May

25

5 and a half week conservative update.

May 25, 2015 | | 9 Comments

A quick update. I have had the vacoped boot set to allow 30-15 degrees of plantar flexion for the last 12 days and all is going well. No pain at all. I have been sleeping without the boot on since week 4. I can get around short distances in the boot with no crutches fairly well. I use the crutches for prolonged distances just to help with the gait pattern. I have been back at work for the past 3 weeks. The last week has been great. I can stay on my feet most of the day and the swelling has stopped.

I can now get more done around the house. I have been out cutting the grass with a plastic bag wrapped around the boot to stop any green stains. I cut the hedges yesterday as they were getting out of control but left the tops as I will not be trying ladders for some time.

Looking forward to changing the boot angle to 0-30 degrees on Wednesday. The rocker sole on the vacoped really helps with the walking pattern. Due to see the hospital physio on Thursday but have been doing my own up until now using the protocols I have found on here and online.

Good luck to everyone with their recovery

May

13

4 weeks after the dreaded incident

May 13, 2015 | | 12 Comments

I am now 4 weeks (and 45 minutes - 2pm football kick off and lasted 5 minutes) post ATR - conservative management. I started in the vacoped boot 2 weeks ago locked in 30 degrees plantar flexion. The last 2 weeks have been great. Pretty much zero pain and getting around fine on the crutches. I have been back working in the physio clinic seeing patients 3 days a week using a saddle stool and have borrowed an automatic car for getting around. I get a bit of swelling by the end of the day but this is sorted easy with ice and elevation.

Today was my OS appointment which involved the usual 6 second check with one of the junior surgeons. The boot was kept on throughout the appointment and was advised to start adjusting ROM and return in 4 weeks. Physio appointment has been booked for 2 weeks time. I have adjusted the boot to enable 30-15 degrees of plantar flexion. When the boot gets near to 15 degrees of plantar flexion I get quite a lot of tightness in the lower calf / Achilles tendon. I am presuming this is natural and will ease over a few days. I feel I am being more protective with the weight bearing since I adjusted the ROM earlier today. Anything near full weight bearing at 15 degrees is uncomfortable. Has anyone else found this? How long did it take to ease?

Looking at some of the protocols I have seen people advised to sleep without the boot from 4 weeks onwards. Have any of you done this or all left it until later on. The boot isn’t really bothering me at night and I would happily leave it on if needed. However, if it is no longer needed it would be great to sleep without it.

Apr

29

ATR conservative protocol advice

April 29, 2015 | | 9 Comments

Hi. If you have read my earlier posts you will know that I nearly had surgery as I was initially advised that the ‘newer’ conservative protocols were not an option at the hospital I attended and my options were serial casting or surgery. Out of these options I picked surgery due to the better results. I met the surgeon for the first time 5 minutes before the surgery and he wanted to know why I was so keen to have surgery when modern conservative  treatment weight-bearing in boots from 2 weeks gave the same results. I agreed and skipped the surgery.

I attended my appointment today with the surgeon and was seen by his understudy. He met me by the door and said I was 2 weeks post rupture and should follow him. Nothing else was said and he asked me zero questions. He took me to the plaster room and advised that they would be putting me in serial casts with the angle altered every week. I informed him that I had spoken to the surgeon last week and agreed to be put into a boot this week with early weight bearing. He didn’t seem to think I was right initially until I pulled out the Vacoped boot that I has bought privately from my bag that I had discussed with the surgeon last week. He seemed very impressed with the boot and went for a 10 second chat with his boss. He came back and agreed with the boot and said he wanted to see me in 3 weeks.

The cast was cut off and I was left to put on the boot as the plaster room assistants hadn’t seen one before. The surgeons had long gone by this point. I have been given zero advice on weight bearing, ROM or exercises. I have read through lots of research over the last 2 weeks on protocols etc (which is a good job now!). I have put together a protocol from using the Royal Exeter and Devon protocol on Suddys blog, the UWO study protocol as posted by Normofthenorth and the protocol advertised by VACOcast on their website with a small sample sized study. I have made a few tweaks regarding small regular adjustments in movements instead of jumps every 2 weeks. I am an experienced physiotherapist but have only treated one person post ATR several years ago. I would be very interested on your thoughts and any suggestions for improvement or exercises at different stages.

Weeks 0-2 - NWB in equinas cast (finished!)

Weeks 2-4

Vaco boot set static at 30º PF

WB as able

Wear boot at night

Active plantar and dorsi flexion to neutral, inversion /eversion below neutral

modalities to control swelling

knee/hip exercises as appropriate

Hydrotherapy - Walking in pool with orthosis (within motion and weight-bearing limitations)

Regular icing with foot relaxed in plantar flexion.

Weeks 4-6

Progress ROM to 30-15 degrees PF

ROM 30-25 degrees on day 1 of 4th week. Increased every few days as tolerated by 5 degrees until at 30-15 degrees PF in the 5th week.

Full weight bearing and wean off crutches

Remove boot at night

Active plantar and dorsi flexion to neutral, inversion /eversion below neutral

Knee/hip exercises as appropriate

Hydrotherapy - Walking in pool with orthosis (within motion and weight-bearing limitations)

Regular icing with foot relaxed in plantar flexion.

Weeks 6-8

ROM 30º PF – 0º neutral

To be increased by 5 degrees every few days until reach 30-0 degrees

Full weight bearing

dorsiflexion stretching, slowly

Graduated resistance exercises - open kinetic chain (theraband) and closed kinetic chain.

Proprioceptive and gait retraining

Hydrotherapy

Modalities to control swelling

Static bike (can this start sooner?)

Week 8

ROM 30º PF to 10º DF.

Full weight bearing

dorsiflexion stretching, slowly (if needed for ROM)

Graduated resistance exercises - open kinetic chain (theraband) and closed kinetic chain.

Proprioceptive and gait retraining

Hydrotherapy

Modalities to control swelling

Static bike

Week 9,. Shoes ok indoors with heel pads. - Boot outdoors as per week 8.

Week 10-16  Out of boot indoors and out. Use heel pads as comfortable. Can take boot outside too as a precaution if desired or ‘hazardous’. Increase exercise tolerance with gentle and frequent walks, cycle, swim.

Aerobic gym work as comfortable e.g. x-trainer, treadmill walking, stepper

Not running or jogging for 4 – 5 months post ATR.
OK to make the calf ache, but rest before carrying on. Change activity frequently to avoid fatigue and rest when and if you get tired/ache or ‘burning’ feeling around injury site.

Not advisable to
• Play explosive sports e.g. squash/ badminton
• Do maximum resisted weight work for lower legs, or use rowing machine
• Go up and down rung ladders
• Horse ride (heels go down in stirrups)
• Do loaded passive stretching of calf (heel hangs on step)
FOR 6 MONTHS AFTER INJURY DUE TO THE POTENTIAL RISK OF A RE-RUPTURE!

Apr

24

Swelling and ice treatment / cryo cuff

April 24, 2015 | | 6 Comments

Just looking at the rehab further down the line. Do people generally get a lot of swelling? Do you find you end up using ice quite a lot? I’m thinking of buying a cryo cuff. Has anyone used one and found it helpful?

Apr

24

Hinged boot or static boot with wedges?

April 24, 2015 | | 7 Comments

Hi, I am now 9 days post ATR - conservative treatment. I am due to go in a boot next week. I spoke to the OS and the plan is to go into a boot with wedges. I mentioned the vacocast / vacoped boot. He is happy for me to buy this and use a hinged type boot. Does anyone know of any research comparing hinged boots to static boots with wedges? Does the hinging give you any benefits / increase risk? Functionally is it easier to manoeuvre in when FWB and when progressing to 2 shoes?

Apr

21

A Physiotherapist 1 Week Post Achilles Tendon Rupture - Surgery or Conservative Management?

April 21, 2015 | | 7 Comments

Hi,

I am a 34 year old physiotherapist from the UK and I ruptured my Achilles Tendon playing football 7 days ago. It was my first football match in 7 years and I lasted a full 5 minutes! I went to push off from my left leg to go from standing to jogging / running and felt a sudden pain in my left Achilles and heard a ‘pop’. I remember thinking someone had kicked me from behind or thrown a water bottle at me that had exploded. As I was falling down I looked behind and didn’t see anyone. By the time I had landed on the floor I knew exactly what I had done!

Whilst waiting for a lift to the local A and E  I spoke to a friend that had been involved in recent research on Achilles’ tendon rupture protocols. His advice was conservative management and early weight bearing in an orthotic boot locked in plantar flexion and gradually decreased. I was 500 yards from local A and E department when it happened so was taken there. I generally avoid this hospital and recommend to friends, family and patients that they go to the local teaching hospital with a large orthopaedic department. This wasn’t an option unfortunately.

The accident and emergency doctor gave me the option of surgery or a cast and non weight bearing. I mentioned recent research and weight bearing in an aircast boot with heel wedges. He advised this maybe an option in an orthopaedic specialist hospital but not there. He then made arrangements for me to attend the next day to see an orthopaedic surgeon.

First thing I did the next day was to call the teaching hospital and ask if I could be seen there. Not without a referral from the hospital where I attended A and E was the answer. I tried talking to the secretaries of the foot and ankle consultants of the teaching hospital and got the same answer. Also was advised that if I was referred from the other hospital I would be on a long waiting list. This isn’t acceptable with an Achilles’ tendon rupture. I then even contacted the local private hospital where the specialists from the large teaching hospital work but got no response.

The options I was given were for surgery and rehab or the old fashioned conservative management of none weight bearing in a cast and serial casting. The research gives better outcomes for surgery with these 2 options. The orthopaedic surgeon I saw (shoulder specialist) advised a 2% rupture rate with surgery compared to 15-20% with ‘conservative management’. He also advised that conservative management would leave me with decreased power. Given these options I opted for surgery as I am keen to get back on my feet as soon as possible, do not want a further rupture and want as close to full power to enable a return to an active lifestyle. If the conservative management of early weight bearing in an functional orthotic brace was an option I would have gone with this.

I was then seen by the orthopaedic nurse who advised I would likely be for surgery the next day. He asked me to fast from 8 am and they would call at 9am to let me know what time I would be in. I called them at 10am and they did not realise that anyone asked me to fast and that my operation would not be until the middle of next week. I received a phone call from another member of the orthopaedic team the next day requesting I brought Callum in to the children ward as they could do his surgery that day. Who is Callum?

Anyway today was the day of my surgery. I spent half of last night looking at the research for modern early weight bearing conservative treatment compared to surgical treatment and couldn’t understand why this wasn’t an option. I arrived at the hospital this morning and was admitted. I met the anaesthetist just after lunch and agreed on a spinal block. I changed into my fashionable hospital gown, had a black arrow drawn on my left leg to indicate which to operate on (this gave some confusion as all my notes said it was the right Achilles I had ruptured) and had all my obs taken.

I then met my orthopaedic surgeon for the first time (foot and ankle NOT shoulder). He wanted to know why I was so keen on surgery. I advised him of what had happened and the options that were given to me. He said he hadn’t operated on an acute achilles tendon rupture in over 2 years. All the research suggested that conservative management was as good as surgery but without any of the complications. He does 2 weeks NWB in a POP followed by an orthotic boot with wedges that are gradually decreased. He stated if it was his achilles tendon he would treat it conservatively but he would operate if that was my wish. At last someone at the hospital that talks sense! I quickly put my clothes back on and made my escape to the plaster room to change my back slab for a lightweight cast.

I am back again for a review with the consultant in one week. I will then be placed in the aircast boot with wedges. I have looked into the Orthped / orthocast boot and mentioned this to the OS. He would be happy for me to use one of these instead of the aircast boot but this is not available from the NHS trust I am at. For anyone that has tried to Orthoped / orthocast, is it better than an aircast boot? If it is more comfortable and lighter I would be happy to pay the money as I will be in it for a while!

Kristian