A more complete review of the options — surgical vs. non-operative

Written on March 8, 2010 – 4:14 am | by normofthenorth

[Note: While this review, now 3 years old, is still a pretty good summary of the evidence on "op vs. non-op" and how it has changed since 2007, we've been having some more modern discussions, partly at my "The case for skipping ATR Surgery" page. And there are two new articles -- one a meta-study and one a journalistic summary of the "debate" -- that are especially worth reading: The meta-study is Soroceanu A, Sidhwa F, Arabi S, et al. Surgical vs. Non-surgical treatment of acute Achilles ruptures: a meta-analysis of randomized trials. Presented at annual meeting of the American Academy of Orthopaedic Surgeons, San Diego, February 2011.
And the journalistic summary is at http://lowerextremityreview.com/cover_story/battles-of-achilles-the-operative-vs-nonoperative-treatment-debate , entitled “BATTLES OF ACHILLES: The operative vs nonoperative treatment debate”. Following is my March 2010 summary of that debate. -Norm]

I just did a bit more online research of my “new fave” subject:
Is there any significant benefit to ATR surgery compared to the newer and quick-ish non-surgical protocols, like the one I’m following?

I keep hearing, even now, that serious athletes just HAVE to have the surgery if they’re serious about (a) avoiding re-rupture and (b) regaining their past (or achieving their best) strength and ROM. But the recent scientific studies I’ve looked at — one from NZ and one from Canada — both say (”prove”?) it ain’t so. But I keep hearing it, as if it is so.

Today, I looked harder to see what’s out there, and here’s what I found.

1) In the “old days” — including late 2001, when I tore my first ATR — there had been many studies that compared surgical vs. non-operative outcomes, and most of them concluded that at least some of the “athletic” outcomes (usually re-rupture rates) were better with surgery. That understanding was nicely summarized in a 2005 “meta-study” of all the earlier studies:
The Journal of Bone and Joint Surgery (American). 2005;87:2202-2210. Treatment of Acute Achilles Tendon Ruptures: A Meta-Analysis of Randomized, Controlled Trials, Riaz J.K. Khan et al: A 2005 meta-analysis of earlier studies, involving 800 patients and with “a variable level of methodological rigor and reporting of outcomes”. It found a 3-fold increase in re-rupture rates with non-operative care, and an 11-fold increase in other complications with surgery (both statistically significant). It also found that boots produced better outcomes than casts, and (slightly) that percutaneous surgery was better than open surgery.

2) Those studies may have randomized the two streams of patients, but they did NOT treat the two groups the same! Back then, the non-operative approach REALLY WAS “CONSERVATIVE”!! I.e., it was slower, and involved more immobilization and NWB than the post-op approach. And the evidence is very clear, especially now, that long immobilization and NWB (and no physio, etc.) are all BAD for outcomes.

3) The situation changed a LOT in 2007, with the publication of the study from New Zealand, which I think was the first to (a) use rapid rehab for everybody and (b) use the SAME rehab for everybody. So this study tested scientifically for the effects of the SURGERY, rather than mooshing the effect of the surgery into the same “soup” as the effect of the faster rehab protocol that usually went with surgery. That study is as follows:
Aukland, NZ, 2007: Bruce C. Twaddle, FRACS†,* and Peter Poon, FRACS, Am J Sports Med December 2007 vol. 35 no. 12 2033-2038, “Early Motion for Achilles Tendon Ruptures: Is Surgery Important?: A Randomized, Prospective Study”, http://ajs.sagepub.com/content/35/12/2033.abstract: (The number of patients randomized is not included in free Abstract.) “There were no significant differences between the 2 groups in plantar flexion, dorsiflexion, calf circumference, or the MFAI scores measured at 2, 8, 12, 26, or 52 weeks. One patient in each group was noncompliant and required surgical rerepair of the tendon. There were no differences in complications and a similar low number of reruptures in both groups.”

4) The next three studies, all from 2009, follow that same practice, thereby isolating the claimed (but maybe fictional) benefits of surgery from the ACTUAL benefits of rapid rehabilitation:
a) http://www.ncbi.nlm.nih.gov/pubmed/19825777?dopt=Abstract — Netherlands: Metz R, et al, Sept. 2009. 83 patients randomized into two streams. Excluding the patients (8 surgical and 9 non-surgical) with “major complications”, strength testing at 3 months and 6 months revealed only one statistically significant difference, in which the NON-surgical patients were stronger.
b) http://www.medscape.com/viewarticle/588904 — Canada: Kevin Willits, March 2009 paper at AAOS 2009: “Nonsurgical Rehab After Achilles Tendon Rupture Better Than Surgery”. 145 patients randomized. No statistically significant difference in strength or ROM or re-rupture rate between the two groups, in two years of follow-up. Very significant difference — 2.6 x — in the rate of “complications”, with more in the surgical group, of course. “This is a great study and a landmark paper, and it’s a model of how to perform a randomized controlled trial,” commented Paul Fortin, MD, director of foot and ankle surgery at the William Beaumont Hospital, in Royal Oak, Michigan, who moderated the session at which the paper was presented. “The data are very clean and it’s potentially practice-changing.”
c) Gothenburg, Sweden, May 2009: http://www.physorg.com/news161516132.html — Katarina Nilsson Helander randomized 100 patients. The study found “no difference in the re-rupture rate. A year after the injury, there was no difference in the patients’ own impression of symptoms and function”.

5) ALL of those studies from 2007 on, find that there’s NO benefit from the surgery, as long as both groups get identical and rapid rehab. And both groups do just fine, in all those studies. (In one of the studies, the NON-surgical patients are stronger on one test at the final check, and that’s the only difference that’s statistically significant!) And I’ve included all the recent studies I can find!

6) So, as far as I can see, there really is no excuse for some otherwise intelligent person to claim that the evidence shows that surgery produces better results, or better results for athletes, . . . than the non-surgical approach. Than the approach that’s still sometimes called “conservative”, though it shouldn’t be! The non-surgical approach seems to work just fine, just as well as surgery but without the pain and complications. A really CONSERVATIVE approach, however, does NOT work fine, with or without surgery!

As “regular readers” already know, I’m following the protocol from 4b, above. And so far, so good — though (at 12.5 weeks) I’m getting tired of waiting for a good stride push-off, and then for a 1-legged heel raise. But so far, I’m very impressed with my progress on the non-surgical protocol — and I’ve also got experience with the surgical side, from 8 years ago. My life is back to normal except for the volleyball and stuff, and way quicker than I recovered the first time, post-op. It’s hard to complain.

If anybody’s got anything to add, like good studies I’ve missed, please respond here.

Finally, in my research, I also found a new surgical article from Japan that is a real eye-opener:
Novel Approach to Repair of Acute Achilles Tendon Rupture: Early Recovery Without Postoperative Fixation or Orthosis(!). Am J Sports Med February 2010 vol. 38 no. 2 287-292, Tadahiko Yotsumoto et al. The abstract’s at http://ajs.sagepub.com/content/38/2/287.abstract .

They only had a small group, but they applied a surgical “technique of their own design” to the whole group. Here’s more:
“The patients started active and passive ankle mobilization from the next day, partial weightbearing walking from 1 week, full-load walking from 4 weeks, and double-legged heel raises from 6 weeks after surgery.

Results: The range of motion recovery equal to the intact side averaged 3.2 weeks. Double-legged heel raises and 20 continuous single-legged heel raise exercises were possible at an average of 6.3 weeks and 9.9 weeks, respectively. T2-weighted magnetic resonance signal intensity recovered to equal that of the intact portion of the same tendon at 12 weeks. The patients resumed sports activities or heavy labor at an average of 14.4 weeks. The Achilles tendon rupture score averaged 98.3 at 24 weeks. There were no complications.”

These are truly spectacular results, by anybody’s standards! (Doug53, eat your heart out!) I mean, 20 continuous single-legged heel raises at an average 9.9 weeks post-op! That’s Very Good.

If I were making the choice today, anywhere near Shimane University School of Medicine (wherever Shimane is!?!), I think I might just go for the surgery — THIS surgery!

The good news for all the future American ATR sufferers, is that it’s probably easier to teach an old ortho-surgeon “dog” THIS kind of “new trick”, than it is to get him — yes, him! — to admit that it’s better to skip the surgery altogether.

  1. 103 Responses to “A more complete review of the options — surgical vs. non-operative”

  2. By chocolata on Mar 8, 2010 | Reply

    Norm wrote:
    > If I were making the choice today, anywhere near Shimane University School of Medicine (wherever Shimane is!?!),
    >I think I might just go for the surgery — THIS surgery!

    Hey, it’s HERE!


    1-hour flight from Tokyo plus about 40-minutes bus ride to get there. ;-)
    Thanks a lot for sharing your research with us, Norm. Well done!!

  3. By doug53 on Mar 8, 2010 | Reply

    I think you have analyzed this well, Norm; the rehab looks to be the key issue. It is nice to see that nonoperative treatment is compatible with a fairly rapid rehab.

    As you know, I’ve mentioned before that surgery does give the tendon a little strength up front, and that it seems a shame to waste it with conservative rehab programs. My approach was to use that tendon strength to get ROM and strength back earlier.

    That new study from Japan looks like my approach on steroids, with a new operative technique to get the fastest possible start.

    I don’t remember exactly when I was able to do 20 single leg calf raises in a row. I know I could first hold up my weight for a moment at just past eight weeks, and I was doing several sets a day of 30 consecutive raises at about 12 weeks. That study’s average was probably a week or so ahead of me, if I had to guess. If the average was that fast, where were the go-getters on the leading edge?


  4. By dancingdoug on Mar 8, 2010 | Reply

    Maybe the non-surgical approach (I won’t call it conservative) becomes the preferred path someday due to the research you quoted. I had similar questions after rupturing mine back in May 09, i.e. why do some places seem to prefer non-surgical over surgical approaches. It seems that the surgical approach is standard operating (pun intended) procedure in the U.S. and the non-surgical approach is more accepted in other locations.

    I had surgery, no complications, (thank god) and have what I believe to be a very strong repair. In my case the scenario was:

    1. Ruptured Achilles (who knew it could even rupture until I heard it snap)
    2. Visit to the ER w/referral to an Ortho Surgeon.
    3. Ortho visit and surgery schedule.
    4. Surgery and Re-hab

    At no point was a non-surgical option even presented to me. So, I trusted the system, trusted the Doctors (at least 2) and trusted most of the web sites that I visited.

    So, I ask a question that I asked back in July, once again. Is surgery mostly an American thing?

  5. By mikek753 on Mar 8, 2010 | Reply

    very good summary.
    As I got both options and was not pushed by my doctor to ether one I run crazy for a week.
    And with all US kinda pro surgery way I even setup surgery date.
    But, then spoke to my doctor again and as result reconsider and will go without surgery.
    However, my doctor will guide me with early PT way.
    Now my head stopped spinning - at least for a while.

    I’d like to know how to get any confirmation of healing? What test can provide it and how?

    MRI is expensive and doesn’t show very clear as I understand.
    Ultrasound (UT) is cheap, but not many knows how to read Achilles tendon.

  6. By normofthenorth on Mar 9, 2010 | Reply

    Doug53, I agree completely with what you said. But I’m also wondering if the Japanese docs did the right kind of “on steroids”. E.g., it’s great to have early motion and stretches post-op, but if they HAD used a boot, they could have had early WB as well, instead of 3 weeks NWB. Heck, you can always take off your boot to do your exercises, right?

    Dancingdoug, the US doesn’t have a complete monopoly on ATR surgery, but it seems the most extreme home of the “old wisdom” that surgery produces better results, especially for people (athletes) who CARE about better results.

    I discussed that with my physio today — same sports-med clinic as the fancy surgeon who turned me away from the surgery. I told him I was puzzled by the apparent difference between the ortho surgeons in the US and Canada. Sure, our insurance is public and in the US it’s mostly private, but the surgeons in both countries only get paid when they cut, so why so different?

    He told me that my fancy surgeon has a 7-month waiting list for surgeries, so he turns away a lot of patients, and has no time for extras. But, I said, there must be lesser surgeons in Toronto who could use a few extra surgeries to help pay the rent? He thought that those guys were having trouble finding operating-room availability, whereas the US has operating rooms lying idle. These things I know from nothing, but there’s an opinion, FWIW.

    mikek753, I think you’re making the right choice based on the facts. And if that’s your FINAL decision :-D you’ll have the luxury of being more in control of your own care than 99% of the people here.

    I’d probably choose the UWO protocol I’ve been following (study 4b, above), though I’d choose a hinged boot like the Donjoy MC Walker or (maybe better) the new-fangled waterproof VacuCast (”VacuPed” in Europe), rather than a fixed or rigid boot. Of course, you should start with the boot adjusted to be rigid, until maybe 7 weeks in, then hinged for a while. (The UWO protocol says “wean” from rigid boot straight to shoes starting at week 8, but I think the hinged boot makes a much friendlier and smoother and safer transition.)

    For me, the first signs that I had a continuous AT again were my own impressions — like, when I was increasingly pushing down on the bottom of the boot, I could see and feel my calf twitching — and a Thompson test by my Physio, though I forget when.

    There’s an old joke about a farmer who was so careful about his seedlings that he kept digging them all up to check that their roots were growing properly! (They died!) I wouldn’t get too aggressive about testing for an AT in the first few weeks of rehab, especially with the non-surgical approach. The studies say that the thing re-builds itself (SOMEhow!!), and so does my personal experience, FWIW. God Willing, yours will, too!

    As you may have read, I added three expensive PRP injections to my own rehab. PRP was NOT part of the UWO study (on either “track”), and it also has NOT been tested in careful studies yet for ATRs. (The results of a careful-looking study with AT tendinosis were negative, i.e., it was no better than saline solution.) I’m not mentioning this because I recommend the PRP — only because part of the PRP procedure is an Ultrasound, so that the injection can be guided into the “gap”, supposedly to promote healing and tissue repair right there.

    So I had 3 post-boot Ultrasounds. (NB: I had NO Ultrasound before starting the non-surgical therapy, just a palpation and a Thompson test.)

    Starting with the second US, I started quizzing the Doc (the head of that fancy sports-med clinic) about what he saw. The results seemed confusing and “not obviously right” to me, and this guy is an experienced hotshot — the former Chief of Medicine for the Toronto Maple Leafs NFL hockey team, and the current CoM of the Canadian Ballet Company, etc.

    He told me I had a rather large gap — maybe 6 cm, maybe 4, I forget — but that it only looked like a 50% tear(!?). And the third time, he said it looked like MULTIPLE tears, which nobody had said before. (I do have a small bump near the bottom of my soleus, so maybe that part was right, and there’s a second tear healing there.)

    Meanwhile, the answers affected my curiosity, but they did NOT affect my treatment! The non-surgical cure for all these variations is exactly the same, and all the variations on total ATRs (not partial) were included in the randomized studies I linked above (3, 4a, 4b, & 4c), and the results were almost all good, and quite good on average.

    So, Mike, I’d focus more on chasing the healing, than on confirming it. If yours goes like mine, you’ll get little signals almost every day that your ankle is getting better.

  7. By mikek753 on Mar 9, 2010 | Reply

    I plan to be working home for whole this week.
    And from the next week start coming to office.

    what did you mean by “get little signals almost every day that your ankle is getting better”?

  8. By normofthenorth on Mar 9, 2010 | Reply

    Mike, I meant that both the rehab protocol and your ankle itself will keep letting you know that you’re on the (long) road to recovery. There isn’t a lot of progress during the first 2 weeks of NWB immobilization, but at 2 wks, you start with Protected Weight Bearing, and you’ll probably find that you’re more comfortable with that (and with a bit more weight) just about every day.

    Also at 2 wks or so, you can start Physio, which means getting out of the boot and moving your foot around. Just DOING that is a serious move in the right direction, and you’ll probably also find that it’s more comfy and more capable just about every day.

    I think it was also around 2-3 wks when my physio told me to start pushing against the boot — not with my leg and calf muscle and AT, but with my internal foot muscles. Like lift your arch and push down with the heel and the ball of your foot. Along with wiggling toes, pushing left and right, and rotating L & R along the foot’s axis. And doing similar exercises OUT of the boot (though I skipped a lot of those). All these moves start out weak and scary and feel/work better just about every day.

    And so it progresses, into FWB, ditching the crutches, doing more strength exercises, starting to work on proprioception and balance, etc., etc., and moving to maybe a hinged boot and definitely 2 shoes. Then you’re working on being able to step past your “bad” foot farther and farther without hurting yourself, and that usually improves just about every day.

    In fact, the rapid and steady progress that most of us experience on the quicker protocols is the main reason why the push for calf strength is, in doug53’s words, a “frustrating plateau”. That is a big step, even for the “go-getters on the leading edge” (like Doug in our group), and it takes weeks if not months.

    During that time, there are still multiple little improvements, to ankle stability, pain/discomfort, swelling, balance, lifestyle, etc., etc., but nothing quite as dramatic as the improvements during the earlier period. Of course, the good news is that your life is pretty much back to “normal except for sports” by then, so waiting a few more weeks for a PERFECT stride without that tiny limp isn’t all that bad.

    Mind you, everybody’s different, and rehab protocols are WAY different. And nothing is ever guaranteed. But you’re planning to follow the same protocol I’m following, and with any luck at all, you’ll also find your progress from around 2-to-8 weeks pretty quick and steady, with improvements just about every day. God Willing, Touch Wood, Inshalla, All’vai, etc., etc., of course!!

  9. By normofthenorth on Mar 9, 2010 | Reply

    If anybody wants a description of my own protocol, I described it in some detail on jenn’s page, at http://achillesblog.com/jenn/2010/03/03/good-bye-crutches/#comment-41 .

  10. By mikek753 on Mar 9, 2010 | Reply


    would you email me or ping via IM? pls.
    I’m at my login gmail com


  11. By normofthenorth on Mar 10, 2010 | Reply

    Done, Mike.

  12. By normofthenorth on Mar 10, 2010 | Reply

    I’ve now posted an OCR’d and corrected version of the actual protocol I’ve been following since Dec. 10, **NOT** at http://achillesblog.com/normofthenorth/?page_id=53 . No, it’s really at http://achillesblog.com/normofthenorth/the-non-surgical-protocol-ive-been-following/ ! This is from a piece of paper I got from my fancy surgeon (Dr. Rick Zarnett) at a fancy Sports Medicine Specialists clinic in Toronto.

    It comes from the folks (Willits et al) at Univ. of Western Ontario who did the study I listed as “4b” in the post at the top.

    One puzzle, though, is that the protocol they listed for the study at http://clinicaltrials.gov/ct2/show/study/NCT00284648?show_desc=Y#desc (in all versions there) is different! This link says they started the study in 2000, and my piece of paper is dated “March 2002″, but their postings to clinicaltrials.gov are much more recent.

    I’ve been assuming that I’ve got the edited, changed, new-and-improved version of an earlier version that they posted at clinicaltrials.gov, but the chronology doesn’t fit very neatly. I’m seeing Dr. Zarnett tomorrow anyway for my 3-month follow-up, and I’ll see if he can explain it.

    The differences are not trivial, and they’re almost all in the direction of the clinicaltrials.gov version being faster and more aggressive than the printout I’ve been following. WBAT from 2 wks vs. 4, heel-lift out at 2 wks vs. 6 (!!), and weaning off the boot at 6 wks vs. 8. I’m certainly curious. . .

  13. By normofthenorth on Mar 11, 2010 | Reply

    mikek753 pointed out to me that the link to the OCR’d protocol I had posted didn’t work (unless you were me!). I think I’ve solved the problem now, with a new link posted above.

  14. By normofthenorth on Mar 12, 2010 | Reply

    I saw Dr. Zarnett for my 3-month follow-up visit. Basically “carry on” from him, though my ankle and foot were on the puffy side when I was there — maybe because I’d been sitting, standing, driving, and walking for 3 or 4 hours straight without elevating.

    He recommended a compression-type drugstore ankle brace to control the swelling. The kind with the hole at the heel. I said “Spandex?” and he said “No, that’s too hot. Get one that’s basically fabric.” I’m not sure I understand perfectly, but I bought a couple, one from Wal-mart ($8.37) and 1 from Dollarama ($2). The Wal-mart one actually does NOThave the hole at the heel, the $ama one does. They both seem a bit uncomfortable to me, no substitute for getting the leg up on a table every few hours. . .

    In early May — 5 months in — we scheduled “Biodex” (performance tests) and another visit.

  15. By normofthenorth on Mar 12, 2010 | Reply

    I also showed Dr. Zarnett my annotated printout of the UWO study protocol as it’s posted online at clinicaltrials.gov/ct2/show/study/NCT00284648?show_desc=Y#desc . He was unaware that there were different versions.

    He said that after he heard the results presented at two different conferences (NOT including AAOS 2009), and discussing them with the main authors, he just phoned the clinic and got the study protocol faxed to him by one of the nurses, and that’s what he’s been using — and so have I.

    When I suggested that I’d e-mail Dr. Willits (chief author) he said not to bother, he doesn’t answer e-mails, but that his co-author probably would. I probably will try.

    When he read the details of the clinicaltrials.gov version of the protocol, he responded (un-prompted, I SWEAR!) exactly as I had: “Wow! Removing heel lifts at 2 weeks sounds very soon. I don’t think that sounds like a good idea.”

    The rest of that version of the protocol is a bit more aggressive than what I’ve been doing, but would probably work fine. But stretching a semi-existent new AT into the neutral position, after only 2 weeks of immobilization, seems like “a stretch”, to both of us.

  16. By doug53 on Mar 13, 2010 | Reply

    Hey Norm,

    If you’re really bored:


    At least the Orthopedic Powers That Be are getting away from many weeks in a cast, so this could ammunition for those of you trying to escape from a conservative treatment plan.

    Did I see you mention that you are originally from Boston? You’re not THAT Norm, are you?



  17. By doug53 on Mar 13, 2010 | Reply

    Hi again,

    I’ve been dong a little reading about ATRs this morning, and I ran across a couple of other things that I thought you (as an “information hound”) might find interesting.

    First, this article about how the “sleeve” around a bone fracture can, if left in position, lead to “miraculous” healing:


    Maybe something similar happens with nonoperative healing of the Achilles. It occurs to me that animal models of nonsurgical healing involve cutting the tendon in half, *which would also cut that sleeve*, and therefore interfere with this natural process.

    Then there is this article:


    which points out that the tendon has a poor blood supply, which we already knew, but adds the important point that sutures placed in surgery could decrease that blood supply further, which could, in turn, interfere with healing.


  18. By normofthenorth on Mar 13, 2010 | Reply

    I’ll try to follow those links, Doug, thanks. “Information hound” sounds about right. I’ve also been called a “curious person” — sometimes as in “What a CURIOUS person!?!” (preferably with a British accent)

    No, I’ve never been in Cheers on TV, or even set foot in that bar — though my Dad did pronounce my name about the same way, R-less.

    I can see how a bunch of stitches could tend to “strangle” some capillaries, but I can also imagine the opposite effect on healing. We all know that the tear of an AT triggers an aggressive healing response from the body: inflammation, clotting/bruising, “knitting”, etc. People whose ATs have healed “wrong”, like the wrong length, can’t avail themselves of non-surgical cures, because the healing process has stopped, and won’t re-start without some kind of “injury”.

    I’ve been wondering if all the surgical “injuries” to the ruptured tendon itself — the ends are often trimmed, and then it’s “shot full of holes” for the sutures — could actually lead to a stronger healed repair. Of course, it can also promote unwanted healing/repairs, like “adhesions” that tie the tendon to the sheath or tie other adjacent tissues together that should slide free. . .

    What’s interesting here, in a general sense, is that (1) the precise mechanisms seem to be poorly understood (though everybody’s got their own ideas) and (2) the effects of a range of “cures” are only vaguely understood, mostly from the scientific studies we’ve seen.

    Obviously there’s a relationship between the two, though the direct approach to answering the two questions is different. To answer #1, you could (e.g.) torture a bunch of lab animals in various ways while actually LOOKING at their healing ATs in ways that would be impossible in human patients (and maybe not as easy with bunnies or pigs as it used to be). Or a bunch of human patients could be subject to frequent Ultrasound and/or MRI. . .

    The “direct” way to find better surgical and non-op protocols is to run more randomized studies that “bracket” some protocols that are known to work well. I’m using “bracket” the way it used to be used in photography: if your light meter said the right exposure setting was x, then you’d also take shots at x+1 AND x-1, to help ensure that ONE of your shots was properly exposed.

    In this case, after (say) the UWO study established that their protocol works quite well, somebody could do a study comparing variations on that protocol — e.g., does putting randomized patients into “2 shoes” sooner, with instructions to be “cautiously aggressive” the way you were, Doug, give statistically better results? There might (e.g.) be quicker healing among most, and also a few extra reruptures among some . . .

  19. By normofthenorth on Mar 13, 2010 | Reply

    BTW, I’ve encountered a couple of comments here (one from doug53 and an earlier one from chocolata) that were “awaiting moderation”. I think that meant that others couldn’t see them until I “approved” them. (I think it’s a WordPress thing, bigger than dennis’s achillesblog.)

    I think I’ve figured out what triggers that, and that’s the inclusion of a URL link that includes the http:// prefix. Links now work fine if you leave that prefix off, so I think we should leave it off.

  20. By chocolata on Mar 13, 2010 | Reply

    I see. I wondered about the same thing when someone’s comment required my approval. Thanks for sharing your finding with us, Norm!

  21. By dennis on Mar 13, 2010 | Reply

    Norm, the reason that some of the comments are held in moderation is if they contain 2 or more links. I’ve upped that number to 5 or more on your blog. And yes, it’s a wordpress thing.

    You can change that number by going to the menu “Settings -> discussion” on the upper right of your management console and changing the number for “Comment Moderation”

  22. By normofthenorth on Mar 13, 2010 | Reply

    Thanks, Dennis. Lots of choices under that “Settings” heading (some of which I even understand)!

    BTW, I think it might be useful to link or list this page under one of your front-page heading about the various protocols — either “ATR Rehab Protocols, Publications, Studies” or “Treatment Protocols”. (I’m not clear on the difference, BTW, and I may not be alone.)

    A few of the critical research areas seem to be moving fast with new studies, maybe especially the surgical vs. non-op comparison, outlined above. It’s still very possible that new approaches to surgery will achieve outcomes that the non-operative option can’t match — as the new Japanese report above suggests — but for now, the oft-repeated advantage of surgical outcomes seems to have been debunked, as I read the evidence post-2006.

    The Internet is naturally one of the repositories of the old “mythoid”, and will continue to be until it’s all corrected — and in “archive” form even after it’s corrected! We should lead here, because this is the best online source of ATR info I have found.

  23. By dennis on Mar 14, 2010 | Reply

    Norm - thanks for all the helpful info about the various protocols. I’ll create a link from “ATR Rehab Protocols, Publications, Studies” to this page. The “Treatment Protocols” is actually under a sub category called “Posts worth reading”, which is a compilation of posts that I’ve come across from various places (like other forums, sites, etc.., that I found interesting.)

    Yes, I agree the main site’s info can be organized more clearly. I think the layout of the front page can be done a lot better, but that requires me to get a professional web designer to do the work, which can cost a lot of money. I am just using one of the built-in templates for wordpress mu, and this theme that I picked met a lot of the criteria that I was looking for, but it doesn’t do the sidebar indentation very well. If you have any suggestions on improving the site, and if you have electronic documents of the latest studies on ATR, please let me know. I’ll upload it so that everyone has access. thanks, and happy healing!

  24. By normofthenorth on Mar 15, 2010 | Reply

    Thanks, Dennis. I’ve never done any WordPress blogging before, and I still find parts of this system mysterious — despite HOURS of hanging out here!

    The links above indicate which of the latest studies on ATR I’ve reviewed. If the link is to an Abstract, it’s because I was too cheap to pay for the full text, and I don’t have any special access, sorry.

    I plan to try to contact one of the co-authors of the U. of W. Ontario study in the next few days, at least to clarify the conflicting info about the rehab protocol. I still haven’t seen a “real” publication of their results in a peer-reviewed journal, although they’ve been delivering the results in a series of conference papers, including the one I’ve linked. (I may know more soon about their publication schedule, too.)

  25. By normofthenorth on Mar 15, 2010 | Reply

    OK, I THINK I may be REALLY getting a proper stride!

    As regular readers will recall, I’ve felt just on the edge, on the cusp, of being able to “push off” at the end of a stride and walk 100% like a NORMAL person. . . for several weeks now! Well, tonight, walking between the car and the house, I gave it everything I had, and I was actually doing it!

    The only part that was different from a NORMAL person was that I was concentrating 100%, and whenever it was time for my wimpy calf-and-AT to do the “push off”, I was clenching my fists and gritting my fists and grunting and Just Doing It!! But with that level of effort, it did seem to work, and there was no hint of a dip in my stride, even though I was going fast and taking very long strides.

    I’m not necessarily planning to walk like that from now on (until it becomes easier) — partly because it reminds me too much of the grunting effort I put into 1-legged heel raises 8 years ago, which set my rehab back a MONTH!! But I think it does indicate that I really am close to having enough strength to get my stride back — hopefully soon, and without grunting and concentrating and straining!

    BTW, I started popping MSM pills a week or so ago, just ’cause some people think they help and I doubt that they’ll hurt. And I’ve increased the frequency of my PT visits, at my Physio’s suggestion. I’m seeing him tomorrow (Mon.), having just seen him on Friday!

    He’s started on the Interference Current again, and dropped the Laser. I’m not sure if there’s really any science to this, but he never seems in doubt or at a loss. And I’m doing a bunch of heel-raise (and -lower) type exercises, both with knees straight and with knees bent.

    Today, while hustling down the stairs in the house, I planted my left foot square on a step (rather than pivoting it around the edge of the step) and felt a brief “zing” that reminded me that I’m not quite there yet. No real harm or even fear — just Mother Nature’s way of reminding me that 13-ish weeks of rehab isn’t the end of this marathon. . .

    Good healing, everybody!

  26. By dennis on Mar 15, 2010 | Reply

    norm - I’ve added this page to: http://achillesblog.com/atr-rehab-protocols/

    Please let me know if there is anything else. Thanks for your efforts in adding to the knowledge to share with everyone here.

  27. By dennis on Mar 15, 2010 | Reply

    everyone - If you need to get in touch with me about anything related to AchillesBlog, you can reach me at: achillesblog@gmail.com

    Or you can also put the word “Dennis” in your comments. :) I do a quick search on the front page to see if someone needs help with the site.. almost every day.

  28. By normofthenorth on Mar 15, 2010 | Reply

    Folks, I have some little incremental updates about my own rehab, but I’ll put it in a new post. Let’s save this one for discussions about the options, surgery vs. non-surgery.

  29. By normofthenorth on Mar 17, 2010 | Reply

    I’ve been writing that the UWO study by Willits et al hasn’t actually been published in a “real” peer-reviewed journal (though it’s been presented at MANY professional conferences) — but I might be wrong. (Wrong and cheap, but still wrong.)

    The article at http://bit.ly/aH81yz may be that article. It’s listed as “Operative Versus Non-Operative Treatment of Achilles Tendon Ruptures: A Randomized Controlled Trial (SS-66)” in Arthroscopy: The Journal of Arthroscopic & Related Surgery, Volume 25, Issue 6, Supplement 1, June 2009, Page e36. By
    Kevin R. Willits, Nicholas Mohtadi, Crystal Keane, Dianne Bryant, Robert Giffin, Annunziato Amendola.

    They want US$31.50 for a copy, and I’m not paying, sorry! If anybody has access to this paper, please share some excerpts. (The listing I’ve found doesn’t even show an abstract!!)

  30. By normofthenorth on Mar 18, 2010 | Reply

    One of the co-authors of the UWO study was just kind enough to respond to my questions about the conflicting versions of the study protocol. It’s not a 100% definitive answer about WHAT THEY DID, though it at least adds one more opinion to WHAT WE SHOULD DO. Here’s the whole thing:

    “Leave the heel lifts in longer to maintain correct length for 6 weeks boot for 8.

    Weight bearing is not likely an important issue. Our study allowed wt. bearing at 4 weeks but it probably does not matter.

    The article has yet to be published but will be coming out this year officially.”

    So this expert agrees with Dr. Zarnett and me, that “my” protocol seems more appropriate, especially for non-surgical patients.

    His reference to WB at 4 weeks means Full WB As Tolerated, I believe.

    I believe this expert is correct that the duration of NWB on crutches (and the speed of transition to WB) “probably does not matter” to the eventual OUTCOMES. But it matters HUGELY to the PATIENT!! It matters in lifestyle, in general fitness (including leg strength and proprioception), and probably also in the amount of foot (heel) pain and discomfort when FWB is introduced! If we could get off the crutches and get walking in boots a week or 2 or 5 sooner with no effect to our eventual outcome, ALL of us would do it in a heartbeat!!

  31. By gunner on Mar 19, 2010 | Reply

    Hi Norm: I finally got into the boot yesterday, 2 days shy of 4 weeks. Got a Vaco Cast and you should have seen the commotion in the south georgia ortho offices looking at it!

    Also did first round of therapy and got prepared for the home exercises. We are following your protocol word for word, with the addition of pulsating ultrasound while at the PT office.
    Not sure I understand your comment above about removing the lifts and boot wear. Can you clarify?
    You are totally right about the improved functionality and quality of life with the boot. I’ll keep the crutches for a week or so, but even with crutches life is so much more normal.
    You’ve been a great help.

  32. By normofthenorth on Mar 19, 2010 | Reply

    Thanks, Gunner, you made my day — and it was already a pretty good day!

    There’s a discrepancy between two versions of the protocol used in the study that I’m following. The one I’m using (and which I prefer)
    - keeps the 2cm heel lifts in for 6 weeks,
    - keeps the AirCast (fixed) boot on for 8 wks (though I started my hinge-able boot hinging at 7 weeks, and even earlier might have been fine), and
    - does “protected WB” from 2 wks, and WBAT (WB as tolerated) from 4 weeks.

    The other version (published in clinicaltrials.gov) is a little different, and generally more aggressive:
    - It seems to be WBAT (WB as tolerated) from 2 weeks on, which might work fine;
    - It tosses away the (fixed Aircast) boot at 6 weeks, which might be scary — but that does suggest that letting your Vaco boot hinge at 6 weeks might be OK; and
    - It tosses away the 2cm heel lift at 2 weeks, which seems TOO QUICK (at least for us non-surgical patients) to me, my surgeon, and the one co-author of the study that I’ve corresponded with.

    I hope that’s clear.

    At “WBAT”, I did a quick transition from crutches to a cane to “forgetting where I’d left the cane”(!). Others have used one crutch as a transition. If the bottom of your foot can take the weight without complaining a lot, it goes pretty quickly.

    I had Ultrasound, too — and Lasers and Interference Current, and 3 very $$$ injections of my own “PRP” blood fraction. None of it is proven to help, AFAIK, but it probably can’t hurt, at the worst.

    Good Healing, all!

  33. By mikek753 on Mar 19, 2010 | Reply

    Hi Norm,

    I didn’t get any Ultrasound or electricity to my foot / calf. Were no mentioning for that and I didn’t ask about it :-( ether.

    It’s kinda strange to me policy in USA - “if you didn’t ask, no one will tell you”.
    Maybe I should ask about Ultrasound as I read its very common for ATR PT.
    I asked about “PRP” - got back kinda its too new and so far unproved by large / legit studies, no recommendations for or against it.

    When I was in sport school - like a 30-20 years ago - almost for every treatment after 1-3 days of injury we got ether ultrasound, ultraviolet, plain heat from lamps (that was for back) or Electrophoresis for a week or months based on injury.
    So far I don’t see any - may be I just have ask about it from PT?

  34. By gunner on Mar 19, 2010 | Reply

    Norm. I’m sure you’ve made a lot of people’s days a lot of the time.
    I think we’re on the same path now though I did not start as soon as you. With this Vaco Cast I can put full weight on it already save for the awkardness of the height differential between the two legs. The PT recommended a cowboy boot or something for the other leg. Did you do anything to equalize the lengths of the two legs?
    I’ll keep you posted on how things go the next few weeks.

  35. By normofthenorth on Mar 19, 2010 | Reply

    Mike, I have no idea about those extra therapies that Physiotherapists do. Even the massage and manipulation that’s their “bread and butter” probably hasn’t been validated very often in careful studies. At least it feels pretty good most of the time!

    Yes, Gunner, I worked VERY HARD to equalize the lengths of my two legs when I was FWB in a boot, and I recommend that everybody does that somehow. You don’t want to throw knees and hips or back etc. out of line, just because a big boot with a huge fat sole is good for ONE leg!

    My own tricks are here somewhere (from back when I was WBAT, I guess. Basically, for indoors, I found a “cast shoe” (a sole with big fabric-and-Velcro “flaps” not unlike the bottom of a conventional Ortho boot) and I stuck a bunch of footbeds and foam slabs in it until it was the same height as the boot. In the end, I found that one of my cheap molded Chinese “flip-flops” was the right size when I slipped it inside the cast shoe and tightened the Velcro around it.

    For outside, I found the tallest weatherproof shoe I owned — same type as the Merrell Mocs, a fat-soled slip-on, like a low boot — and stuck as many footbeds in it as I could, and still get my “good” foot in it. That may have still been a couple of mms short, but it was close, and it seemed close enough.

    Different folks, different strokes. Some people have gotten shoemakers to “cobble” something together, others have gone DIY. But balance is important for the several weeks that you’re going to be FWB. I was clomping around very agressively and very fast for most of that time, and I think a seriously lop-sided “gimp-walk” would have done damage.

  36. By normofthenorth on May 13, 2010 | Reply

    I’ve tracked down a formal abstract of the U.W.O. study from 4b, above. Conclusions as listed above, no stat-signficant differences except in surgical complications. Here are the specific numbers and confidence intervals and p-values, for stats-geeks:

    Operative Versus Non-Operative Treatment of Achilles Tendon Ruptures: A Randomized Controlled Trial (SS-66)
    Kevin R, Willits MD, FRCSC, Nicholas Mohtadi MD, Crystal Keane MSc, Dianne Bryant PhD, Robert Giffin MD, FRCSC and Annunziato Amendola MD

    Available online 22 May 2009.

    Article Outline





    The purpose of this randomized controlled trial was to compare outcomes of operative and non-operative management of Achilles tendon ruptures.

    Patients with acute complete Achilles tendon ruptures were randomized to receive open suture repair followed by graduated rehabilitation or graduated rehabilitation alone. The primary outcome measure was re-rupture rate. Assessments at 3 and 6 months and 1 and 2 years included a modified Leppelhati score (no strength data), range of motion, calf circumference, and isokinetic strength at 1 and 2 years. We report the 2 year findings.

    Two centres randomized 145 patients (118 males and 27 females), mean age 40.9 ± 8.8 years (22.5 - 67.2) to operative (n=73) and non-operative (n=72) treatment. Fourteen were lost to follow-up. Re-rupture occurred in 3 patients in both groups. The mean modified Leppelhati score (out of 85) was 78.2 ± 7.7 in the operative group and 79.7 ± 7.0 in the non-operative group, which was not significant (-1.5 95%Cl -6.4 to 3.5, p=0.55). Mean side-to-side difference in plantar flexion and calf-circumference in the operative group was -2.0 ± 3.2° and -1.4 ± 1.2cm, and in the non-operative group -0.9 ± 3.0°and -1.6 ± 1.8cm respectively. Mean isokinetic plantar flexion strength was 62.4 ± 24.2 for the operative and 56.7 ± 19.3 for the non-operative group, which was not significant (5.7, 95%Cl -3.1 to 14.5, p=0.20). There were a greater number of serious adverse events in the operative group, including pulmonary embolus in 1 patient, deep vein thrombosis in 1 and deep infections requiring irrigation and debridement in 3.

    This study suggests that non-operative management of Achilles tendon ruptures utilizing an accelerated rehabilitation programme may produce comparable results with fewer adverse events.

    Arthroscopy: The Journal of Arthroscopic & Related Surgery Volume 25, Issue 6, Supplement 1, June 2009, Page e36.

    It’s possible to make a big deal out of some of these non-stat-significant differences, but I don’t think it’s worth it. But there’s more specific proof of the biggest “magic” of the non-surgical healing: On average, the non-surgical group had a bit MORE plantarflexion ROM than the surgical group — 0.9° deficit compared to the other foot, vs. 1.6°!!

    The difference isn’t significant (statistically or otherwise!), but since all of them (and us) started with a GAP in the torn AT, which always gets closed up in surgery, it is mind-boggling (”magical”!) that the non-surgical results in this measure — how much the calf-and-AT can TIGHTEN — are identical, if not better!

    A number of other differences go in the other direction, but again, “too close to call”, or too close that they wouldn’t often happen randomly even if there’s no “real” difference.

    I wish they’d listed the UNITS for the measurement of “isokinetic plantar flexion strength”. That’s the same fancy Biodex test I just had recently — see my blog “And the Results Are IN!” — but I’m not sure which of the measurements they’re reporting, so I don’t know how to compare my 5-month results to their 2-year results.

    Their “bad foot” results after 2 years averaged 56-ish and 62-ish SOMETHINGS, plus-or-minus a LOT (i.e., very variable within each group). My GOOD foot numbers were 77.5 ft-lbs peak torque, 73.1 ft-lbs average torque (in 5 60-degree pushes), and 65.2 watts average power, and my BAD foot was 29-37% lower, after 5 months. (55.0, 50.8, and 41.1, resp.)

    With luck, the “real” results will be officially published soon, and will include the units. This curious mind wants to know!

  37. By normofthenorth on Jun 3, 2010 | Reply

    I just posted this as a Comment on the “ATR Rehab Protocols, Publications, Studies” page (linked from the Main page):
    I’ve just started slogging through the various linked reports and web-pages that Dennis has linked above, and I find it a “mixed” group. Naturally, many of them were current in early 2008 when D tore his AT, which was a time when the consensus was still that surgery produces better results than non-surgical immobilization. (Heck, that’s why I had my first ATR repaired surgically, in late 2001! But not my second one, in late 2009.)

    If anybody wants to see a copy of a fairly fast rehab protocol that’s been proven to produce good results in a large number of patients, both WITH and WITHOUT surgery (and you SHOULD!!), I’ve posted one at http://achillesblog.com/normofthenorth/the-non-surgical-protocol-ive-been-following/ . It was faxed to my sports-med surgeon by the staff at U. of W. Ontario that did the latest randomized study of “op” vs. “non-op”. The discussion of that protocol and that study and others is on my blog, on the page that D has linked above (with “Thanks Norm”).

    For those pondering or facing ATR surgery, D’s first link above on that subject. entitled “Surgery or Casting, a meta analysis. Debate continues” is a very interesting article, but I don’t think it’s really about “Debate continues”! (Except maybe in the US, which is so biased in favor of ATR surgery that anything that shows that it’s not useful is considered a “debate”!)

    Here’s the “bottom line” of that article:
    “In Conclusion

    Based on a critical analysis of the best available evidence, active, healthy adults with acute Achilles rupture should undergo conservative treatment with functional bracing and early weightbearing.”

    (1) That sounds much more like “Debate Over” than “Debate Continues”, doesn’t it?
    (2) “functional bracing” means a HINGED BOOT. That’s my fave “appliance”, too, after two ATRs!
    (3) “Early weightbearing” in this article means starting immediately, post-op or post-non-op. The article cites two studies that show benefits from that “instant” FWB, which I haven’t read yet. That is MUCH quicker than in the UWO protocol that I followed, which (a) included 2 weeks of NWB and 2 weeks of PWB, (b) used a FIXED boot not a HINGED one, and used it for EIGHT weeks, so ankle flexion was only in PT and home exercise until then.

    Below that link, we find “WebMD’s nice overview on ATR surgery and whether it’s right for you.” I find this much less “nice” than Dennis does, because it repeats a number of pro-surgery myths that have been disproven by the best and newest studies — higher AT strength from surgery, better performance in sports from surgery, etc., etc. It seems like a typical US-based pro-surgery “summary”, whose bottom line hasn’t changed since the last 4 studies showed that it’s based on old myths. Misleading vulnerable people who’ve just had a crushing injury and are facing an important decision is NOT “nice”, in my books!

    BTW, I am this site’s biggest fan, recommender, and participant, so please don’t take these comments as putting down “our” Dennis! He’s put together the best site on the Internet on this subject, working harder and better at this “sideline” than many of work at our jobs! And he’s still “spilling blood” over it, almost 2.5 years after his own ATR! God Bless, and Please Don’t Stop!

    Unfortunately, the job of maintaining a full and balanced and up-to-date Annotated Bibliography of ATR Rehab Protocols, Publications, and Studies is a monster job, which I think no FIVE of us have the energy to do. . . Heck, huge “professional” sites like WebMD SHOULD be doing a good job of it, and they’re blowing it badly, IMHO!

  38. By normofthenorth on Jun 3, 2010 | Reply

    BTW, I quoted the “bottom line” of that article without commenting on its use of the phrase “conservative treatment” to refer to non-surgical immobilization with INSTANT full weight-bearing in a HINGED boot(!).

    Regular readers will know that I bristle whenever the non-surgical cure for an ATR is called “conservative”. And the protocol recommended here is VERY FAR from what most people would call “conservative”, since the instant FWB and the instant mobility/flexion in a hinged boot are both extremely aggressive compared to the average clinical practice and the average randomized study.

    That word often means “slow as molasses” or “old-fashioned” or “suitable only for old fogies and sick people who can’t withstand surgery”, so I try to avoid it. It’s also mis-used in another way, which is to imply that SLOWER is SAFER, which the best evidence says is simply false. (”I know you’d like to get out of that cast now, but I think we should be conservative. . .”)

  39. By normofthenorth on Jun 22, 2010 | Reply

    I’ve been “collecting” a number of old-fashioned, misleading, or Just Plain Wrong online statements on this topic from sources that should know better. And I think I’ve just found the GrandDaddy of them all, a real Lulu!

    University of Michigan has a website for unsuspecting ATR patients that says flat out “Surgical correction of the ruptured tendon is necessary.”!! I guess the debate is over, eat your heart out scientific study authors, AAOS, Normofthenorth, and everybody else who doubts the simple truth of this amazing statement!!

    Here’s the question I just sent to them, through their website:

    “Your guide to Achilles Tendon rupture –at http://www.med.umich.edu/ortho/patient/pdf/ACHILLES-TENDON.pdf — says the following:

    “While it is possible to treat this ruptured tendon without surgery, this is never ideal since the maximum strength of the muscle and tendon never returns. Surgical correction of the ruptured tendon is necessary.”

    How can you people justify the repetition of statements like that following the publication of the latest (and only) four randomized trials of this subject, which ALL apparently found the contrary to be true?

    I am referring to
    1) Bruce C. Twaddle, FRACS†,* and Peter Poon, FRACS, Am J Sports Med December 2007 vol. 35 no. 12 2033-2038, “Early Motion for Achilles Tendon Ruptures: Is Surgery Important?: A Randomized, Prospective Study”, ajs.sagepub.com/content/35/12/2033.abstract

    2) http://www.ncbi.nlm.nih.gov/pubmed/19825777?dopt=Abstract — Netherlands: Metz R, et al, Foot Ankle Spec. 2009 Oct;2(5):219-26. Epub 2009 Sep 4. “Recovery of calf muscle strength following acute achilles tendon rupture treatment: a comparison between minimally invasive surgery and conservative treatment.”

    3) Gothenburg, Sweden, May 2009: http://www.physorg.com/news161516132.html (”Surgery may not be necessary for Achilles tendon rupture”)

    and 4) http://www.medscape.com/viewarticle/588904 — Canada: Kevin Willits, March 2009 paper at AAOS 2009: “Nonsurgical Rehab After Achilles Tendon Rupture Better Than Surgery”. (formal publication forthcoming)

    Are you unaware that these randomized trials have been done, or that they produced identical or marginally better results without surgery? Or do you have good reasons to doubt these results?

    Can you recommend, or are you publishing something, in the peer-reviewed literature (preferably since 2007, when the scientific studies began) that documents your extreme claim?

    I am sure nobody at UMich intends to mislead vulnerable AT Rupture patients, or to bring disrepute to your fine institution. But I am puzzled by this apparent ignorance of the scientific literature on a topic that is of vital importance to a great number of AT Rupture patients.

    More information on these studies and others may be found on my personal ATR blog, at achillesblog.com/normofthenorth/2010/03/08/a-more-complete-review-of-the-options-surgical-vs-non-operative/ .

    I look forward to your response.

    Norm Rubin (in Toronto)”

    P.S. I’ve slightly expanded and improved the citations for the middle two studies, which are my 4b) and 4c) in the original post above.

    I’ll let you know what response I get.

  40. By normofthenorth on Jun 23, 2010 | Reply

    Wikipedia’s article on Achilles Tendon Rupture (en.wikipedia.org/wiki/Achilles_tendon_rupture) was inaccurately pro-surgery when I looked there a few days ago, citing a 1994(!) German study that showed higher re-rupture rates from immobilizing the “crocks”, compared to operating on the “jocks”(!).

    I’ve just edited that article to include the four modern studies. The changes probably won’t last long before somebody makes it pro-surgery again. If anybody “here” is good at editing Wikipedia articles, I’m not! Please dig in.

    Here’s the start of the section on Treatment:

    Treatment options for an Achilles tendon rupture include surgical and non-surgical approaches. Among the medical profession opinions are divided what is to be preferred.

    Non-surgical management traditionally was selected for minor ruptures, less active patients, and those with medical conditions that prevent them from undergoing surgery. It traditionally consisted of restriction in a plaster cast for six to eight weeks with the foot pointed downwards (to oppose the ends of the ruptured tendon). But recent studies have produced superior results with much more rapid rehabilitation in fixed or hinged boots.

    Some surgeons feel an early surgical repair of the tendon is beneficial. The surgical option was long thought to offer a significantly smaller risk of re-rupture compared to traditional non-operative management (5% vs 15%).[4] Of course, surgery imposes higher relative risks of perioperative mortality and morbidity e.g. infection including MRSA, bleeding, deep vein thrombosis, lingering anesthesia effects, etc.

    However, four recent studies have scientifically tested the benefits of surgery, using randomized streaming of patients into surgical and non-surgical protocols, and applying virtually identical (and aggressive) rehabilitation protocols to both types of patients. All four such studies completed to date have found no benefit from the surgery, separated from the other confounding variables. They have all produced statistically indistinguishable results in re-rupture rates, strength, and range of motion, while most have reaffirmed the greater complication rate from surgery.[5] [6] [7] http://www.medscape.com/viewarticle/588904 — Canada: Kevin Willits, March 2009 paper at AAOS 2009: “Nonsurgical Rehab After Achilles Tendon Rupture Better Than Surgery”. (formal publication forthcoming) [I obviously screwed up the Reference code here, and I've since fixed it, so this shows up as citation "[8]“. –Norm]

    Judging by the consistent results of these modern randomized trials, it now appears that the long-believed benefits of surgery, reinforced by virtually all studies done before 2007, were primarily artifacts of a selection bias, directing younger, healthier, and fitter patients to surgery, and the rest to non-surgical immobilization. Nonetheless, many “experts” continue to promote Achilles repair surgery, often citing older studies and statistics.

    And here’s how I left the beginning of the section on Rehabilitation:

    Non-surgical treatment used to involve very long periods in a series of casts, and took longer to complete than surgical treatment. But both surgical and non-surgical rehabilitation protocols have recently become quicker, shorter, more aggressive, and more successful. It used to be that patients who underwent surgery would wear a cast for approximately 4 to 8 weeks after surgery and were only allowed to gently move the ankle once out of the cast. Recent studies have shown that patients have quicker and more successful recoveries when they are allowed to move and lightly stretch their ankle immediately after surgery. To keep their ankle safe these patients use a removable boot while walking and doing daily activities. Modern studies including non-surgical patients generally limit non-weight-bearing (NWB) to two weeks, and use modern removable boots, either fixed or hinged, rather than casts. Physiotherapy is often begun as early as two weeks following the start of either kind of treatment.

  41. By normofthenorth on Jun 24, 2010 | Reply

    My version’s still standing at Wikipedia, now with four clean footnotes pointing to the online writeups of the four randomized trials showing no benefit from the ATR surgery. I thought the trolls would have changed it back immediately (based on my experience with Wikipedia when somebody tries to put in the actual CV credits of a scientist who’s critical of IPCC on man-made global warming).

    Either the pro-surgery trolls take Thursday mornings off, or they’re starting to get embarrassed about pushing ATR surgery in public, based on a 1994 study showing high re-rupture rates from non-surgery! (Give me a break! I had no trouble finding a 2005 meta-study supporting “the old wisdom”!)

  42. By normofthenorth on Jun 24, 2010 | Reply

    Still no response from U. of Michigan, and still nobody’s undone my Wikipedia edits. I just sent this e-mail to Mayo Clinic through their website:

    Your article on “Achilles tendon rupture” contains a wealth of excellent information and a few statements that can no longer be supported by the best scientific studies! For example, the claim that “the likelihood of re-rupture is higher with a nonsurgical approach” has been tested in FOUR randomized trials, dated between 2007 and 2009, and has been found to be FALSE in all four! They also found statistically identical rates of strength and ROM in the patients that received surgery and those who did not.

    I would expect Mayo Clinic Staff to be avid readers of the scientific literature, and “early adopters” of the facts revealed by carefully done randomized trials like these.

    If there are valid reasons to doubt these results, I would appreciate your sharing them with me. I am actively involved (through http://www.achillesblog.com/normofthenorth) in helping a number of AT Rupture patients make decisions about their treatment, including the urgent decision to undergo surgery or forgo it.



    P.S. I believe the article’s suggestion that pre-sports stretching can help avoid AT ruptures is also contradicted by the best evidence.

    I’ll post if they respond, as I hope they will.

    The article I found at emedicine.medscape.com/article/85024-treatment has some very good info on this subject, including a reference to the first of the four randomized trial reports, from New Zealand in 2007. But when it gets to the “bottom line”, it still suggests that jocks should probably have surgery and crocks should probably avoid it — and expect to be immobilized much longer and have worse outcomes! It’s as if the author read the study, paraphrased its results accurately, and then more-or-less ignored it! (I can’t see an easy way to respond, or I probably would.)

  43. By normofthenorth on Jun 26, 2010 | Reply

    You may recall that two of Dennis’s high-level pages here — “Just ruptured your Achilles?” and “ATR Rehab Protocols, Publications, Studies” — have a link to “WebMD’s nice overview on ATR surgery and whether it’s right for you.” I’ve posted above (and maybe on one of them, too) that I don’t think the flamingly pro-surgery message of WebMD’s overview (which I believe is contradicted by the 4 randomized prospective trials that have tested the benefits of surgery) is at all “nice”.

    Well, I’ve found a way to send my concerns and questions to WebMD, too, and I’ve already gotten a substantive response! One of the related articles at WebMD listed their authors and consultants. I tracked down the e-mail address for the “Specialist Medical Reviewer” for the articles, and wrote to him, including the links to the four studies — and the 3 WebMD articles that say the opposite.

    He is, BTW, a very senior and “fancy” orthopedic surgeon, author of a well-reviewed book on sports injuries, etc. — no slouch, professionally!

    He responded remarkably quickly, as follows:

    Thanks for taking the time to write me. I review medical information for Healthwise, a company that provides content for numerous sources, including WebMD. I am not able to change WebMD content. I do however spend considerable time ensuring the source info is as up to date as possible. The literature indicating re-rupture rates are higher with nonoperative treatments was not prospective and randomized. So, I will certainly review the information you have provided in the event Healthwise again asks me to review information on AT. Again, thanks for your time.

    In addition, he CCd his response (with my e-mail quoted in it) to somebody at Healthwise.

    So, although he’s not the author and has no direct control, there’s some basis for hope that “WebMD’s nice overview” will become nice enough to reflect
    the results of the best studies on the subject at hand. I’m a bit encouraged. . .

    OTOH, I got more of a form-letter brush-off from the Mayo Clinic, as follows:

    Thank you for contacting MayoClinic.com.

    Your feedback is valued, and we will certainly forward your information to our staff.

    New content is added daily, so please visit us for all your health
    information needs.


    Mayo Clinic Online Services

    Maybe I’ll respond with the actual links to the four studies, though I don’t find that response anywhere near as hopeful or open-sounding as the one from WebMD.

  44. By doug53 on Jun 26, 2010 | Reply

    Hi Norm,

    I wouldn’t assume that letter from Mayo Clinic is a brush-off. Your note was received by a secretary, who will forward it to the right person. The question is what happens next.

    If you don’t get a satisfactory answer, let me know, and maybe I can make something happen. I have been on staff at Mayo for 22 years, so I might be able to get something moving. My surgeon might have written that article!


  45. By normofthenorth on Jun 26, 2010 | Reply

    Thanks, Doug, that’s both hopeful and hilarious!

    Having moved pretty far away from my High School and ALL of my (3!) universities, I often notice other people “getting things done” with a local network that I don’t have. This may be Karma compensation, thanks to AchillesBlog!

  46. By normofthenorth on Jul 1, 2010 | Reply

    OK, I finally got bit.ly/achillesstudies to forward to my review of the studies comparing surgical Achilles-rupture repair to non-surgical, and bit.ly/UWOProtocol to forward to the protocol my surgeon got from the U. W. Ontario study authors. (There now, THAT wasn’t hard!!)

    With luck, I’ll be able to remember them!

  47. By normofthenorth on Jul 7, 2010 | Reply

    I’ve also added a “postscript” to the UWO protocol at bit.ly/UWOProtocol to explain what it is, where it came from, and how I would tweak it if I were starting over.

  48. By normofthenorth on Jul 26, 2010 | Reply

    There are some interesting discussions about the two approaches and other variables — especially the size of the gap in the torn AT. Basically it sounds logical that big gaps need surgical repair, and do worse with non-surgical treatment. Logical, but apparently Just Not True!

    One discussion is at achillesblog.com/how-did-achillesblogcom-start/comment-page-2/#comment-1805
    (and just before that), one is in a discussion on Rougemac’s blog at achillesblog.com/rougemac/2010/07/02/surgery/#comments , and I think another is in some recent comments on my blog, the “The Results Are In!” page.

    As far as the evidence goes, neither initial measured AT gap size nor ATR location is correlated with the success of the non-surgical approach. More evidence of the “magic” we’ve discussed before — how the Heck the AT heals “by itself” to its former length when there’s obviously a good-sized gap in it. The intact paratenon (”sheath”) surrounding the gap may be a key to the magic. We know WHAT happens, but not WHY or HOW. . .

  49. By brock on Jul 29, 2010 | Reply

    Hi Norm,

    I’m pretty new to all this and have been reading your blog since I had my ATR back in mid May this year. Unfortunately I recently re-ruptured the same tendon completely and I am now faced with the decision of whether or not to do surgery.

    For the meantime I have opted for the non-op method so I am currently in a rigid boot with heel lifts and the doctor says I can do weight bearing without crutches. He also mentioned that surgery may be more of a sure thing than the non-op method however he did acknowledge the UWO protocol as being just as good since he graduated from there himself.

    I am a fairly active and young individual (20yrs old), playing rugby for the most part and I was just wondering what your thoughts are on my situation?

    p.s. ultrasound showed that my tear has about 2cm in separation which the doctor said was fairly small margin.

  50. By normofthenorth on Jul 29, 2010 | Reply

    Brock, you should start a blog and tell us all the details. And install the little timeline widget — at http://achillesblog.com/dennis/2008/03/08/achilles-timeline-widget/ — that reminds us all which leg, where you are, how long ago, etc.

    For an initial ATR, complete or partial, with only a few odd-ball exceptions, I think the evidence is now clear that surgery poses unnecessary risks in return for no benefits.

    Unfortunately, for a re-rupture, there’s no good evidence either way, and there may never be. (Good news in a way, because the “problem” is the scarcity of data, because re-ruptures are relatively rare.)

    Most Docs put their re-ruptures under the knife, even if they’re relatively anti-surgery for initial ATRs. That doesn’t prove much by itself, since most Docs put all their INITIAL ATRs under the knife, even when the evidence says “No” — but it is the fact, apparently.

    Here on this website, we’ve seen a number of re-ruptures, both post-op and post-non-op — the latter overwhelmingly after archaic “conservative” treatment, which always has had high re-rupture rates — that have been treated surgically. I think most of them have done OK. (There are no guarantees in ANY of this, which is why randomized studies and statistics are the best indication of meaningful truth.)

    We’ve got ONE blogger here — “Scott”, check out his blog — who recently re-ruptured after surgery and then went non-surgical, basically following the UWO protocol. So far, he’s doing well.

    My GUESS is that a good non-op protocol like UWO’s should work well for re-ruptures, whether the initial rupture was treated surgically or not. I think the body usually produces a healing response the second time around that’s similar to the first time around, and the important paratenon (the sheath surrounding the tendon) should be either still intact or mostly healed up (post-op, because it’s sliced open lengthwise in an ATR repair, not cut cross-wise).

    In other words, if the evidence supports UWO’s non-op protocol for initial ruptures, I THINK it’s LOGICAL to ASSUME that it makes sense for re-ruptures, too.

    But logic doesn’t really prove what the facts are, and the standard practice of doing the opposite could give you pause. Heck, the UWO-study authors themselves operated on all three of their own re-ruptures (out of 145 patients)!

    Sorry I can’t be more absolute in the advice department, Brock, but that’s what I think we know, and what people are guessing about what we don’t know.

    BTW, jumping straight to FWB without crutches after ANY ATR (1st or re-) is NOT part of the UWO protocol. A few studies have produced good results with immediate WB (not always F) after surgery (definitely including experimental super-strong surgery), but I don’t recall any that did so without surgery. That may be a bigger experiment than going non-op.

    Me, I’d stay off that foot for a couple of weeks, then go partial for two, like the UWO protocol at bit.ly/UWOProtocol . The problem probably isn’t be the weight itself, but the little “moves” our muscles — including the gastroc and the soleus — naturally make all the time whenever we’re standing and walking.

    You obviously don’t want ANY tension pulling up on the top of your re-torn AT while it’s still ruptured, and the two ends are trying to find each other and paste themselves back together, first with quick-and-weak stuff, then gradually with strong stuff (collagen).

    Your boot should keep your ankle angle just fine. But you might have to be a Zen master or a Shaolin monk to have the self-control to eliminate all the little pulls from your calf muscle while padding around FWB. Again, this is logic and mechanics, not evidence or proof.

    I’m usually negative on MRI and Ultrasound, too, but I’d make an exception in your case. If you do the non-op approach and your gap hasn’t shrunk significantly in a couple of weeks (with US and/or palpation), it might be time to stop that experiment and get ‘em stitched together. Hard to be confident. . .

    Good luck, and good healing!

  51. By brock on Jul 29, 2010 | Reply

    Thanks a lot for the information Norm. I understand what you are saying about the weight bearing but the thing is I fairly confident on what I heard from the doctor and for the most part I usually follow what they say.

    Could the differences between what I’ve been told and the UWO protocol be a result of the fact that it’s a re-rupture, the intial “conservative” treatment I received before the re-rupture, me being able to still move my foot and toes fairly well or a possible combination of everything?

    I feel really stupid asking this but is there a difference between re-rupture vs. complete tear? I’m assuming they are used interchangeably.

  52. By normofthenorth on Jul 29, 2010 | Reply

    You’re welcome to follow your Doc, Brock, and it may make life simpler for you — though not necessarily better!

    You started with what I’ve been calling an “initial” AT rupture, probably a complete one (tear). The second time you tear the same AT, it’s not “initial”, it’s a RE-rupture. Either tear (1st or 2nd) might be complete or partial, or possibly even partial and multiple. Lots of things can tear in different ways, including Achilles Tendons. When it tears from being over-stressed (the most common case), and leaves a palpable gap, it’s usually complete.

    Most people who tear their AT, initially or in a re-rupture, can still move their foot and toes fairly well, especially with the foot up in the air, NWB. There are several other muscles and tendons that can even move your foot down (plantarflexion), just not nearly as powerfully as the AT and the calf muscles.

    But with a (completely) torn AT, there are a few things you definitely canNOT do.

    Walking up stairs normally in shoes or barefoot — with your heel hanging out over air — is one. (It’s scary or creepy just to try.) Walking normally at all is another. Watching your bare foot straighten out (plantar-flex) when somebody squeezes your calf muscle (”Thompson Test”) is another.

    It’s always comforting to think that our Docs know all the answers, and that anything in their treatment for us that seems strange is the result of their careful consideration of our unique circumstances. In the case of ATR treatments, I’m afraid there are pretty compelling reasons to doubt that comforting assumption:

    - Most Docs are very busy, at least marginally overworked. They also didn’t get 100% at school, and they’re not getting 100% at work — just like the rest of us.
    - ATR is usually a minor sideline, not very “sexy”, not life-threatening, not a good way to get promoted or rich or famous or respected by your peers. Every surgeon knows how to do the operation, and nobody specializes in it. (Somebody once called it “the tonsillectomy of the leg”.)
    - Surgeons often don’t pay a lot of attention to the latest scientific studies in general, and are often slow to change their ways. The four scientific studies that have revolutionized the evidence on ATR repair and rehab were all done since 2007, which is long after most surgeons left Med School and Internship and started being treated as if they knew everything. The studies say that what all those Docs were taught — that surgery produces better results, and so do slower rehab protocols — doesn’t turn out to be true.
    - If they don’t even take the time or effort to put ALL their patients on the “one size fits all” protocol that produced the best results in the studies (like the UWO protocol without surgery), what makes you think they’ll take the time or effort to put EACH ATR patient on a CUSTOM protocol that works even BETTER? And since the UWO protocol worked better than the average protocol for almost everybody in the whole study group, where’s the evidence that a custom protocol would actually work better?

    So I think there’s a fork in the road for most ATR patients, with the psychological comfort of trusting an all-knowing all-caring doctor down one road, and questioning, learning, and taking some responsibility for your own leg down the other one. Getting a busy surgeon to listen to our questions and concerns is a challenge for most of us, and may be especially tough for a 20-year-old, so I do sympathize.

    In your particular case, all I know for sure is that you tore the same AT twice. (Bummer!) And now you’ve mentioned that your initial treatment was “conservative”. (Details, please — preferably on your own blog!) That doesn’t immediately suggest to me any good reason why you should be fully WB when the patients in the modern studies (who generally did very well) were NWB.

    That’s just the view from here, of course!

  53. By tony on Jul 30, 2010 | Reply

    Norm I have to say you are spot on in your analysis of this entire situation. You just outlined in brevity my entire situation with my surgeon. Of course behind that brevit for a number of us is a lot of turmoil, and conflict as we try to do our actual jobs, become a quasi learned medical practitioner pouring over studies, attempt our own protocol against trained professional who threaten that we are now on our own all while dealing the actual fact that we cant do what we need to do (at least in any reasonnable time frame) to be as effective as we were before. What am I learning in this? Lots of things. but personally i am learning to be positive and resilient. I am also learning that hopefulness is a great strength and possibly one of the most impactful things we can do with our time, money and influence or talent is attempt to inspire hope in others. I know an Achilles tear is not the end of my world or nearly as dramatic as an infinite number of others tragidies that can occur in my frailness but i can extrapolate. These professional mills that many surgeons operate have so missed the satisfaction that their vocations could inspire. I hope I dont waste my life in that manner and pity them for the great quality they are missing as they work with people in very dark times.

  54. By normofthenorth on Jul 30, 2010 | Reply

    Tony, I think you might be more negative about the average OS than I am. I find there are delightful people and jerks in every line of work, and most of us are in-between, and with better days and worse ones. And if people always treated me like a God, I’d probably have more bad, jerk-like, days than I do now.

    A lot of the difficulty in getting new evidence spread through the medical profession is structural or institutional, and could be solved if society or government set its mind to solving it.

    We didn’t used to be smart enough to recall defective cars, or to put warnings on drugs; now we are, Halleluiah! I don’t think the people who make cars, or drugs, have gotten any smarter or any nicer than they used to be. But the cars and the drugs are safer now.

    I hope that advances in REALLY IMPORTANT medical procedures make it through the ranks of doctors faster than advances in cases like ours, which must seem like minor distractions to the average surgeon. Unfortunately, given my experience here, that hope isn’t as confident as it used to be.

  55. By brock on Aug 3, 2010 | Reply

    Thanks for the info once again Norm. I e-mailed my doctor and he was pretty good about responding. When I asked about the weight bearing issue he said that it was “OK” for me to do weight bearing with the boot and heel lifts but that I was certainly free to do partial or none. I have opted to stay off it for the first two weeks.

    He was also fairly helpful in my decision making process. He told me he normally has initial ATR patients do the non-op method and said in the case of my re-rupture that I could do either op or non-op but that I should do fine non-op.

    As for starting my own blog, I seem to be having a little trouble since I’ve never actually blogged before. Every time I click on the “create your own blog ” link I receive message saying I don’t need to register since I am a member. I assume this may not be the correct thing to do, so if you could please direct me to where I am suppose to go that would be much appreciated.

  56. By gerryr on Aug 3, 2010 | Reply

    Read the third paragraph on the main page, it explains all you need to know about getting your own blog here.

  57. By normofthenorth on Aug 4, 2010 | Reply

    +1 to Gerry’s advice, Brock!

    And congrats on having such a meaningful dialogue with your Doc! Heck, just getting your Doc’s e-mail address is farther than most of us have gotten!

    There are now TWO ATR patients posting here who are being treated non-surgically and were told to go to FWB in a hurry. Maybe there’s a study I’ve missed somewhere that indicates that that’s a good idea? Or maybe not.

  58. By normofthenorth on Aug 16, 2010 | Reply

    There’s an interesting discussion at http://achillesblog.com/kaston/2010/08/14/motherfer/ concerning some of these studies, and whether they justify my (or their) conclusions, and whether they’re actually published (yet) or not.

    BTW, I’ve just contacted Katarina Nilsson Helander (author of study #4(c) above) to see if it’s actually been published, or if it’s going to be.

  59. By assumptiondenied on Aug 16, 2010 | Reply

    Norm, I won’t disagree with the conclusions you’ve supported here, I’m not and ortho surgeon so my opinion about technique and choice is unsound, but I would like you to add one thing to your “campaign”.

    The pursuit of less invasive repair, especially non-surgical repair, MUST be accompanied by better diagnosis techniques or the more rare cases will not be repaired.

  60. By normofthenorth on Aug 16, 2010 | Reply

    Assumptiondenied, there’s already a lot of non-random diagnosis-led streaming of ATR patients going on. I’m not sure that much of it is evidence-based, but that’s what ALL of this discussion is really about, isn’t it?

    E.g., many surgeons refuse to operate on high ATRs and old ones, so those patients get immobilized (maybe quickly and properly, maybe “forever” and “conservatively”). Many OSs stream their ATR patients based on partial vs. complete, and based on gap size — both with no evidence to support the decision, AFAIKS.

    Most OSs also operate on all their RE-ruptures, regardless of their preference for primary rupture treatment. That may or may not make sense, we just don’t have evidence either way.

    I’m not sure how AT lacerations are usually treated, vs. over-stress ruptures. Most lacerations that deep would need sutures to close the wound anyway, so I’m guessing they’d probably get the AT stitched up at the same time.

    I just looked at a very old (1972) report that reported very good results from 8-weeks non-op cast-immobilization of a bunch of ATR patients, including eleven (11) AT laceration patients. If I read the report right, their ATs generally healed a bit SHORTER than before (less dorsiflexion, more plantarflexion), as opposed to the Rupture patients, who were the same as before or a smidge longer.

    AT laceration patients would probably have smaller initial gaps, but would also have a lacerated paratenon (and there’s a theory that the patatenon helps direct the meeting of the tendon ends during non-surgical healing). I would have expected them to heal long, but that’s not what this small sample found (if I’m reading it right).

    The article is ROBERT B. LEA and LYMAN SMITH, “Non-Surgical Treatment of Tendo Achillis Rupture”, J Bone Joint Surg Am. 1972;54:1398-1407. Online at http://www.ejbjs.org/cgi/reprint/54/7/1398 .

    Their findings on lacerations:
    “Among the patients with lacerations, a higher percentage (four of eleven) had between 3 and 10 degrees of decreased ankle dorsiflexion.”
    [8 yrs ago, my surgeon said he WANTED me to have decreased ankle dorsiflexion, and I did. I think the direction is the same in this study.]

    Their (confusing?) conclusion on lacerations:
    “We do not advocate non-suture of Achilles lacerations, but have deliberately left them alone in eleven cases to prove the point of Achilles tendon reconstitution.”

  61. By normofthenorth on Aug 20, 2010 | Reply

    As I posted just above, “I’ve just contacted Katarina Nilsson Helander (author of study #4(c) above) to see if it’s actually been published, or if it’s going to be.”

    And she just replied (as I recently posted on kaston’s blog):
    “Thank you for your e-mail. The study will be published in American Journal of Sports Medicine.
    Best regards
    MD, PhD Katarina Nilsson Helander”

    So two of my fave and oft-cited 4 recent randomized studies are still “forthcoming” when it comes to formal publication in a peer-reviewed journal. OTOH, the results of those two have now both been presented at AAOS conferences.

    The AAOS report of Helander’s study (ref #6 in the Wikipedia article & #4(c) above) is available online as “Acute Achilles tendon rupture: an RCT comparing surgical and nonsurgical treatments” AAOS 2010; Abstract 712, at http://www.medpagetoday.com/MeetingCoverage/AAOS/19017 .

    As I posted on kaston’s blog:
    “The results may be a bit unsettling to my fellow non-op “crusaders”:

    “Through one year, re-rupture occurred in 12% of the nonsurgical group and 4% of the surgical group, which was not a significant difference (P=0.377). [Kaston and others may well disagree, and a meta-study might also find stat-significance in the totals.]

    “There were some complications in the surgical group, including one contracture of the tendon, two wound infections (one deep and one superficial), and two nerve disturbances.

    “Thirteen patients had concerns about the scar — 10 for cosmetic reasons and three for scar contracture and pain.”

    “Patients who received surgery performed significantly better on tests of heel-rise work, heel-rise height, hopping, and concentric power at six months (P=0.05 for all).

    “However, by 12 months, the two groups had similar function and differed only in heel-rise work (P=0.012). [That's not a trivial difference, especially at such a high significance level. Funny that heel-rise HEIGHT did NOT differ, though.]

    “At one year, there continued to be functional limitations in the injured leg compared with the uninjured leg, regardless of treatment group.”

    And as I also posted on Kaston’s blog:
    “Note that the UWO study did NOT confirm these strength differences, and one of the studies (Wiki #5 = Metz) actually found GREATER strength among the non-op patients in one single measurement (”isokinetic strength”).

    “BTW, FWIW: I know how you get a sural nerve injury during ATR surgery, but how the @#$%^& do you get one during non-op rehab, as Metz reported?!? DVTs are also more common post-op than non-op, according to almost everybody. Did Metz report his results backwards??”

    So there are still a bunch of residual questions, as well as some apparent answers. I think a lot of the “surgery vs. non-op” debate now really hinges on conflicting views on burden of proof:

    To me (and my surgeon), the pain and risk and cost (and extra days out of commission) of surgery have to produce a clear benefit for surgery to be defensible. At least in the case of “ordinary” ATRs and “ordinary” open surgery, the latest 4 studies (even with 2 of them still forthcoming and this one showing slightly “messy” results) show pretty clearly that there’s no “clear benefit”, and likely no benefit at all.

    To those who disagree, the burden of proof is reversed, maybe something like this: ATR surgery has been the “gold standard” for fit, competitive athletes for decades, esp. in the USA. The bulk of evidence up to around 2007 also suggested a very significantly higher re-rupture rate without surgery. All that has created a “reality” which can’t be overturned easily, without rock-solid proof beyond a reasonable doubt that surgery really conveys absolutely no benefit.

    There may be another aspect as well, which is the different values some of us put on evidence vs. expert judgment. When a trusted health professional says (as many still do) that surgery is the way to go, many people simply won’t disagree without gold-plated proof that it’s wrong, seriously wrong, and maybe even dangerous. And except for the lopsided costs and the risks of complications (and maybe the scarring), reasonable people could still call this a toss-up (and many do).

    A final factor is the obvious conflict between the evidence (the 4 studies) and “common sense”. Heck, there’s usually a big gap between the tendon ends, and NOBODY finds it easy to believe that they’re just going to “find” each other by themselves, every bit as well as if they were drawn together and physically stitched together — “REPAIRED”!! For some people, even 10 studies involving 1000 patients showing that it happens, won’t overcome that obvious “logic” that it can’t! (Those people probably also have trouble with relativity and Heisenberg uncertainty and string theory, but that doesn’t affect their real lives as much as this!)

  62. By doug53 on Aug 20, 2010 | Reply

    Hi Norm,

    I always assumed that the sural nerve could be damaged at the time of the rupture, as it is very close to the tendon.

    I imagine, as an example, two handles at either end of a piece of strong rope (the tendon), but there is a thread (the nerve) going between the handles, too. You could pull hard enough on the handles to break the thread if the thread was the only thing there, but the rope prevents you from doing so. If you pull hard enough to break the rope, however, the thread will break (or stretch a lot), too, as soon as the rope gives way. I’m guessing that’s what happens with the Achilles tendon and the sural nerve.

    I hope that makes sense,


  63. By normofthenorth on Aug 20, 2010 | Reply

    Doug, what you say is clear and totally sensible for a rope and a thread with two handles. My problem is this: If the sural was related to the AT as you describe, it would get damaged most of the time when an AT gets ruptured. Instead, sural nerve injury seems to be (according to my reading) a rare complication, only worth mentioning after surgery, and especially after minimally invasive (not “open”) surgery.

    The latter was touted in some studies (including the 2005 meta-study by Khan, IIRC) as producing better outcomes than open surgery, except for the higher rate of sural nerve injury. Other than the Metz study, I don’t recall any study linking it to non-op treatment, do you?

  64. By doug53 on Aug 20, 2010 | Reply


    I found this paper


    that discusses some of the ways the sural nerve could be damaged without (and with) surgery. It also discusses how the sural nerve position varies from person to person, perhaps explaining why some people have sural nerve troubles and while many others don’t.

    It is kind of sad that their main concern seems to be avoiding getting sued for operative complications.


  65. By normofthenorth on Aug 22, 2010 | Reply

    Again, the two documented cases of non-surgical ATR injury to the sural nerve — compared to a significant percentage of ATR patients who get percutaneous surgery, and a smaller but still measurable percentage of ATR patients who get open surgery, still makes me wonder if Metz’s paper contains a little “lapsus occuli” that reversed (at least) this part of their results.

    Nobody here but us fallible humans, after all, and peer review doesn’t eliminate all of that fallibility, either!

  66. By assumptiondenied on Aug 22, 2010 | Reply

    Norm, I’m not sure where you went with my concerns about diagnosis but let me word it as clearly as I would like to see anyone promoting non-surgical protocols should.

    If you are encouraging or have been encouraged to pursue a non-surgical approach to an Achilles injury, please ensure that the Ortho has used MRI or other high detail soft-tissue aware imaging for diagnosis - ultra-sound it NOT good enough.

    I was given the Thompson Test and its indication of a rupture was confirmed with ultrasound. Neither of these tests were good enough to catch my Avulsion and since my avulsion was clean (there was no bone chip attached to the tendon) an x-ray would have proven useless.

  67. By normofthenorth on Aug 22, 2010 | Reply

    Assumptiondenied, your personal experience and your reporting of it were all well before I arrived here after my own (second) ATR in Dec. 2009, so I’d missed all the context. I just skimmed through your remarkable presentation of your remarkable experience — and right here in Toronto, too!

    It’s impossible to argue against accurate diagnosis as the start of any good treatment. OTOH, there will always be rare complications of common conditions (including yours, a “clean” fracture-free avulsion presenting as an ATR) whose diagnosis may be missed — or whose diagnosis may be reliably “caught” only by submitting the other 99.999% of routine patients to diagnostic procedures that have no other purpose.

    IOW, there will always be a tradeoff in deciding the extent of diagnostics to be done. Many medical patients (IMHO) are now being subjected to expensive, extensive, and relatively useless diagnostic procedures, partly (esp. in the US) because doctors find it easier and safer (vs. possible lawsuits) to order lots of tests, than to exercise judgment on the basis of evidence that eliminates 99-odd% of the uncertainty.

    As part of that ongoing experience, one of those “unnecessary” tests will occasionally catch something that’s important! The interpretation of that experience will naturally vary, depending on whom you ask — from “even a stopped clock is right twice a day” to “NOW do you see why everybody has to be subjected to all these tests?!?”

    There are similar questions involved with mass chest X-ray screening for tuberculosis, mass inoculations for a number of diseases, whole-body scanning of healthy people, and other similar tradeoffs. Given your experience with a very rare AT non-fracture avulsion that wouldn’t show up on an X-ray, I can understand why you’d think every ATR should be double-checked to make sure it isn’t like yours. You may not have similar views on the analogous examples I’ve mentioned (or many others) where you haven’t had such a personal and strong experience. (Our own CBC Radio, on “Ideas” recently had an excellent program on the harm done by the nascent fad of whole-body scanning of healthy people. It’s probably available online on podcast, and you may find it interesting.)

    My personal approach to the diagnosis of my own second ATR (being a semi-expert from surviving my first, 8 years earlier!) was almost diametrically opposed to yours. Having been convinced in 2001 that surgery was the only way to go for an athlete with an ATR, I was looking for a surgeon to repair my ATR surgically.

    My injury felt just like my first ATR, and happened while I was doing the same “move” in the same sport. So I had already diagnosed it to my own satisfaction. After my first ATR, the head of the UofT Sports Med. Clinic sent me for an Ultrasound — the best diagnostic in their opinion — “just to make sure”, even though he had already correctly diagnosed my complete ATR. When I then saw a different doctor (a surgeon) at that Clinic to discuss the US results, he said he personally wouldn’t have wasted the time and money ordering it. “As soon as you told me how you changed the way you walked up stairs, I would have scheduled you for ATR surgery,” he told me. (In fact, that test helped delay my ATR surgery to 9 days post-ATR, which was near the end of my surgeon’s favorite range.)

    This time, December 2009, when I went to the same Clinic looking for a surgeon, I was given a prescription for an US “just in case”, but was told that the surgeon I was seeing (at a different clinic) might not consider it necessary. He didn’t (even though he put me into a NON-operative protocol), and I was happy with that decision.

    As luck would have it, I actually had THREE US exams of my AT in the next few weeks, to guide the 3 PRP injections I soon agreed to undergo (and pay $$$ for). During those injection sessions, when I quizzed the medical professionals (same ones, 3x) about what the UltraSounds showed, I got conflicting answers. They consistently told me I had a large gap (6cm initially, IIRC), but one scan apparently suggested a partial tear, and one suggested multiple partial tears. I still don’t know exactly what happened, and I don’t especially care, because the best treatment seems to be the same for all. (Given the rarity of your kind of avulsion, I assume there is no evidence about what makes it heal the best and the fastest. Maybe it’s the kind of surgery you had, but I used to believe that about ordinary ATRs, until I saw the evidence from the most recent studies. I can’t disprove your assumption that your surgery was vital to your recovery, any more than you can prove it.)

    BTW, I’ve repeatedly read (mostly here) that ATR diagnosis with MRI is also more art than science, highly dependent on the skill of the interpreting Doc or technician. So insisting on MRI exams for all routine ATRs (or even just those of us who are escaping without surgery) may create as many problems, through “false positives”, as it eliminates. (My Dad was almost subjected to invasive back surgery at ~95 years old, based on very clear — and very wrong — evidence from MRI exams of his spine. Our neighbour “The Back Doctor” says that MRI exams of the back are so rife with false positives that they should only be done on your worst enemy!)

    So I don’t think your prescription is necessarily, or even likely, a good idea. In addition to all the likely “false positive” mis-diagnoses, if it creates (or sustains) a bias for routine surgery for routine ATRs, in the interest of avoiding mis-diagnosis of your vanishingly rare variant, it could easily do much more harm than good.

    And all of that is before we even GET to the potential waste of money!

  68. By normofthenorth on Aug 27, 2010 | Reply

    I don’t think I’ve commented on the eMedecine write-up of ATR treatments and the evidence supporting them, but it’s interesting. At emedicine.medscape.com/article/85024-treatment . It’s by 3 US OS-types, last updated Jun 24, 2009.

    I think it has a good balanced presentation of the latest studies showing non-op results — including low re-rupture rates — that are as good as surgical results. They very reasonably suggest (as I often have) that the key to those excellent results — instead of the unacceptable re-rupture rates from “your grandfather’s conservative casting” — seems to be fast rehab. They discuss Twaddle and Poon’s results in greater detail than I do above (because they saw the whole study!). Very interesting stuff. I’m not sure they saw the other 3 modern studies before going to “print” (and 2 of them are STILL unpublished).

    After that fair review of the facts, for the bottom line, they still suggest that surgery is for jocks while non-op is for crocks — though they make a few nods in the direction of the recent evidence. Here’s their whole “suck and blow” “evidence isn’t everything” conclusion:

    “In general, surgical treatment is advocated for young and athletic individuals who frequently subject their Achilles tendon to relatively high-demand activity. Conservative approaches with lower rerupture rates are being investigated. These conservative protocols show rerupture rates approaching those of surgical rerupture rates and have the advantage of fewer complications, in particular infections of the surgical wound and other wound-related problems.

    “In summary, operative repair of Achilles tendon ruptures has been reported to have lower rerupture rates; increased postoperative muscle strength, power, and endurance; and an earlier return to activities compared with nonoperative treatment. Wound complications occasionally do occur after operative treatment and may include infection, drainage, sinus formation, and skin sloughing.”

    The following section, entitled “Other Treatment”, is really a second summary, focusing on REAL crocks and sick people who are ineligible for surgery. It concludes with a bullet point on “Disadvantages of nonoperative treatment include. . . ” which I would call Just Plain Wrong, because all of the disadvantages are disadvantages of INCOMPETENT non-op treatment!! Heck, while you’re at it, why not compare those with the disadvantages of incompetent SURGICAL treatment, which are TRULY AWFUL?!?

  69. By normofthenorth on Sep 5, 2010 | Reply

    More interesting and (potentially) important medical research from UWO: http://www.theglobeandmail.com/life/health/hair-may-signal-pending-heart-attack/article1694502/ — cortisol levels in hair were found to be a stronger predictor of heart attacks than high blood pressure, diabetes, smoking, cholesterol levels or genetic predisposition!!

  70. By normofthenorth on Nov 13, 2010 | Reply

    If any “study geeks” are using this page to keep up with the ATR research, here are a few updates. (If you’re not a “study geek”, you should probably change the channel now! ;-) )

    Just recently, the last two of my fave 4 studies have finally been formally published. The Swedish one actually shows quite disappointing results on the non-op side, though not stat-significant in that small study. (Maybe it’s NOT a “fave” of mine!)

    The UWO study continues to look like the Gold Standard to me.

    The Swedish one is at http://www.ncbi.nlm.nih.gov/pubmed/20802094 . The UWO is at http://www.ejbjs.org/cgi/content/abstract/JBJS.I.01401v1 . The same issue of that journal has a “Commentary” (full-text FREE!) that tries to undermine wholesale adoption of the main message from the UWO study. Read it, see what you think. (I think a lot of it is silly and unworthy. A bit of it does make some sense.)

    I’m still waiting for one of my well-connected buddies to get me free copies of the full texts of all four studies. (Yes, I’m a SERIOUS “study geek”!)

    There have also been other new pubs of interest to ATR patients:
    http://www.ncbi.nlm.nih.gov/pubmed/21051425 is entitled “Autologous Platelets Have No Effect on the Healing of Human Achilles Tendon Ruptures: A Randomized Single-Blind Study”. This is a test of the results of “PRP” injections alongside surgical repair.

    The WORST sentence in the abstract is this: “The Achilles Tendon Total Rupture Score was lower in the PRP group, suggesting a detrimental effect.” Yikes! I paid $1200 for 3 PRP injections last December, and they may have done HARM?!? (They also hurt a lot, physically.) There was an earlier study that showed no benefit from PRP for AT tendinosis, but this one is actually about ATR recovery.

    Another interesting result from this small (30-patient) study: “The mechanical variables showed a large degree of variation between patients that could not be explained by measuring error.” I take that to mean that we’re all different, down to the legs, and so are our outcomes at the end of this journey.

    Another interesting new study, this one about surgical techniques: http://www.ncbi.nlm.nih.gov/pubmed/20696369 = “Factors influencing the tensile strength of repaired Achilles tendon: a biomechanical experiment study.” In China, a study on 48 live RABBITS compared the results of 4 different ATR-suture methods (stitches), 4 different suture materials, and 4 different epitenon (sheath) suture techniques.

    They got superior results from the parachute-like (”Pa” bone) suture method for ATR repair. Nothing else mattered much. I’m no expert in ATR surgery, but I’m pretty sure that this “parachute-like suture method” is NOT the one I got, or that most surgeons use. It’s just one study, but if there’s a clearly-best stitch, for the surgical crowd, and it’s not the one that’s in common use, it would be nice if that “memo” got around! (I don’t know why the word “bone” appears above.)

    I’ve also found a number of interesting studies (including some of the ones cited above) that correlate ATR elongation with clinical results. They’re interesting because the issue of “healing long” is important, and often the subject of discussion elsewhere on this site.

    Several studies find that “healing long” is very common, after either kind of treatment (op or non-op), and that it is associated with functional deficits. One introduced me to a new exercise/test: doing 1-leg heel raises on an INCLINED surface!! If you try it on a downward-facing slope, it really challenges the very top range of your lift, which is always the toughest — but especially if your AT is long. It’s a little like measuring the height of a lift on a flat surface, but it makes the test “pass/fail” binary, rather than “more/less” analog. For me, those studies are reinforcing my bias against recommending lots of aggressive dorsiflexion STRETCHING to recovering ATR patients.

    Good Healing all!

  71. By normofthenorth on May 12, 2013 | Reply

    I just noticed that the chief author of the 2010 Cochrane review of op-vs-non-op — Riaz J.K. Khan — is the same person who was the chief author of the 2005 meta-study I cite above. I think the 2005 metastudy was an excellent summary of the evidence to date, but I think the 2010 metastudy is an embarrassment to the authors and the (very prestigious and usually trustworthy) Cochrane establishment. That’s because the 2010 study lumped all the well-done non-op trials together, regardless of whether they used an effective modern fast good-results protocol, or the ineffective, old-fashioned, slow bad-results “conservative casting”!!
    Fortunately, a more recent meta-study out of Montreal has made that distinction, and confirmed the conclusions above: fast non-op rivals op in results but without most of the complications, slow non-op avoids those complications but has much worse results, including much higher rerupture rates.
    I think I read recently that Cochrane has reopened this subject. I sure hope so, because it’s important for doctors and patients to have info-sources they can trust to get it right.

  72. By kellygirl on May 12, 2013 | Reply

    Thanks for keeping us up to date. I have a lot more reading to do.

  73. By normofthenorth on May 13, 2013 | Reply

    KellyGirl, I hate to state the obvious, but your AT — heck, your whole leg! — doesn’t know the meaning of “randomized control trial”. :-) So your ATR priority is to keep your leg on a rehab path that’s been proven to work well! And if that gives you time to read randomized trials and meta-studies and the like, then BONUS!!

  74. By mtmtl on May 18, 2013 | Reply

    Hi Norm- love reading your blog. Having rutured my achilles 3 weeks ago today, and deciding to go non-op (32/m/active), you have kept my faith regarding the healing process i took. The only issue I have with my OS, is that it seems he is being too conservative. I was in a cast for the first week, then put into a cam walker at 45deg plantar flexion (nwb) for 3 weeks (i go back next week to see him- 4week total nwb/zero PT). He said he will then adjust the angle of my foot, and still nwb/PT for another 2 weeks. Having read so many articles/ studies, I want him to be more aggressive with the current protocol, but not sure how to approach it with him. I want to ask him to follow the UWO protocol, but don’t want to insult his ‘expertise’ as well… Thoughts?

  75. By normofthenorth on May 19, 2013 | Reply

    Thanks for the nice comments, mtmtl. (Are you in Mtl = Montreal?) As you’ve probably read already, going too slow non-op is the “best” way to run a high risk of re-rupture, so you don’t want to go there. With an ankle-angle change before any WB starts rather than the other way around, your Doc’s schedule looks closer to Twaddle’s 2007 NZ-study’s protocol (which I think is posted here, on bronny’s web page) than to bit.ly/UWOProtocol from Willits’s 2010 Canadian study. But I think it’s slower than Twaddle. You should check, because Twaddle also got excellent results. (IIRC, his is the only study in which the non-op patients got one strength result that was stat-significantly HIGHER than the post-op patients.)

    Unfortunately, you can’t expect a working surgeon to be an expert in the recent randomized-trial evidence on ATR treatment. Period. They’re usually run ragged with long waiting lists of patients, their job is to treat people not to study or do science, and most of their job involves much “sexier” and trickier ailments and operations than ours. (ATR repair has been called “the tonsillectomy of the leg”.)

    So it’s up to us, at least until so much time goes by that Twaddle and Willits etc. become the “new normal”. That’s starting to happen in some regions, but it’s very spotty, this soon after those publications.

    I can’t tell you how to deal with your Doc, but many modern Docs — even OSs — are getting used to dealing with some well-informed patients (and lots of misinformed ones, too, alas!), and many are also relieved that they are NOT assumed to be omniscient Gods any more. I’ve often recommended that ATR patients print out the UWO study and the UWO protocol and offer their wisdom to their OS. And if that doesn’t work, roll them up and bat the OS over the head with them! ;-) But different approaches work better with different Docs — and different Docs also deal differently with patients who responsibly follow a protocol that’s more aggressive than the one the Doc prescribed. Again, as time goes on, it’s easier to find an OS who him/her-self has had an ATR and skipped the surgery, or has a pal who has, etc., etc. But it’s not easy enough YET, so you still have to do some work.

  76. By mtmtl on May 19, 2013 | Reply

    Thanks for that great reply. Very appreciated! As for the username- born and raised in Montreal, but now living in Ontario.

    I decided to take my foot out of the boot, and can barely move it. When I try (and im scared to move it) it almost jerks… like I cant control it. I even changed the degree of the flexion on my boot from 45 to 37.5, and at this position, the achilles even feels like it wants to pull apart… Is this a normal sensation, or a mix of me being petrified to move it combined with some muscle atrophy? Thanks Dr. Norm.

    Your patient,

  77. By normofthenorth on May 19, 2013 | Reply

    That Dr. Norm & patient stuff is dangerous talk around here, Martin — especially if anybody falls for it. Just a guy on the Internet who’s ruptured both ATs and read studies and hung out here a lot. . .

    I’d be very gentle with changing your boot angle. UWO leaves it at the same place (though not as PFlexed as you) for 6 weeks. Many people find any move toward neutral to be “a stretch” — pun intended, especially if their ankle isn’t ready for it yet. I don’t know if the NZ protocol on Bronny’s site here mentions specific ankle angles, but I suspect it does.

    I don’t think my foot felt jerky when I took off my boot and started writing the alphabet with my toes, etc. I have heard others describing something similar, and you may be able to dig up their stories by searching the site.

  78. By ripraproar on May 19, 2013 | Reply

    Hi mtmtl
    Yes I remember the jerky foot , I think it’s more the brain being cautious , after a couple of days you do get more sensibly confident, check out altons rom on you tube, it’s much better then I was , my moves very jerky but like I say it was nervousness I think

  79. By mtmtl on May 20, 2013 | Reply

    Hi ripraproar,

    Glad to know that I’m not the only one, and actually experienced it first hand. I also believe the ‘jerky foot’ has to do with nervousness- just don’t want to move it too much and ruin the past 3 weeks progress imprisoned in a boot :o

    I’ll check that out that youtube.


  80. By normofthenorth on Jun 13, 2013 | Reply

    I just posted this on loumar747’s blog, and it seems to make an important point or two, so I’m copying it here:

    “I’ve never seen a study that split the patients between a PT track and a “No PT” track, so there’s only more circumstantial evidence. But as you’ve seen, UWO and the other most successful modern non-op studies all seem to have used PT, usually early on. I’d talk to your PT neighbour. Obviously, the first few PT sessions are very gentle, then they gradually get more aggressive. The painful sessions are usually only for post-op patients, to try to break up inappropriate scar tissue, especially “attachments” or “adhesions” that glue together adjacent tissue layers that should slide over each other.

    It’s important to realize that most of the Post-Op studies on fast-vs-slow (like early WB) show that you “may As well” go fast, because the results are comparable or maybe a smidge better with fast rehab. And going faster is obviously WAY more convenient.

    But the NON-OP evidence clearly shows that a non-op ATR patient MUST go fast — e.g., at the speed of bit.ly/UWOProtocol — in order to have the best chance of the best clinical results, and the lowest risk of rerupture. It seems so logical that suffering longer will yield long-term benefits, that many “experts” can’t wrap their brains (or their “hearts”) around all the clear evidence that points in exactly the opposite direction.

    It doesn’t help that nobody’s ever done a randomized trial that split non-op patients between a fast modern track and a slow “conservative” track — and given the evidence from the other recent studies, most good hospital’s Ethics Committees probably wouldn’t approve one, because it’s unfair to the “conservative” patients. The evidence is technically indirect, because we’re comparing the wonderful non-op results from a few modern fast studies with the unacceptable non-op results from a big number of old slow studies. And comparing one study’s results with another’s is not as “scientific” as comparing one randomized cohort of patients with another in a single study. But the evidence is so clear and consistent that no intelligent person — trained scientist or not — can reasonably doubt the results.

    One excellent recent meta-study, combining all the studies that compared surgery with non-op, highlights this little “scientific blind spot”. The authors clearly saw that fast non-op patients did WAY better than slow non-op patients, but they ALSO saw that those two kinds of patients were never treated in the same study. So they never actually said that fast non-op knocks the socks off slow non-op! Instead, they said that fast non-op gives comparable results to surgery without all the risks and complications, and that slow non-op avoids the risks and complications, but has significantly worse clinical outcomes (like rerupture rates)!!

    Now, I was raised and trained to be a scientist, and I learned in math class that if A=B and A>C, then B>C. Period. EVERY time!! But these trained researchers can’t bring themselves to make that leap. So we technically have to read between the lines to conclude the obvious: that no sane Doctor should treat any ATR patients with a slow “conservative” non-op protocol, ever again, and that every Doctor should explain to every ATR patient that fast modern non-op treatment seems to produce comparable strength, ROM, rerupture rates and recovery times as surgery, with much lower risks and complications.

    We’re not there yet, alas!”

  81. By bribur on Oct 11, 2013 | Reply

    Well my surgeon never got back to me. Nurse called and said I would have a few minutes pre-op to talk. Grr. So I sit on the precipice of surgery.

    My questions are:

    Anybody on this board have a good result with non-op method starting a week after injury?

    Also anyone with non-op doing rehabbed calf raises, jumps with non-op?

  82. By normofthenorth on Oct 11, 2013 | Reply

    Bribur, a lot of people here drift away before (or as) they get fully recovered, so it’s not a great or scientific sample — though we’ve had some, for sure. Bronny from NZ got great non-op results a year or two ago, and I think Hillie is in that club here and now, too. There was another shockingly fast and successful non-op example here recently, too, but I’m blanking out on his name under pressure, sorry. (I think it was the guy who posted the photo of himself wind-surfing in his boot, but I may be wrong.)

    There are also a few shocking examples on YouTube, including Brady Browne, a Canadian pro football player who went non-op and posted his “video blog” there from the initial decision. Last I saw he was literally running up walls in running shoes, and in record time. Should be easy to find him and others with a YouTube search.

    Me, I tend to focus more on the aggregate results in good-sized randomized studies, but if you’re looking for individual non-op athletic “role models” for inspiration, there are a few here and also some more rock stars on YouTube.

    The randomized trials all had the same exclusion criterion for “stale” ATRs, namely 14 days post-ATR. I’ve never seen the raw data for how many days the mean or median patient waited to start treatment, but it took many of us a few days to figure it out and get it sorted out, op or non-op. I’ve also asked the UWO study’s authors to analyze their data to see if there’s a correlation between post-ATR delay (within the 14 days) and non-op clinical results (strength, ROM, reruptures), but they don’t feel any pressure to respond to “some guy off the street”. (I recently got a new grad from UWO’s medical school to ask a classmate who’s still working at UWO’s sports-medicine clinic to ask, but I haven’t heard anything back from her yet either.)

    So the notion that every single day post-ATR before treatment begins increases risks and decreases benefits is one of those logical-sounding assumptions that may or may not turn out to be true. (They’ve already tested the notion that smaller ATR gaps respons better than larger ones to non-op treatment, but that study indicated that that logical-sounding notion was NOT true, though the sample was pretty small.)

  83. By hillie on Oct 11, 2013 | Reply

    Hi Bribur

    It’s true that I dip into these pages every now and then. Just lately it seems that most(?) posts seem to be from either worried (maybe imminent) operated-on patients, or those who went non-op and are maybe concerned that their repair won’t be as effective as one involving surgery.

    My atr was almost 2 years ago and my treatment started 10 days after injury - why that late is another story but there are plent worse cases here. My consultant, a leading ortho surgeon at Exeter, advised non-op to start with, using the Vaco boot after a cast for the first 2 weeks, and early mobilisation by which I mean that was beginning full weight bearing at about 3 weeks and therefore weaning off the crutches at that time.

    I didn’t see a doctor again, but I was well looked after by the centre’s physio’s, who knew to consult the medics if they needed to. With plenty of the right exercises, at a quite quickly increasing rate, I made a great recovery and my leg is now at full strength and getting to do a lot of hard work. By the way, single-legged calf raises weren’t achieved satisfactorily until about 16 or 17 weeks. Dead easy now of course.

    Best wishes for your recovery.

  84. By ripraproar on Oct 11, 2013 | Reply

    Hi bribur
    For visual evidence why not check out brady browne achilles recover on YouTube. He’s a non op success what’s more hes a pro footballer
    Good recover

  85. By rseiter on May 29, 2014 | Reply

    Hi Norm,

    I’ve been looking at the Willit’s study (thanks for the reference!)
    but have been unable to find the supporting material or commentary. The paper gives the links
    which are dead
    Other links I have seen for the commentary:
    (my library credentials fail)
    http://jbjs.org/data/Journals/JBJS/181/e32.full.pdf (dead, first hit of Google search “aronow commentary achilles”, says accessed 5/1) I am unable to find any cahed versions of this at: http://www.cachedpages.com/
    http://www.ncbi.nlm.nih.gov/pubmed/21037027 (full text link dead)

    Do you have access to this additional material?


  86. By normofthenorth on May 29, 2014 | Reply

    Rseiter, I may or may not have saved that old commentary on a PC, but not on this phone. If you can figure out how to send me your email by email (several have, though I can’t recall the trick now!), I’ll send it if I’ve got it. But it’s pretty out of date since the newer metastudy has come out, and the 2 newer studies linked and summarized in AchillesBlog.com/Cecilia/ protocols - especially the Wallace study, which I think has changed this debate forever.
    Not only did Wallace get great better-than-surgical results with 945(!) non-op patients, mostly by adding a simple “trick” to a pretty average - maybe even suboptimal! - rehab protocol. But he also duplicated those results with his reruptures AND a bunch of “stale” ATRs - two groups generally considered poor candidates for non-op treatment pre-Wallace.
    He still sent a few patients go the OR - the small minority of stale ATRS whose ends would not approximate in equinus - so we’ll still need a few ATR surgeons in each country after enlightenment dawns in all the info backwaters. :-)

  87. By rseiter on May 29, 2014 | Reply

    Thanks Norm! You can send it to me at sonic.net (same username). I just downloaded the Wallace study and will be going through it soon.


  88. By normofthenorth on May 29, 2014 | Reply

    I think I’ve found it, just a straight-text RTF file. So here’s the cut-and-pasted text:

    Commentary and Perspective
    Commentary and Perspective On
    “Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures: A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation” by Kevin Willits, MA, MD, FRCSC, et al.
    Commentary and Perspective By
    Michael S. Aronow, MD*

    Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, Connecticut
    Posted on October 29, 2010
    0 Comment

    It is fairly well accepted that nonoperative treatment of Achilles tendon ruptures with cast immobilization has a higher rerupture rate, but an otherwise lower complication rate, than surgical repair. It is also fairly well accepted that early postoperative weight-bearing and protected range-of-motion exercises are beneficial after surgical repair of Achilles tendon ruptures. A recent guideline and evidence report on the diagnosis and treatment of acute Achilles tendon rupture produced by the American Academy of Orthopaedic Surgeons and endorsed by the American Orthopaedic Foot and Ankle Society gave a moderate strength of recommendation for only two treatment options: (1) early postoperative protected weight-bearing (at two weeks or earlier) for patients with acute Achilles tendon rupture who have been treated operatively, and (2) the use of a protective device that allows mobilization by two to four weeks postoperatively1. On the basis of the literature that supports these recommendations and other data that also suggest that protected motion has a beneficial effect on ligament and tendon-healing in humans and animals, there has been interest in whether early protected range of motion might improve the outcomes of acute Achilles tendon ruptures treated nonoperatively.

    In their excellent randomized prospective study, Willits et al. treated patients with acute Achilles ruptures either nonoperatively or with open repair. In both groups, two weeks of non-weight-bearing immobilization was followed by protected weight-bearing and motion in a walking boot with a 2-cm heel-lift. The authors noted a rerupture rate of 4.2% with nonoperative treatment and 2.8% with surgery. This difference was not significant, although the study was underpowered because of a much lower than expected rerupture rate with nonoperative treatment. With respect to other clinical findings, except for a difference in the ankle plantar flexion strength ratio between the affected and the unaffected limb at 240°/sec at one and two years postinjury in favor of the operative group and a lower side-to-side difference in ankle plantar flexion at two years postinjury in favor of the nonoperative group, there were no significant differences in outcomes, including the Leppilahti score. There was a higher rate of complications (13%), including superficial and deep infection, small openings in the skin, scar formation, and pulmonary embolus, in the operative group. These specific complications were not seen in the nonoperative group, which had an 8% rate of complications, including a primary rupture in one patient that failed to heal and was not counted as a rerupture and substantial pain in another patient. While some orthopaedic surgeons recommend the use of ultrasound or magnetic resonance imaging (MRI) to confirm that the two ends of the ruptured Achilles tendon align closely together in plantar flexion before commencing with nonoperative treatment, it is not clear if this was done in the study by Willits et al., nor is the method of measuring ankle dorsiflexion, particularly with respect to knee position, described. The authors state that the results of their study support the use of accelerated functional rehabilitation and nonoperative treatment for acute Achilles tendon ruptures.

    There are at least three other prospective randomized studies in the literature in which surgical treatment of acute Achilles tendon ruptures was compared with nonoperative treatment with early functional range of motion. Thermann et al.2 noted similar results between a group of twenty-two patients who underwent surgical treatment and a group of twenty-eight patients who underwent functional treatment with a newly developed walking boot. There were no reruptures in either group. Twaddle and Poon3 treated twenty patients operatively and twenty-two patients nonoperatively with early motion controlled in a removable orthosis and noted similar clinical results including complication rates in the two groups. There were three reruptures (15.0%) in the operative group and two reruptures (9.1%) in the nonoperative group. Metz et al.4 noted a rerupture rate of 15.0% (six of forty) in patients treated with functional bracing and 4.7% (two of forty-three) in patients treated with minimally invasive surgical repair followed by taping. This difference was not significant, and there was also no significant difference between groups with regard to the mean time to return to work, non-rerupture complications, return to sports, pain, or satisfaction with treatment.

    Additional studies on multiple different nonoperative functional treatment protocols for acute Achilles tendon ruptures have demonstrated rerupture rates of 5.0%5, 5.3%6, 13.0%7, 6.7%8, 2.0%9, 2.1%10, 4.5%11, and 6.4%12. Pooling the results of Willits et al. with the results of the above studies2-12 leads to an overall rerupture rate of 5.2% (thirty-six of 688) with nonoperative treatment including early functional motion for acute Achilles tendon ruptures. While this pooled rerupture rate of 5.2% is certainly lower than the 11.7% and 13% rerupture rates with nonoperative treatment consisting principally of immobilization noted in the literature review and meta-analyses by Lo et al.13 and Bhandari et al.14, respectively, it is also higher than the 2.8% and 2.5% rerupture rates noted with operative repair in those same two papers. Therefore, while functional treatment appears to be preferable to cast immobilization in patients with acute Achilles tendon ruptures treated nonoperatively, particularly in those who are compliant, there is not yet enough evidence to abandon surgical repair with open or minimally invasive techniques followed by an early protected functional range of motion and weight-bearing. However, studies such as the one by Willits et al. will help us determine which patients with acute Achilles tendon rupture might be best served by nonoperative treatment as opposed to surgery and, in such cases, by which functional rehabilitation protocol.

    1. Chiodo CP, Glazebrook M, Bluman EM, Cohen BE, Femino JE, Giza E. The diagnosis and treatment of acute Achilles tendon rupture. Guideline and evidence report. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2009.

    2. Thermann H, Zwipp H, Tscherne H. [Functional treatment concept of acute rupture of the Achilles tendon. 2 years results of a prospective randomized study]. Unfallchirurg. 1995;98:21-32. German.

    3. Twaddle BC, Poon P. Early motion for Achilles tendon ruptures: is surgery important? A randomized, prospective study. Am J Sports Med. 2007;35:2033-8.

    4. Metz R, Verleisdonk EJ, van der Heijden GJ, Clevers GJ, Hammacher ER, Verhofstad MH, van der Werken C. Acute Achilles tendon rupture: minimally invasive surgery versus nonoperative treatment with immediate full weightbearing—a randomized controlled trial. Am J Sports Med. 2008;36:1688-94.

    5. Saleh M, Marshall PD, Senior R, MacFarlane A. The Sheffield splint for controlled early mobilisation after rupture of the calcaneal tendon. A prospective, randomised comparison with plaster treatment. J Bone Joint Surg Br. 1992;74:206-9.

    6. Reilmann H, Förster EW, Weinberg AM, Brüggemann F, Peukert J. [Conservative functional therapy of closed rupture of the Achilles tendon. Treatment approach and analysis of results]. Unfallchirurg. 1996;99:576-80. German.

    7. Richter J, Pommer A, Hahn M, Dávid A, Muhr G. [Possibilities and limits of functional conservative therapy of acute Achilles tendon ruptures]. Chirurg. 1997;68:517-24. German.

    8. McComis GP, Nawoczenski DA, DeHaven KE. Functional bracing for rupture of the Achilles tendon. Clinical results and analysis of ground-reaction forces and temporal data. J Bone Joint Surg Am. 1997;79:1799-808.

    9. Roberts CP, Palmer S, Vince A, Deliss LJ. Dynamised cast management of Achilles tendon ruptures. Injury. 2001;32:423-6.

    10. Wallace RG, Traynor IE, Kernohan WG, Eames MH. Combined conservative and orthotic management of acute ruptures of the Achilles tendon. J Bone Joint Surg Am. 2004;86:1198-202.

    11. Costa ML, MacMillan K, Halliday D, Chester R, Shepstone L, Robinson AH, Donell ST. Randomised controlled trials of immediate weight-bearing mobilisation for rupture of the tendo Achillis. J Bone Joint Surg Br. 2006;88:69-77.

    12. Hufner TM, Brandes DB, Thermann H, Richter M, Knobloch K, Krettek C. Long-term results after functional nonoperative treatment of Achilles tendon rupture. Foot Ankle Int. 2006;27:167-71.

    13. Lo IK, Kirkley A, Nonweiler B, Kumbhare DA. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a quantitative review. Clin J Sport Med. 1997;7:207-11.

    14. Bhandari M, Guyatt GH, Siddiqui F, Morrow F, Busse J, Leighton RK, Sprague S, Schemitsch EH. Treatment of acute Achilles tendon ruptures: a systematic overview and metaanalysis. Clin Orthop Relat Res. 2002;400:190-200.

    *The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

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    Commentary and Perspective articles are solicited by The Journal from experts in the field and are not peer-reviewed.
    Level I article: Surgical vs Functional Treatment for Ankle Fractures http://bit.ly/9tQYgH

    Commentary on an article by Kevin Willits, MA, MD, FRCSC, et al.: “Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures: A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation” by Michael S. Aronow, MD
    Commentary on an article by Stephen S. Tower, MD: “Arthroprosthetic Cobaltism: Neurological and Cardiac Manifestations in Two Patients with Metal-on-Metal Arthroplasty. A Case Report” by Joshua J. Jacobs, MD
    Commentary on an article by B.H. Currier, MChE, et al.: “In Vivo Oxidation in Remelted Highly Cross-Linked Retrievals” by Jevan Furmanski, PhD, and Victor M. Goldberg, MD
    Commentary on an article by David D. Greenberg, MD, et al.: “Allograft Compared with Autograft Infection Rates in Primary Anterior Cruciate Ligament Reconstruction” by Martin Boublik, MD
    Commentary on an article by R.W. Draeger, MD, et al.: “Corticosteroids as an Adjunct to Antibiotics and Surgical Drainage for the Treatment of Pyogenic Flexor Tenosynovitis”
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  89. By normofthenorth on May 29, 2014 | Reply

    As I think I’ve written here before, I think most reviews of op-vs-non-op studies — including the still-latest Cochrane meta-study (done by the same guy who did the then-state-of-the-art 2005 meta-study) and the “informal metastudy” in Aronow’s commentary — answer the wrong question.
    The vital question that any brand-new ATR patient wants answered, IMHO, is: “Do I need or want surgery for this? Will it add significant benefits to my “cure” compared to the best non-op treatment I can get — enough to justify the cost, pain, scar, extra time off work, and risk of infections and clots and other complications? Or can I skip it and still have a great prognosis for a full recovery, including returning to my fave sports?”
    To answer that Q, in a field where treatment keeps evolving and improving, it makes sense to focus primarily on the BEST studies. Of course, if all the different studies use essentially the same treatment, then any differences may be random and should be included in a meta-study for greater statistical significance. But if the treatments are changing, and some produce better results than others, I think it makes sense (a) to focus on THOSE results and (b) fight hard to get THAT treatment.
    By separating out the fast-modern-rehab studies from the older-slow-”conservative-casting” studies, the 2011 meta-study by Soroceanu et al (cited at the very top of this page) basically answered that vital question. By lumping good and bad non-op studies together, Aronow (and Khan/Cochrane) did not.
    Also, although Wallace in Belfast didn’t include any randomized operative patients, his great results with a huge non-op sample (~945!) gives that one study the force of most meta-studies, IMO.
    It’s interesting that Aronow suggests that it’d be (or is) a good idea to use a diagnostic scan to check that the torn tendon ends are approximated in equinus, before beginning non-op immobilization. Of course, that’s exactly what Wallace did — though just with his hands and his eyes — that seems so obviously sensible (in hindsight), and that seems to help explain his wonderful results, even with reruptured and stale ATRs (except for the few he excluded because the torn ends would NOT approximate). AFAIK, none of the randomized trials of op vs. non-op customized the immobilization angle based on palpation, observation, or scans. (E.g., UWO here used the same 2cm of heel wedges for everybody, op and non-op.)

  90. By jonathangoh on Dec 8, 2015 | Reply

    Hello Norm,

    My name is Jonathan and I’ve been reading over your posts for many hours and have gleaned a ton of great information from them. You are obviously very passionate about this topic and have been very generous in sharing your knowledge and research with the rest of us. As you can imagine, I have just had a ATR of my own and it has been difficult deciding what to do about it.

    I was wondering, given your research and your own personal experience, are you still an ardent supporter of the non surgical approach? Or have you changed your mind over the years?

    FYI, I have had an MRI done and here are the results: “There is an acute complete tear involving non-insertional fibers of the Achilles tendon. Torn tendon stumps are markedly irregular and retracted. There is approximately 7.5 cm between normal appearing Achilles tendon segments. There is marked peritendinous edema about the Achilles tendon.”

    I talked briefly with a surgeon and he felt the large gap would require me to have surgery but I am in the US and surgery always seems to be the recommendation. I’m wondering if you think I could be a candidate for non surgical treatment (I’m currently in a boot with splint) since many doctors here ignore the studies that you regularly cite?

    Another factor to consider is that I have limited health insurance and limited means to pay for a costly surgery. I would be very grateful for any advice you could give me during this difficult time and what you think I should do next. Thank you.

  91. By xplora on Dec 8, 2015 | Reply

    Jonathangoh - I hope Norm get to this as his enthusiasm led to some restrictions on this site but this message should go to an email. The gap in the tendon ends is quite large. One most important factor for a good non op recovery is for the tendon ends to approximate when you foot is plantar flexed or pointed down. If they do not touch then the gap will be filled but your tendon will be longer. This means you will have less push off strength. A gap of 5mm is enough to make a significant difference and is considered a clinical failure. The only way to fix an elongated tendon is surgery. You should discuss with your doctor whether you can achieve this approximation and if not then I would advise surgery. Also if you undertake the non op approach do not put up with the old protocols. Norm is still a strong advocate for early weight bearing and movement and if you go that way I am sure he will be most helpful. Sometimes convincing doctors is a bit harder but if you arm yourself with the studies from UWO in Canada, Exeter in England, Twaddle in New Zealand and Richard Wallace in Ireland you should present a convincing argument and if not find another doctor.

  92. By normofthenorth on Dec 8, 2015 | Reply

    Thanks, colors, that’s exactly right. Jonathan, you have to find a pro - though not necessarily an OS - who will supervise your “cure”. Get somebody, ASAP, to check whether your torn ends will approximate at any reasonable plants reflex angle. A la Wallace. I wouldn’t worry too much about the MRIs of the size of the gap when your not in equinus. The UWO folks did two little studies looking for (1) a correlation between initial AT gap size and non-op results (no correlation!) and (2) a benefit from pretreatment UltraSound to stream ATR patients into op vs non-op (none).
    But Wallace found great benefit from his simple low-tech screening, with his eyes and his fingers.
    So yes, I’m still a huge advocate of skipping ATR surgery, PROVIDED you can get treated properly non-op.
    BTW, I’ve played competitive (indoor) beach volleyball twice this winter already, most recently a bunch of killer 3-on-3 games 3 nights ago. After the first outing (>2 hours!), my left (non-op) calf was extremely tight, though the rest of my 70-year-old bod was almost that tight. After my 2nd outing, my right knee (messed up by my too short ATR repair on that side) was my worst part, but not too bad. And my bicycle-fall-injured right shoulder is finally OK with comp volleyball! :-)
    And BTW, Dennis never restricted my freedom to speak my mind here, on “my” pages - just when responding on other pages here. My absence these days is mostly because I’ve finally cured my addiction and gone on to spend time elsewhere - not always more productively! So feel free to ask and comment away on my pages, especially if you think I can help.

  93. By normofthenorth on Dec 8, 2015 | Reply

    Jonathan, I can’t dispense medical advice, but if I were you, and I had a hinged boot or a fixed boot with wedges, AND a PT or a wife or friend who was willing to make believe they were Dr. Wallace, I’d probably proceed without an OS. If you’ve got a good GP, that would probably work well, too. I’m just sayin’…

  94. By jeffsol on Dec 23, 2015 | Reply

    Dear Norm,
    I too have learned a lot from reading your posts–thanks for writing them! After reading your convincing review of the literature (and the literature itself) I was pretty sure I wanted to avoid surgery for my ATR, and initially my OS seemed to want to go that route. However, when he saw my MRI, he changed his mind. Apparently the tendon is avulsed from the heel bone. In other words, instead of snapping in the middle, it mainly tore away from the bone in the bottom. He says surgery is the better route to reattach the tendon to the bone. Does that make sense? This may be too detailed for you to have advice on, but I couldn’t resist asking. Again, all your efforts here are much appreciated. The surgeon says he definitely believes in early mobilization after surgery, so that encouraged me (I only knew to ask about that from reading your posts.)

  95. By normofthenorth on Dec 23, 2015 | Reply

    Jeff, if an XRay shows some bone broke, I agree.

  96. By jeffsol on Dec 24, 2015 | Reply

    Thanks for the reply, Norm. The x-ray did not show any broken bones. The surgeon says he wants to attach the tendon to the bone using some sort of a plastic thingy. He compared it to fixing a torn rotator cuff. It sounds a bit different from the other cases I’ve read about on this blog, but like most medical patients, I really have no idea.

  97. By normofthenorth on Dec 24, 2015 | Reply

    Jeff, sorry I had no time yesterday.
    In a real avulsion, the AT is intact, but it broke off a piece of heel bone. Same hobbling, similar pain and swelling, and nonop treatment probably won’t work. Some surgeons tell post-op stories about avulsion (though I’m suspicious of all surgeons’ postop “It’s lucky you came to me!” stories), but most avulsions are caught in the typical (and otherwise useless) post-ATR X-rays. Even small bone fragments show up clearly on X-rays, so if your X-rays don’t show a chip, maybe it’s because it’s not there. (Both MRIs and USs are usually much fuzzier and subject to interpretation and error, in my experience.)
    I’m still no MD, much less an OS, but that’s my informed techy understanding of the situation. Good Luck!
    BTW, I don’t know what Wallace did with his avulsions, but I suspect he’d tell you quickly if you asked him by email! (One guy here got a quick response from him a year orm2 ago.)

  98. By jeffsol on Dec 24, 2015 | Reply

    The way the surgeon described it to me is that the tendon snapped off the bone and now there isn’t much tendon left on the bone for the rest to reattach to. Therefore he has to anchor the tendon to the heelbone surgically. But the bone itself didn’t break or chip. (Maybe the distinction is between an “avulsion” and an “avulsion fracture”? But I don’t know.) Anyway, I like the idea of contacting the legendary Wallace (legendary on this blog anyway, which is enough for me). Do you know how I can find his email?

  99. By normofthenorth on Dec 24, 2015 | Reply

    I think the guy here just followed a link from the article, but I remember little about it. Try the article, or use this site’s Google search to track it (him) down…

    It’s possible that a REAL doctor like Wallace will be more hesitant to volunteer something this close to medical advice than “some guy on the Internet “, though he was helpful to the other guy. Definitely worth a try, IMO!

  100. By jeffsol on Dec 24, 2015 | Reply

    Yeah, that thought occurred to me too. Anyway, thanks again for being “some guy on the internet” who actually has done his homework. I’ll probably end up getting the surgery, but at least I know more about what I’m getting into and what kind of rehab seems to work best and so on.

  101. By normofthenorth on Dec 24, 2015 | Reply

    Thanks for the thanks, and good luck.

  102. By xplora on Dec 25, 2015 | Reply

    Jeffsol - the only way to attach a tendon back to the bone is by surgery. Had it happen to me on the bicep tendon last year.

  103. By jeffsol on Dec 25, 2015 | Reply

    Thanks, xplora. Hope it went well and not too painfully–for your sake and mine

  104. By normofthenorth on Dec 25, 2015 | Reply

    I understand it the same way xplora does. OTOH, Wallace did a few things we all knew were impossible until he succeeded brilliantly at them - curing stale ATRs non-op, and curing reruptures nonop. So I’d contact him anyway, if you can.
    Worst outcome, if he responds, is that he reinforces the general understanding that you need surgical reattachment. But even that’s a win, because you know you went the right way.

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