May 24 2010
Re-casting (Pt.2!!)
Met with my surgeon today - yes, the man himself! I was attending his clinic, six weeks post op and in a NWB cast. I attended anticipating that I would have my cast removed, and replaced by another NWB cast for 2 weeks, with my foot coming up towards neutral, with a view to a third NWB cast for a further 2 weeks after that. Then into a boot. At least, that’s what I expected based on my initial post-surgery meeting with the surgeon’s team - as before (see previous posts), however, with multiple medics in the clinic the protocol changes according to who you meet. This time, I was lucky enough to get the top dog - with the following conversations taking place…
My surgeon reviewed the notes - “ah, yes, we’ll replace your cast with another. If we can get to neutral we will see you in four weeks, otherwise we will see you in two weeks for a further cast in neutral”. Ok, thinks I, this is what I expected. So, in all innocence, I ask “And then into a boot?” And that’s where it gets interesting…
“A boot?” Say’s the surgeon “Hmm, you could have a boot today, in fact you could have had a boot 2 weeks ago [4 weeks post-op]. We will put you in a boot today instead of the cast - if we can get you to neutral, we will see you in 4 weeks, if not, we’ll see you in two weeks to get you to neutral”
“That’s great” I say, wondering why he would have suggested NWB casting for another 4 weeks. “PWB?” I ask?
“FWB as and when we get you to neutral” and off I go to have my cast removed and boot fitted!
In the event I ended up with 10 degrees of plantar flexion (I think thats the right term, toes slightly down still) in a ROM boot, with instructions to continue to be NWB until I return in two weeks to be set to neutral.
So, in a sense, I am happy - better a boot than a cast, and I feel confident to add a little PWB into the mix over the next couple of weeks. I am, of course, once again struck by the differences in protocol between medics within a team, and also the somewhat ‘on the fly’ nature of the decision making. Also struck that, once again, the medic did not examine my achilles - he reviewed with me when the cast was on, and despatched me to the plaster room to have the cast removed and the boot fitted. This means that my wound / AT region have not been reviewed by the surgeon or any of his team since the day of the operation. I wonder if this is common practice.
Both of my surgeons (”op” and “non-op”) examined my ankle in detail each time I went back to them, after both of my ATRs. No idea what’s “common practice” anywhere.
It’s good you piped up some, the results should help! Your docs linkage of WB to “neutral position” is not generally observed in the studies and protocols I’ve reviewed. Some begin some WB very early, but most maintain some plantarflexion longer. Mind you, most of the studies I’ve reviewed have included a bunch of NON-op patients, and it may be more important to keep that group plantarflexed for ~6 weeks than the post-op patients.
I think many of us have been shocked at how haphazard — semi-random, even — the various “protocols” used seem to be. For patients who assume that doctors know exactly what they’re doing, and always follow the best evidence-based practices, it’s certainly an eye-opener.
I’m also perplexed that so many medical institutions — many of which are now facing budget constraints, if not downright strapped for cash — persist in wrapping ATR patients in a series of labour-intensive casts. Often they finish off with a boot ANYWAY, so the cost of the boot is added to the cost of 2 or 3 or even 4 casts! Who comes out ahead? There’s certainly a case for a soft dressing for a week or two after surgery, but after that (or from day one for the equally effective non-surgical protocols), there’s nothing a boot can’t do better than a cast — and cheaper, too, especially if a boot is a later part of the protocol. Different opinions and beliefs are fine, but this just seems silly.
(If you ever try buying some of that water-activated fiberglass tape that they use to make many casts, you’ll discover that it’s not just the LABOUR that’s expensive, either!)
Hello David
I am Annie also from Manchester but my achilles injury was 2 years ago, but like lots of others we still check in every now and again. I have also found email friends from all over the world who started this journey at the same time as me and we are still in regular contact so this site is a fantastic help.
I notice you say you are from South Manchester, so am I, are you at Stepping Hill or Wythenshawe Hospital.. I was operated on at the Alexandra in Cheadle but my surgeon is also at Stepping Hill.
Unfortunately for me my recovery is still ongoing as I had various problems en route. My blog is:
http://achillesblog.com/annieh/
If you are from the ‘red’ section of Manchester you will not like the front page of my blog…
Good luck
Annie
Cast vs Boot
Lets be practical here and not logical.
How many people have top self discipline not to take boot off especially in 1st weeks?
I think this is risk management to avoid re rupture or etc complications.
In OP case 1-2 weeks no washing and no scraping and no to minimum mobility
In no OP case you can wash, but immobility is far important IMHO.
How better to enforce it than using cast?
Every ATR patient released in minutes to go home.
It’s easy to cast someone than explain in all details what not to do after ATR and who knows how many hours it may take for such knowledge transfer. Think liability.
From logical point of view after I been through ATR recovery it’s some how is different.
Yes, I’d like to be in precise splint / half cast for 2 1st weeks instead of full cast and be able to wash my leg once a week with extreme cautions.
Then get the boot for day, but keep splint for night as sleeping in the boot wasn’t so good after cast to me.
And so on …
Mike, even in the US, ATR patients who re-rupture don’t usually sue for malpractice. (Do they?) And if they did, I doubt many would win. And we’re talking about the UK here, which is WAY less litigious than the US, so I don’t think the casting craze has anything to do with that kind of liability.
I had oral surgery recently — 4 teeth pulled, and “bone grafts” to rebuild my jaw so I can get implants later. When I went home, I took along a ~5-PAGE booklet on what I should and should NOT do (and eat, and drink, etc.) in the first day, and the first week, etc., etc. And what to expect, and when and where I should phone for help if it’s worse than I should expect. I don’t think my Periodontist is a genius, or the nicest guy in the world — but he certainly made most ATR surgeons look like dummies and ogres by comparison!
If you were fitted with a boot and told that it had to stay on 24/7 for the first week or you’d be in great danger of re-rupturing your AT, would you take it off and play around? Maybe after a couple of weeks — but by then, our protocol let us take the boot off for PT and exercises anyway. . .
Hi David, I am Annie also from Manchester but my achilles injury was 2 years ago, but like lots of others we still check in every now and again. I have also found email friends from all over the world who started this journey at the same time as me and we are still in regular contact so this site is a fantastic help.
I notice you say you are from South Manchester, so am I, are you at Stepping Hill or Wythenshawe Hospital.. I was operated on at the Alexandra in Cheadle but my surgeon is also at Stepping Hill.
Unfortunately for me my recovery is still ongoing as I had various problems en route. My blog is:
http://achillesblog.com/annieh/
If you are from the ‘red’ section of Manchester you will not like the front page of my blog…
This is the third time I have tried to post on your site David so I hope you don’t get lots all at once.
Good luck
Annie
Annie
Thanks for the comment - I am actually in Cheshire so come under neither of the ‘big city’ hospitals! And neither a red nor a blue, but a magpie by birth and long term season ticket holder at Stockport County (to laugh would be cruel!)
Reading through your blog, it seems you have had several challenges along the way. I picked out a couple of pointers which will be helpful to me (not all physios give the same value and don’t be slow in asking for a second opinion). After my initial rupture, physio was going extremely well (i supplemented the NHS physio with a second i went to privately - a piece of advice i picked up in the fracture clinic from someone who had just reached ‘two shoes’ status!). Having had my cast off two days ago after my re-rupture, i was really struck by how noticeably my muscle had wasted this time. I guess it’s an accumulation, having not been able to walk since January. My calf muscles were pretty substantial prior to my injury, after decades of competitive badminton and squash. Now, a bit sad looking!
Having read your blog, i am going to call my private physio now and see if we can get an exercise regime underway - seems no point in waiting longer than necessary.
Thanks and good luck!
daviduk
[WORDPRESS HASHCASH] The poster sent us ‘0 which is not a hashcash value.
David,
My nextdoor neighbour is a County season ticket holder but originates from…. Portsmouth… how cruel is that. I too played Badminton for years up at Woodford and really miss not being able to play again. We are in Bramhall (I refer to it as Stockport) hubby being a snob says Cheshire.
My first private physio was at the Alexandra and I went for about 3 months twice a week costing a fortune with no improvement at all. Eventually after 18 months I went to the David Roberts centre at Lancashire Cricket Club (my hubby is a member there), and they worked miracles with very painful intensive physio, I really should be working harder on the exercises myself but time is always hard to find.
Annie