Jun 30 2012
Contralateral Rupture Musings
Interesting factoids I’ve found online about what ails us:
- The Achilles tendon is one of the most commonly ruptured tendons (it has to cope with far more mechanical loading than most other tendons which may explain the relatively high incidence of Achilles injury)
- Achilles ruptures generally occurs in males between 30-50 years of age, participating in recreational sports (basketball, racket sports)
- 75% of complete tendon ruptures occur during sporting activities that require quick & repetitive movements like jumping & sprinting. (These overexertion activities most commonly occur while playing basketball (US), badminton (Sweden) & soccer (Germany))
- Most ruptures occur 2-6cm above where the tendon inserts into the calcaneus. This is the narrowest portion of the Achilles tendon & is also the area with the poorest blood supply.
- Achilles tendon rupture is five times more likely to occur in men than in women
- Most experts agree that there are no warning signs of an impending rupture
- Fluoroquinolone antibiotics, such as ciprofloxacin (Cipro) or levofloxacin (Levaquin), or steroid use, increase the risk of Achilles tendon rupture
- Each Achilles tendon may be subject to up to 3-12 times a person’s weight during a sprint or push off
- The Achilles tendon is the thickest, strongest, most powerful tendon in the human body & connects the gastrocnemius and soleus to the heel
- Individuals with blood group O have been shown to be at higher risk of tendon rupture
- A complete tear is more common than a partial tear
- Nonsurgical treatment has a higher incidence of re-rupture than surgical repair
- Most studies indicate a better outcome with surgery
- Athletes can expect a faster return to activity with a lower incidence that the injury will happen again
- Physical therapy can expedite recovery time
- Risk of sustaining a rupture of the contralateral (other) side may be as high as 26%
Looking thru this AchillesBlog (Thanks, Dennis), I see many have re-ruptures, either contralateral or same leg. Looks like once you get a rupture, you have greater chances of re-rupture. Not to sound like doom & gloom, but we all know coming back takes time, but it IS there- for some a light at the end of a very far tunnel, for others, just around the corner. One good blog here from Brendan about re-ruptures including some stats he’s found. Another from Tom’s perspective. Both good reads.
So what does this all this tell me- what’s my take-away? The best way to prevent an Achilles tendon injury is to (a) Stay in overall good shape, and (b) warm-up, stretch & strengthen the Achilles. The best way to prevent an Achilles injury from getting worse is to address the injury immediately: it WILL get worse if not addressed. I thought I’d warmed up & done enough stretches specifically for the tendon. Apparently not. But it’s probably been building up in most of us over our years of activity. According to what I’ve read, usually they are the result of many micro tears to the tendon that have happened over time. If you’re not in good physical shape now, don’t overdo it & try to come back all at once. (That’s probably what got many of us here to begin this adventure.) Gradual improvement with sensible strength & flexibility exercises increasing in duration and intensity.
Could I have prevented my re-rupture? Probably not. Can I prevent further re-rupture? Only by God’s grace & watching where I step. Friends have suggested wrapping in bubble wrap to begin my day, but where would be the fun in that? Changing our lifestyle out of fear of re-injury would be to live in fear. Making allowances for our age & other factors we can alter (such as getting in shape), we should welcome with open arms. Change for the better, get in shape (wisely), stay in shape, warm up always, stretch well after warmups, live long & prosper!
7 responses so far
Gnt, most of us do NOT refer to tearing the OTHER AT as “re-rupturing”. You lump both sides together in that term, which masks the fact that actually RE-rupturing (the same tendon) is vanishingly rare once the initial rupture has healed. The vast majority of reruptures occur before 12 or 13 weeks after treatment begins (op or non-op).
The stats on op vs. non-op were clearly as you describe until the mid-90s, but have since changed sharply — mostly, I think, because the most recent studies have applied fast and aggressive rehab protocols to their non-op patients, rather than babying them through “conservative casting” while repeating logical-sounding-but-false mantras like “You can’t be too safe” and “Better safe than sorry” and “You don’t want to have to go through this more than once”. The largest randomized trial so far (”UWO”, pub. 2010) went fast, and produced strength, ROM, and re-rupture results that were statistically identical (in a population of ~150 patients) with and without the surgical repair. Raw results did generally favor the op, like 2% re-rupture rate vs. 3% (both numbers “effectively zero” IMHO), and slight strength variances, too. And complication rates always favor the non-op. (E.g., nobody ever complains about their non-op scar!
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Gnt,
As Normofthenorth points out, with the results of modern, fast rehab protocols indicating that re-rupture rates and time to 2 shoes being about equal for both op and non-op, I’m having a hard time understanding why so many operations are still being done. This is especially true when you factor in such things as the risk of infection, dealing with incision scar tissue and the shear pain and inconvenience of surgery. I hate to be cynical but my only conclusions are that either too many orthopedic surgeons are stuck in the past or there isn’t much money for them if a patient goes non-op. Unfortunately it seems that too few ATR patients have enough time to do enough research on their own before signing on to go under the knife.
@starshep,
USA doctors are more aggressive offering surgery than their Canadians, Australian or British counterparts. You have probably noticed a lot of the non-ops on the blog are from these countries.
After my rupture ten months ago I consulted four orthopedic surgeons. Only one gave me the option of avoiding surgery, and I quote him “these days we only operate on professional athletes or very active people under 40 (nevermind I was exercising two hours a day at time of the injury).
The other three doctors agreed on one point: my 2.5 inch gap was too big to heal well without surgery and I would be at higher risk for rerupture. At the time getting the surgery was a no brainer.
A few days into recovery I found the blog and read everything about the UWO protocol. So I printed a copy and brought it to my doctor. He said “Oh yes, they do that in Canada, but we can’t do it here. People don’t want to be in cast”…Needless to say, he did surgery on my first rupture (it was my left tendon), but he won’t get a chance on my right tendon…Next time I’m going non-op.
Some good notes there, as has been said, a new rupture to a previously never been torn tendon cannot be a re-rupture, it’s simply a new rupture.
Good info from norm on actual re-reuptures and the percentages being highest in the “up to 12 weeks” bracket, timely reminder that we ned to be vigilant during our recoveries.
I’d like to know the % of people whom have suffered ruptures on leg suffer with the other at some point - problem I can see is that people being people, all are different (age, lifestyle, exercise habits etc…) so it would be a challenge pin-pointing why this is the case.
But my guess (and it’s a real guess) is that once a tendon has ruptured, the patients tend to lean (or rely) more on the uninjured leg for support even after recvoery and the other tendon simply basically takes too much stress……probably another good reason to keep working on those calf muscles, balancing and warm up extensively before any exercise.
Thank you all. True, the more correct title should be Contralateral Rupture musings.
housemusic,
There are certainly cases where surgery is required, and when 3 of 4 doctors agree that surgery is required, I could see why you would go surgical. Still your doctor’s statement that, “People don’t want to be in cast” is beyond ludicrous in so many ways. First, most people go into casts after surgery. Second, it implies that people want to have surgery over not having surgery. Huh? I can only hope that the doctor’s surgical skills are far better than his market research skills. That’s a great example of how some doctors push their own agenda over what their patients might really want.
In LA an Achilles repair runs in the $ 8K - $10K range. Nice pay for 40 minutes of work. No denying the surgeon had to go through extremely expensive medical schooling to get the skills. But makes you wonder if there is a bit of personal interest in performing the surgery.
Ultimately, I survived an aweful injury that nearly costed me my job and the health insurance that goes with it.
As a single woman without relatives or support system near me, I have to do everything in my power to prevent a contralateral rupture.
A recent ultrasound showed partial tears in my “good” tendon and the doctor told me it may go. Nobody should have to go through this once, let alone twice. But if it happens I will be prepared with the knowledge and go non=op if possible. In the meantime all I can do is avoid the high risk activities and do my daily heel raises.