May 27 2010

bigbill

February 23, 2010 - What’s the Prognosis Doc?

Posted at 12:20 pm under Uncategorized

The following Tuesday, 2 days after injuring, I met with the Doctor. By that time I had been on the internet for probably the past 48 hours straight trying to absorb every ounce of information I could on Achilles tendon rupture trying to figure out an explanation for the injury how long I would be down and out for. I did learn that the people that are typically affected by this injury are males (check), 30-60 years old (double check), that are weekend warriors (triple check.) But what I couldn’t get a handle on was how long it would be before I get back to normal. I had read so many people’s stories, that I didn’t know what to expect. So that was my main question going into the appointment.

After a painful Thompson test confirmed it was indeed ruptured, the doctor explained the two options I had for treatment (surgical vs non-surgical) and the pros and cons of each. Knowing (from my reading) the rerupture rates and the amount of strength expected to be recovered for each approach, there was no doubt in my mind which approach I was going to elect; surgery. My question to the doctor was then, “What’s the prognosis? When can I expect to be back to normal?” And to my amazement he said, “You’ll be back to basketball in 3 months.” Say what? 3 months!!!! At the time I was just so happy at the thought of having my summer back and being able to play golf this year that I never stepped back to think that, “doesn’t 3 months seem a little too optimistic?” But it didn’t matter. I got the answer I wanted to hear. That I was going to be back to normal SOON. I was anxious to get this show on the road.

After informing the doctor of my decision to go with surgery, I was told that I could be brought into surgery the very next day. So that required us (myself and my wife, who had become my care taker) to make an appointment with my primary care physician that afternoon to get a pre-operation check up. Fortunately, he was able to get me in and I was ready to go for surgery the next day.

10 responses so far

10 Responses to “February 23, 2010 - What’s the Prognosis Doc?”

  1. normofthenorthon 27 May 2010 at 7:07 pm 1

    2 comments:
    (1) The suspense is ALREADY killing me! How long are you planning to take before we get to the “punch line”? I’m guessing that if you were playing basketball 3x/wk now, at about 3 months, as your Doc promised, you wouldn’t have much time to tell your story here. But that’s just a guess. AAAARGH!!
    (2) It hurts me, almost physically, that somebody who’s obviously “smarter than the average bear”, who’s really comfortable with the English language and the Internet, and who’s AMAZINGLY motivated to find the truth, can search the Internet for the truth about the two main approaches and convince himself that a myth is true! Ouch!
    As you say, “Knowing (from my reading) the rerupture rates and the amount of strength expected to be recovered for each approach, there was no doubt in my mind which approach I was going to elect; surgery.”

    But until 2007, there never was a single careful randomized study comparing the outcomes of the two approaches scientifically while using the same (modern) rehab protocol on all the patients. And ALL FOUR studies that have done that since 2007 have found NO better rerupture rates OR strength (or Range of Motion, which is also important) from surgery than from no surgery. And of course, surgery brings nasty complications that “no surgery” avoids.

    Of course, I also keep bumping into “experts” — online and elsewhere — who keep repeating the old myths about ATR surgery long after scientists have tested them and found them false. But you sound as if you were educated to be a critical reader, to tell the difference between a scientific study and an old saw, no? Four carefully-controlled randomized studies say one thing about a testable technical claim, and four THOUSAND drunks at the bar say the opposite, now THAT’s a slam dunk, in favor of the studies!

    How did you convince yourself that post-ATR surgery gives better re-rupture rates and strength?

    BTW, I was also convinced after my first ATR, in late 2001 that surgery produced a much better outome, based on coming to the same conclusion you did. My excuse is that the TWO fancy sports-med doctors I consulted both agreed completely with that old myth, and THEIR excuse is that no studies had been done yet that proved that it WAS a myth. Fair enough in 2001, but not in 2010, after ALL FOUR of the careful studies came up with equivalent strength, ROM, and re-rupture rates from “the boot” as from “the knife”! (AAAARGH!)

    (BTW, I’ve posted before on how the myth spread and stayed alive when it was never really true. The short version is non-randomized “streaming” into the two approaches: “Jocks” got surgery and “crocks” got immobilized. The jocks ended up doing better than the crocks — stronger and more flexible with fewer re-ruptures — which just “proved” that everybody was doing the right thing and Already Knew Everything.)

  2. gerryron 27 May 2010 at 8:49 pm 2

    Maybe he ended up with one of the many complications from surgery like I did. My surgeon was optimistic too and even before the fourth surgery last week I was, at most 75% of normal. I could ride my bike and swim, but neither of those put any stress on my Achilles. I managed to ski many days this past season but some of those days were painful. I could manage to run, but only marginally faster than I can walk. Oh yeah, I ruptured on July 27, 2009. The best laid plans . . . . .

  3. bigbillon 27 May 2010 at 9:35 pm 3

    Hi Norm,

    I really wasn’t trying to make things suspenseful, I just wanted to try to recall exactly what was going on at all these critical points in the last 3 months. There was another blogger’s story that I read while I was in my early stages of recovery that was not progressing very well. He wrote about some of his set backs and frustrations with having to rely on others. And I was like, wow, I can feel what the guy is going through. So I wanted, the best way I could, to capture my feelings with this blog because, as I’m sure you know, the emotional part of this injury is just a challenging as the physical part. But anyways….

    Don’t want to kill the suspense or the story, but as you can guess, at 13 weeks I’m not at Basketball playing status yet, but I am VERY VERY VERY PLEASED with my progress, especially given the fact that I thought my summer was lost. I’ll continue to try to catch up to the present as quick as possible with the blog so you can read the details. =)

    As for surgery vs non-surgery route, I found it pretty consistent from the research I did (if you call Googleling research) that rerupture rates were smaller than the non-surgical approach. I can’t give any exact references or site any studies, but that’s what I remember seeing. When I went in to see my doctor, he pretty much confirmed what I read. As for the strength of the repair, the explanation I remember getting from the doctor about why surgery is better than immobilization, is that when the tendon heals while being immobilized it tends to heal longer resulting in less strength. At the time, the risks of surgery was a risk I was willing to take to have a better prognosis.

    I had never read anything about surgery yielding better results being a myth. Maybe I’m not that smart after all…. or at least not as diligent in my “research.” At the end of the day, I tried to inform myself as much as possible but still relied heavily on my doctors advice. I made the best decision I could given the information knew (or thought I knew.)

    Now that you bring this up, I’ll definitely read into it more.

    Bill

  4. sullypaon 27 May 2010 at 9:54 pm 4

    Hi Bill

    At 11 weeks I started playing softball and tennis. Now, at 18 weeks I’m playing softball in the outfield and 2 weeks ago hit the cycle - single, double, triple, and home run (no fences). I do not chase the really hard shots, but enjoy my sports very much. My doctor and PT both agreed that playing them, in addition to my daily now 1+ mile beach walks with my dog (started 1 week post-op with 1/4 mile), were the best ways to improve my strength and endurance.

    Lou

  5. gerryron 27 May 2010 at 10:18 pm 5

    “As for the strength of the repair, the explanation I remember getting from the doctor about why surgery is better than immobilization, is that when the tendon heals while being immobilized it tends to heal longer resulting in less strength.” If that is what your surgeon actually said, he/she ought to be dope-slapped. Surgical or non-surgical, we all get immobilized for some period of time. I was in the boot from late July until just before Thanksgiving. If I had it to do over again, there is no way I would go for surgery. The risks, although small in the general population, seem damn significant when they occur in you. I took antibiotics continuously from August 22 until early December. And it was all because my body rejected the internal sutures and created an abscess around it. Three surgeons refused to believe that was the problem because they had never seen it but there is evidence all over the net that it is actually not uncommon. My fourth surgery was done by a foot/ankle specialist who took one look at the latest MRI and said the sutures need to come out. So at about 42 weeks after the rupture I had surgery again. The only good part is that I have already done most of the re-hab and the tendon is about as healed as it will get.

  6. bigbillon 27 May 2010 at 10:47 pm 6

    Hey Gerryr,

    Damn, you guys are a tough crowd!

    Sorry to hear about your experience.

    As for the elongated tendon due to non surgical approach, see bullet #3 in the link below. Honestly, I’m not sure the exact explanation I got from doctor vs what I was reading at the time (I might have gotten the two confused.) But one thing was for sure, outside of the risks associated with surgery itself, everything pointed to surgery as the way to go.

    http://www.emedicinehealth.com/achilles_tendon_rupture/page8_em.htm

  7. normofthenorthon 28 May 2010 at 12:16 am 7

    Bill, I love details, so don’t rush your posts on my behalf!

    About “knowing” that surgery produces better results than non-op, it’s repeated way too often these days by people who should know better. And if you’re in the US, well. . .!! In the US, “everybody knows” it’s true, even though the authors of several of those recent studies have either published their results in the US or delivered them at national conferences in the US, or both. The US is so advanced in so many fields, including education and science and most parts of medicine, but it seems like a third-world “last to know” when it comes to this issue!

    Some smug Canadians blame the incentive structure facing US surgeons. But — although we Canadian patients are all totally covered by government insurance — the incentives facing US and Canadian surgeons aren’t that different. Canadian surgeons also don’t get paid for NOT operating. I may have been unusually lucky in choosing a fancy sports-med surgeon who’s so famous he has a 7-month waiting list for most procedures, so it was easy for him to stop doing ATR repairs after attending a presentation by the authors of the latest of the four studies (from UWO), and discussing the study with them.

    If you really want to see the studies and such, you can either find my blog or go the Main Page and click on “ATR Rehab Protocols, Publications, Studies” then scroll down about 3 screens (’til you see “Thanks Norm”!). Mind you, that link is one of FIVE that Dennis has provided on the subject of surg vs. non-surg, and I’m afraid the other four may all repeat the pre-2007 “state of the art”! Meaning no disrespect to D, but on this subject that’s like quoting an old Physics book that says the Atom is indivisible, or a Geology book from the 70’s that says the continents are fixed in place. Just because the smartest scientists in the field used to believe something is true. . .

    My research (and I DO call online research “research”!) is focused strongly on Surgery vs. Non-operative treatment, as you will see. And I actually try hard not to be biased — heck, I’ve had one ATR fixed each way, and I can easily believe that future surgical repairs may well “beat” any non-surgical repair, and the old myths may come true again. But for now, for conventional surgery followed by a relatively modern rehab (or, God Forbid, a slower, more old-fashioned rehab!), surgery produces the same results if you don’t count the complications,
    and worse results if you do.

  8. normofthenorthon 28 May 2010 at 1:06 am 8

    Bill, I’m afraid that emedecinehealth page you linked is pretty typical of a lot of ATR info that’s floating around the Internet (maybe esp. from the US?): Some of it’s true and factual, some is “factual” and looked true 5 or 10 years ago but turns out to be false, and some of it is irrelevant but “sounds” relevant. Here’s my quick analysis of this particular page:

    “Nonsurgical treatment involves extended casting, . . .” No, it often involves NO casting at all, or in-boot immobilization that is LESS extended than that often used after surgery!” This is at least misleading.
    “Avoids the normal complications and expenses of surgery.” Factual and True.
    “Some studies show the outcome is similar to surgery in regard to strength and function.” Factual and True, though I believe it’s ALL carefully controlled randomized studies that show that, and they also show it in regard to ROM (which may be their “function”) and the all-important re-rupture rate. NB this is the ONLY appearance of the word “study” or “studies” on this page! You might expect a source like this to talk about scientific studies a lot — but no!
    “There is risk of an over-lengthened tendon with inadequate tension.” True, of course, but Misleading as Heck, because that risk (according to the studies) is identical after surgery! (That’s why there’s no significant difference in ROM between the two groups in those studies.)
    “Extended immobilization can lead to more muscle weakness.” This seems to be true, but since “my” non-surgical protocol has LESS extended immobilization than most of the surgical patients here are getting, I’d say it’s misleading, a Red Herring.
    “Has a higher incidence of re-rupture than surgical repair.” This is a myth, a false statement of “fact”. It was believed for a long time because “crocks” have a higher incidence of re-rupture than “jocks”, and crocks got immobilized (way too long) while jocks got surgery. If you send people with odd-numbered birthdays to bad schools, and the even-numbered ones to good schools, you can “prove” that people with even-numbered birthdays get into better universities. That’s why we need to assign the patients to the treatments RANDOMLY to tease out the effect of the TREATMENT!
    “Nonsurgical treatment is often used for nonathletes. . .” This statement describes that non-random selection — standard practice in the US & Canada (etc.) until the latest studies were published and internalized by the clinical docs (or not). When we all still believed that surgery helped produce better outcomes, it still made perfect sense to withhold it from people who couldn’t tolerate it. That doesn’t prove it helps, of course!

    Other parts of the eMedicinehealth.com on ATRs (I mostly looked at the page on surgery) repeats a lot of the same misleading statements and myths about the benefits of surgery. One of the pro-surgery claims may or may not turn out eventually to be true:
    “[ATR surgery] Allows return to pre-injury activities sooner and at a higher level of functioning with less shrinkage of muscle.” That was NOT shown in the 4 studies I cite, but they kept everybody on the same rehab schedule, with or without surgery. Using that approach, they DISproved the last two claims. BUT it’s very possible that surgery — maybe especially new-fangled surgery that adds more suture strength, like the one I link and discuss, done by two Japanese surgeons — can permit faster rehab protocols (maybe as fast as doug53’s DiY approach) with acceptable rerupture rates. If so, that faster rehab may well lead to less muscle shrinkage (even though the one early Weight-Bearing study I’ve read recently, of several linked by Dennis, does NOT show that effect).

    Lots of claims seem logical and reasonable, but so did a lot of similar claims that have since been proven false. Only carefully controlled randomized studies can give us the facts. And these two pages from a source I would normally consider trustworthy are blissfully ignorant of the facts established by the best randomized studies.

    I’ve found many examples of this kind of pro-surgery propaganda on less authoritative sites — like blogs from a trainer or a PT or a small medical clinic — and from lots of old sources that just haven’t been updated since 2007. (This site, too, has a lot of documents and even studies that date from a time when we thought we knew that surgery produced more strength and ROM and fewer re-ruptures. I can certainly understand why Dennis hasn’t “purged” all the old papers and summaries on this site that no longer conform with the latest studies.)

    But it’s depressing to see this kind of misleading pap on an authoritative-looking site that’s on the Internet today. And I fear it’s not alone, either.

  9. 2ndtimeron 31 May 2010 at 11:22 am 9

    Curious to hear how you are actually doing…. I can not believe you could have been back to basketball after 3 months. As you are young (yes, 31 is young) I would say 6 months is more realistic. For the majority full recovery is 8-12 moths I think.

  10. Gerryron 31 May 2010 at 12:02 pm 10

    I would say 3 months is overly optimistic. David Beckham ruptured his left Achilles tendon March 13 or 14 and had surgery within a couple of days. Granted it hasn’t been three months but he’s a world class athlete and they still don’t know when he will be able to return.

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