Written on October 23, 2010 – 12:48 pm | by normofthenorth
Many people come to AchillesBlog.com because they’ve just torn an AT and are wondering what to do. Their first important decision is whether or not to “go under the knife”, to get the ATR repaired surgically. The alternative — non-surgical care — is often badmouthed by “experts” (who should know better, IMHO). Following is an e-mail I just sent to “Rafael” in response to a post where he asked for information on recovery without surgery. If it helps you make a more informed decision . . . well, that’s the main theme of this web-site!
Here’s what I sent Rafael:
Rafael, you can see on the early pages of my blog — http://achillesblog.com/normofthenorth/ — my own story, which partly addresses your question. In late 2001, I tore my right AT (playing competitive volleyball) and got it repaired surgically, because everybody knew that we athletes need surgery to get a good result. Everything went well, and I did get a good result. Back to competitive volleyball at around 10 months, no noticeable deficit.
Last December (2009) I tore the other one (playing even MORE competitive volleyball — 4-on-4 instead of 6-on-6, at 64 years old!) and went to Toronto’s “fanciest” sports-medicine Ortho Surgeon — the chief surgeon of our pro football team — assuming I needed the operation.
He confirmed my ATR, apparently a complete one, and told me that he’d stopped doing the surgery 4 months earlier, after hearing a presentation at a big AAOS conference from the authors of a new study that seemed to prove that ATR surgery has NO benefit! The study randomized 145 patients, half got surgery, half skipped the surgery but got the identical immobilization and exercise and PT protocol. At the end of 6 months and a year, there was NO difference between the groups in strength, Range of Motion (ROM), or re-rupture rate! (BTW, ROM is a key measure of the healed LENGTH of the AT, which is a key factor in functional abilities like jumping and agility. A longer AT limits performance.)
He got a chance to discuss the study with the authors, at the conference, and they answered a lot of his questions. He told me “I didn’t become a surgeon to do surgery that has no benefit, so I’ve stopped doing Achilles repairs.” He gave me a copy of the protocol from that study, done at U. of W. Ontario (”UWO”) — I’ve posted it at bit.ly/UWOProtocol — and he sold me a $150 boot instead of scheduling me for ~$15,000 surgery!
My personal experience is just one “data point”, and I think it’s important not to over-generalize from any individual’s experience. In my case, everything’s gone much faster and more easily and less painfully than it did last time, except recently, when the return of my calf strength seems slower than it did 8 years ago. (I’m about 10 months “post-non-op” now, and my 1-leg heel raise is still hard, and “wimpy”, not full-height.) That’s me, and there’s a growing group of people at AchillesBlog.com who have followed a similar protocol, and most of them are regaining calf strength faster than I am. (There are also lots of post-op people on AchillesBlog.com who are still waiting for calf strength like me.)
Here’s the scientific evidence:
There have actually been FOUR recent randomized studies (all since 2007!) with a similar approach, all showing very similar results. The non-surgical patients get the same strength, ROM, and (very low) re-rupture rates, and they skip almost all the complications, which were significantly higher in most of the studies — things like wounds that don’t heal, infections, and Deep Vein Thrombosis.
If you go to the Wikipedia article on ATR — quick-link bit.ly/Wiki-ATR — the section “6 Treatment” partly reflects my own edits, and the end-notes 4-7 link to online presentations of those four studies. The UWO study is at end-note 7.
Earlier studies, at least up until 2005, seemed to show the opposite — that surgery really was needed to get a good result! My explanation in that Wiki article — that the old results “were primarily artifacts of a selection bias, directing younger, healthier, and fitter patients to surgery, and the rest to non-surgical immobilization” — is only half the story. The other half seems to be that the new studies all gave both kinds of patients a new-fangled fast rehab protocol, with early weight-bearing (WB), exercise, and PT. The old studies used “conservative casting” for non-op patients, with a very long period of total immobilization. Ironically, that approach seems to have produced the high re-rupture rate that many health professionals still associate with non-operative treatment of ATRs.
For a number of understandable reasons, the vast majority of “experts” in this field have NOT changed their practice, or their advice, or their version of “the truth”, since the new studies started coming in. And most surgeons like to do ATR surgery SOON, so way too many patients are being rushed into surgery, even though it seems to be a waste of time and money, and a needless source of pain and risk of complications! Several of us have discussed the “understandable reasons” at AchillesBlog.com.
There are many other often-repeated stories — many of them compellingly LOGICAL-sounding — that seem to be WRONG, according to the evidence. Including these:
“If you have a big GAP in your torn AT, you should get the surgery for sure.” According to the only (small) study on the subject, the size of the gap in the torn AT has NO effect on the non-surgical results! (The POSITION of the tear — high, middle, or low on the leg — also seems to have no effect.)
“Non-op might work OK for PARTIAL tears, but a COMPLETE tear needs surgery.” All FOUR of the modern studies that showed the benefits of skipping surgery, were done on COMPLETE AT ruptures! It may well be true that a good non-op approach works EVEN BETTER on PARTIAL tears, but there’s no evidence either way, AFAIK.
“You don’t want to rush your rehab, because you don’t want to go through this TWICE!” Both surgical and non-op patients seem to show lower re-rupture rates from relatively fast rehab protocols, and higher re-rupture rates from old-fashioned slow protocols with long immobilization and long NWB on crutches. Being on crutches also has its own risks, including falling on the injured leg and re-rupturing!
“Especially if you skip the surgery, you’ll never go back to that high-risk explosive sport. Get used to the couch!” Again, the strength results are the same with and without surgery in all 4 recent studies. And the risk of re-rupturing a torn-and-healed AT after it’s substantially healed — some say 6 months, some say 10 or 12, some say when you can easily do 1-leg heel raises, etc. — seems to be vanishingly small. The vast majority of us CAN return to high-risk explosive sports, and a lot of (probably most) actually DO. Some of us feel 100% or better, many do feel slightly impaired (with our without surgery), especially at first.
You say your “achilles tendon got injured.” I’m assuming that it got ruptured from being over-stressed, like in a sport. If it actually got lacerated, rather than ruptured (i.e., if a broken sheet of glass fell and sliced the back of your foot), then all this evidence and advice is NOT directly relevant to you. The advice may still be good — or not! We’ve got one or two success stories with non-op treatment of AT lacerations at AchillesBlog.com, but they’re just stories, not scientific evidence. The evidence is all about ruptures. Lacerations may turn out to work the same way, or there may turn out to be a benefit from surgery; we don’t know yet.
So, if you’ve torn your AT, I’d say skip the surgery, get a boot, and follow a modern protocol like the UWO protocol. (If anybody does want the surgery, they should also get a boot and follow a modern protocol like the UWO protocol.) I personally recommend a boot that can hinge, like the Donjoy MC Walker I used, or the new VacoCast that’s advertised (and much beloved) at AchillesBlog.com. But initially, you want to be immobilized — boot set NOT to hinge — at a gently toe-down angle, according to the successful UWO approach. (They used a non-hinging AirCast boot with 2cm of hard-rubber wedges under the heel.)
I hope that makes sense, and helps. Good Luck and Good Healing!!
[I used bold instead of underline, because I can't get UL to work here. I also used block quotes instead of bullet points. Anybody know how to get bullet points working here?]