biodirector’s AchillesBlog

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Aw, this was a really nice post. Finding the time and actual effort to generate a superb article… but what can I say… I
put things off a whole lot and don’t manage
to get nearly anything done.

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hi i put some weight on my foot at about fuor weeks i walk no problem by fifth week with the boot , am about a week behind you on my recovery i rupture mine on april 30th . i’ll keep checking on your progress to compare it with mine.

As I’ve said before, I think the key issue here is approachability, teachability, willingness to change. With the web and what we’re doing here, there should be an increasing stream of new ATR patients coming to the orthos with knowledge of studies and options both on the repair and the recovery side. If the doc is any good, he will hear the evidence, put aside his/her historical bias and make an honest decision as to his/her recommendation. That’s what I got and, although I would have preferred someone with the independently developed research of Norm’s ortho, at least I did not have an instransigent “know it all” ortho with whom I could not work.

That should be the least we all ask for, in my opinion.

Bio, you’re welcome to debate the evidence, and I’ve tried to engage your earlier claims about the evidence, and about the motivations of the medical establishment. But I don’t find it helpful when you imagine stories from my past, or accuse me of embellishing many facts, without making any testable or refutable statements.

BTW, I have the highest respect for lots of clinical doctors, and I tend to get along very well with my own. Most of all, I usually have no trouble “finding” credible and tremendous professionals in the medical field — despite your strong suggestions to the contrary. In fact, my own experience with my recent ATR is an excellent case in point!

When I tore my AT in December, I phoned several and saw two, all of whom acquitted themselves admirably. When I went to arguably the most prestigious sports-medicine surgeon (the Chief Surgeon of our pro football team!) in the great city of Toronto (a very fancy medical/hospital city, and I’m originally from Boston!), he told me that he himself had stopped doing ATR-repair surgery completely 4 months earlier, after hearing a presentation from the authors of the U. of

Norm, you must have had some bad experiences because what you’re describing (and of often times embellishing many “facts”) is displeasure against all the medical community.

Your points about MRSA and C-difficile COULD lead you to statistics of increased rates in countries like the UK. What a healthcare system they have…

Your articles around 1000 MIGHT be located somewhere hidden deap within your blog. I’m not seeing them on pubmed, medline or highwire (my favorite since more full articles are available).

I believe, and have witnessed, new medical practices being accepted into our health care system. I have attended the conferences of physicians reviewing new procedures, and I can report that many of them are not like those you describe.

My physician was well aware of the research, and even published many articles of his own. You might be surprised to learn that many physicians, especially those associated with research organizations, are actually credible and tremendous professionals. You just need to find them.

Bio, your doctor’s “evidence” to support his super-slow protocol is tiny compared to the evidence in the 4 most recent studies, cited on my blog — and the other studies that specifically compare early WB to delayed WB, too. Those studies produced statistically significant results, so the burden of proof is on the people who say it ain’t so, not the other way around.

Describing your doctor’s approach to the studies as if he’s read them and rejected them is fantasy, because I think you know he’s done neither.

Look, the evidence that hand-washing decreases infection rates is pretty rock-solid, but all the investigations show that doctors and nurses can’t be bothered to wash their hands between patients! That’s why so many hospital patients get preventable infections like C-diff and MRSA and others. Wherever infection rates for hospitals are published, so patients can see them, that’s enough motivation — enough ACCOUNTABILITY — to change BEHAVIOUR, which changes RESULTS. Studies alone don’t do that.

Do you really think your surgeon thinks his evidence is better than the evidence in the published studies?!? I don’t think you

You can bang your head against the wall trying to convince physicians, but the statistical evidence of your position is not quite there to make the impact you’re looking for.The sample sizes of the studies I’ve read are just too small. This is one of the major issues of health care, the cost to validate a theory. In this case, who’s going to pay for the clinical validation of the early weight bearing theory for lets say 1000 patients? The system will be stuck until this gets done. Is it necessary, you bet. What if pharmaceutical companies could release drugs with only a sample population of dozens or hundreds? There are even more variables with surgery, and this is another reason why it doesn’t get done.

Since the evidence is not considered overwhelming by the medical community, doctors will do what they believe is necessary to minimize the re-rupture rate. Although there are a handful of papers, with a small sample population of evidence (needs to be thousands not dozens), doctors will follow the protocol which they believe reduces this risk. Does a medical provider evaluate a surgeon’s re-rupture rate, or success of surg

Bio, very glad for your fast recovery.
I’m at 14 weeks and I’m not pain / swelling free for a while.

Norm, when you go for surgery you asked to sign “release” form at hospital that you understand all risks and etc.

unless surgery went out of ordinary ( malpractice case ) not much you can do after hospital has your signature - IMHO
meaning if you don’t heal fast or tendon shorter or longer - nothing you can do
if somehow surgeon left something inside that again out of ordinary than you may have bases for the case

Bio, I get off the boat when you say things like “It increases his liability to have an aggressive protocol so why recommend one. Their recommendations are based on reducing liability. . .” All of that is based on myths that have been proven false!

Do you have any evidence that what you’re saying — even its “sign” (positive vs. negative), let alone the magnitude — is true?

Early weight-bearing has found to be at worst neutral for AT healing and re-rupture, and at best beneficial, in a series of randomized scientific studies. That means it’s associated with LOWER “liability”, doesn’t it?

Then there’s the risk of falling accidents and accidental AT re-ruptures — both of which increase with extended NWB, because using crutches is OBVIOUSLY MUCH RISKIER than walking in a boot!

You may be right that many Ortho Surgeons do dumb and hurtful things to their ATR patients IN THE MISTAKEN BELIEF that their slow protocols (and the initial surgery, too) are “conservative” or “safe” or “helpful”. If you leave it there, I’m aboard!

And speaking of liability, have you ever heard of an ATR patient successfully suing a doctor afte

My doctor asked if I was in pain and I answered honestly and said no. He evaluated my reflexes, which is something I do all the time via the Thompson test, and it all checked out.

Having conversation about how I’m putting weight on my foot was not necessary, and I think if I was completely honest with him it would have undoubtedly lead to a more conservative protocol. My doctor doesn’t want or need to hear about how well I followed the protocol. He cares about the results like reduced swelling, discoloration, range of motion, strength, appearance of scar..ect.

Hiding is different than not communicating. I think it’s important to answer the questions, but the doctor didn’t ask and I think this is standard practice for him. It increases his liability to have an aggressive protocol so why recommend one. Their recommendations are based on reducing liability and then healing the patient. Doctors are there to answer patients questions and by all means ask all the questions you want.

It sounds great, though I’m not a great fan of hiding things from my Doc.

At 7 weeks, I let my boot hinge, from neutral (90 degrees) to way toe-down (plantarflexion). The only time it came close to getting me into trouble was once when I was walking fast with a bunch of friends. I got so far ahead of them(!) that I tried continuing to walk-and-talk by walking backwards. Well! Walking backwards is VERY MUCH harder on a healing AT than walking forwards!! ‘Nuff Said!

I got my temp (red) disability permit at local SJ,CA DMV in about 30 min +$6.00 just brought paper from my Doc.
May be you asked for permanent license plate with imprinted symbol?
I don’t use this permit much as I don’t go much out for a while.
And whole disabled parking for PT building are taken anyway 99% time when I come for PT session.

In Ontario (Canada), the handicapped-parking permit is issued instantly, once you present the form, signed by your health professional. My gripe with that system is that you HAVE to show up IN PERSON to get it! If you want to register your 4-axle truck, or your car, or renew any license, you can do that all online or by fax. But if you have trouble getting around town. . . (!!!)

Thanks Norm, good points about the boot, it sounds like a good investment. I hope theses aren’t my famous last words, but I’m showering without the boot and don’t feel uncomfortable. I’m being very careful, and it sure helps washing the leg. All weight is on my
heel, no toes and I’m keeping the knee scooter close by for an swift escape. I think weight on the leg is good. I’ve had minor pain but nothing intense. Swelling is minimal. No symptoms to concern me from not showering or following the 4 week protocol from Boston on this site.

My wife wanted me to ad a gripe to the blog. That California DMV has taken over 4 weeks to get the placard, and we still haven’t gotten it yet. We’re making due, but it sure will be nice to have one. VIP parking will be nice.

I’m thinking about renting the knee scooter for 1 more month. It enables me to do things without getting tired. It gives me a needed break in the evenings, and I really enjoy racing around the house. Anyone on the fence about getting one should really consider giving it
a try. For me, it may be the most effective rehab tool.

I had the hinged version of that boot (with “MC” for “Motion Control” in its name) for the end of my first ATR rehab, and I dug it out of the basement for this one, as a transition between a fixed boot (AirCast) and 2 shoes. The hinge-able boots have the ability to limit your ankle’s (scary) dorsiflexion, while permitting its (helpful) plantarflexion. At first, your weak calf and AT will just make little imitation pushes at the end of each stride, then they’ll do more and more as you recover. And the whole time, your ankle is secure against virtually all accidental injury.

With a fixed/unhinge-able boot, it’s a bit of a scary leap from the boot to a shoe. There are work-arounds — like wearing shoes at home and in other safe places, and wearing the boot when you go out or bicycle, etc. — but I think the hinge really adds some benefit to the “cure”. OTOH, having to cope with 2 shoes earlier gets all the other muscles and tendons in your ankle working sooner than if you stay in any boot. . .

Standing up to take a shower at 4 weeks sounds close to the local record, if you’re talking about barefoot, out of the boot. If you mean I

I have a CAM walker which looks like this one, ttp://www.dme-direct.com/donjoy-maxtrax-air-walker. The doctor’s office mentioned it would cost ~$250 but this one is half the price.

the PWB is working well for me. Still feeling some slight reminders that my Achilles has been sewn together, but no intense pains.

Range of motion is good. Strength is bad. Foot is slightly swollen, especially when out of the boot for a while. Can stand up to take a shower without any problems, which is very nice.

No back problems, but my left knee started to ache when crutching back from the graduation. No pain the next morning so let’s hope I don’t become a super gimp.

There’s a picture of your boot on your profile? It’s not on your “About” page. Any idea how we get to see it?

Dennis?

I am on a boot called “Equalizer Air Walker” (I have a pic on my profile).. I have Not had surgery my MRI results are still pending.. I have been in this boot 3 weeks now and I like gunner realized I needed elevation on my good leg to level it with my Boot so that I was able to walk better. It was difficult to walk on it at first and I needed crutches to help me out but after a while I got the hang of it, now I don’t use my crutches as much. So I guess it depends on how you feel.. Do you have a good shoe with a good heal level to your boot? If not if my cause you some uncomfort in your back.

What type of boot are you using? Norm referred me to the VacoCast, which we tracked down in Mass., and ordered. It allowed full weight bearing with no pain from day one, though the 3 inch elevation in the heel makes walking difficult without crutches or cane and requires replicating the elevation in the good leg with heel lifts, which I did.

I have had swelling off and on since getting into the boot, but have never had any real pain. I did not have surgery, so that may account for the lack of pain.

You might want to experiment with a cane when you need support. Good luck

A bit swollen after the first day. Ice and NWB for the  rest of the
night. Don’t know if this is normal, since the cast has been on it.
Not too worried, but will be seeking suggestions at my sisters
graduation tomorrow. What timing!

Bio, I still see “Your comment is awaiting moderation.” on my comment of 4:27 PM yesterday. I think that means nobody can see it but you and me. To fix that, one way is to go to “Dashboard” at the top of the page here. From there, you should see your total # of comments, and a breakdown of comments Approved and Pending and Spam. I think you’ll see that 1 is Pending.

If you click on that, you should be able to select it and choose from Approve, Mark as Spam, and Delete. (If somebody’s got a better way, please share!)

Thanks for the posts everyone! I’m very anxious but also content with the PWB in 4 weeks. I’m optimistic the recovery will be smooth at the 4 week mark. Although it has been debilitating, I have been able to do many things. In the spirit of notsorad’s response, here’s what I’ve able to accomplish:

- work. I’ve been able to go back into work with a week off after surgery;
- going to restaurants. No problem, but I was quick to get to and from the table;
- baking pizza
- carrying things, with a satchel;

Once I got the knee walker, I could do so much more;
- bring coffee to my wife (to wake her up to take me to work);
- cook, BBQ, make my lunch;
- clean carpets after our dogs;
- go to the mailbox and show off my new wheels to the neighbors!

I’m not trying to sell one of these things, but renting has made a big difference for me. I had only crutches for 2 weeks and getting one of these made life much easier. http://www.specialtymedicalsupply.com/files/images/ambulatory/TLC-X_PRD.jpg

Cheers, Matt

Casts and boots are pretty identical in function for the first few weeks, when the boot should be 24/7 anyway. The boot still has a few advantages, like the ease of solving pressure points and such. Only one disadvantage — that you could take it off and screw things up.

BTW, I’ve got a comment above “waiting for moderation” because it includes some links — mostly to my protocol and my blog page of annotated links to ATR-rehab studies. PLEASE approve it, Bio!!

Bio-
Great post! I do think that it is good to take Dennis’ outlook that this is an injury that requires 1 year for full recovery, but:
My two cents’ worth: my surgeon was actually more aggressive than my PT. At the surgeon’s suggestion, I was PWB after 2 weeks and got rid of the crutches a week later. I started PT at 6 weeks and my PT thought I was starting too soon. More than once, my surgeon (I am an anesthesiologist, so I tend to see my surgeon in passing more than I see him officially) told me that he wished that my PT was moving me along faster. That said, I was back to playing my sport (Ultimate Frisbee) indoors at 6 months and outdoors at 8 months. Yesterday, I wore cleats for the first time since my ATR and it felt great.
Cheers, Ron

That’s the problem, isn’t it, finding a doctor who will go along with a more aggressive protocol that doesn’t leave you locked in a cast for weeks with increasing muscle atrophy. My doctor’s protocol wasn’t particularly aggressive, but, necessity being the mother of invention, I pushed as fast as I dared on my own. I was lucky to be in a removable splint after surgery that gave me some options. Could lots of people do what I did? I suspect so, but I can’t prove it.

Good luck,

Doug

All excellent points! I would add…
- Focus on what you CAN do and not on what you can’t.
- If your injury is to the left leg start driving (automatic) when you are off pain meds.
-Exercise anyway possble. Upper body with weights or bands, Core work.
-Get outside for some fresh air…BREATH
- Remember that this is a temporary condition, we WILL get better. (even if it’s not as fast as we would like)

You’ve chosen a “theme” for this page that doesn’t show your home town (or the weeks and days since ATR & “op”). Where are you? (I’m guessing the US, if nobody made a convincing case for skipping the surgery.)

For a quick laugh, check out http://www.en.wikipedia.org/wiki/DPM ! I’m going with “Doctor of Podiatric Medicine”, though a bunch of the others produce funnier results.

Check out http://www.achillesblog.com/normofthenorth/the-non-surgical-protocol-ive-been-following/ for the UWO protocol I followed, with PWB starting at 2 weeks, and WBAT at 4.

This protocol produced excellent results with and without surgery, and there are several indications that even faster can produce good results after surgery — including Doug’s personal experience. So I don’t think there’s any advantage from going slower, and there are obvious disadvantages, some of them clinical (and lots of them personal!).

The studies I found — including a fascinating one on a new super-aggressive super-strong Japanese surgery — are all linked and discussed at http://www.achillesblog.com/normofthenorth/2010/03/08/a-more-complete-review-of-the-options-surgical-vs-non-

I’m thinking about trying out one of those Hover Rounds at Costco. There’s a chance it could be fun. Still waiting for those handicap tags, which will be huge when it comes to going out. The wife asked the doctor for that, good idea.

I contacted 2 DPMs, 1 Orthopedic surgeon, and 2 sport doctors to find the fastest rehab protocol. I went with a DPM, even though they have 4 years less residency, because he seemed to be the most aggressive. The current plan is to go to physical therapy in 4 weeks when starting with the boot. So far, no complications with swelling on last 2 post op visits. I’m ok with the additional NWB, but wish I could have found the 10 day post op PWB plan. I think it’s difficult to find a physician to take this risk.

A cast is very effective at keeping injury secure. If I were to get in a car accident, my leg we be completely unharmed.

While not part of the usual rehab program, I wouldn’t say NWB for four weeks and a badly atrophied calf are inevitable. Faster rehabs are possible, although the advisability of such a program for common use isn’t yet clear.

Doug

As you already said (twice!), shopping is the WORST!! To me, it always seemed way harder than it should have, and (at ~21 wks) it STILL does!

Check out my blog page for a fairly fast rehab protocol that was proven in scientific studies to produce good results, with and without surgery. It calls for PWB at TWO weeks, and WB “as tolerated” starting at FOUR weeks. That usually means “goodbye crutches” by five weeks.

Take a copy of the protocol (or even the study summary with the good results) to your 4-wk appointment to make sure you’re not immobilized or NWB longer than necessary, or longer than optimal!

And of course, when you’re “here”, you can keep talking about your devastating injury as much as you like!