durwood’s AchillesBlog

Confirmation of re-rupture

Posted on June 1st, 2012 by durwood

I saw the orthopedics today (a different PA as my usual one was not there) and they confirmed that I did fully re-rupture my Achilles on Wednesday. So I guess it’s back to square 1 with the non-op rehab protocol although I’m not 100% convinced that will work. My other PA basically said we should give the non-op method a go and if it didn’t work we could always have it surgically repaired later.

Well, now that we’re at that point the PA today said that surgery at this point would be extremely complicated because of the amount of elapsed time from injury (Feb 21st) and that it could require a graft or extensive cleaning up of the scar tissue.

So I’m a bit lost right now. If all that is true about things that would complicate surgery, then it seems to me that all of those same factors would also complicate another attempt at non-op rehab. Plus, I know that’s already failed once…what was it that Einstein said was the definition of insanity? Trying the same thing over & over and expecting different results, right?

Right now I’m back in the boot (not a splint) with a heel lift and NWB (hellllllloooooo crutches!) for a few weeks and they also put in a referral for me to see a foot/ankle specialist surgeon to discuss surgical options.

I just want the damn thing to heal so I can resume an active lifestyle. I have little confidence (right now, anyway) that another chance at the non-op route will work…and the PA today made it seem like surgery would be a difficult choice too. Neither path sounds very appealing right now.

I know Norm has said maybe the fresh tear will provide a conducive environment for it to heal properly. I hope that’s the case. Maybe that makes it different than the original injury since 3+ weeks passed before I started the protocol. But what happens with all that scar tissue? The entire lower part of my leg is hard as a rock. How in the world will this thing heal with all that scarring?

Durwood

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19 Responses to “Confirmation of re-rupture”

ryanb, on June 1st, 2012 at 4:21 pm Said:

You’re initial protocol didn’t start until 3+ weeks. I think the reason that’s risky, is because you start to develop scar tissue that inhibits the non-op healing process. Now it’s been 3+ months.

> it seems to me that all of those same factors would also complicate another attempt at non-op rehab

Yep. I would, of course, listen carefully and diligently to what the doctors say…. but if it were me, I think I’d be leaning pretty strongly towards the surgical route at this point.

If nothing else, 6 or 7 months from now, I wouldn’t want to have lingering questions about the integrity and strength of the repair- I’d want the confidence needed to pursue an aggressive rehab program. After 2 back to back stints of NWB/PWB, you’re probably going to have significant atrophy and strength deficit to rebuild.
marklewis67, on June 1st, 2012 at 6:01 pm Said:

Sorry to hear about the re-rupture … That’s one of the things I’m most scared about …. Couldnt imagine going through all this again … Stay strong .. Good Luck ~ Mark
durwood, on June 1st, 2012 at 6:56 pm Said:

Thanks Ryan and Mark for your comments. Ryan, I am anxiously waiting for that referral to figure out exactly what I’m going to do. I saw a reply from Kirk on my previous post and he reruptured after 3 weeks of two shoes and he said the surgery was a blessing because it let the docs clean out the scar tissue from the injury as well as his tendonitis. I’m just a bit anxious now about surgery because of why my PA said about that being really complicated at this stage and likely requiring donor tendon. But then again, she isn’t a surgeon and maybe it won’t be all that complicated? I just don’t know. That’s the problem–they are trying to put this decision in my hands and I don’t feel as though I have the training (duh!) or enough information to make an informed decision! Thank goodness for this forum because it’s the best resource I have.
Durwood
Xpf72q, on June 1st, 2012 at 8:59 pm Said:

Durwood google around and check out material on an fhl tendon transfer. It’s not so much a graft as its is a successful way to transfer the big toe tendon and really strengthen that thing up along with sewing up the Achilles tendon ends. Aggressively question your surgeon referral about this option.
durwood, on June 2nd, 2012 at 9:17 am Said:

Xpf72q, interesting info. I did some reading this morning on the fhl transfer. I will definitely ask about it when I meet with the specialist.

While browsing some papers online, ~~I saw one that referenced a Scottish study from 1999 that looked at 4,201 ATR cases over a 15-year period (1980-95~~). I found one that referenced a 1989 study of 292 cases that said 71% of reruptures were in people with Type O blood (see footnote 20). I am O+. There was no causal mechanism suggested in the paper–just an observation. But it would be interesting to know if the O blood type and vascular theories (reduced blood flow as we get older) are somehow related.

Link to the paper: http://info.theclinics.com/mdconsult/pdf/Clinics_in_Podiatric_Med_and_Surgery_sample_article.pdf

Not that it would have helped or changed the way I lived my life!

Durwood
Xpf72q, on June 2nd, 2012 at 11:27 am Said:

Yep do ask him Durwood my surgeon has done several and had excellent results it’s a tough tendon the fhl and studies show it really strengthens and augments the damaged Achilles tendon. Fascinating on the blood type never heard that one! Keep at it and keep us posted you will be back before u know it!
hillie, on June 2nd, 2012 at 11:27 am Said:

Hi Durwood

I did my ATR same time as you but didn’t receive the correct treatment until a week later - originally diagnosed as a calf tear because of its position. How did your re-rupture happen? I’m especially interested because of the timing of original ATR being similar to mine.

Good luck this time round.
starshep, on June 2nd, 2012 at 2:36 pm Said:

Durwood,
Interesting find on blood type and re-rupture rates. Do you have a link to that study or can you remember what it said about other blood types?
durwood, on June 2nd, 2012 at 2:45 pm Said:

Hillie,

My rerupture happened when I was just walking along on flat ground. I was entering the building to attend my 2nd physical therapy session.

Sounds like we had similar injuries. Although my rupture was just above the heel and not near the calf, my calf was incredibly swollen and that’s what had the attention of my primary care doc. He was worried about a calf muscle tear and blood clots and never thought to check my Achilles.

No doubt in my mind that lost time cost me and contributed to the failed rehab. Oh well. Can’t look back now. It was worth a shot. Now I just have to figure out what to do from here.

Good luck!

Durwood

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durwood, on June 2nd, 2012 at 2:52 pm Said:

Starshep,

Link to the paper I found is below. It’s a year old and has a lot of good info about different tendon repair procedures. The study referencing the O Blood Type is not the Scottish study I referred to in my post–it’s a different study of 292 cases that was published in 1989 (see footnote 20).

I just looked at your blog and was curious about your rehab. You have had a TON of PT sessions!!! When did you start those? It’s interesting that I only had my first one while I was still WBAT in the boot and my 2nd one was scheduled 3 weeks later (which was 2 weeks after I’d been in two shoes). Note that I had been going up & down stairs and had no restrictions other than to “take it easy and don’t do anything stupid”.

Makes me wonder if I needed to be more cautious and if I had been would I be in this mess now??????

Good luck with your rehab!

Durwood

http://info.theclinics.com/mdconsult/pdf/Clinics_in_Podiatric_Med_and_Surgery_sample_article.pdf
normofthenorth, on June 2nd, 2012 at 3:49 pm Said:

Interesting research! Tough decision, too, D. Definitely talk to a surgeon or two. Go where you’re most comfortable (or least un-).
starshep, on June 2nd, 2012 at 6:00 pm Said:

Durwood,

My rehab sessions started at week 7 after my ATR. I see that you were in 2 shoes 8 weeks after your diagnosis. While everyone recovers at different rates, it would be hard for me to imagine walking in 2 shoes that early. It would also be hard for me to imagine walking in 2 shoes without all the balance and strengthening exercises I went through before going into 2 shoes. Some people have recovered without formal physical therapy but knowing what I know now, I wouldn’t have accepted anything less than what I have gotten in terms of PT so far. Despite that, there are no guarantees for me either, even at the point I am now at.

I also see that it took almost 3 weeks before you were treated for your ATR,. That could also be a big factor in terms of your re-rupture.
suthrnman, on June 2nd, 2012 at 11:47 pm Said:

Hey Durwood,
I am really sorry for you . . . I was in a similar place and went non-op again.
My Achilles partially ruptured at 13 weeks and I kept pushing through pain until it fully ruptured at 19 weeks. I believe the partial rupture complicated the healing process; it was half tore at 13 wks and then the other half at 19 wks. Anyway, I am 11 months down the road and I am doing pretty well. I am cycling hard, slow jogging and walk uninhibited. I believe the key is to get it set in a boot or splint in plantar flex ASAP after rupture. If I understand you correctly, then you have done this. Tough decision to face, but I couldn’t bear the surgery option.
In response to Einstein’s quote; you might consider how many people have had really bad experiences w/ the surgery option too. So, your re-rupture is unfortunately something that just happens occasionally regardless of technique.
I sincerely hope the best for you regardless of which option you go with. pk
Durwood, on June 3rd, 2012 at 11:59 am Said:

Pk,

Thanks for sharing your insight. How soon after your original injury did you get it diagnosed and begin the non-op protocol? That’s my big dilemma right vis-a-vis surgery or not. I went 3+ weeks before diagnosis so I’m wondering if the delay will always preclude non-op from doing the trick.

Because it had been healing very well I’m unfotrunately in 2nd guessing mode right now wondering if I did overdo it by rushing into two shoes and not weaning off the boot more gradually. It just seemed like more activity was better in terms of building up strength just by walking but maybe it was too much too soon?

So will non-op work again and the only change is to take it easier? Or did the original delay create conditions that were preventing non-op from really ever realistically succeeding? Tough choice indeed.

Hopefully surgical consult will help but I expect I know what he/she will say…I mean, surgeons get paid to do surgery, right.

Good luck to you in your continuing recovery!

Durwood
suthrnman, on June 3rd, 2012 at 2:19 pm Said:

You might want to skim over some of my posts since they are better informed than my memory.

Originally I only waited a few days before splinting for non-op; however, I pushed things way too quickly, so both waiting too long to place original splint and rushing protocol contributed to poor healing.

I didn’t even consult a surgeon after re-rupture because I new what they would say. I just laid there until my crutches were brought to me and iced it for about an hour then put on my boot at 30 degrees plantar.

My conclusion was to chill in the beginning because the gains in time of recovery are far outweighed by the risks of poor healing and re-rupture.

I was really depressed when I was at your place and didn’t know if it would ever work right. I am certainly not 100 percent, but I am doing normal or better in recovery.

Certainly every rupture is somewhat different, but mine seemed really messed up and seems to be healing okay. All the talk of grafting, etc. kinda freaked me out, so I thought I would let it ride and see if non-op worked out before going crazy with surgery. I have had doubts along the way, but now I am glad for my choice.
normofthenorth, on June 3rd, 2012 at 5:24 pm Said:

Durwood, your main Q is a good one: does your failed initial ATR regrowth (probably because of the initial delay) indicate bad odds starting now?

Your life would be simpler if there were a great (evidence-based) A for that Q, but no. All we’ve got is logical-sounding answers — and they have a habit of being disproven by evidence in this field! I think the logic works like this: After a trauma like an ATR (or AT surgery), our bodies respond with a flurry of intense
Inflammation and tissue formation. Successful ATR rehab — post-op and post-non-op BOTH — relies on that response. Your first time, you’d already missed the most intense 3 weeks of that response — 1 more week than the “stalest” ATR in the UWO study, and probably 2 more than average. That made you a bad non-op risk the first time.

And now? OT1H, you’ve caught the full “wave” of healing response this time. OTOH, your earlier phases may have done bad things — e.g., hardened up and matured your torn AT ends, so they aren’t super-receptive to re-forming into one strong continuous AT (even after re-rupturing), without being trimmed (=~re-injured and renewed) with a scalpel.

I don’t think anybody (including your experts and mine) has the answer. The only possible way to hedge your bet is probably too unattractive for you — i.e. to risk losing another 15 weeks seeing if prompt UWO-style rehab works for you. If it doesn’t, you’ll have lost the time and gone half-nuts on crutches, and you’ll be back roughly where you are now.

As you know, I think the case for skipping surgery after a normal ATR is very strong, and that ATR surgery is over-sold and overdone. But in you’re spot I’d never make those claims.

Good luck whatever you choose.
Ultrarunning316, on June 3rd, 2012 at 7:45 pm Said:

Wow, durwood very sorry to hear of the setback you’ve suffered…Just wanted to throw my two cents in, I too was very delayed in beginning of my treatment much more so than you in fact…I was over 2 months down the line before I began the non-op treatment. I would say that my leg feels and act as if it’s almost totally recovered, I’m 16 weeks into treatment and have already began running again, 14 miles 3 days ago…I just wonder if the difference between our situations may be the treatments themselves, I have taken a specific supplement that nourishes the tendon & daily ultrasound therapy. Also a lot of early mobility, compression, ice & heat and massage…We both had similar starts & I am very happy that I went non-op as all the surgical risks and costs are very scary & people that have surgery re-rupture as well…I met a emergency room nurse a few weeks back that shared some of her ER horror stories associated with atr surgeries and she was delighted when I told her I was non-op…I feel so badly for you & I know I’ve dreaded even the thought of re-rupture so my heart goes out to you. I’m going to pray for you right after I press enter, God bless you everything in life can be used to refine us, I’m just sorry you have to go through this again, I hope whatever option you choose gets you back to full health and quickly.
durwood, on June 4th, 2012 at 9:32 am Said:

Thanks Norm & Ultra,

Norm–as always, I can count on your posts to distill the dilemma(s) into simplistic terms. You hit the nail on the head (again). So we’ll just have to see what the foot & ankle specialist says.

I did get a call from my normal orthopedic PA that had been seeing me (she was off last week) and she said she’s going to goose the referral system to make sure I’m seen within 72 hrs. So hopefully this week I’ll know what I’m going to do with this. And if it’s surgery, then maybe I’ll have a date set.

Ultra–thanks for the kind words & positive thoughts. I considered us kindred spirits given our similar timeframes, circumstances, and non-op treatment. I’m very glad to hear you are not just getting by but THRIVING. I cannot believe you are running like that at this point. That’s fantastic.

What supplement were you taking? I’d be interested in getting some myself!

I think in hindsight I should have slowed down these past couple of weeks and truly weaned off the boot rather than getting into two shoes & staying there. There were a few days where it was a little swollen & sore but not really too painful so I figured it was all part of the healing process. Perhaps those would have been good days to go back into the boot and taken it easy.

Oh well. Nothing to do now but move on, get a treatment strategy figured out, and go for it.

Durwood
Ultrarunning316, on June 5th, 2012 at 1:44 am Said:

Durwood I take Cissus Quadrangularis, I take @ 2.8g a day 1.2g in the morning when cortisol levels are highest then 800mg mid-day & 800mg before bed…when I was doing ultrasound therapy 3xs a day I would usually do the therapy after taking the cissus as ultrasound brings blood to the site, then hot bath with massage in tub, after followed by ice on the atr, with periods of rom exercises…God bless Durwood, I’ll pray for wisdom for you & your Docs Bro. P.S. I get my Cissus from Swanson, it’s reasonably priced and comes in capsule form.