Well, so much for that….no surgery for me.

I was supposed to have AT repair surgery this morning. But, I had a heart attack at the end of November and had a stent put in. And, the cardiac protocols say that I shouldn’t have surgery until 6 months after the heart surgery. The anesthesiologists (3 or 4 of them discussed my case) all agreed that the risk was too high, and convinced me to cancel the AT surgery. I messed up, and didn’t time my AT rupture very well!

Six months is up at the end of May. So, I needed to talk to my orthopedic surgeon to figure out what I’m supposed to do, now. I can’t wait another almost two months - by that time, my AT could be totally messed up, for sure! The doc decided it would be best for me to try to heal non-op. Yes, the tendon won’t be quite as strong. And, yes, there’s more likelihood for a re-rupture. But, he thinks we should be able to make this work, and I should be fine.

I don’t know what the protocol is for non-op AT recovery - gonna have to do some reading on that. I thought you still start in a cast for a week or two, and then transfer to a boot. But, my doc said the cast isn’t necessary, and put me back into my boot from 5 years ago, with three-high wedges at the heel. I’m supposed to weight-bear whenever it feels comfortable to do so. Tried it. I can put some weight on it, as long as the foot is in line with my body or slightly in front of it. But, I tried to take a step with my foot going behind, and that was NOT working.

So, are there any non-op people out there? What protocol are you going through? Is it odd that I’m directly in a boot, and weight-bearing as tolerable?

Thanks, and Happy Healing to everyone!!!

20 Responses to “Well, so much for that….no surgery for me.”

  1. My surgeon led a very comprehensive study on surgical vs nonsurgical ATR recovery and found the re-rupture rate was virtually the same. The healing time is a little slower, but the outcomes very similar, and much fewer complications in the non- surgical group. Here’s the protocol my surgeon uses: http://fowlerkennedy.com/wp-content/uploads/2015/11/ACHILLES-TENDON-RUPTURE-ACCELERATED-REHAB-PROTOCOL.pdf
    I’ll find you a link to his study as well.

  2. http://achillesblog.com/files/2008/03/jbjsi01401v1.pdf

  3. Thanks for the pdf, shell37! Maybe this is the protocol my doc is using. We’ll see.

  4. Oh man, second time around! Sorry to hear that…. At least you know something about this injury this time around. I am non op, 10 months in 3 days since rupture and am pretty much recovered as far as the achilles goes. Still working on regaining some strength in the calf, but can do everything with that leg. You can check out the details of my nonop recovery on my blog (agesatr) and vlog (links to videos on the blog).

    As far as protocols for nonop there is Canadaian UWA protocol, which is early weight bearing protocol and people have good success with it. I was on a Twaddle protocol, which is very similar, but starts weight bearing bit later. I was, however, putting pressure on my leg earlier than my protocol calls for. My protocol also called for early mobilization, which means I was doing range of motion exercises (all in plantar flexion) from 2 weeks onwards. I was to do it for 5 minutes once an hr or so. I can tell now, looking back, that it helped with my quick return to walking as my ankle was in alright shape.

    Seems your doc might be going with the former protocol, which is good. The achilles heals better with applied force. This is forcing the collagen creation.

    I was also not casted. Was put in the boot immediately. I was supposed to be in it 24/7 except for the range of motion exercises. I read some studies, where prolonged immobility increases risk or re-rupture.

    You can heal well with non-op as well. You know from your first time, I guess, the importance of PT. :) The only difference now will be how early you should stretch. Nonops have greater risk of healing long, so stretching should not be introduced as early as in op patients. That will be different for ya this time around. Another thing, find a PT that knows nonop protocols!

  5. Hi agnesatr. Thanks for your reply. I’ll have to look up the Canadian UWA protocol.

    My doc said the cast isn’t necessary, and I can start weight bearing as soon as I’m comfortable doing so, as long as there is no pain. I see him at 2 weeks to see how it’s coming along. Exercises at home at 4 weeks. Driving at 4-6 weeks. Rehab at 6 weeks. Hiking at 4 months. Vball again at 4-6 months. Seems faster to get back to vball than my op recovery was, which is great!

    I don’t know the science behind it. I would figure that I’m not going to heal if I’m weight-bearing right away. How do the ends meet and mend, if my ankle is moving around and getting pressure?

    We’ll see, I guess!

  6. Hey ericbabula, it’s actually the UWO protocol. I tried linking it for you, but the moderators didn’t allow my post. If you google Fowler Kennedy Sport Medicine Clinic in London, Ontario, then look up Patient Resourses, then Physiotherapy, you’ll see the Achilles protocol there. It’s a great Clinic, I feel very lucky that I’m being treated there.

  7. My surgeon is the one who came up with the protocol - nice to know I’m being treated by someone who knows what he’s doing!

  8. Thanks, shell37! I’ll read it, for sure!

    Happy Healing!

  9. Eric, check out this paper on the tendon reattaching itself naturally: http://www.danmedj.dk/portal/pls/portal/!portal.wwpob_page.show?_docname=10547073.pdf

    The initial stage when tendon reattaches itself takes about 2 weeks. It is a weak link initially as collagen type 3 mainly is created in that stage.

    The range of motion exercises that are given after this stage are all in plantar flexion, with your toes pointing down and you always keep your foot in various degrees below neutral - depending which week you are in. This ensures that you are not stretching your tendon.

    As far as deadlines for returning to activities, I would not really look at them as such strict ones. Your PT will be clearing you gradually for them as you progress. You will see some will come sooner and some later depending on your calf muscle regain and ankle strength.Here there is no template as everyone is so different. But I guess you know that from your first time around. Hope there is more of these “sooner” deadlines for you this time around! :)

  10. Hi Eric, Re the “how can it heal” thing - it’s surprisingly hard to find info and it drove me crazy whilst I was in the cast wondering how it could possibly be joining back together.

    There were two things I found out that gave me the lightbulb moment:

    1. The tendon is housed in a sheath, so it’s not just two ends flopping about all over the place inside your leg that you’re relying on to miraculously sticking back together!

    2. When it ruptures, it’s not a clean tear as if the tendon was sliced in half with a knife. It’s more like broken strands of spaghetti on either side - if you imagine bringing your hands together with the fingers interlocking - your fingers being the strands of tendon.

    Boot vs Cast - as I understand it - the key thing is that your foot is being kept in plantar-flexion (toes pointing down) so that the strands of spaghetti are being kept close to each other where they can mesh and re-join. I think they usually still use the cast to prevent the temptation to take the boot off and move the ankle or weight-bear too soon.

    I’m 4 months into non-op now after a complete rupture and I’m very happy with how it’s going. :)

  11. Hi morcs,

    I kinda understand how the tendon heals, now. I was mostly worried about being in a boot right from the beginning. I do take the boot off to ice the foot and to wash it and put new socks on, but try really hard not to move it. Although, I’m sure it moves slightly (maybe even more in plantar flexion than the boot/heel lifts). So, is that going to hinder the healing process? I don’t know. I’ll have to ask the doc when I see him on 04/21.

    So, how long did it take you to:
    * Partial weight-bearing
    * Full weight-bearing
    * Two shoes
    * Driving (if right foot)
    * Rehab
    * Walking

  12. Regarding tendon healing. If you go to my page (Xplora) and look under the tab ‘further reading’ I have a link to how tendons heal. It is a bit scientific but there is still some good info for lay people. Understanding the phases of healing will help you. The first phase is 3 weeks where a weak and disorganised form of collagen is laid down but that is what will join the tendon ends. The process is exactly the same with or without surgery. Sutures are used to position the tendon ends and hold them in place while your body does the rest. Without sutures the cast or boot will do the same. After 3 weeks, gentle Active ROM exercises can be started. This involves writing the alphabet with your foot while your leg is supported. Weight bearing can start whenever you are ready but should start before 6 weeks. I would not take the foot out of the boot until 3 weeks for any reason.

    [WORDPRESS HASHCASH] The poster sent us ‘0 which is not a hashcash value.

  13. Hi Stuart,

    How do you ice your ankle, or change your socks and wash your stinky foot (well, maybe yours don’t, but MINE get stinky! LOL!), if you don’t take it out of the boot for any reason?

    Thanks for the info. I’ll try to read your page tonight!

    Happy Healing!

  14. Or, take your pants off???

  15. My foot was in a splint/cast for 3 weeks so it didn’t get washed that entire time :) It wasn’t doing much either since I put no weight on it so the only thing I had to deal with when I finally did get the boot and could wash it was major amounts of dead skin to scrub off - ick! LOL! I just wore shorts the whole time since my pants won’t fit over the cast. They don’t fit over the boot either so I’m still wearing shorts.

  16. And - regarding icing - put the ice behind your knee. It works well since the blood supply is running through the leg there. That is what they were doing to me when I came out of the surgery and what I did, often, until I was in the boot.

  17. Hi cserpent,

    Thanks for the icing tip - I’ll try that today to see if that works!

    I understand about the cast. When I had a cast 5 years ago, my pants (most of them) did fit over the cast. But, definitely not the boot.

    As for the shorts - that doesn’t fly for me. I work at a professional office: dress pants and dress shirt required. Need to change every day.

    Happy Healing!

  18. The advantages of being in engineering - shorts are OK for a bit in case of injury. :)

  19. Eric - simple answer is you put up with it for 3 weeks. If you were in a cast it would be the same. The icing tip above is a good one. It is most important for non-ops to restrict movement in this phase. Sutures will give you some protection but without them, even a small movement can undo the healing which has already started and may increase the chance of healing long.

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  20. Yep, icing behind the knee helps (it’s a tip given to ppl in cast usually), but what also helped me was keeping my foot in the boot, place it on a pillow, so it’s secure, undo couple of straps and place ice bag inside of the boot on the top of the ankle.

    As far as cleaning the foot/boot, I was told to always wear the boot in the shower with the cover on and after shower I was allowed to spot clean my foot. That way you are taking the foot out of the boot for few minutes in a controlled environment and can make sure the foot does not change the plantar flexion position. I was using adult wipes for the foot each morning, changing the sock and then applying a spray to the boot: Odor Eaters. That did the trick and the boot never got smelly and it was summer. Always wear sock in the boot. You can see all these on my ATR Equipment tab.

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