Richard Wallace from Belfast called me…
So today I go to see the foot and ankle surgeon at 8am, he fitted me in before he started to operate for the day. He acknowledges that there is a lot of controversy re surgery versus non-operative treatment, but still insists return to sport, recovery, will be even better with surgery, and risks are low. However he can see that I’m not for budging so at this point he sort of loses interest and says, “come back and see me in 4 weeks.” In the meantime, I have no advice on whether to weight bear on the boot I was fitted with after 1 week etc etc -other than the advice I have gotten from you wonderful people.
Luckily, I have e-mailed some of the authors of the best studies you guys have pointed me towards - got a reply from a lovely physio in Denmark, who said that I could feel free to e-mail him anytime. I also got this reply from Richard Wallace in Belfast, the orthopedice surgeon who has now treated close to 2000 patients conservatively.
“I routinely keep my patients in an equinus cast non weight bearing for 4 weeks. Occasionally I would shorten this period where appropriate. The period in the pneumatic walker is 4 weeks. During this time weight bearing is allowed, but only while wearing the boot.
For the first 2 weeks in the boot you should have 4cm. heel raise and for the 2nd two weeks half this, to 2 cm.
During the time using the boot remove it regularly for active ankle exercises – this is very important.
I am not convinced about DVT chemoprophylaxis, but use it, as appropriate after “risk assessment”.
If this regime is followed the results are excellent. I have now treated over two thousand patients this way and still get slightly better results than published for surgery.”
Richard Wallace.
i then panicked, because i have had boot on for 3 days (since week 1) and have been partially weight bearing on it, so fired another e-mail off to him. He then picked up the phone and called me, reassuring me I was ok in the boot as long as I didn’t weight bear, so have now gone back to using 2 crutches. My knee scooter also arrived yesterday (available to hire by the week in the UK for 15 pounds a week) so will be using that a lot too. I know some of the SCandinavians remove the equinus cast after only 2 or 3 weeks; Wallace said he just sticks with his original formula “because it works.”
it was so reassuring to get this call, and I am so stoked that this man picked up the phone. Please don’t all e-mail him as he will probably kill me! but I hope the advice as above helps reassure someone else.
if I get any other tips from anyone else will share.
And finally, as an interesting aside, my husband - who is not from the UK but from Indonesia - keeps reassuring me that all will be well. He looked at me aghast when I first said, “I might have to have surgery.” He said he saw many people with this injury when he was younger: he was in the military (national service) and did martial arts. They all got better without any surgery or fancy boots.
Feeling calmer now, on day 10
Thanks everyone for all your help and advice
October 16th, 2014 at 5:47 pm
Wow! That is very cool. Thanks for sharing. I’m all done with my post-op ATR recovery, but I’m still very intrigued with the non-op route. If I knew then what I know now, I would’ve gone non-op, too. -David
October 17th, 2014 at 1:56 am
Wallace is obviously a nice and conscientious physician, as well as a genius for publishing a huge study of patients whose ankle angles were individually optimized based on his visual and palpation exam. BUT, it’s clearly possible that the other modern studies that got virtually (nearly, almost, essentially…) as good non-op results as he did with a simple crude “one size fits all” ankle angle actually used BETTER rehab schedules than he did.
We don’t know, because nobody’s combined his personalized immobilization angle with their somewhat faster rehab protocols.
As he says, he uses his protocol “because it works.” Fair enough, but so does surgery, and Wallace is part of a revolution that is showing that it’s unnecessary and more-or-less without benefit!! And the extra cast and extra weeks of NWB and immobilization of his approach (compared to Devon and UWO) may also be unnecessary and more-or-less without benefit.
Among the other studies (with every patient getting immobilized at the same angle), the best results are associated with the fastest schedules, so it seems unlikely to me that Wallace’s wonderful results depend on his slightly slower schedule. I can’t prove that, but he can’t prove the opposite (and he doesn’t claim he can), either.
I would hesitate to add WB in the first 2 weeks, but after that, I don’t think I’d hesitate to follow one of those other slightly faster protocols.
BTW, it’s interesting that the same expert who showed the inferiority of “one size fits all” ankle immobilization has recommended a “one size fits all” ankle angle for you — 4cm lift for 2 weeks then 2cm for 2 more. Again, that is slightly different from the others (I remember that UWO used 2cm for 6 weeks then 0=neutral), and there’s no proof that the schedule Wallace recommends is optimal — especially because his impressive results did NOT come from following that schedule, but by beginning with the angle that was dictated by each patient’s torn AT ends!
I’ve forgotten exactly how long it’s been since you first got immobilized (pease install the ATR Timeline Widget), but I think I recall it’s been around 2 weeks-ish, which probably means that getting somebody to play with your AT and ankle the way Wallace does might do more harm than good. (You don’t want to uproot the carrots to check that they’re growing, or they won’t!)
So I think it’s probably best to follow SOMEBODY’s “one size fits all” immobilization schedule, and at least 3 of them seem to have produced excellent results, so … I’m with your husband!
BTW, your NYMarathon widget seems to be messed up — it suggests that you’ve almost reached your goal, 25.83 out of 26.2 miles to full recovery. And it says that the goal is 16596 days from the “surgery” date. Neither of those numbers makes sense, right? (I’d check the dates you entered into your personal profile.)
October 17th, 2014 at 5:05 am
Richard Wallace’ approach seems very similar to the non-op treatment I had. With the difference being that I was given a hinged boot as the hospital had run out of wedges for the fixed boot. I was in an equinus cast NWB for 4 weeks (no position changes with the recast) and then fitted with a boot and advised I could FWB from that point.
The first day in the boot was tough as it was set to hinge at neutral, so it felt like quite a stretch going from equinus to neutral. I feel wedges and fixed boot may have been a gentler transition and made walking easier initially. Looking back I think the hinging boot was probably better as it seemed to exercise the achilles more even if it did take longer to get used to. I don’t think hinging boots are commonly used on the NHS though as my surgeon told me that he hadn’t used one for over a year.
October 17th, 2014 at 8:09 am
Thanks normofthenorth
For some reason, when I try to install the NYMarathon widget, it goes all wrong -even though the ‘goal’ date I am putting in is 06/10/2015 - a year after my injury (6th October - writing it in UK fashion!). I will keep trying this but it’s driving me bananas - might e-mail Dennis and see if he can help. Ditto the time since op/injury widget.
I’m only 10 days out from injury as we speak.
I’m thinking now that I will take it easy for another 10 days and start to partially weight bear at about 3 weeks post injury. This seems to me, as Cecilia pointed out, to be a good ‘average’ of the different rehab protocols. Given that I was weight bearing this week for a few days, after only 1 week (because was not given correct advice), I will err on the side of caution and go to week 3. All of this advice is much appreciated. Knee scooter will help and is a great conversation starter. I was whizzing about the hospital on it this morning when I went for an ultrasound and getting lots of bemused looks, and questions.
The ultrasound was a good thing too: the radiographer said the gap wasn’t great, and that the tendon was ‘healing well’ on its own, and was aligned. So I just have to be patient for another 10 days …
On another note, I have just started to have cramps - I’m wondering if this is anything to do with stopping Clexane, which I took for the first 10 days? Obviously the blood is now clotting that maybe didn’t before so everything is starting to stiffen up. But I’m not sure this should cause cramps - maybe I just need some salt? sorry, thinking alound here - will look at the advice on cramps on the blog.
Hang on in there everyone, no matter where you are with your recovery: have great weekends!
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October 17th, 2014 at 6:42 pm
Calf cramps are very common, especially with casts. Usually just a nuisances, though strong cramps can be scary for a recently ruptures AT. Some need attention, usually muscle relaxing pills. I know of no correlation with LMW Heparin or other anticoagulants (”blood thinners).
The marathon widget is cute, but it’s the other widget - ATR Timeline - that’s really helpful to readers. I think they both get their dates from the same database of profiles. When you move from NWB to PWB and then to FWB and then 2 shoes, you enter those dates into your profile. I don’t recall ever setting a “goal” date. I thought it was automatically set a year after the start of treatment - which the Marathon widget text unfortunately calls “surgery”!
October 17th, 2014 at 6:44 pm
While you’re changing settings, enable AJAX Editing, so we can fix our typos for a short period…
October 17th, 2014 at 8:03 pm
arman79, your treatment was genuinely scary — NOT because you were given a boot with a hinge (that’s great!), but because that hinge was initially set free to hinge all the way to 0=neutral! That’s awful, and you’re lucky to didn’t hurt your AT while you were trying to WB in it. AFAIK, all the responsible and successful protocols that use hinged boots start with a couple of weeks with the hinge set “fixed”, then gradually adjusted to hinge, at first not very far.
Incrementalism wins in ATR Rehab!
October 18th, 2014 at 7:02 am
Hi Arman
So you went from the fixed equinous position to range of movement of around 30º. Potentially a bad move but could have been worse as many (all?) hinged boots also allow for dorsi flexion (DF) of up to 10º which would have a range of 40º! OK for a fit person but not when fixed immediately before.
2 years ago, probably still the same, the Exeter (in Devon, Norm) rehab schedule, whether surgical or non-op, was for 2 weeks cast equinous, then 2 weeks in Vaco boot at same angle (around 30º); 2 weeks set to ROM 30º PF - 15º PF; 2 weeks ROM 30º PF - 0º’; 1 week 30º PF - 10ºDF as you prepare to transition to 2 shoes.
So, as Norm says above, gradually and not far at first, but still getting to 2 shoes in 8 or 9 weeks. Safe and sustainable but not too conservative either. FWB and light physio started at around week 3, losing crutches around week 4 variable, dependent on conditions (floor surfaces, etc).
I realise that this information may be late in the day for you personally, but there are new readers/victims every day. We post here to help anyone coming here, and the many who trawl back through the months and years of past posts.
Good luck to you and to Healing for a sustainable recovery. There are very very few failures with these modern progressive rehab protocols, and the time will fly by.
October 19th, 2014 at 7:54 am
It certainly felt scary that first day in the boot, especially when i thought i may have re-ruptured it. I remember that day the surgeon did offer to lock it out in equinus If required but I decided to try and get used to the set ROM. I think it would be tricky to walk with the boot locked out like that though but definitely safer. The calf tightness and discomfort from stretching was acting as my restrictor so walking was slow and uncomfortable progress. As you say I don’t believe this was really a good thing.
Hillie those hinge boot ROM settings look far more sensible. I wasn’t able to hinge to neutral until about 10 days into the boot and that was with gentle active stretching. After 2 weeks the rom was increased with a lock out at 7.5 degrees PF before going 2 shoes two weeks after that. I have no real complaints though, It all worked well in the end. Maybe my experience reflect perhaps my O/S possible inexperience with hinge boots. So i’d hope that other patients would be served better.
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Yes - fine, please do. Happy to help anyone who needs advice! As an addendum, I spoke to Richard Wallace again last week, for an article I am writing on achilles tendon rupture (see my 6-months post). He said: “I cannot justify doing an operation when not doing an operation gets a slightly better result.”
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