New Doctor, New Protocol, New Mindset

After I re-ruptured my my Achilles I ended up waiting in the ER for SIX hours before I was told I had an appointment at the fracture clinic the next day and the ER doctor didn’t even take a look at me! I mean come on. I know the hospital I went to deals with a lot of traumas so granted I would be pushed down to the bottom of the list but I mean if its just for me to get an appointment I shouldn’t have to wait SIX hours. Anyways I was back to the unfortunately familiar fracture clinic at my hospital. This time I got a different doctor since I was there on a different day, so different shift I assume.

The new doctor was very personable, unlike my first doctor who barely talked, and he had them do an ultrasound scan of my Achilles.  It was a complete rupture with two cm of separation. My new doctor gave me the choice do a non-op approach very similar to the one discussed in the UWO protocol or to do surgery. I picked the non-op approach as my logic was if I don’t need to cut myself open why bother.  So the doctor had me remain in my walking boot except added in these four pads for heel lifts to close the gap in my Achilles. I going to have this for five weeks, go back to the hospital and they will take out two of the pads. I assume it will be a few more weeks before I get the final two out.

By this point I had done a little more in depth research and knew about the different protocols and asked my doctor about them while I was at the fracture clinic. He told me since he was a UWO grad he would have never casted me but he would have put in a walking boot with heel lifts instead. I also asked him if my re-rupture was because I was overeager in my healing process and he said it was possible but that it was more the case of doing calf/heel raises too soon considering I had the uber “conservative” protocol. He also said he would just have me work on ROM for the first month of rehab.

After going home I began second guessing my decision to go non-op. I knew from my research that non-op can do just as well as surgery but that was for initial ATRs not re-ruptures. I became very concerned and that is when I began posting on this site seeking help.  Unfortunately the responses at the time just made me worry even more so I decided I was going to contact my doctor again. The fracture clinic was closed so I could not call, instead I googled my new doctor’s name in hopes I would find his e-mail. I found it since  my hospital apparently has a very comprehensive website for the fracture clinic as it has all the staff and their contact info/mini bio. I felt on a roll so I did some more digging about my new doctor and the first one I had. Turns out the first doctor I saw who gave me the “conservative” approach specialized in SPINAL injuries whereas my new doctor specializes in hip & knee reconstruction and LOWER EXTREMITY TRAUMAS. After reading that I was a little pissed off that I got a doctor who did not specialize in my kind of injury but at the same time I was a little more confident in the new protocol and doctor.

I was still on the fence about whether or not to do surgery so I sent my new doctor an e-mail asking what does he normally do with initial ATR patients and re-ruptures. He was extremely good about responding as I got an e-mail back later that same day. He said that he normally treats his initial ATR patients with the non-op method but that in the case of my re-rupture the choice between non-op and op was 50/50. He did however go on to say that he believes the non-op method should work well for my re-rupture since the gap was relatively small and that I still had movement with my foot. My mind was put to ease after reading that. My mom also had me talk to my cousin who is in his residency in the States to become an orthopedic surgeon and he also said that if he was in my situation he would go with the non-op method as well.

Reading the stories and comments of others on this site has taught me that I can’t always take an “experts” word and that I should always do research and ask questions whenever I am unsure. That said I had only one more concern which was addressed very quickly by my new doctor once again through an e-mail. He mentioned that I could do FWB with the walking boot and I told him I did not feel comfortable with that. In his e-mail he said that its was OK if I did FWB but I was free to whatever felt comfortable. I decided to go NWB for the first two weeks, though I do put my left foot on the ground for better balance when standing still with crutches but ALL the weight is still on my right leg. Eventually I’ll move to PWB for the next two and FWB after that.

8 Responses to “New Doctor, New Protocol, New Mindset”

  1. Nice work, Brock. Your approach sounds very sensible to me, and should give you the best possible chance of a good recovery.

    Unfortunately, even surgeons who specialize in legs don’t spend much time and effort on ATRs. And the more the evidence from good studies shows that surgery doesn’t add any value, the less time they’ll spend on it!

    My Dad used to say “Go to a carpenter, he’ll tell you to make it out of wood.” Kind of like Mark Twain’s(?) “If your only tool is a hammer, all your problems look like nails.” Surgeons repair things surgically. If they didn’t want to do that all along, they wouldn’t have become surgeons in the first place! Then they trained in surgery, surrounded themselves with other surgeons, and kept seeing the near-magical results from their surgery. It’s not reasonable to expect them to be neutral on this subject!

    So it’s remarkable and kind of heart-warming that you’ve had a few suggesting non-op treatment of your ATR — even just a few miles up the road from UWO! Now if we can just get more adherence (from the OS’s AND the PTs!) to rehab protocols that actually seem to work well. . .

  2. hey brock

    good luck with it all, hope your decision for non-op is the right one, i’m counting on it too!

    happy healing…

  3. I admire your courage to stick with the non-surgical treatment again. I guess I never had confidence in it so the 2nd time around I wanted surgery. I am amazed your doctor gives you all these options. Mine insisted on keeping me in the boot after the re-rupture for 11 weeks even though I told him I am feeling great!

  4. Thanks for all the support guys and best of luck to you as well gqsmoove7.

    I understand where you are coming from 2ndtimer as I was strongly considering opting for surgery. I guess having a family member who is becoming an OS describe the surgery process and suggest I stick with the non-op gave me that confidence.

  5. so, you cling to the thought that non-op management is best for ATR??? in a blog of 5 people, 2 are talking RERUPTURE. in this day and age, why would any active person attempt non-op management??? the tendon ends do not get back together without putting them back together. historic re-rupture rates approach 20%! that is why you have it fixed. you shouldn’t be congratulated on opting for non-correction a second time… you should be mocked. glad your non-doctor family member recommends this choice. my herbalist gives me financial advice.

  6. Wowreally, there’s a huge difference between the old “conservative casting” that produced rerupture rates in the 15% range (especially with non-randomized patient selection, when “jocks” got surgery and “crocks” got casted for way too long), and the new-fangled non-op protocols with early mobility, weight-bearing, and PT.

    The latter non-op protocols have now (since 2007) been tested in four randomized prospective trials, each using the same protocol on both surgical and non-op patients (all complete AT ruptures). In all four studies, only ONE measurement of strength, ROM, or re-rupture rate showed a statistically significant difference between surgery and non-op, and it was in favor of the non-op. Of course, the rate of complications WAS statistically different, as we all knew all along.

    Check them out, either on my studies page, or follow the links at references #4-7 on the Wikipedia article on ATR.

    Me, I’m “clinging” to the latest and best evidence on the subject; what are you clinging to?

    BTW, ROM is closely related to healed tendon length. So the fact that measured ROM with the non-op protocols is indistinguishable from measured ROM with surgery seems to give the lie to your assertion about the tendon ends not getting back together without surgery. If that were true, healed AT length would always be too long, and ROM would suck. It doesn’t. Deal with it!

    Many people here have suffered through archaic “conservative casting”, and some have experienced re-ruptures. Others have suffered through needless surgery, including many bloggers here who have had multiple complications like infections, wounds that wouldn’t heal, and multiple repeat surgeries. We even have one (past) blogger (Mazmouza) here who had the new-fangled non-op protocol and healed improperly (too long).

    Stuff happens, and all anecdotes about bad outcomes are powerful and emotional, but only randomized trials can produce credible evidence. Check them out and see what you think, and what you want to cling to.

    BTW, I had my first ATR “fixed” surgically 8 years ago, because I heard what you’ve heard. Last December, I tore the other one (doing the same “move” in the same sport!), and I’m eternally grateful that I went to an Ortho Surgeon who had heard a presentation (at AAOS 2009) from the authors of the latest and biggest randomized trial. He had stopped doing ATR surgery 4 months earlier. He told me he didn’t become a surgeon to do surgery that had no benefit. God Bless Him! Too bad most ortho and sports-med surgeons apparently aren’t much like him. . .

    Getting financial advice from a herbalist may or may not be crazier than getting scientific advice from the average surgeon. But the latter is pretty crazy, even if most ATR patients are forced to do it — and while crippled, in pain, scared, and under enormous time pressure!

  7. Norm,
    I’m surprised you didn’t recognize wowreally for what it is, just an internet troll with nothing better to do than troll around trying to insult people.

  8. You might be right, GR, but the statements made were commonly held beliefs, most of which were believed by virtually all the experts just a few years ago — e.g., when I tore my first ATR. So I didn’t mind summarizing the case for the evidence one more time, whether it’s for wowreally or for anybody else who has heard those same opinions expressed with similar conviction.

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