surgery vs non-surgery
Posted on March 17th, 2010 by garethcope
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.”
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garethcope - Thank you very much for sharing this with us. I can’t agree with you more that Norm has done much contribution to this site! I’d suggest we should give him a big kiss/hug/high five/etc over the Internet (pick on as you wish!), although he called me a “wimp” earlier today and I’m not sure if I still want to be his ATR friend, though.
When I was reading the last part of your post, I smiled a lot because every little progress you described sounded like what parents with a new-born baby would talk about. We feel happy for others when they post their progress even if it’s so tiny and we know our progress report will be welcomed by our friends here!
Gareth, I’m very glad you posted that. Your story is amazing, and your insights are wise and delightful!
Badminton, like squash, tennis, football (both versions), basketball, volleyball, ultimate — all the sports that involve aggressive fast stops and starts and reversals of directions, and “getting faked out” — are all very tough on ATs, and a great way to tear one! As a result, they should naturally be the last thing we return to as we heal.
BTW, I’ve been very serious about squash and tennis over the years, and somewhat serious about badminton and (N.A.) football. And I’ve been nuts about volleyball for a few decades now.
Eight yrs ago, my first-AT surgeon told me that the time to return was just after I could do a bunch of 1-legged heel raises without groaning, and I think that’s a reasonable rule of thumb. Cycling, jogging, skiing, lots of less “violent” activities can come much sooner. And activities like those, where you don’t have an opponent working hard to fake you out and MAKE you reverse your momentum ASAP (and load up your AT), are surely a bit more controllable. (I may change my mind about that in 4 weeks, the first time I’m skiing at Whistler in zero visibility!)
Some “sensible” people even give up the “high-risk” sports completely, after they tear one AT, for fear of tearing the other one. Me, I went back to volleyball at a MORE aggressive and strenuous level (4-on-4 vs. 6-on-6), despite being understandably worried about my unruptured left AT. And 8 years and a couple of weeks later, I tore the thing. No regrets here, and I’m still pleasantly surprised how well the repair and rehab are proceeding, and all without any surgery!
I just thought I would add my few pence worth to this thread as I too have returned to sport following non-surgical treatment.
I ruptured my right achilles about a year ago now and followed a pretty standard non-surgical approach here in the UK, spending 10.5 weeks in a cast with the foot in various positions.
I had a few problems early on, particularly a lump around the site of the rupture which was causing discomfort with every step I walked. It didn’t really stop me doing things, but just meant I could never forget the injury.
The pain did reduce to nothing over time and the lump has pretty much gone - with progress primarily after my physio started ultrasound treatment on the area weekly.
Much like Gareth, I too did enormous amounts of exercise, going to the gym to (over time) swim, cycle, walk on the treadmill, use the stepper, and finally jog. I also did some light weights on my legs. I used to go five or six times and week and had one or two hands-on physio appointments a week.
I guess my question is, is undertaking a lot of exercise important in a full recovery following non-surgical treatment?
Like Gareth too, I am back to playing all the sports I was pre-rupture. I don’t feel that I am a worse player than I was pre-rupture. The sports I have gone back to are football, skiing and badminton, as well as regular running.
I started running after about five months, badminton after seven and skiing and football after nine.
I too have a thickened tendon, so am interested in experiences others have had about this issue.
If you want to read the detail of my story
http://www.achillesblog.com/thedukester
On the one hand, Simon, answering your question about exercise would make an interesting study. On the other hand, both you and Gareth got a rather conservative conservative approach! I.e., the modern studies producing good results from a non-surgical approach (including the latest 4 studies comparing that approach to surgery — see my blog page) all move much more quickly than you two did, especially from NWB to PWB to FWB and into physio. And they all do it with boots, not casts, which is HOW they do the early physio and exercises!
So one question is whether the kind of super-physio and uber-exercise that you and Gareth did can make up for the muscle atrophy — and maybe even poor tendon healing (like high re-rupture rates) from long immobilization and NWB — the treatment that was traditionally associated with the “conservative” approach. I’d say “Maybe” for sure!!
Now that the newer studies have ALL shown that non-surgical immobilization with relatively quick and aggressive rehab produces results that are statistically identical to surgery with that same rehab, somebody should probably write a PhD dissertation on how the Old Story arose and sustained itself so long, that surgery produces way fewer re-ruptures and better strength and ROM. (That story is still alive and well on the Internet, throughout the US, and even on corners of this site!)
Part of it was surely the non-randomization of the two patient streams: “jocks” got surgery, and “crocks” — the old, the halt, the lame, the ill, the obese — got immobilized. And “jocks” heal better than “crocks”, surprise, surprise! It looked like scientific data about surgery, but it really never was.
I think that part of it was probably also that the non-surgical patients got immobilized way too long, and probably quite a bit longer than the post-op patients. The studies are quite clear that quicker rehab protocols work better, with or without surgery — though at least one study I saw showed weaker results in that area on the non-surgical side. In other words, the post-op patients were helped MORE by quicker rehab (in that study) than the non-surgical patients.
So for sure we don’t know. Who knows, you gang of “keeners” who hang out at Physio and the gym a lot after the non-surgical cure may include the best results AND the worst ones — i.e., most of the re-ruptures! We just don’t know. Without a real study, it’s just a few data points, like the two blind guys trying to figure out an elephant.
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I’m curious…how many people who took the non-surgical approach had a full rupture as opposed to a partial rupture and what is their activity level 6 months and 1 year after the injury
Parisgirl, I’m not sure how many 6-month and 12-month ATR “veterans” — post-op OR post-non-op — are still around to answer your question. In addition, many of us got diagnoses of how “complete” or “partial” our ATRs were, that are suspect or worse. (E.g., I was initially told that my second ATR was complete, based on a Thompson test and the first of 3 UltraSound exams to guide PRP injections. But after the second US, the same Doc said it looked like a PARTIAL tear, and after the third one, he said it looked like a partial-but-multiple tear. So what kind of tear was mine?!?)
It’s true that some Docs apply a non-surgical approach to ATRs they think are partial, as well as complete tears that are unusually high, near the AT-calf join. But others (like mine) guide most of their patients to a non-surgical approach with a fast modern protocol, and a few (maybe mostly in the UK) still recommend non-surgery with old-fashioned slow “conservative casting”. And of course many guide the vast majority of their patients under the knife.
The modern studies (discussed above, and refs 4-7 in the Wikipedia ATR article) all dealt exclusively with patients with FULL ATRs, confirmed with a Thompson test. And they all tested strength and ROM & rerupture rates at 6 and 12 months, and often 24 months, too. Many of them also applied the Leppilahti score (or index), which is a combo of subjective and physical and lifestyle outcomes.
In most of the studies, there was some measurable residual performance deficit in most patients (with or without surgery), and a fair amount of “scatter” or variability among patients. The two biggest studies (refs 4 & 7) both found statistically identical results with and without surgery, apart from the rate of (surgical) complications. (The middle two claimed to find statistically identical results, though some “normal people” would conclude that the post-op patients did somewhat better, apart from the higher complication rate.)
It sounds logical that partial ATRs would respond even better to a good non-op approach than full ones, but nobody’s ever tested it with a randomized study, AFAIK. (And LOTS of things that sound logical in this field seem to turn out to be WRONG!
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