Thursday, March 14th, 2013...11:48 pm

Rollercoasters of optimism and frustration…

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Arrrgh! Had been feeling pretty good this last week or two.  I’ve been kayaking for some cardio and was growing tired of waiting to see someone for follow-up (OS said I could come back in 5-6 weeks and to take one heel wedge out of my boot per week but offered no other info).  I’d been reviewing the literature on this site and other sources and decided to take some initiative so I booked an appt. with a physio.  Their centre’s site impressed me because it included posts summarizing relatively recent studies about ATR:

The physio agreed that early motion was important to keep the rest of the foot/ankle joint healthy but was leery of early weight-bearing (b/c I’m non-op) without an ok from the OS or seeing an ultrasound.  She did at least say she would look into recent research I’d mentioned and ask some of the specialists about it at her next shifts at the hospital.  (She works part-time at the sports centre and part-time at the hospital).  First person I’ve met who’s actually said, "I’ll look into what’s been published lately!!!"

She started me on some very light, basic ROM ankle exercises seated with the boot off (eg. gentle massage of ankle, heel, arch, toes, some toe scrunches, small ankle circles/alphabet but NO dorsi-flex past neutral).  I immediately felt less stiff in the ankle/foot and my swelling went right down (i.e. My foot/ankle almost looks normal with a tiny bit of swelling below inner ankle).  I was feeling very pleased with the "feel" of it all (never mind the mental state of finally being able to DO something).

Today, I needed some more paperwork signed for work/insurance so I went to see my GP (she’d been away and her locum was the one that had done all my previous paperwork/decision-making, etc. when the ATR took place).  She is not pleased that the boot has come off at all and doesn’t think I should be doing any physio yet.  She wants me to see the specialist and get the green light from him on these physio exercises and to get another ultrasound again before proceeding.  Tried calling the specialist’s office and got an answering machine of course.  Who knows when I’ll get an appt. for an ultrasound or a green light for physio?!?  Not excited about more waiting and wondering for ?!? weeks without any answers, especially if the ortho ends up saying, "Oh no problem, some light ROM physio, seated and out of the boot is just fine at this stage (4 weeks)."  Meanwhile, I’m sitting on my duff waiting for another 2-4 weeks just to get an appt. to find this all out!  At this point I really feel like ignoring today’s appointment and continuing on the schedule I’ve started (and that others on this site have successfully followed).  I don’t want to risk not healing properly/re-rupture and be labeled a "non-compliant patient", but I also don’t want a slow, crummy recovery if I’m stuck on a path that’s too conservative.  Any other non-op experiences out there (besides Norm of course :) ) to back me up on this?  I really can’t stand these head games…


  • Not just Norm, there are others here (Hillie pops to mind) and ~75 in the UWO Study and others in the other studies. Just because they’re not all blogging here…
    As you’d expect, I’d give several extra votes to any health pro who looks at the evidence…

  • Thanks Norm. I think I just needed to blow off some steam yesterday. Things had been going so well lately so it was a discouraging visit. I’ll at least continue with these gentle seated ROM exercises on my own since there’s been no adverse side effects (other way around really) and I’m hearing from you, research, others… that these shouldn’t inhibit tendon/muscle attachment, growth and repair at this stage (week 4). Planning to see another doc this week for a second opinion and hopefully some peace of mind? Also, did finally get another appt. with the specialist, but not until beginning of April…

  • Agreed! I followed the UWO protocol and was cleared for all activity in a little over 30ish weeks. As Norm states above, if you look at the evidence it’s easy to see the merits of an aggressive recovery protocol.

  • Thanks for chiming in Eva. Nice to hear from some more non-op folks and congrats on the great recovery. So encouraging to see your positive words.

  • I would agree that you are not doing anything wrong by gentle ROM with your leg supported. It is interesting that your physio has posted summaries to references regarding early ankle movement where the study referred more to early weight bearing. I have the link to the full version on my further reading page. I think it is also good to read the full versions or as much as you can get from the original source. One of the links from the physio refers to a study with just over 20 people and has a number of shortfalls. I am not saying to disregard it, only how much weight may be placed on it (pun intended). In my early days of this injury I sought out any information that told me what I wanted to hear. It took a while to gain some perspective and my physio helped in that regard. I am a big fan of early weight bearing and movement. It worked for me and many others but I was a surgical patient and would not like to comment directly about Non Op. One of the studies referenced by your physio does indicate that the tensile strength of the tendon is enhanced in the early stages of healing by sutures but is less significant later. If you copy and paste in a google search the actual reference at the bottom of summaries in your links, you will find a huge amount of information. I found an actual dialogue with the author of the UWO study that Norm refers to. It sounds like you have a good phsyio and I am sure you will find a balance and heal well. It is still early days and as I remember at 4 weeks I was still looking for a short cut. Balance and perspective in the mind is not far away. Balance and perpective in the body will follow once the mind is properly taken care of.

  • Thanks for this Xplora. Yes, I’ve been looking at studies other than these as well (though I admit to only having access to the full text of some) and wasn’t putting that much weight on these specifically, I was just pleased to finally find someone who was looking at relatively current research at all or willing to at least talk about/explore it :) I haven’t felt that the professionals I’ve seen so far have really offered much in the way of info. Most are very busy - which I know I need to respect - but it’s frustrating to not get anything. GP doesn’t want to do anything without OS approval. OS didn’t do surgery on me and originally rejected my referral altogether so isn’t particularly invested/interested in ‘taking on my case’. So I’ve just felt brushed off by everyone. The doc in ER who originally had me in a cast up to the top of my thigh did it saying to just trust him and that this is what he had experienced with his ATR… but that was in the 70’s! (OS agreed it was totally unacceptable). I guess that started me off on a bad foot (ouch!) and didn’t inspire a lot of confidence.

    All that said, you’re right that I’m likely not being very objective and only seeking out what I want to hear. I will try to take your advice, embrace some mindful patience and stay balanced (besides when using the crutches :) This is quite the journey and I guess I just hit my first mental stumbling block.

  • I really think you will be fine. You are already being an advocate for your own rehab. You are becoming well informed and you have a health professional willing to listen and maybe learn. You are way ahead of many others. My Doc saw me twice - 1 week and 5 weeks and was not all that interested either. He pretty much left me on my own with the physio. I only attended physio once a week from week 4 and then cut it back to once a fortnight when I was walking fine in shoes but I did all the exercises and worked hard. I had a good result from an accelerated program much of which was derived from research and this forum. I would not be too concerned about your GP. It is your PT that will bring you through. A functional rehab is so important. You can be ascertive without being non compliant. It is your body and a doctor has no right to force treatment on you that you do not want. Good luck with it all. Another couple of weeks and things will be looking better.

  • Jdrg, you raise an interesting point a out the role of the OS in a non-op treatment. Theyust wonder about it, too. In a way, they’re more superfluous in a smooth rehab than an ob-gyn doctor in a home-birth with a midwife. In both cases there could be complications that require a doctor or a hospital, but normally Not So Much. And if they haven’t been keeping up…
    It’s impossible to be an expert on everything, and if an OS is doing joint replacements and a dozen other ops, it’s easy to forgive them for ignoring the ATRs, especially the non-op ones — easy unless you’re the non-op ATR PATIENT, that is!!!

  • If everyone with an atr went non-op, there would be many less posts than there are in reality. This blog just wouldn’t be as interesting, in a kind of macabre way.

    Obviously though, everyone (?) understands that there are cases which absolutely do require surgery - I read an article in the UK press about a tv presenter whose damaged tendon was described as looking like a spaghetti dinner (or something like that). Others simply leave it too long between rupture and correct diagnosis>treatment - in my case it was 10 days but was treated successfully with no surgery (admittedly a borderline case) and on an aggressive modern protocol.

    The inherent risks and effects of surgery give those contributing here much more to talk about and ask about, although there are also many non-ops requiring reassurances about their treatment. This is usually because their process seems just too simple to them, especially compared to the very many US examples where patients don’t appear to have a treatment option even considered.

    I saw my ortho consultant only once. After that it was over to the physiotherapists. My protocol, given to me in writing, was called ‘Complete Achilles Tendon Rehab - Conservative or Surgical Management’. i.e. the same for non-0p as surgical and at a rate comparable to the often-mentioned-here UWO findings but with a more advanced boot (time has passed since the excellent UWO research took place). In reality, not so conservative!

    Every 2 weeks my boot’s range of movement (ROM) was increased and by the end of week 8 I was in 2 shoes. I had dispensed with crutches at less than 4 weeks (but kept them available ‘just in case…); didn’t wear the boot in bed after 4 weeks either.

    Basic exercises started at about week 3 and gradually increased. The static bike stuff began by week 4 or 5, and by week 10 the regime included swimming, plenty of gym work, increasing level of weights, etc.

    After hospital sign-off, I had regular NHS physio sessions for a few weeks, then at about week 16 or 17 started 8 weeks with a sports physio.

    A year on, my hill walking and trekking is completely back to normal (and pretty heavy duty too), maybe even better than pre-atr because of more disciplined, instructed. However, I did not do enough upper body work in the early days, not enough to maintain core strength, and my weight carrying capability subsequently suffered - whatever you think you are doing, it is probably not enough.

    No, I don’t post often these days, which must be a hell of a relief after seeing how long this one is.

  • +1 to Hillie’s, with one minor tweak:
    There is NO evidence that especially gnarly ATRs — like “spaghetti” or “horses’ tails” — respond better to surgery OR do worse with a non-op treatment. The reuth may even be the opposite:
    (1) My 2001 OS who repaired my ATR #1 complained about my “horses’ tails” and was worried about the outcome. (He kept me immobilized extra-long to “make sure”, which is probably exactly backwards, though my results are OK except too short.)
    (2) My much fancier 2009 OS (chief surgeon of Toronto’s pro football team!), who guided me into a UWO-Protocol NON-op treatment, told me that (before he abandoned ATR surgery) he had always avoided repairing “horses’ tails” by delaying surgery for 14 days post-ATR. With the patient hobbling around in 2 shoes, the torn ends stay separate but start healing separately, tightening up the messy strands into neat “end caps” that he found much easier to stitch together, and he trusted the results more, too.
    All of this suggests that IF an ATR patient somehow found out that his/her ATR was like “horses’ tails”, that should probably bias their treatment toward non-op. I said “suggests” because this is way less evidence than a randomized controlled trial like the UWO study — but it’s about all we’ve got.
    BTW, we DO have some randomized evidence that UWO-non-op works as well on big gaps as on small — details of that UWO sub-study on my “studies” page (I hope!).

  • A minor tweak, Norm?

    You know that I am a fan of modern non-op rehab protocols whenever possible (I’ve banged on about it enough and benefited myself from an enhanced version of the UWO regime), but I simply cannot believe that non-op is as successful, or more so, than surgery for some of the cases covered by your examples. And of course there are AT injuries that it would be impossible to fix without surgery.

    As for delaying surgery for 14 days, doesn’t this get close to the end time by which, if no action has been taken to bring the ends together (as in 2 shoes) it becomes too late for a natural ‘coming together’? My memory might be failing me too because I felt that you had even made comments to this effect in the past - I would emphasise that I could be wrong here…

    There may also be no PUBLISHED evidence but the true ortho specialists out there do have the evidence of their own experience and they are not all influenced by income generation, and they do follow best practice. At ‘my’ ortho centre, one of the best in Europe, they handle many sports injuries in addition to those suffered by more sedentary members of the population. They are vastly experienced and capable. In this blog I haven’t yet seen a protocol better than the one that I followed.

    So, there it is, merely to generate a bit of debate and perhaps create more understanding.

  • Hillie, it was a minor tweak (despite how many word I used!), because I was disagreeing with ~4% of your post, and adopting the other 96%. In the real world — since few or no ATR patients will know pre-op or pre-non-op that their ATR ends look like horses’ tails (I’ve never seen an MRI or US image that shows it clearly) — our disagreement is purely academic and untestable, IMO.

    I have recommended surgery to several people on this site, despite my general support for non-op treatment for routine ATRs caught promptly. Did I contradict that in my “tweak”? There are conditions that indicate surgery, but “horses’ tails” probably isn’t one of them, and it may even go strongly the other way. That’s all.

    Is your clinic’s “enhanced” version of easily accessible online? Even without published superior results, some folks here may want to check it out. I posted the UWO Protocol myself, and also created that memorable URL for it, and you could do the same with yours.

    BTW, I don’t get your point about the 14-day delay. Dr. Z now recommends non-op with UWO’s protocol, but before he met the UWO authors, he was scheduling repairs for ~14 days post-ATR. Different legs, different treatments, where’s your problem?

  • Norm, if we’re just ~4% apart then that’s a pretty healthy disagreement, although I would say that a quick read of your post could imply a totally anti-surgery viewpoint, especially to a new ATR casualty. This is where I was coming from, mainly because I knew, after the past 12 months, that you were more open-minded than that, which you have confirmed and clarified this time round. The part of your diatribe that I read poorly was about the 14 day post-atr wait.

    My protocol was based around the use of Oped’s VacoCast hinged boot but I haven’t seen it online so far. I’ll see what I can do.

    Reminds me of a pub near to my old college where, after classes, our tutor would say something out loud and controversial to get a debate going. Always worked, often with another drinker also asking where’s your problem?” and as far as I know he never got a punch in the face either. Instead he was usually given a pint for his troubles.


  • Hi Guys
    Sorry to post on here….but how do I get to start my own blog? Ive registered and emailed to hopefully start one but that was like 10 days ago is that the norm?
    for now all i can do is comment am i missing something obvious?

  • If you’ve registered successfully and sent the appropriate email to Dennis, then i’d just be patient. Maybe he’s “gone dark” to have a restful March Break? (It’d be hard to dock his pay, when he does all this for love…) check the new Blogs on the main page, that’s where it will show up.

  • And now I see that you’ve got it, and found it, and populated it with your story! :-)

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