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!


Comments

9 Comments so far

  1. herewegoagain on April 30, 2015 3:30 am

    Looks like a great plan to me and really similar to the one I used.

    I started using a spin bike just before 4 weeks and it was fine- no resistance and the boot centred on the pedal. I will be interested to hear how hrydrotherapy goes in the vacoped!

    I slept with the boot on until 7 weeks- longer than my protocol allowed but I felt it best for me.

    The gait issues and boot height variation can play havoc with the rest of your body. For me it was my hips that suffered- I wish I had of spent more time exercising my glutes etc to support the wonkiness!

    I think you are doing a great job of acting as the best advocate for your own recovery- how lucky to be armed with a boot and avoiding the dreaded serial casting!

  2. donna on April 30, 2015 4:58 am

    I concur with Herewegoagain…Also, she said: “…and avoiding the serial casting!” I’d add and avoiding the trauma of surgery! YAY you!

    Good job on your research, on your ability to be proactive, and my very best to you in your rehab plan!

  3. Kristian on April 30, 2015 10:46 am

    Thanks for the support Donna and for the advice herewegoagain. I’ll start the bike at 4 weeks. Non of the protocols started them this early but if you can FWB at this stage I can’t see why an exercise bike would cause any issues.

    Plan on starting my own hydro sessions either tomorrow or early next week at the local pool . I bought a drycast pro for showering that works well so will use that in the pool. You can use the vacocast without a cover in the pool and swap the inner section after. Prefer the idea of keeping it dry. Will just walk in the pool for the first few weeks a couple of times a week.

    Started icing last night as have quite a bit of oedema. Going to order a cryo cuff later today as think I will be needing it a bit. Also going to order some compression socks to wear under the vacocast unless anyone knows of a reason not to?

    First nights sleep in the boot wasn’t the best. Was getting numbness in my toes so loosend the boot and ended up taking the front plastic section off and kept my foot in the cushioned wrap section with Velcro straps to keep it in place. Much better after this.

  4. Doug on April 30, 2015 12:07 pm

    Great stuff here Kristian. I trashed my Achilles on April 6th (Easter Monday). Back slab put on next day, then into Ossur Rebound Airwalker with full set of wedges - local NHS have policy of avoiding surgery and very good success rates with circa 5% rerupture rate using boot. Was advised I could weight bare as long as no pain and I’m now getting about pretty well, one crutch only required if going out. Had first wedge removed last week and can certainly feel gap in tendon is closing.

    Next hospital visit is end June - helps that I know the lead clinician and he trusts me to do the right thing!

  5. kristian on May 1, 2015 9:41 am

    Sounds good Doug. Did they give you any advice regarding exercises? Is it wrong that I am glad I am no longer at the back of the group marathon tracker?

    Looking at the dates of everyones injury and surgery dates (where applicable) it appears that most people are going the surgical route. This seems strange with the current evidence. I am naturally fairly cynical. This site has mainly americans on. Americans have a private health care system where the hospitals make the money from surgery. Is this one of the reasons why most people on here are advised on surgery still?

    It would be great if the tracker that works out averages for PWB etc could work out the averages for surgery / conservative treatment by country and year. I am not volunteering to go through and work it out though. I would imagine the UK would have a higher conservative approach over the last few years as the NHS would look to save money if possible given the same functional outcomes.

  6. donna on May 1, 2015 3:50 pm

    Good points Kristian. My persona take on why anyone has surgery is that it seems, my observation obviously, that bloggers often report medical professionals telling them surgery is better. Perhaps not outright but they’ll give the old re-rupture rate data and or say you won’t be as strong with non-op if you’re going to go back to sports. Lots of uneducated Docs out there, not up on current “evidence based research”.Not sure of the country by country take, never looked at it that way.

    As you spend time here or go back to old blogs you’ll see lots of folks who were ill advised regarding surgery. I personally don’t care what a person chooses (op or non-op), I do however care that they are well informed with current information in making their choice. I personally don’t think individual Docs are doing surgery to make money (for the most part, however, perhaps the “system” is set up that way), as I said it’s more that they are just not current.

  7. kristian on May 2, 2015 12:09 pm

    Hi. I am working through the protocol listed above and am a few days into weeks 2-4. For anyone that has done a similar protocol how many times a day were you advised to do the ‘active plantar and dorsi flexion to neutral, inversion /eversion below neutral’? I’ve started on 3 times a day. I have just plucked this figure with no reasoning but would like to make sure I am doing similar to the participants of the studies / protocols that had such good outcomes.

  8. donna on May 2, 2015 3:58 pm

    Week 3 - 6 I waved my foot back and forth(active plantar and dorsi flexion to neutral)several times a day. It was the only ROM I did. Usually when I took the boot off to ice/elevate…or just while elevating while sitting at desk or on couch.

  9. donna on May 2, 2015 4:09 pm

    Also, I had very limited ROM those 3 - 6 weeks. At week 6 I started several ROM sitting exercises when I started PT and within a very short time (a week to 10 days) I had full ROM back and began my transition into two shoes between weeks 7/8. I had been full weight bearing in the boot when the cast came off at week 3. Hope that helps. We are all individual in these things but it is nice to hear from others. There seems to be many roads to success. I continue to progress well, though even at 6 months and with good care it is very slow. I am not 100% but way way better than I was a month ago and most certainly two or three months ago. My only issue is hypersensitivity of the tendon/incision which comes with it’s own issues but was caused by the fact that I had surgery and nerves were traumatized. So I’d say I am one of many here, who even with different protocols, are progressing well.

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