New ATR (11/222/11) going non-surgical Route

First post for me, but I have read many of the posting and have received some great information. I slipped off the bottom two rungs of an extension ladder on 11/22/11. Went to the hospital the next day and was informed that I had an ATR. I was informed by the Othop MD of the two school’s of thought on treatment. He thought the non-surgical treatment would be best for me. I am 64 year old retiree and he thought the pros out weighed the cons on the non-surgical. I am now in a splint type cast. heavly wrapped. I go back in two weeks. My concern at this point after reading other posts and comments is that this splint type cast does not have my toes pointed down at a big angle. Is this an issue ? Also, should I be looking forward to a WB type boot at my next apppoinment. Any information is welcomed.

7 Responses to “New ATR (11/222/11) going non-surgical Route”

  1. Welcome to the ATR club, although sorry you qualify for membership :)

    It’s impossible to speculate whether the angle of your foot is correct although presumably it is. Having said that I would strongly suggest being an advocate for yourself with your doc and all the professionals you will be seeing in the months ahead.

    Don’t be afraid of asking “too many questions” or insisting on explanations about why you’re being treated in such and such a way. Certainly don’t be concerned about ruffling any professional feathers, after all it’s your leg not theirs and the quality of your recovery will be with you the rest of your life.

    And, be aware that there is a tendency to assume ATR patients >50 yrs don’t need an aggressive recovery since they are older and not active (I’m 57, and definitely not a couch potato).

    My experience is similar to yours, I tore my achilles tendon on a Sunday and on Tuesday was given a cursory examination by the ortho. Heard the same pros and cons to surgery schpiel and then told I’d heal the same way regardless with a slightly higher risk of re-rupture at 9 to 12 weeks taking the non-surgical route, but there would be no risk of surgery infection,

    The ortho strongly suggested the non-surgical route and at the time I took it. Was given a non-hinged boot with no heel wedge and told to resume normal FWB activities immediately. That evening I discovered achillesblog and began my ATR education. Went for a second opinion by a sports medicine doc later in the week that specialized in non-surgical treatment.

    After examining me and getting some images he said my best chance for recovery was surgery. Seems I did quite a number on myself (who knew tennis was such a dangerous sport?) and it was unlikely I’d have a satisfactory recovery without surgery, the gap between the ends of the damaged bits was 6cm.

    Had the surgery, I’m in week 8 of recovery and things are going well.

    My takeaway from the experience with the first doc is she saw me as a middle age guy who was pretty sedentary and would get more so as time went on. So why bother with the time and effort to further diagnose my injury and assess what was best for my needs.

    So … if you feel you did not get the best diagnosis and treatment for yourself, question it. Or to put it another way, feel free to be a pain in the ass.

  2. I would suggest that if the two ends of the tendon are touching then the angle is sufficient. If they do not touch then the body will naturally fill the gap and there is an increased chance of elongated healing and a significant strength loss when healed. Surgery will ensure the ends touch but there are other complications. Surgery has worked for me though I would not advocate it for everyone.

  3. Hello Consi and welcome,
    Get an MRI. If the gap between the two ends of the tendon is too large (as in my case, 6 cm), you will get better results with surgery.
    Read my story. After injury I saw four doctors and got conflicting information. The MRI helped me make the best decision for myself.
    Good luck on your recovery.

  4. An MRI is the best way to see the gap. There is still time but I would not change the treatment after 3 weeks. They are not cheap and you will probably need a referal from a doctor. There is also time to increase the angle of the foot if it is needed. It may not be needed so don’t go worrying without getting the facts. Regarding this getting old determining the type of treatment. My father’s surgeon decided non surgical AT treatment for him because he was at a higher risk of infection but he also said that he needed to have good mobility and strength. He was still very active for 81 and had plenty left in him even after the fractured neck of femur 12 months ago. We need every bit of strength as we get older. Our strength naturally will decline but to have it sucked away by poor treatment will only put us in a walking frame earlier so treatment for older people is MORE important. Doctors do not like to have their opinion questioned so you will have to be gentle but make sure you get anwers that will satisfy you, if not then think about getting another doctor. After all that, please do not think I am telling you to have surgery, just ensure your tendon ends are touching.

  5. Consi, if your ankle has been immobilized at NO angle, i.e., at 90 degrees or “neutral”, then I fear you may have a problem — and quite possibly one that will need surgery to cure, unless you can address it promptly.

    OTOH, one of the most successful studies on non-surgical treatment of complete ATRs (of varying gap sizes, with NO statistical relationship between measured gap size and non-op clinical success!) used only a relatively modest amount of ankle angle — 2cm of heel lift in a fixed (90-degree) AirCast boot, for 6 weeks. (I’m referring to the so-called “UWO” study, aka Willets et al 2010.) So excellent results can be had (on average) without surgery with only that modest amount of plantarflexion.

    Like the logical (but apparently false) relationship between AT gap size and non-op success, there’s a logical fear that insufficient plantarflexion will lead to increased healed AT length.

    For sure, “healing long” is to be feared and avoided, but the mechanism is either poorly understood or not understood at all, AFAICS. The simple fact that non-op patients (e.g. in the UWO study) show NO significant difference in healed ROM (the best indicator of healed AT length) from their post-op randomized counterparts, suggests that there’s a “near magical” mechanism that directs the non-op AT to heal at close to its pre-injury length. And the apparent fact that this mechanism overcomes the wide variation in the initial ATR gap size, suggests that it is a powerful bit of magic! (The most logical theory I’ve heard for the magic, is that the non-torn “sheath” or “paratenon” that is left intact in non-op patients, guides the reattachment of the torn ends of the tendon. But that’s just logic, and I don’t think anybody has much of a clue.)

    So I’m not sure we can even say that an ATR patient who is immobilized without ANY plantarflexion is at higher risk of “healing long”, though it certainly sounds logical. But I think you’re right to be concerned, especially if your ankle does NOT have the kind of modest amount of plantarflexion that proved so successful in the UWO study. I like to “go with the winners” wherever possible, myself, so I’d try to mimic the UWO study’s protocol — there’s a version at bit.ly/UWOProtocol — or the protocol from one of the other modern, highly successful non-op studies.

    It sounds like you’re still less than a week post-ATR, which bodes well for your prognosis, providing you’re either (a) already at an angle that works or (b) can get to one in the next few days.

    Most of the studies (including UWO) disqualified patients whose ATRs were more than 2 weeks “old”, and I suspect that most were quite a bit younger. I’ve suggested to a couple of the UWO authors that they analyze their data to see if non-op patients who began treatment sooner demonstrated superior clinical outcomes, but those folks don’t respond to e-mails from us folks, apparently. (The analysis of ATR gap size was done by a few of the same authors, “mining” their own study’s data.)

    I hope you discover that you’re already appropriately plantar-flexed. If not, I hope you can get it fixed.

    BTW, I’m one of the leaders of the “Non-Op Glee Club” around here, based primarily on my reading of the modern studies that produced the best non-op results — probably especially the UWO study and the 2007 study from New Zealand.

    As you can see from the UWO protocol, they did use a boot (from the start), and maintained 100% NWB only for the first 2 weeks, with FWB very soon after 4 weeks. Plantarflexion for 6 weeks, and boot for 8. Exercise and PT began at 2 weeks, obviously very gently at first. I chose to follow that protocol myself, at about your age, for my second ATR, and I’m now back to competitive volleyball (court and beach) and everything else that I did before the ATR.

    Good luck!

  6. Again new to this bloging. I believe that I have respond directly to your e-mail accounts on your posts. If I am in error on this please forgive me. But again thanks for everyones advice.

  7. I had my ATR on the 20th and I did RICE for 4 days and wore an ankle brace with plantarflexion till today when I received my Aircast boot and made my own 2cm heel lift. My question is can I take the boot off to shower if I am careful? I don’t have insurance so I opted for the non-op protocol. Boot kind of hurts my toes and heel right now. Hopefully I will get used to it.

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