Feb 21 2012
I chose the non-surgical route
I met with the Orthopedic surgeon on Wednesday 15/Feb/2012.
Having done some preliminary research, I thought I was set on surgery. It seemed to me that if you wanted to return to full strength and have less chance of a re-rupture, surgery was the choice.
To my surprise, the doctor advised against surgery. He was a fan of a study published in the Journal of Bone and Joint Surgery (JBJS) that showed the non-surgical route being just as effective, and without the complications of surgery. The problem with past studies was that the conservative methodology was just that, it was too conservative; it required immobilization for about 6 weeks before even beginning rehab. This study used a much more "aggressive" rehabilitation approach.
(I would later find the link to the article here: Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures )
In the end he mentioned it was my choice, but I listened to him. There were some other factors as well, main one being that I did not want to miss work for any longer than I would have to.
I was strapped into an AirCast Boot fitted with heel wedges (to provide a 20 degree plantar flexion), given crutches, and advised to go non-weight bearing (NWB) for 2 weeks before seeing him again.
Though with my arrogance, impatient nature, and very (overly) optimistic view I haven’t been NWB but that’s a blog post for another time.
* On a Side Note *
I just wanted to add that I was actually misdiagnosed when I went to a walk in clinic the day after my injury. I expressed my concern that I was afraid I had an ATR, so the doctor gave me a couple tests to see if I could exert pressure against her hand with my foot. She said I had simply strained the tendon and to rest up for 2 weeks and then come back and see her.
I was relieved, but I still had a lingering in my gut that it was worse than she said it was. I went and got a second opinion the next day, and was told immediately to go to the ER after the doctor performed the Thompson Test. It was then that I got scheduled to meet with the Orthopedic surgeon.
I have all the respect for doctors in the world; many of my close friends are pursuing that path. It is rigorous, demanding, and most often at times an under-appreciated profession. Doctors make mistakes, I understand that. But if you are unsure, I do advise to get a second opinion.
Hello KM, thanks for the update. I have my meeting with an orthopedic surgeon tomorrow so will be interested to hear how my consultation compares with yours. Good luck and look forward to reading your future posts as we are on similar timescales (my ATR occured 15/2/2012). I am in the UK so not sure what is favoured here, I am sure it varies depending on consultant, let alone country.
Good luck with your tendon and its repair.
I too chose non surgical and the use of a Vacocast boot (in the UK), and I haven’t had any major problems beyond irratations and feelings of insecurity about my leg etc.
If my blog can be of any help, please have a read at http://achillesblog.com/adamp/
Good luck. I wouldn’t improvize on the rehab, though. The studies with good non-op results all started with an interval of NWB. Some day, we may discover that it’s safe to skip that, but I wouldn’t bet my AT on it.
As many ATR patients have discovered, there is another muscle-tendon pair in the leg that can also plantar-flex (extend) the ankle, but not with much force. So checking if you can push your foot down with some pressure is not diagnostic; the Thompson test is, and it’s very simple to do. (One smart Ortho sports-med surgeon even told me that he diagnoses ATRs as soon as he hears that the patient has begun climbing stairs by squeezing their whole injured foot on the step! That other muscle-tendon pair is nowhere near strong enough to support our whole body weight.)
BTW, that study you linked is the one that most of us here call the “UWO study”, because most of the authors teach at the Univ. of Western Ontario, a few hours drive from here. (I’m in Toronto, they’re in London, ON, Canada.) It’s a good one, probably the best so far.
you might want to look at my rehab protocol which mostly follows the New Zealand Bruce Twaddle non surgical protocol. It has early movement and at 15 weeks I’m really pleased with how it’s gone. However I agree with Norm you must not mess with the rehab, heeling long and re rupture being real risks to avoid at all costs
Hey Norm,
Ya I learned that you can still (weakly) apply force with the foot despite a ruptured Achilles afterwards; I was kind of disappointed the walk in doctor I went to see did not know this and I am glad I got a second opinion.
Unfortunately both my parents are out of the country right now (in fact my mother does not know yet) so I still have to look after the house. Cooking can be a bit of a hassle, and now I have just switched to using one crutch when cooking but obviously being careful not to put to much weight on my left foot.
Immediately following my injury, I drove myself to the doctor, using my right foot with a total rupture. On the way there, I sort of rationalized that this must mean I didn’t have a complete tear.
It’s surprising to me how many people (including myself) are mis-diagnosed, when there is such a simple (Thompson test) to check for an ATR. Some unlucky folks have gone months before a correct diagnosis/treatment.
Mostly my own fault but I went six weeks without a correct diagnosis. Part of the problem was I had good strength with plantarflexion, with “pumping the gas.”
I think the window of opportunity to have the conservative option is pretty much within a few days of the injury. Otherwise, ff you walk on it, the separated parts tendon become chronically inflamed and start to unravel, turning into mush.
By the time I got it straighted out, surgery with the FHL tendon transfer was best viable treatment.
So I applaud kilomike for getting the second opinion right away, and getting treatment started.
Common sense for everyone but me, I’m sure, but if someone has any doubt, get the first and second opinions ASAP. The sooner you start treatment, the more options you have.
Back to the conservative approach. Yes, the Achilles tendon will heal by itself but only if the injuried person co-operates! That means both the boot and accepting some real limitations early on. I placed too much trust in my body to magically solve the problem — and not enough attention to what my leg was telling me. Never again! Pain is your body’s way of saying: “Listen, stupid …”
Janus, I think you’re probably 100% right. I wish the authors of the UWO study would take my suggestion to analyze their data on their ~75 non-op ATR patients, to see if there’s a correlation between (a) how soon they began treatment (immobilized in the AirCast boot), and (b) how good their clinical outcomes were.
They’ve already published an analysis of the possible correlation between ATR gap size and/or gap location, and clinical outcomes, and they found (surprisingly) that there was NO correlation. Like you, I expect that a quick and easy analysis would find that the patients who got “booted” very quickly, came out better than the ones that hobbled around in shoes for a week first. (The study excluded anybody whose ATR happened more than 2 weeks before they entered the program.)
Of course, our expectations are based on logical-sounding conclusions from what little we know, and many such expectations about ATRs have already been overturned by evidence from carefully controlled studies, so who knows?
Hello.
I went the non- surgery route and I have to say I’m a fan. I did have a bit of a set back with a partial re-rupture but now that’s passed I think that could of happened if I’d gone either route. (I also got mis diagnosed at this point at my ultra sound, and it was the darkest part of my injury, they said it was a full re rupture and it wasn’t. Mistakes can happen)
I’m in the UK and and on the NHS, I had really good people looking after me, and my consultant was very much it’s 50/50 on if you should operate or not.
I’m now nearly a year down, at the end of my physio and discharged from the doc. It’s been an experience to say the least.
Good luck with your healing up.
Mark
http://meandmyachilles.wordpress.com/
mit MADSAKI Crazy Love Levis 517-Version von Art-Design aus Tradition, an der Zukunft schaffen begrenzt den Trend eines einzelnen Produkts.
I’m now nearly a year down, at the end of my physio and discharged from the doc. It’s been an experience to say the least.
I am from Argentina, living in the USA. I am 31 years old. I also was given the choice of nonoperative or operative treatment. I am leaning towards the nonoperative treatment. I asked the doctor if he could do an MRI since I read that some suggest that nonsurgical management should be used only when there i a coaptation of the tendon ends with the ankle in 20 degrees of plantar flexion. I had a splinter for 5 days now and waiting for the doctor to give an answer regarding the MRI. I am wondering if some of you can update us on some of the progress you are having and what age you are. Thanks to all of you for the info provided in this blog.
Marcos,
I went non-op and am 33 weeks into my recovery. Things went well. I can walk without a limp and jog. About the only thing I’m still working on is recovering the strength in my calf but that is going to take a while. If you go non-op there is no need for an MRI. The biggest reason to get an MRI is if you go surgical so the doctor can identify the exact location of the rupture and reduce cutting.
As is point out often on this site, the key to a fast and high quality recovery is using modern protocols such as the UWO.
I went 2 months walking on a ruptured achilles not knowing what I had. Things were getting progressively better and I was walking around albeit with a limp. But things did seem to be getting better-I guess some of the othe tendons took over the weight bearing. Went I went to my surgeon and he did an MRI, I had a 4 CM gap. Thought surgery was the only way to go but he said non-operative was also an option if I could accept not getting back to 100 %. I am 61 years old, fairly active-golf walking etc. but do not run, play BB or do any kind of competitive sports. Thought about it and said OK to non-operative. Thought was if I was getting around after 2 months and did the 8 week protocol-4 weeks in a cast and 4 in a boot, I would at least have to have more mobility than I had after 2 months of walking around and that seemed good enough for me. Anyone have a similar experience. I am worried that I will still need the surgery and have to go through this all over again. Thanks. JR
JR- I had a smiilar experience (a long delay between injury and treatment), but I opted to go surgery, since I’m only 32 and wished to still maintain my somewhat active lifestyle. I guess my doctor’s didn’t believe it would heal correctly at 3-4 months out, but neither of them gave me a very good explanation. Both doctor made me to believe that I could only go non-op if I stated that treatment right away I told me to go for the surgery if I was healthy and under the age of 65. I wish I could be more help and ultimately the decision is yours. Good luck with your treatment.