Case 25: Non-operative treatment

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Non-Operative Treatment

March 13th, 2009 · 16 Comments

February 18th, 2009. I was playing basketball with my fellow PhD students. Roughly 30 minutes in the game (for which I spent a good 20 minutes warming up and stretching), I felt someone had shot me, with a gun, and hit my calf - or somewhere back of my left leg.

Half an hour later I made it to the “urgent care unit” of one London Health Sciences Network hospitals (London, Ontario). Soon enough I learnt that I had completely ruptured my Achilles Tendon. They put me in an aircast (aka the boot), gave me crutches and sent me home. The doctor that night told me that I should consider myself very lucky since the orthopedic surgeon who’s going to take care of me was a lead scientist on a massive study completed at the University of Western Ontario on non-operative treatment of ATR.

Thirteen days after the injury I went to see the surgeon. His assistant walked in and explained the whole study that they had completed on the non-operative treatment. Essentially they had a random assignment of 118 cases, over a span of 7 years, in two groups of surgical and non surgical treatment. At 12 and 24 months they had compared several conditions of both groups and were not able to detect any advantages of the surgical group. They compared range of motion, re-rupture rate, patient satisfaction, etc. There were no differences tracing back to the treatment. In fact, the cases in the surgical group had demonstrated some (and often normal) complications of the surgery, i.e., scarred tissue, etc.

So, the assistant was telling me that in that clinic, Fowler Kennedy, they now treat all ATR patience non-operatively. Being a phd student myself, I needed to see the study and check for any methodological issues that might have led them to wrong conclusions.  I didn’t find anything!  That day, I became a new patient being treated non-operatively. Soon enough I’ll write the details of the non-operative treatment.

The assistant goes on explaining that they have a new study going on now, that would draw my blood, put it in a centrifugal machine, extract the plasma part (all the warrior cells, in a manner of speaking) and reinject it back in the tendon. OUCH!   I signed up as - was then known as case #25!

Since then I have had 3 physio sessions, dorsiflexion, ultrasound and micro-electric therapy. Wednesday March 18th, nearly 4 weeks after the injury, I’ll be getting my 2nd plasma injection…. stay tuned.

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16 responses so far ↓

  • 1 Smish // Mar 14, 2009 at 7:05 am

    Mazmouza: I actually think I know someone who was in that study on the non-operative treatment for an ATR. He is VERY happy with his results. He is a young guy that is active in sports. He is also very opinionated about going non-operative and basically stopped short of telling the rest of us we were stupid for getting the surgery. Ha! We all laughed him off but my point here is that his results were awesome and he is very active and very happy with his treatment. You’ll do really well.

  • 2 dennis // Mar 14, 2009 at 11:11 am

    mazmouza - thanks for that post. It’s very helpful for people who are in the process of making the decision to go the operative or non-operative route. I’ll add your post to the main site: http://achillesblog.com/atr-rehab-protocols/

  • 3 creaky // Mar 14, 2009 at 8:27 pm

    It sounds like you had a PRP (Platelet Rich Plasma) Injection. I beleive there is solid science behind it. I had surgery on 1/2/09 including a tendon transfer and about 8 weeks post-op I had a PRP Injection to accelerate the healing process. I beleive it made quite a difference. I asked about it before surgery but my doctor felt there was too much damage to use it as a sole course of treatment but as an adjunct treatment it would be effective. Here is a link I found to the treatment http://www.myctm.org/articles/q2-2008-np-prp.php?category=prolo.
    BTW Heinz Ward of the Pittsburg Steelers had this treatment prior to the Super Bowl for a knee injury and attributed his quick recovery and subsequent ability to play in the SB to the PRP treatment.

  • 4 kyoung // Jun 3, 2009 at 12:00 pm

    I had a complete rupture of my achilles on May 17–playing basketball. I chose the non operative repair. I was wondering what the time frame is before any of you have been able to walk without the use of crutches.

  • 5 andrew5600 // Jun 3, 2009 at 10:13 pm

    Hey Kyoung, I too suffered ATR back in April 4th playing outdoor basketball. Like many others on this site, I wasnt too sure whether I should opt for surgical or non-surgical method to treat my injury. I was fitted with Bledsoe Boot with two heel wedges for 8 weeks and it was just two days ago, I started to wear normal shoes with a heel lift. I walk with limp and have difficulties walking down the stairs (normally). I attend physio 1-2 times a week and it seems to help. My goal is to be back on my feet and be able to jog lightly at the end of July and I dont think this is far fetched.

    Be patient, and do what doctors/physio tell you to do.

    Hopefully this helps.

    Btw, I am a super active 30 year old male working in law enforcement field.

  • 6 doug53 // Jun 3, 2009 at 10:51 pm

    Regarding walking down stairs, I think that is a time to be particularly cautious, (even putting aside the risk of an awkward fall). The abnormal walk down the stairs is largely due to the weakened calf, although less flexibility can certainly be an issue, too. (Notice how your weight rolls up onto your toes on your good foot while your bad foot steps down. The weak calf can’t do that, so that heel is stuck to the stair.) If the strength isn’t there, one might be tempted to make up for it by overstretching the tendon. Especially with the nonsurgical route, one could end up with a tendon that is too long.

    I hope this makes sense,

    Doug

  • 7 normofthenorth // Feb 28, 2010 at 2:33 am

    My own blog, starting at http://achillesblog.com/normofthenorth/page/2/ , could also serve as a reference point to the protocol used in the study from Univ. of W. Ontario. Mazmouza hasn’t had good results, unfortunately; so far (11 weeks now), I have. (I’m continuing to report the good and the bad, though it’s mostly good so far.)

    Also, the link to the best presentation of the study and its results is online at http://www.medscape.com/viewarticle/588904 . Further info on the study protocol (though this link also contains some details that were NOT followed) are at http://www.clinicaltrials.gov/ct2/show/NCT00284648 .

    The results are as mazmouza has said: the patients who avoided the surgery achieved identical strength and ROM results as the surgical ones, and avoided the complications of surgery. The re-rupture rates were statistically identical, though (IIRC) the raw results were a tiny bit higher (worse) on the non-surgical side.

  • 8 normofthenorth // May 23, 2010 at 11:53 am

    At ~5.5 months, I’m still progressing well without surgery, as are two other folks “here” (mike753 and gunner) who decided to follow the same non-surgical protocol. Check my blog for all my results, and for a fairly thorough review of the new protocols and studies — esp. studies that scientifically compare the results of surgery and NO surgery.

    In theory, it still seems logical that surgery should at least help shorten recovery time, but those cases seem to be the exception rather than the rule. Two surgeons in Japan doing experimental surgery with blazingly fast rehab are the best examples of this “exception”.

    The facts are pretty clear from the studies:

    When a large number of randomly-selected ATR patients get ordinary open surgery then a relatively quick rehab protocol, they do very well, but NO better than the large number of randomly-selected ATR patients who get NO surgery and the same rehab protocol! And they do suffer some surgical complications — like infections, incisions that don’t heal, and the occasional DVThromobosis.

    I believe that about 99% of ATR surgeries are only done because of “force of habit”, old myths, and perverse incentives. And I’m glad I found a fancy surgeon who’d figured it out , or I would have gotten my second ATR operated on!

  • 9 Scott // Jul 5, 2010 at 10:45 am

    I’m one of the rerupture folks, had the surgery in March of this year. Did very well with surgery and rehab. But was in water to my waist and attempted to push off to start swimming and felt an explosion in the ankle. The force of dorsiflex was the cause of the retear. Too weak in the gastroc to over come the push off. I’m in week 5 post reinjury and more tentitive now but have been in the boot and PWB mode for the whole time. I have just ordered the vacocast boot for the next 4 weeks of rehab.

    My experience is when you can do the bad leg toe reaises at the least 5 times you will be well on your way. Until then be very careful on stairs and slipping etc.

    Is there a resource for the exact rehab protocal for non surgical folks to download and give to PT\Ortho?

  • 10 normofthenorth // Jul 5, 2010 at 2:04 pm

    Scott, your writeup sounds like you got surgery the first time, but you’re proceeding with non-surgical immobilization after your re-rupture. True? (Start your own blog and share the details, please!!)

    Most re-ruptures are treated surgically, even if the original protocol was non-surgical, though it’s all based on logic, not evidence, facts, or science — and recent studies have generally highlighted the huge difference between logic and those other things!

    The rehab protocol that was used in the most recent randomized trial, at U. of Western Ontario (UWO) — for BOTH surgical AND non-surgical patients — is here in my blog, at bit.ly/UWOProtocol . There’s actually a bit of confusion about a few details, but this is the version that the staff who did the study faxed from UWO to my fancy sports-med surgeon in Toronto, and which I’ve been following, along with mikek753 and gunner here.

    The final peer-reviewed publication on the UWO study hasn’t appeared yet in print or online, though it’s “forthcoming” for sometime this year. And the results have been presented in one or two prominent ways, including at a big (annual?) meeting of the AAOS in 2009. I’ve linked to that on my blog, at bit.ly/achillesstudies .

    The protocol they SAY they used, on several web-sites that SHOULD be right, is different, and one of the differences seems important, and the published version seems wrong and potentially dangerous, esp. for non-surgical patients. It says the heel lifts (plantar-flexion, “equinus”, “ballerina position”) is withdrawn at TWO weeks (or maybe even 7 days?!?), which seems nuts. The version I got and uploaded says SIX weeks, which seems much more sensible to me and to the two experts I’ve consulted (my own surgeon and one of the UWO study co-authors). Neither of those experts can believe that the study actually changed the ankle angle as fast as the web-sites say it did!

    BTW, if I were starting a rehab protocol today, I’d apply two “tweaks” to the UWO protocol: (1) Instead of staying on 2cm of heel lifts for 6 weeks then taking it all out at once, I’d spread it over a week or so, and (2) I’d opt for a HINGE-able boot (aka a “functional orthotic brace”) rather than the fixed AirCast boot. (AirCast sponsored the UWO study, and presumably provided the 145 boots, and maybe more.)

    I’m not sure when I’d start the boot hinge-ing (from neutral to full plantar-flexion), especially without surgery. (One or two studies have shown good results with immediate boot-hinge-ing and early or immediate WB after surgery, but that sounds very aggressive for non-surgery, and there’s no evidence to establish its safety or efficacy, at least so far.)

    What I actually did this time worked fine, and probably makes a good model, though it might be slower than necessary: I switched from the AirCast fixed boot to a hinged boot at SEVEN weeks. I started “wean off boot” at 8 weeks, as the UWO protocol says, but for several weeks I returned to the hinged boot for “scary” situations like bicycling, going outside into crowded subways, and the like.

    BTW, I think your bio-physics is a little off, concerning the Gastroc muscle, etc. That muscle was pulling hard at one end of your Achilles when it re-ruptured, so it was probably too strong for the tendon, not too weak. A kind of “compromise” is that the Gastroc was atrophied and undeveloped, and still incapable of reaching its full extension (”stretch”), which subjected your AT to a high shock load as you dorsiflexed on the bottom of the pool. (BTW, I’ve torn both sides now, doing similar moves on the volleyball court, but never re-ruptured — touch wood!!)

  • 11 gunner // Jul 5, 2010 at 2:05 pm

    Hi Scott: Welcome to the site. The rehab protocol is on normofnorth’s blog. Excellent map for a good PT to follow. I’ve got a VacoCast also. Great choice.
    I’ve spent a lot of time in the pool rehabbing and have become a devoted distance swimmer. Were you pushing off from the wall or the floor? How long after your original ATR? I’ve been urging everyone to get in a pool but might want to put a caveat on about pushing off too soon.

  • 12 Scott // Jul 6, 2010 at 10:20 am

    Thanks for the info guys. I’m a bit of a quandry for my Doc’s here in VA. Yes I has surgery in March. Like you it was on a VB court, was going back and changed directions to lunge forward with the poverbial shot in the leg feeling. After surgery I was on a pretty fast paced recovery and did great. It was 13+ weeks into recovery, walking well, cycling on a road bike and even spin classes. However, I must have been trying too hard and feeling overconfident. PT even saying how well it was going.

    The reinjury wasn’t really “swimming”, I was in the Bay in water to my knees when my daughters raft started blowing off shore, she jumped off and I was going to go get it. I made a few steps and leaned forward to push off and swim, which forced the ankle into dorsiflexion to far. I felt the Talus seperate from the tibia and Achilles snap again. That was why I felt the calf was too weak, The pivot on the Talus wasn’t controled by the calf. Its splitting hairs, botton line reinury occured.

    Now the doctor here want to give me 6 wks to see how it heals, and I would prefer to go w\o cutting again. The hope is stitches are still there giving a substrate to attach the ends to each other. The gap on MR was 2.3 cm. US first day post reinjury showed possible fibers???? I didn’t find your site until 4 weeks in the Aircast boot. On my own I used about 12mm lift all along. And have done PWB all along these few weeks. So I really have a mix of protocals going on here.

    My fear is the reinjury was right thru the old scar. MR showed some “curling’ at the ends. I hope it can get good attachment to that. The gap was well filled with “fluid” I guess its blood and ISF. Logic to me is it wil fibrose, remodel and heal. Lenght of tendon is the main issue.

    So time will tell. I can keep you posted in the next few weeks, as us say ‘touch wood’.

  • 13 normofthenorth // Jul 6, 2010 at 3:13 pm

    According to the scientific studies, tendon length seems to readjust “magically” without surgery in initial ATRs, Scott, probably mediated by the “paratenon”, the (intact) sheath that surrounds the torn AT. There are very few RE-ruptures that are treated non-surgically, so I don’t think anybody knows the success rate or the average tendon length, etc. And everything about this injury is “most of the time” or “statistically” or “logically”, with lots of exceptions and outliers. (We’re having this discussion on Mazmouza’s page, and he was unfortunately a flaming outlier himself.)

    And even the “statistical truth” seems to be doubted or ignored by many experts and practitioners., at least in the first few years after it’s come in.

    Have you been experiencing lots of signs of inflammation since your re-rupture? Inflammation is a pain in the leg (obviously!), but it’s also the byproduct of the healing mechanisms. I think it’s generally believed AND true(!) that “old” ATRs that haven’t healed properly will NOT respond to non-surgical immobilization, because of the absence of those healing mechanisms. Re-ruptures (like yours) may behave just like initial ruptures, or not. I’m curious if yours feels and looks like an initial rupture or if it’s more “comfortable” (which could be a bad sign).

    Of course, a lot of your post-op swelling and pain and discomfort was because you were sliced open and stitched back together, so it’s a tricky apples-and-oranges comparison.

    As you probably know, I’m “Mr. Non-Surgical” around here, but if you start getting strong indications that your leg isn’t healing in the boot, I’d “excuse” you for going back under the knife, without questioning your IQ! I can understand why you’re not eager, but the object is to get this “journey” finished, and that might — MIGHT — turn out to be the “short cut” (no pun intended!) in your case.

  • 14 gunner // Jul 6, 2010 at 4:25 pm

    Thanks Scott. I guess you were in a position to really stress the tendon. Without surgery, at 13 weeks, I’m sure it would have taken a serious jolt to tear mine (now 18 weeks). So this is another example for us non surgical folks of how surgery is no magic elixir for preventing rerupture (and a host of other problems). As Norm said, we’ll be very interested in your progress so get your own site and join the fun.

  • 15 Maxx // Jul 20, 2010 at 3:12 am

    Hi. I recently had a complete rupture of my right achilles. I had surgery 5 days after the accident and have decided to go with the more agressive post op treatment.(Early ROM and Weight bearing).I am doing the Range Of Motion exercises and started careful weight bearing at 3 1/2 to 4 weeks after surgery. So far so good. It feels tight but there is no pain and it feels good from full flex to neutral. Thanks for the info on your blogs it is very helpful. My goal is to return to work (light duty) 8-10 weeks post surgery.

  • 16 lifeofbrian // Apr 7, 2011 at 7:02 am

    For those who wonder about forgoing the operation, please read this little item from our friends at Wikipedia:

    http://en.wikipedia.org/wiki/Achilles_tendon_rupture

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