Friday, March 1st, 2013...8:06 pm
What? You’re not going to ‘mend it like Beckham’?
Cheesy, I know. Couldn’t help it…
It probably sounds odd but I was initially upset when I heard that the orthopedic surgeon said I wouldn’t be having surgery. At that point, every study I’d come across said that those who’d had surgery after an ATR recovered more quickly and that there’s a smaller % chance of re-rupture than a conservative, non-operative approach. Provided the patient was young, healthy, athletic and wanted to return to sport, surgery sounded like the way to go. I felt cheated. Wasn’t I young/healthy/athletic enough?
Thanks to this site (Yay Dennis!), and ‘normofthenorth’ in particular (thanks Norm!) and some perusing of the grey lit., I’m beginning to feel more optimistic. Norm will quickly point out that recent (2010) research out of the University of Western Ontario (UWO) found that "accelerated functional rehabilitation and nonoperative treatment for acute Achilles tendon ruptures" indicates that, "all measured outcomes of nonoperative treatment were acceptable and were clinically similar to those for operative treatment. In addition, this study suggests that the application of an accelerated-rehabilitation nonoperative protocol avoids serious complications related to surgical management" (Willits et al, 2010, conclusion).
- Willits, K. et al., Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures: A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation . The Journal of Bone & Joint Surgery . 2010 Dec;92(17):2767-2775.
The following more recent 2012 study affirms these findings…
- Alexandra Soroceanu, MD, CM, MPH, et al. Surgical Versus Nonsurgical Treatment of Acute Achilles Tendon Rupture: A Meta-Analysis of Randomized Trials. The Journal of Bone & Joint Surgery . 2012 Dec;94(23):2136-2143.
Experts in the field are definitely still debating this topic (Battles of Achilles: The operative vs. nonoperative treatment debate ) but for my situation, rupture above/upper area of the musculotendinous junction, most surgeons will elect not to operate. This is because sutures at or above this musculotendinous zone will not hold.
- The Achilles Musculotendinous Junction: A Survey of Orthopaedic Surgeons. Retrieved March 2, 2013, from http://faoj.org/2009/12/01/the-achilles-musculotendinous-junction-a-survey-of-orthopaedic-surgeons/
Short story - I am officially on the non-operative path and will now need to make sure my OS and PT are onboard with a more aggressive functional treatment protocol like UWO’s. For more great discussion on surgery vs. no surgery for ATR you can also check out Norm’s site and the comments on Ryan’s blog here , and the main Achilles blog page on ATR rehab protocols, publications and studies .
Btw, if you’re interested in more famous folk who’ve been on this ATR recovery marathon, here’s a couple great lists by Brendan and Adam . Thank guys!
3 Comments
March 1st, 2013 at 9:54 pm
I wish you the best of luck! Ive just come home from my second ATR repair and I’m curious to know from your reading or anyone here’s knowledge, if one could go non-op if a) their tendon had retracted “like a window shade” all the way up their calf and b) as was my case with this second leg, the tendon had completely detached from the muscle? I don’t quite understand, since in both cases, the surgeon couldn’t tell until she actually looked at it, how it would have repaired itself non-op?
March 2nd, 2013 at 2:54 am
Lisa, some of the mechanism that closes up an ATR gap during non-op treatment is “magic” — i.e., not well understood. Of course, that’s not very unusual in medicine, where we often know (and care) much more about WHAT works well, than we do about WHY or HOW it works. (I’m not sure we understand yet just how Aspirin/ASA/willow-bark does what it does!) Heck, the reason “Evidence-Based Medicine” is still somewhat controversial, is because the medical establishment often doesn’t even follow the evidence on WHAT works well!
Part of the answer is that the non-op ATR leg is immobilized “in equinus”, plantar-flexed, which tends to bring the torn AT ends closer together, maybe “approximated” (i.e., in contact). And part of the answer (according to some theoretical speculation I’ve read) is that the “paratenon” — the sheath that surrounds the AT — is almost always left intact in an ATR leg that’s treated non-surgically. And according to that speculation, that paratenon somehow effectively “directs” the healing, so the healed ATR has the same length as that intact paratenon. (In contrast, a surgeon who’s repairing an ATR has to slice into the paratenon. And I THINK I’ve heard that they don’t usually bother to repair it, but I may be wrong about that.)
In terms of WHAT works and how well, we obviously have the UWO study and the other 3 post-2007 studies that compared op and modern aggressive non-op treatments. They generally found statistically comparable results, in strength, ROM (a “place-holder” for tendon length), and re-rupture rates, with minor differences here and there. (BTW, I think the Nilsson-Helander cited above is the LEAST impressive of the four, for a number of reasons. The 2007 New Zealand study and UWO are the most convincing IMHO.)
In addition, I’ve seen ONLY ONE study that tried to answer your questions directly. It was a sub-study of the UWO study, published a while before the UWO study was published in 2010. (I THINK I posted a link in my “studies” page on my blog.)
In that study, the authors examined the records from the ~75 non-op patients in the UWO study, looking for patients who had clear UltraSounds at diagnosis. They found 25 such patients. And they “asked” the data two questions: (1) Did the initial ATR gap size predict the clinical success of the treatment? I.e., did patients with smaller tears heal better non-op? and (2) Did the initial ATR gap LOCATION predict the clinical success of the treatment? I.e., did the non-op treatment work better for high, low, or middle ATRs.
In both cases, they found NO significant correlation. Big gaps and small gaps came out “the same” (at least statistically not different), and so did high, low, and middle ones.
Mind you, 25 is a small database, so there may have been a tendency/difference that looks real but didn’t reach statistical significance. (I don’t think I’ve seen the full-text of the article, with the actual data, but it’s been a while. My blog may remember better!)
I also wonder about another little point: Many or most or even almost all Ortho Surgeons hesitate to operate at all on very high ATRs, where the AT has essentially separated from the calf muscle, as jdrg mentions above and elsewhere. But the UWO study doesn’t mention that they excluded very high ATRs from their study — yet they randomized their patients into op or non-op. Don’t THEIR surgeons mind operating on very high ATRs?!? Hmmm.
March 2nd, 2013 at 6:38 pm
Hey Lisa,
As a relative newbie in the ATR community, I’m still on a huge learning curve navigating all the info and trying to discern the best path forward for my situation. Best wishes to you for a great recovery.
Not sure I can add any more info beyond Norm’s detailed reply. He seems to be the resident blog expert on this topic
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