2nd post op appointment
I finally had my second post op appointment today 7 1/2 weeks after surgery, this time with the surgeon who operated on my achilles (not the resident surgeon).
I asked if I could start weight bearing but he told me he would prefer me to stay NWB. When I enquired about wearing a boot he said he would have given me a boot but there were none at the ortho clinic (d’oh).
My foot was moved to neutral and I was re-casted. I’ll be given a boot at my next appointment in two weeks and will then begin weight bearing.
While I had the chance I rubbed some moisturiser into my incision scar and noticed how bumpy my achilles was near the heel. This must be the tendon scar tissue which felt quite significant and I’m hoping will reduce with physiotherapy.
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Wow…you must be well aquainted with your crutches by now. You’ve got a good attitude and you’re staying positive so that’s awesome.
It looks like I’ll be about 6 weeks before I can bear weight.
Have you started PT yet?
it’s about your money if you can afford full boot - cost from $100 and up.
It’s much easier in the boot, however I didn’t stay in the boot for long before transition to shoes.
But, it was huge improvement moving from cast to boot for me.
Are you almost 8 weeks post OP?
May be your doc will transition you to shoes right after cast? Ask your doc for this matter.
Not washing foot for 2 months? Not taking full bath?
This is torture.
With you fast recovery regardless.
I haven’t concentrated on THESE studies, but the Main Page here links to some studies that specifically compared early WB to long NWB after surgery. As I recall, the verdict of the evidence was completely clear — that your surgeon is following SOMETHING, but it’s NOT the best scientific evidence about what will offer you the best results! Of course, none of these folks got 100% in school, either. . . (unlike us, of course!)
If there were a tradeoff — if an extra month on crutches produced BETTER results in a randomized trial — this would be worth some serious head-scratching. But no, there’s apparently no tradeoff at all, so it’s just worth five sharp slaps starting with a backhand!!
Check out the study linked from the main page, and if it says what I think it says, please educate your Doc so he doesn’t keep doing this to the next 50 ATR victims.
Just click on “ATR Rehab Protocols, Publications, Studies” on the Main Page, and you’ll see links to a bunch of studies on the effects of early mobilization and early WB on post-op rehab. I haven’t read them all, but I bet that NONE of them FAILS to find a benefit from early mobilization and early WB. Read some, print them out, roll them up, and slap your Doctor with them!! Do it for the next folks, if not for yourself! Let’s try to stamp out bad medical practice, wherever we find it!
I just looked at one of the studies, 2003 by Maffulli et al. “Early Weightbearing and Ankle Mobilization after Open Repair of Acute Midsubstance Tears of the Achilles Tendon”
OK, they didn’t find a physical BENEFIT, just no physical DISbenefit, and some other benefits. Here’s the summary:
“Results: Patients in group 1 attended fewer outpatient visits, completely discarded their crutches at an average of 2.5 weeks, and more were satisfied with the results of surgery. At ultrasonography, the average thickness of the repaired tendon was 12.1 mm, with no difference in the thickness of the ruptured tendon regardless of postoperative management. There was no
significant difference in isometric strength between the two groups.
Conclusions: Early weightbearing with the ankle plantigrade is not detrimental to the outcome of repair after acute rupture of the Achilles tendon and shortens the time needed for rehabilitation. However, strength deficit and muscle atrophy are not prevented.”
This study took the “aggressive” group to full neutral position (with full WB) at 2 weeks post-op. Based on other studies, I don’t think that’s too early for full WB, but it may be too soon for full neutral position, for best outcoms after standard surgery. (And I’m sure it’s too soon after non-surgical immobilization.)
Anyhoo, there are several other links to several other studies examining early WB. I still bet that none of them shows any physical DISbenefits from early WB, and you could/should educate your Doc with ‘em!
Thenxtgrt1, I’m an expert on using crutches now but would much prefer to be weight bearing. In terms of PT I’ve been doing hip ROM and quad strengthening exercises that my physio gave me early on. If you haven’t started these they might be a good idea as at least they help maintain your upper leg (I can list them if you like). I can’t wait for the Achilles PT to start when I lose the cast. I wouldn’t worry too much about your rehabilitation timescale as most people on this blog seem to be following a similar rehab timescale to yours.
Mike, it was great to wash my leg for the first time in 5 ½ weeks since my last cast change. I had asked the doctor at my first post op appointment whether I could buy a boot to use instead of a cast but he told me that casts were better in his experience. I think he was worried I might get carried away and re-rupture in between wearing the boot.
When I found a couple of studies recommending the use of boots and their advantages over casts for Achilles rupture rehab I tried to call my doctor but couldn’t get through. Instead I sent him the information by fax but didn’t hear back.
My second appointment was with a different doctor, a locum surgeon who had carried out my surgery. I asked him about the boot and he agreed I should be in one by now. Unfortunately, if I order a boot now it probably won’t arrive any quicker than when the hospital get it.
Norm, both the doc’s I’ve seen are not keen on early weight bearing as they are extremely afraid of re-reupture. Most studies I’ve read (such as Maffulli) suggest that EWB is actually less likely to cause a re-rupture and one or two indicate that it may well result in a better long term outcome.
I could try sending another fax to my doctor though I doubt it will do much good! At the very least I will give him a copy of the Maffulli study at my next appointment. As you say there does not seem to be any benefit in being immobilised for so long and I sincerely hope it isn’t compromising my long term recovery. I hope I can make up any ground I might have lost on the boot wearers and EWB’s in physio.
Hi Norm,
Regarding that Maffulli study, they looked at one of the two main things I did against my doctor’s advice. They looked at putting weight on the heel, but being at least reasonably careful about the real worry, weight that would stretch the tendon too much when it is still weak.
Now, if we could just get someone to study early calf strength work, (the other main thing I did against advice), perhaps with vibratory massage added, that might lessen, as it did for me, the weakness and atrophy issues. I still haven’t heard a good reason why straining the tendon some with stretching early on is okay, but straining the tendon to the same degree with calf muscle contraction is not.
How aggressive is best? Maybe we’re getting closer to the answer.
Doug
Dear Donald
I went PWB on the 2nd day post-op by strapping my old Bledsoe Boot over my fiberglas cast. By keeping my weight on the heel, the AT was not tensioned. I saw my surgeon 6 days after while walking my dog on the beach, and he just told me to be careful. At 7 weeks I went from cast to 2 shoes, and last week, at 18 weeks received surgeon’s and PT’s OK to return to all sports. Majority of my rehab: 1+ mile daily walks on the beach with my dog.
Doug, I’m not sure I know what you mean by “straining the tendon some with stretching early on is okay”. The only stretching I was allowed to do was “active plantar and dorsi flexion to neutral” from 2 wks to 6 wks. Only after 6 wks could I gently stretch my AT (dorsiflex my ankle) past neutral.
Meanwhile, I was also actively PLANTAR flexing starting at 2 weeks, which I think included some calf flexion, even without resistance. And I was WB in the boot, gradually between 2 wks and about 5 wks. Even in a fixed boot, I believe that walking around WB (esp. FWB) encourages the calf to “fire” at the end of the stride, even if it’s got nowhere to go except for the boot’s flexibility and “play”.
And don’t forget, it’s still quite possible that your amazingly quick rehab and your aggressive approach are partly or even mostly a coincidence! Without trying to replicate it with a goodly number of other ATR patients, preferably randomized into the Doug53 protocol or a more conventional one, it’s still just one anecdote that “seems logical”. We’re all putting 2 and 2 together, and we don’t know if we’re getting 4 or 6 until we apply some science to it. (The myth of higher rerupture rates, lower strength, and lower ROM from non-surgical rehab also “seemed logical” and persisted for many decades until it was put to the test and found to be wrong.)
Donald, I’m hoping that Maffuli et al is the LEAST convincing of the studies on the subject of early WB that Dennis linked on his “protocols and studies” page, though I haven’t read the others — at least not recently.
Maybe I’m just an unusually scientifically literate person (I am, it’s true, a graduate of MIT = Mass. Inst. of Technology, a top science university), but to me it should be obvious to ANYBODY that if there’s a disagreement between a clinical physician and the best scientific studies, it’s basically because the clinical physician is wrong — either too busy treating patients to keep up with the scientific literature, or not scientifically or statistically literate enough to understand the results of those studies. Even the best guy in town at slicing and stitching human tissue can’t reverse a scientific fact, regardless of how many times he repeats the disproven theory! (Even if he posts it on the Internet!
)
Norm,
I guess my main point is to get strength work going before the atrophy gets severe, and two weeks is a pretty long time. Many in this blog community have commented on how bad their atrophy was after just two weeks. After nonoperative repair, that may not be an option, though. But maybe that vibratory massage could help?
As an aside, there are reasons why randomized controlled trials can lead to wrong answers. They are not foolproof, but they are often the best we have.
We each have our “causes,” yours to get away from surgical repairs for most, mine to get the rehab going sooner after surgery. Your cause certainly has more evidence behind it.
Doug
Doug, there’s statistically rock-solid evidence that at least RELATIVELY fast rehab — going at MUCH greater speed than anything donaldinhio’s doc will let him do — works very well, though not without some muscle atrophy and some long-lingering strength deficit. There’s certainly NO evidence that going at donaldinhio’s speed improves anything, despite his doctor’s “expert judgment” to the contrary.
I haven’t finished going through the studies that D linked on the main page here that test early WB and other “accelerations” for the post-op patients, and it’s possible that some of them establish that even faster rehab can do better. Certainly that new (2010) Japanese study that skipped the cast/boot entirely and produced very quick 1-leg calf raises and return to high-risk sports, provides some powerful evidence that much faster speeds are possible (at least with surgery) and beneficial.
Your own evidence, and the logic behind it, are both impressive and suggestive of where the future of ATR rehab may be heading.
About “causes” — I actually don’t know whether I’m more frustrated by all the experts who still “know” that surgery produces better results than the non-op protocols, or by the clinical physicians who think they’re adding value to their patients by keeping them immobilized and NWB for periods so much longer than those that have been found to work so well (and which may in turn be too long)!
Certainly in our little group of bloggers and posters here, there seem to be AT LEAST as many patients who have been suffering on crutches and in casts for unconscionably long periods, as there are patients who got sliced and stitched based on old unsupported myths. Both groups make me frustrated at the state of the world’s medicine in 2010. And the large intersection of the two groups — patients who were talked into surgery by the repetition of myths and THEN are being immobilized and kept NWB for longer periods than I was WITHOUT surgery — that big group frustrates me the most!
So we both share the “cause” of eliminating the protocols that are so slow they can be proven useless (if not harmful) by good recent studies. Your additional “cause” — to go significantly farther/faster and get strength work going before the atrophy gets severe — is one that may or may not turn out to be sustainable (with acceptable re-rupture or long-healing rates) with today’s standard surgery and a large population, some of which may lack your good judgment or (who knows?) your blessed physiology.
It may well be sustainable with the stronger sutures used in that Japanese study. As I’ve said, if I were David Beckham (or were advising him), he’d have flown to Japan for that new surgery and its ultra-fast protocol!
Sullypa
I did think about weight bearing early on but my consultants mantra ‘stay NWB and don’t re-rupture’ kept me compliant. Did you know about the possible benefits of early weight bearing at the time? Yesterday, out of sheer frustration, I fixed a temporary sole to my cast, did a little PWB to see what it was like and my leg felt good, no pain at all.
(Edit note: I would like to add I am doing only very minimal PWB at the moment until I can clear this with my doctor as I am concerned that with my foot at neutral I may over stress my tendon if I do anymore. If you are unhappy with your treatment please discuss it with your doctor. As Norm and Mike have commented below you have to be persistent.)
Norm
I agree that the latest clinical studies show good results for aggressive rehabilitation. I got a letter yesterday advising that the next appointment is on 17 June meaning 10 ½ weeks of casted NWB which I am not too happy about. I’m trying to arrange for my cast to be taken off and get my leg in a boot & weight bearing and maybe update my doc’s achilles rupture rehab.
I was feeling real good going without my boot until I decided to use my Crocs while I was at work. By the end of the day, my ankle was swollen more than I had ever experienced it this far. …bur there was no pain. Fortunately, by the next morning, the swelling had resolved so I decided to use my cross trainers with my orthotics inserts. I wore these all day- from 7 am to about 11pm and I was impressed that there was only a minimal amount of swelling. My orthotics have about a centimeter heel raise, on booth feet and this feels more comfortable.
Dear Donald
I went PWB and 1 crutch early because it was safer - PWB eliminated the slips and near-falls of NWB. My 10 yr old Beldsoe boot has a great non-slip sole.
Regarding risk of re-rupture. Put your “good” foot into equine and press its heel against your ATR’d knee. Feel how loose that “good” AT is, indicating lack of tension. That’s the same as NWB for the AT and calf muscles, whether NWB, PWB, or even FWB!!!!! That’s the physics of the foot.
Let pain anywhere be your guide. Your body will tell you when you have done too much. I was in an equine cast for 6 weeks, but went FWB in 4 using the cast in boot combination. At final PT and surgeon visit received release to all sports at 18 weeks.
Lou
Good luck, Donald! The good news is that the rehab paths tend to converge eventually, no matter what. And a number of people here (including Lou/Sullypa) have managed to “catch up” after a slow start, with aggressive PT and exercise later.
Ifixteeth, I’m surprised how much your leg disliked the Crocs! I’m still padding around in mine most of the time I’m home — mind you, my leg still likes to be elevated when it’s convenient, even after 5.5 MONTHS, so maybe the Crocs aren’t helping in that aspect. . .
Like lots of older guys (65), I’ve got overlapping “issues”, so it’s not always easy to tease out cause and effect. E.g., I had varicose veins long before I tore this AT, and I’ve never enjoyed standing for long periods, even as a kid. . .
Norm: I’ve had the same questions recently, just “rediscovering” some prior maladies, like cartilege/arthritis in the top of my feet and varicose veins in my “good” leg.
Speaking of the veins, when I’m wearing shorts and see people who ask about the ATR, they immediately assume its the other leg since the VV’s look so ugly!
Have you gone through a rigorous examination of whether or not to have the veins treated? I have not and just decided to let it go so long as the only real problem I’ve got is cosmetic - no pain to speak of.
Just like you on the V Veins, Gunner, I’ve been ignoring them. My GP-doc didn’t seem to exercised about them, or the little “venal lake” that I’ve got on one thigh. . .
Donald,
It will be very interesting to me your progress after you get to shoes. Pls. keep posting about your progress.
I’m more or less back to “normal” life at about 10 - 12 weeks, just no any sport activity, while I do road bicycling as it’s safe to AT.
Did you try to point your doctor to all those studies that at Norman page?
I think while been on crutches it was most dangerous time for me - in cast or in NWB boot, so easy to misplace / misstep crutch while been one footed.
Norm, my challenge with the the Crocs could be due to pronation. I overpronate and have had the orthotic for the last 5 years. I was weaning myself off the orthotic as the physiotherapist gave me excercises to do that would help. It seemed to be workink, or do I thought, until this injury. There seems to be some relationship between pronation and Achilles injuries.
When I ruptured my AT, I was playing tennis using my dress Rockports without my orthotics…… a stupid decision in retrospect, and I hadn’t played tennis in over 10 years.!
Sorry for the typos as I do most of my postings from my iPod. This little gizmo kept me sane especially during the first 6 weeks in bed.
Thanks Norm, I hope you’re right and we all get there in the end.
Mike,I was a bit pathetic in my attempts to discuss the clinical studies with my consultant. I had several studies with me in a folder but my appointment was so brief. I asked about EWB and should have piped up about the studies after my consultant said he would prefer I stayed NWB. He left the room in a bit of a hurry, I thought he was coming back but he didn’t, he was rushing for the plane home!
I think my best chance of changing things will be by speaking to my GP.
IFixTeeth, I can see how Crocs and serious pronation would be a bad combo. I’ve got one arch (on my “good” foot!) that collapses too easily, especially when I ski, but I don’t think I pronate in general.
Donald, it’s not enough to print out the studies and take them with you in a folder. You’ve got to ROLL them UP and smack your Doctor “upside the head” with them!!
You still have the option of being a “bad patient”, like Doug53 (and a few others here) did. You’re way too late to catch up with Doug, but the principle still applies. Buy yourself a boot (preferably hinged), take charge. . . (This is not medical advice, nor does it come from a licensed medical practitioner! In fact, I’m not sure it’s even advice, exactly. But you do have options.)
Donald,
I don’t want to sound harsh, but we are just another wining patient to our doctor, unless we politely demand more.
Here in US it’s more if you don’t ask than doctor will not tell much or above absolute minimum.
I think I was “bad” patient, who called and emailed to my Orthopedic and PCP (GP) multiple times a day almost all 1st week, while I was tried to figure out to do surgery and not with all kind of questions.
I sent several protocols and spent time on phone with Orthopedic Doc discussing pros / cons and diff protocols.
I think I was big pain in A..
This is your leg and you have to be in charge even it might not look most polite.
No I didn’t scream or said any harsh words, just been persistent.
However, you will be just fine - just little bit later than sooner - that’s it.
Don’t downplay yourself as everyone is unique individual.