surgery vs non-surgery

Below is the text from an email to Norm of the North who, as far as I can tell, has added more to this site than anyone else.  He suggested it might be useful to post, so humbly presented here it is, I will post a separate thread on the :
“You have posted many messages that I am sure many other will find of great value.  I went for the non-surgical approach in the end.  The docs gave me the choice and I had to force it out of them by asking what they would do in my situation.  I guess they are worried about getting sued as the personal claims industry which has become a real problem - there are many genuine cases where help is justified but a whole lot of other frivolous and dishonest complaints that are causing us all to suffer in the long run - but that is a different story.
I have pretty much recovered now after 8 months.  There were quite a few cock-ups along the way, including 14 weeks in cast/boot which as the hospital physios have sort of admitted (off the record) was the wrong thing to do.  I don’t hold it against them though, they are overworked and under heavy pressure to meet targets set by politicians that seem to have little to do with patient care.

Once I realised I was way behind schedule I did a ridiculous amount of excerise (5 half hour physio sessions per day 6 days a week) and this seems to have done the job.  Back to playing badminton now and 50 mile cycling training sessions, albeit at a lower average speed of around 16 mph rather than the 19mph I used to do.  If you don’t cycle these aren’t impressive stats - good club cyclists can do well in excess of 20 mph for this sort of distance, so it places me as smack bang average, but I do it for fun and fitness so I am happy with that.

I have even started playing badminton again, which caused the original problem.  The only issue I have is that my recovered tendon is around 4 times the width of the healthy one.  The hospital has put this down to tendonitis which may require surgery in the future but they are going to see how things turn out.  I met with a sports physiotherapist today who used to be the physio for a professional football team here, and he has said that some deep soft tissue work is in order, cue the Voltarol, plus neoprene supports (I cannot remember what he said these are or what they are for) and some shoe inserts.  This should take around 3 months to get the tendon back to normal.
From reading some of your posts, I think you have come across the same surgical vs non-surgical confusion that many of us have come across.  The medical professionals seem to be as confused as the rest of us.  My sister is a GP and sent me a load of research that appeared to suggest that surgery may be the better choice for those returning to competitive sport, but that was mainly old stuff and there doesn’t seem to be that much by way of current studies.  I think we also have to be wary of drawing too many conclusions from anecdotal evidence and the sources you cite on proper studies are very good.
Other than the surgery/non-surgery debate there also appears to be another important one: that of eccentric exercise.  The health service here are particularly keen on that, but some of the professional sports physios I have spoken to say that eccentric exercises should only be done once the tendon has repaired fully.  I don’t know much about health treatment, but enough to know that it isn’t the precise science that some of us, me included until my achilles experience, thought that it was.
I got a bit carried away, I was only going to point out the error message on the posting.  I have to say that I think the achilles blog site is a very good support network, to which you have valuably added.  Friends can sometimes get a bit bored of hearing about the latest small step success - out of cast, first walk in boots, first day out of boots, first walk without crutches et al - that are so important to our progress but not properly understood bymost of those not affected.
Good luck with the rest of your recovery and keep posting - they are most informative and enjoyable.”

David Beckham

I am sure all on here will join me in wishing David a full and speedy recovery.  I hope that he will be playing for Milan next season.  Whatever he chooses to do, he has achieved what most of us can only dream of and I am sure that he will become a model as to what is possible to do after enduring this injury that many of us have been through.  Good luck mate.

11th July 2009 MRSA positive screening pre-surgery

First post - ruptured my left achilles whilst playing badminton on 26th June 09.  I have read a lot about many such injuries happening to individual’s participating casually in sporting events.  Although I am in the expected age range for potential rupture (38), I have been far from inactive - triathlon is my preferred sport, although I am not very good at it (405 out of 418 at my most recent event, the Little Beaver triathlon!)

I recently took up badminton again after a long absence, as we started a sort of league at our office.  The day I ruptured my achilles was only my second outing and I was starting to get back some of my sharpness.  3o minutes into the session (although I did not bother to warm up as I thought it was unnecesary for such an easy outing) my tendon went.  Usual story, felt as though I had backed up into a low bench or something - looked around in amazement and whilst collapsing onto the floor knew instantly it was my achilles.  My co-competitors thought I was larking about at first, but quickly got help.  45 minutes wait for an ambulance, so we decided to drive there.  After about 1 minute the pain went almost completely away but I could not even stand up.  Felt pathetic!

We drove from the NIA in Birmingham - good sports hall by the way if anyone lives here - and not particularly well known - to City Hospital.  This was a mistake.  Although it is the nearest hospital to Birmingham city centre, where I live, it falls under the Sandwell trust.  This caused problems later on as I was asked to relocate to Sandwell for treatment, miles away and not a particularly pleasant journey for visitors etc.  I would suggest to anyone having any sort of injury in Birmingham to ask to go to another hospital, Selly Oak maybe or Solihull.

Usual tests at the hospital, including MRSA swab taken from nose.   7 hours in the hospital the first day.  Finally told that I could either have surgery or conservative treatment.  Surgery would not be able to be done until the Monday (Friday was the day of my injury) and they wanted to send me to Sandwell Hospital for the weekend.  I managed to persuade them to let me go home for the weekend and research the options, in particular to talk to one of my sisters who is a GP.  She managed to access research papers for me and I decided that surgery would be the better option, as I wanted to recover to full strength to be able to continue to do sport in the future.  A cast was put on and off I went.

Arrived home on Friday to find an answerphone message to say that I had screened positive for MRSA colonisation.  This is a fairly common thing.  I called them back and they told me not to worry, but that I would have treatment for this alongside the surgery. 

Went to Sandwell Hospital on the Monday, all packed up and ready to stay.  After a brief check up at the fracture clinic, I was relocated to the trauma ward.  Arriving there, a bed was arranged on a ward and I started to settle in.  I completed the patient questionnaires with the ward manager and casually asked about the MRSA issue.  He went a bit crazy when I told him I was MRSA positive - I was immediately bumped into a side room for isolation treatment.  The ward I had been on was then immediately deep cleaned.  There was a communication issue as City Hospital had not passed on the test results. 

The treatment for MRSA colonisation is fairly straight forward - full daily washes with surgical scrub and nasal antibiotics for 5 days.  However, as the surgery option was elective, that the operation would be delayed until the MRSA treatment had been completed.  This should have been done whilst I was at home, but another administrative cock-up and I was retained in hospital for 3 days with no cast or anything.  Finally, on the third day, after pestering everyone I came into contact with (including cleaners) I was fitted with an aircast boot and released. 

Readmission was on Wednesday this week.  Another MRSA swab was taken.  I was informed by Sandwell Hospital that this would take 48 hours and that I would have to wait for the results of this before they would do anything.  There is another test, which apparently looks at the DNA structure of the bacteria that may be present, which only takes around 1 hour to process.  I managed to persuade them to do this test instead.

Another day spent in the isolation room.  The surgeon spoke to me and I was now told that even if the new MRSA swab came back as negative, I would be treated as if it was positive.  I cannot see the point of them taking another swab if they are going to assume it is positive anyway.  I understand the reason why a negative result is not definitive proof - the bacteria could be present but not taken on the swab, but why bother taking another swab if the treatment will be the same?   Anyway, the surgeon informed me that I would not find a surgeon in the UK who would perform achilles tendon surgery when there is MRSA colonisation possibly present and that conservative treatment would be the only option. 

I was handed over to another surgeon due to timings, who said that he would be prepared to operate if I was prepared to take the risk!!  The potential upside - stronger repair, much lower re-rupture risk, the downside - if MRSA infection set in it would at a minimum destroy the tendon, possibly lead to the loss of my foot, and maybe much, much worse.  So I decided on the conservative option. 

Got out of hospital finally yesterday fitted with the same aircast boot.  I have been able to get out and about quite a bit - 9 hours of crutch walking yesterday.  The only problem I have so far are blisters.  Cycling gloves are ideal to stop this happening until my palms harden up a bit.

My experience now is very different from what others seem to be experiencing.  Although there is absolutely no response from my foot on the calf test and visually it is clear that the tendon is well and truly snapped, I have no pain whatsoever and can even put my full body weight on it.  Walking is hopeless and trying it makes me look like some deranged lunatic.  I know I shouldn’t do this, but I can’t be the only one who has tried it early on (2 weeks and one day after the injury).  I don’t feel the need to wear the boot unless I am going out and occasionally at night to make sure it heals at as good a length as possible. I have spoken to a very good friend who works at another hospital and she tells me it will probably start to hurt as the nerves repair, maybe in 4 weeks or so.  The only other symptom I have is weight loss - 5 kg per week at the moment - and my left calf is already starting to shrink.

I guess that many people who have had this inury ask the question why does it take so long to heal?  It isn’t the worst injury in the world by a long way - I was the most fortunate on the whole ward from that point of view, some of the injuries people were coming in with particularly from motorbike crashes were horrific - but it does seem to take the longest of any injury that is usually fully recoverable from.

The aircast is a great invention, mainly because it can be taken off to shower and when sitting.  I would definitely recommend it if is suggested as an appropriate option.  But I do seem to be the only one that has been given the boot right from the off, other than the first weekend when I was given a temporary cast to allow me to go home.

Off to the gym now.  I have been given an upper body workout schedule.  This cannot possibly replace my usually exercise regime (Saturday training  for example is usually a 55 mile bike route), but it is something.  I hope to be back swimming at least very soon.  The only thing stopping me at the moment is the worry that my foot position when swimming would not be conducive to proper healing.

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