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Hi all
Awhile back I said I’d emailed Bruce Twaddle who was one of the authors of the NZ study that Norm has referenced which looked at operative and non-operative recovery and showed similar results for the two. Anyway, he responded with his protocol which he was happy for me to post here (”Knowledge is Power”). The same protocol was applied to both operative and non-operative. I don’t have the full results but you can see the summary on Norm’s blog I think.
In addition to the protocol I asked him about heel raises in particular (as I went to heel raises for the 8-12 week stage) and he commented that while he isn’t a big user of heel raises, he recognises that some people feel more comfortable with them for awhile (i.e didn’t seem to think there was a problem with that). I don’t want to get into a conversation about surgical /non surgical here, but he also commented that he doesn’t see any place for surgery in the primary treatment of ATR even in elite athletes - he will operate if people want it, but would apply the same rehab.
So here it is:
1. For the first 2 weeks after injury the patient should be immobilised in a hanging equinus pop (not forced equinus) and be mobilising non-weight bearing.
2. After 2 weeks up until 4 weeks from injury the patient can be placed in a removal orthosis set at 20deg of equinus. The patient is allowed to remove their foot from the boot for 5 minutes of every hour and move their ankle with dorsiflexion and plantar flexion, being careful not to come beyond a right angle, as the greatest risk is having a tendon that heals long. This should be repeated 5 minutes of every hour where possible.
3. At 4 weeks from Injury the moon boot is brought to 10deg of equinus and the range of motion exercises continue, being careful again not to bring the ankle beyound a right angle position. The patient can be touch weight bearing through the toe of the boot , up to 20kgs of pressure, from 4-6 weeks.
4. At 6 weeks from injury the patient can bring the orthosis to O deg and begin weight bearing as tolerated, weaning himself/herself off the crutches by 8 weeks from injury. They need to continue on with the range of motion exercises of their ankle and can remove the orthosis at night.
5. At 8 weeks from injury they can come out of the boot and start toe raising exercises, increasing the weight bearing on the affected leg. When they can single leg toe raise and support their own weight they can start a stretching and strenthening programme and increase their activity level according to their symptoms. This should allow them a quick and full a functional recovery as possible.
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Twaddle’s was the first of the four recent studies I cite so often, published in 2007. And it’s from NZ, like Bronny. It’s ref 4 in the Wiki article on ATR, and I discuss it — but just from the abstract — in my big “Studies” discussion, at bit.ly/achillesstudies.
The protocol is quite interesting, and of interest to all ATR patients, since it seemed to work well with or without you-know-what!
It’s pretty similar to the one I always steer people to, though the few differences “jump off the page” when I read it. WB a little later here, exercises a little sooner.
It seems to have influenced the care Bronny is getting, though hers isn’t identical to it. Seems most Docs like to put their own (intuitive?) “stamps” on our rehabs. . .
Comment by normofthenorth 10.28.10 @ 8:08 amIronically Norm, I’ve heard (through a couple of people I know) that ATRs in Auckland (where Twaddle is) are being treated by 8 weeks in plaster. Strange.
Comment by bronny 12.13.10 @ 2:54 am