Jun 10 2011

Bruce Twaddle’s recovery plan (copied off Bronny’s blog)

Published by mtbrider at 1:52 pm under Uncategorized

Hi i copied this from Bronny’s blog - hope you do not mind Bronny. It outlines the manner in which Bruce Twaddle approaches an ATR. This is pretty much whay I think I would like to go through:

Hi all

Awhile back I said I’d emailed Bruce Twaddle who was one of the authors of the NZ study that Norm has referenced which looked at operative and non-operative recovery and showed similar results for the two.  Anyway, he responded with his protocol which he was happy for me to post here (”Knowledge is Power”). The same protocol was applied to both operative and non-operative. I don’t have the full results but you can see the summary on Norm’s blog I think.

In addition to the protocol I asked him about heel raises in particular (as I went to heel raises for the 8-12 week stage) and he commented that while he isn’t a big user of heel raises, he recognises that some people feel more comfortable with them for awhile (i.e didn’t seem to think there was a problem with that).  I don’t want to get into a conversation about surgical /non surgical here, but he also commented that he doesn’t  see any place for surgery in the primary treatment of ATR even in elite athletes - he will operate if people want it, but would apply the same rehab.

So here it is:

1. For the first 2 weeks after injury the patient should be immobilised in a hanging equinus pop (not forced equinus) and be mobilising non-weight bearing.

2. After 2 weeks up until 4 weeks from injury the patient can be placed in a removal orthosis set at 20deg of equinus. The patient is allowed to remove their foot from the boot for 5 minutes of every hour and move their ankle with dorsiflexion and plantar flexion, being careful not to come beyond a right angle, as the greatest risk is having a tendon that heals long. This should be repeated 5 minutes of every hour where possible.

3. At 4 weeks from Injury the moon boot is brought to 10deg of equinus and the range of motion exercises continue, being careful again not to bring the ankle beyound a right angle position. The patient can be touch weight bearing through the toe of the boot , up to 20kgs of pressure, from 4-6 weeks.

4. At 6 weeks from injury the patient can bring the orthosis to O deg and begin weight bearing as tolerated, weaning himself/herself off the crutches by 8 weeks from injury. They need to continue on with the range of motion exercises of their ankle and can remove the orthosis at night.

5. At 8 weeks from injury they can come out of the boot and start toe raising exercises, increasing the weight bearing on the affected leg. When they can single leg toe raise and support their own weight they can start a stretching and strenthening programme and increase their activity level according to their symptoms. This should allow them a quick and full a functional recovery as possible.

2 Responses to “Bruce Twaddle’s recovery plan (copied off Bronny’s blog)”

  1. normofthenorthon 10 Jun 2011 at 4:28 pm

    I keep wanting to get a fulltext copy of Twaddle’s study, in the hopes of seeing if his group’s non-op results seem significantly different (better or worse) than those of the UWO study. Haven’t done it.
    The two protocols are quite similar, and I think they’re both probably excellent. Mostly, Twaddle’s changes the ankle (”equinus”) angle sooner and more often, while UWO introduces PWB and FWB sooner. In principle, I’d expect the UWO approach to work a bit better (because I believe in the benefits of early WB more fervently than I believe in the benefits of early angle changes), but the clinical results are way more important than my beliefs.
    If the results are indistinguishable, I’d go with UWO because the earlier WB is much more convenient for the patient (and their friends and relatives).
    When I “presented” to one of Toronto’s fanciest sports-medicine surgeons (expecting to be scheduled for ATR-repair surgery), he told me almost exactly what Twaddle told you. In fact, he told me that he’d stopped doing ATR surgery after hearing the UWO team present their results, and having them answer some of his follow-up questions. He told me “I didn’t become a surgeon to do surgery that has no benefits!” (Obviously this isn’t a universal sentiment among Orthotic Surgeons! ;-) )
    Also, Twaddle’s caution about early dorsiflexion and “healing long” should be universal reading for all ATR patients, IMHO.

  2. suthrnmanon 14 Jun 2011 at 1:21 am

    Good stuff. I believe both protocols are such drastic improvements over the older ways. You can’t go wrong with these; however, I would offer the observation that we all progress at different speeds and there is no need to rush in the early weeks.

    Healing long? I would like to see something definitive on this issue. I am not convinced anyone really has a good idea why some tendons heal long.

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