has requested to attend the appointment with the surgeon to hand over my care and give me an opportunity to speak with them both at the same time.
Siege, congratulations on getting to 90 degrees so soon after surgery. I was unable to get to half equinus 3 weeks after surgery so you’re repair must be good and solid to move so far in one go. Long may it continue.
Siege perhaps you meant neutral and not 90 degrees? Neutral is zero and it’s the position we’re in when we are standing with our feet flat on the ground, as if there is a 90 degree angle between the foot and the leg. You can then raise your toes from neutral and up and that is dorsiflexion, it goes up to about 30 degrees. You can point your toes down and that is plantarflexion and goes down to about 50 degrees.
Our casts are put on such that our toes point down in plantarflexion, this puts the least tension on the tendon so it can heal. When we first come out of the cast the tendon isn’t ready to be stretched back to neutral or up into dorsiflexion too much so boots use heel wedges or if the boot is hinged the hinges change to get the right angle best for healing. Either way the stretch must come on gradually. Early stretching can cause us to heal long which makes for a weakness later as the calf muscles can’t engage normally, think of having too much tendon so that it can’t tighten up to work the calf.
This is also why most protocols don’t call for deep stretching until after the tendon is well healed. As we remove heel wedges over time once we are in the boot, or change the hinge setting we gently stretch the tendon out. There is sometimes slight pain when we remove a wedge and that is why it is done over a few weeks as tolerated. Once you have no wedges or are hinged at Neutral, zero then you are in the normal position.
When you go to PT your therapist will measure your dorsi and plantar flexion to see what your Range of Motion (ROM) is with a small “ruler” device.
When my cast came off at 3 weeks, I was allowed to do active stretching from a sitting position, very very gently and in one direction until week 6 (active means to do it with your own muscles, passive stretching is that you don’t do it, you remain passive and have assistance like someone pushing on it or using a tool to increase the stretch)Active stretching looked like waving my foot forward and backward, or plantarflexion to dorsiflexion from the neutral position. My range was about zero to 10 degrees in each direction. Had I done more stretching or passive stretching I would have been pulling on the tendon at the spot it was repaired…not good. It needs to be strong to really start stretching it.
You can google image these movements.
Skelonas you asked “Does anyone know if the early protocol has anything to do with the way the tendon was repaired?” I am willing to be wrong but I believe early protocols have nothing to do with the type of repair. No matter what type of repair or even op vs non op, early protocols came about when research indicated that the tendon needs a certain amount of tension to heal. Therefore earlier partial weight bearing and PT was found beneficial whereas in the past the protocols called for lengthy casting and a long non weight bearing (NWB) phase. Rupture rates in non-op patients went down when they incorporated earlier protocols.
Skelonas -
I was in a boot right after the operating table. I was told not to move the foot, but after my first follow-up (10 days), I was told to begin range of motion exercises. Nothing crazy, just take the boot off and move the foot back and forth.
In short, his reasoning was that there are moving parts (3) where the surgery occurred. If the foot remains stagnate the scar tissue may connect those three moving parts, thus creating a more difficult rehab process.
I feel for you. It sucks to be given expectations and suddenly those expectations are pulled away. I would try to get out of that cast at 4 weeks. I wish you the best.