Conservative/Surgery

This is more of a question….If one has a complete/total rupture of the AT,  how could not having surgery fix the problem.  There has to be a lot of tension on the AT, so when it “parts”, seems like the upper portion would move further away from the lower part-the longer one goes without addressing it.

Or, is it only a slight/partial tear that really would not require surgical repair in the first place?

So, with a complete tear/rupture,  how could the conservative method provide healing or reattachment of the AT?

11 Responses to “Conservative/Surgery”

  1. I read (on the net) that the ruptured tendon reforms using scar tissue to make the bond between the tendon ends, the tendon itself does not fuse together.
    I was treated by conservative method & it seems to be working (fingers crossed!).

  2. Having just chosen to go the conservative route, my understanding is that when they put on your first cast, the foot is angled downwards to push the two broken ends of the AT together.

    Despite the great tension in a healthy AT, when it ruptures the loose ends are often close enough to be put in contact, allowing them to join.

    At least I hope that’s the case with me!

  3. Here’s my understanding: there is a sheath that surrounds the tendon and muscle (think the thin, shiny stuff on the edge of a steak). This sheath remains intact - unless you’re one of the unfortunates who are cut with something external. My stating that the sheath stays intact is based on my surgeon’s op report that he incised the sheath to get to the tendon. When the tendon ruptures, there is some bleeding. If the ankle is immobilized and the gap is made the smallest possible, then as the blood goes through the healing process the two ends of the tendon are drawn together. As all of us who have reached a certain stage know, the period of mobility causes the muscles to atrophy, helping to greatly decrease the tension on the healing tendon.

  4. pendersnitzel - As mentioned in the other comments, the conservative treatment method relies on casting your foot in a downward angle which places the tendon in its shortest position. This brings the tendon ends into close proximity. Collagen forms around the rupture site and within any gap between the tendon ends, essentially fusing the two ends back together. The tendon heals the same way with surgery but with the advantage that the surgeon can physically align the ends of the tendon, reducing the chances of a gap between the tendon ends. However, there are plenty of studies that indicate the conservative method can be just as effective as surgery for complete ruptures.

  5. This is some good stuff…..I don’t think that physicians do a good enough job of explaining this to a lot of people.

    I did not have the ATR, but I had the achilles detached and reattached during another type procedure. My guy explained in depth with pics of what the procedure would be and what he expected to find…

  6. I would not elect surgery unless it were deemed absolutely absolutely necessary.

  7. I would guess that this approach is going to take quite a long time and that because of the casts you would be on crutches for many months. The longer your leg is immobile, the more muscle mass you lose and therefore the longer it will take to get it back once you can start PT. There was never any question for me, surgery was my choice, although that did become complicated by infections but most people here haven’t had to deal with that. Find out what their plan is with and without surgery: how long to PWB, FWB, 2 shoes, start of PT, etc. Then decide based on how soon you want to stop being an invalid. And if they only use the conservative approach after surgery, go find another doctor who doesn’t believe in that foolishness.

  8. I had an acute rupture last Thursday playing baskbetball after a long layoff. I’m 50 and have been very active…road cycling, skiing, and exercise equipment. I iced it immediately and was able to see the specialists at a university sports medicine complex. The surgeon prefers surgery of course but the others all recommended nonoperative treatment. Under ultrasound the gap is small (8 mm) and the ends are touching in the casted position. I need to let them know today if I want surgery but am leaning against it now. The nonoperative protocol specifies removal of the cast within 2 weeks followed by the boot with some load bearing within 4 weeks. I am still concerned about getting an optimal result. I probably will be avoiding bball again but want full performance in everything else. Someone please talk me into surgery!

  9. Bob- I’m 45 and ruptured 2 mos ago. You can check out my blog for all of the details: achillesblog/ultidad. I am an anesthesiologist and will readily admit that I subscribe to the notion that “a chance to cut is a chance to cure”. When my surgeon was explaining the non-operative vs. operatice options, I nearly cut him off when he was talking about the non-operative part. He didn’t even need to tell me the statistics or answer the “what would you do if it were you?” question. If he’d have said that he could operate on me right away, I would’ve jumped at it. As is was, I had surgery the next day. So, I’ll admit to having a pre-rupture bias towards surgery, but there was no way that I could’ve dealt with the duration of NWB that the non-operative route requires. So I say definitely have surgery.

  10. To follow up, I decided to forgo surgery and so far I’m happy with that. I was in a cast for 2 weeks and have been in adjustable splint for the past 2. I started with my foot at a 35 deg angle and and just got it moved up to 15 deg. I have a wedge fitted to my shoe and have started load bearing exercises that seem rather easy.

    Several factors went into my decision. 1) It was casted the same day I ruptured the tendon, which increases the likelihood of a good outcome; 2) The tendon ends were touching in the equinus position; 3) I intend to remain quite active, particularly cycling, but I’m 50 and have concluded this was one too many severe basketball injuries…won’t be going back for more; 4) I believe there is a great deal of misinformation floating around regarding the nonsurgical protocol. The results and recovery times are similar; 5) The top ankle/foot doc at the orthopedic sports medicine center I use did not hesitate when asked — He would not have surgery.

    The issue is controversial and the docs are not in agreement, but this is my take: The bias toward surgery is based on out-of-date and possibly misleading studies. Many of the more recent studies have concluded that, with a proper treatment protocol, nonoperative results are equivalent to operative. That means limited immobilization time and earlier physical therapy with the proper bracing. Older studies did not take this into account and patients were often in casts for extended periods. Also, the nonoperative path was always recommended for the least healthy population: the elderly, overweight, diabetic, and others who would not handle surgery well. So, the samples were biased. The studies disagree dramatically on rerupture and complication rates, but it appears that the rate of surgical complications (anesthesia, infection, wound healing, skin issues) is far higher (>15%) than the rerupture rate (<8%).

    It’s early and I am hoping this plays out the way it’s intended. Everyone’s case is different. Best of luck to everyone!

  11. Bob, if you’re still “here”, give us an update! Your interpretation of the latest studies is identical to mine (see my blog on the subject, with links) — and I took quite a while to complete my research!

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