Jun 08 2011

A NZ’er joining the club

Published by mtbrider at 11:02 pm under Uncategorized

Hi all,

Looks like you have another achilles tear member. I am 34 and live in New Zealand. I tore my achilles last Saturday (5 June 2011) playing football and am currently spending my days lying on the couch with my right leg elevated above my heart 24 hrs a day. I got my below the knee cast put on the following morning after my tear.

As I am couchridden I have been on the net and have been researching this injury and treatment. My local hospital has a plan of recovery is (if all goes to plan) of 2 weeks in cast where toe points down, 4 weeks in a cast with walking attachment, 2 weeks in a cast with foot in more normal position, then cast off after these 8 weeks and into heel raises on my shoe. It seems different hospitals in NZ have different approaches depending on the preference of the specialists. Some use moonboots, some stick with casts. They all start of with conservative treatment from what I understand.

Now I have been researching and reading about my injury (not much else to do as I am stuck on the couch) and came across that study where after the 2 weeks patients were put into a boot with partial movement. This is basically to get the tendon moving early on in the recovery process to increase bloodflow and promote better healing. It also basically implied that having you foot stuck in a cast with no movement for 8 weeks is not the best option.

Many of you will be aware of the study but if not I have attached these for you to read (if you are interested):

http://achillesblog.com/files/2008/03/jbjsi01401v1.pdf (the study)

http://www.eorthopod.com/content/new-study-challenges-surgery-for-achilles-tendon-ruptures (comment)

http://www.cfas-uk.com/pdf/vacoped-rehab.pdf (a suggested programme)

Now I’m not a doctor but I like what this programme suggests, it makes sense to me.

Now basically I think I want to see if the specialist at the hospital would be interested to allow me to follow this programme. I do not want to come across as some know-it-all who has spent too much time on the internet, he is the specialist after all. In your opinions do you like the approach this takes/would a request like this be ok to ask my specialist? What are your opinions of cast for 8 weeks vs 2 week cast then boot?

Cheers for all your help

a broken mtbrider

4 Responses to “A NZ’er joining the club”

  1. normofthenorthon 09 Jun 2011 at 6:49 pm

    “Welcome”, MTBRider — though I’m sure we’d all rather that you’d skipped the ATR and stayed away!

    As you’ve noticed, your protocol is pretty close to the one in the “UWO” study (in your first link), except that they used a boot, and you’re scheduled to be in a series of casts. The main therapeutic difference is access to exercise and PT, though there are also non-therapeutic advantages to boots, e.g.: easier fit adjustment, quicker transition to unrestricted sleeping, and quicker and easier access to hygiene, like showering. Also, when you’re first moving into “2 shoes”, it’s often helpful to be able to go to-and-fro back into the boot, e.g., for hazardous activities (like cycling or back-country hiking) or outings to hazardous places (public transit and other crowded frantic places).

    I’m a big fan of boots over casts. OTOH, it’s worth mentioning that your non-op schedule is almost exactly as fast as the one in the UWO study (apart from the early PT and exercise). That puts you way ahead of the majority of non-op patients, who often still get granddad’s “conservative casting” (and its inferior results).

    But if you can persuade your Doc and hospital to switch to the boot — and to introduce the early PT and exercise that it permits — I do think you’ll benefit. The people here who’ve used the VacoCast boot seem to love it a lot.

    We’ve had 1 or 2 Kiwis logging on here recently — “bronny” comes to mind, as one who followed a modern fast non-op protocol (though not exactly the UWO one) and was doing great last I heard.

    You might also be interested to know that the FIRST of the modern studies showing essentially “surgical-quality” results from non-surgical ATR treatment, was done in NZ in 2007. It’s ref. #4 in the Wikipedia article on ATR, bit.ly/Wiki-ATR . I think Bronny’s hospital followed that study’s protocol with her, more or less. (The UWO study, published in 2010, is ref. #7 in the Wikipedia article on ATR.)

  2. mtbrideron 09 Jun 2011 at 7:59 pm


    Thanks for your reply, nice and quick. Your advice is helpful and I will look up that Kiwi study, as well as trying to track down ‘Bronny’.

    At the moment I like the idea of the boot over the cast. Your suggestions of the benefits of being able to take off/put on the boot as required is yet another push towards that option.

    I will let you know what happens at my surgeons appt. next Thursday. Then again there is a good chance I will be making a few posts before then as there is not too much else to do whilst on the couch elevating that leg.

    Have you any idea why the need to keep it elevated as much as possible? I thought it would be to reduce swelling, but wouldn’t it also reduce blood flow to the ankle, reducing the healing speed?

  3. Bronnyon 09 Jun 2011 at 10:15 pm

    Twaddle is the Auckland guy who did the study, I had a few emails with him and wrote about it on my page at some point.

  4. normofthenorthon 10 Jun 2011 at 4:54 am

    Yup, Twaddle — thanks, Bronny. He got excellent results, too, and I THINK that Bronny’s posts include his actual protocol, though I may be remembering wrong. He also broke new ground, the first of 4 recent studies with fast protocols showing non-op results that compete with surgical results, w/o the complications.

    mtbrider, the elevation is mostly to control swelling/inflammation. Of course, it does remove fluid from the leg, including blood, and you’d think that would slow the healing. But gorging the area with relatively stagnant fluids slows healing, too. Also, the actual AT area has relatively poor circulation (and maybe especially the “watershed” area that most often ruptures, though one recent study casts doubt on this). So it’s possible that frequent elevation — which really means frequent ALTERNATION between elevating and NOT elevating — creates its own alternative form of circulation that helps healing. Like rinsing out a bucket by adding and removing water. I sure don’t know, but I doubt that anybody else does, either.

    What I do know for sure (from personal experience after bruising my OTHER leg) is that swelling/inflammation creates its own symptoms — including stiffness, discomfort, ROM restrictions — that coincide with a number of symptoms of the ATR and its recovery. BTW, one of the British kings said he’d learned two things during his reign, and one of them was “Never miss a chance to put your feet up.”

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