pete0609’s AchillesBlog






         Just another AchillesBlog

May 3, 2014

Ruptured March 19th - non-op route

Filed under: Uncategorized — pete0609 @ 9:22 pm

Hi there,

I am a 42 year old Toronto expat from Germany and I ruptured my Achilles’ tendon on March 19th while playing soccer. I am very grateful that I found this site early into the deal, some great and helpful comments from Norm and Kelly (and others, of course) that that helped a lot to better understand what that whole protocol is about (my doctors never bothered - in 4 visits to the hospital I was seen by 4 different doctors and each had about 90 seconds of time for me). So hello everyone and thank you to all of you (Dennis, thank you for the site), probably also in the name of all the people who read and benefit and never get around to sharing their own experiences.

I’m a classic, felt as if hit by a baseball bat in a “dead ball” situation when about to do that free kick of my life. Felt the pain, heard the pop, rolled over and was done for the night. At the time I wasn’t yet sure what had happened (had my suspicions, though… ), drove myself home that night and to the ER in the morning. By then I was 99% sure I had ruptured my achilles and I was right. I received a back slab in the ER and was told to come back the next day to see the surgeon in fracture clinic.

Since I am from Germany and the non-op route is not yet very popular there, I expected to have surgery done (also because the ER doctor said the ends of my tendon were 7 cm apart). But in the fracture clinic they refused to do it (I sort of asked if they would do it anyway, but I figured if it’s not standard procedure anymore they don’t have the experience I would want to see in my surgeon). So I gave in, also because I didn’t want an uninterested newbie mess around in my leg. I am fine with the non-op route, my only concern is that no doctor has ever checked if the ends had approximated enough to justify the non-op route (what do you think, Norm? - FYI- I have been to Sunnybrook hospital). Still not sure if that was the best decision for me.

I was given the aircast boot (with the biggest heel lift they had, 4 wedges), and I switched to the vacocast 10 days ago (it’s German engineering, and that’s what I wanted for my foot…). First I was a little disappointed after this boot had received all these rave reviews. I couldn’t walk in it and actually went back to the aircast, but now I am mostly in the vacocast. I am hinging now between 25 and 30 degrees after I was told during my last visit at the hospital to take out one wedge (referring to the aircast) yesterday. I am planning to go to 20 and 30 a few days from now. So far everything feels okay, some tension in the tendon, but I guess that’s supposed to be there.

I have been to the PT since week 3, I also got myself a spin bike and I do between 20 and 40 minutes a day since week 5. Feels good, my PT okayed it and also understands that I want to get back to sports (biking, soccer, skiing, playing with my kids) ASAP.

Swelling and pain has not been a big problem so far, I guess this (pain, at least) might change once I get into 2 shoes. I have a fairly hard and big swelling/knot in the area where the injury was. My PT told me to massage it with a rolling pin 2-3 minutes a day along with all the ROM exercises. I am FWB since two weeks and according to the UWOPROTOCOL I think I am where I should be.

I am planning to have an MRI done (or at least another ultrasound) because my biggest concern is the big gap I’ve had (7 cm between the two ends). Do you guys have any opinion on this? My fear is just that a lot of scar tissue will form (more than would have with more approximation) and I lose more tendon strength and smoothness than I would have with surgery.

Other than that my recovery is coming along fairly well I think, I could work from home a lot (still do - can’t drive since it’s my right foot) and my family and also my employer are very supportive. I have never seen my kids this much since we moved to Canada 20 months ago, so that’s a huge benefit of this injury. It also happened at the right time of the year - the ski season was already over, and since this winter drags on forever and not much to be done outside I am not yet missing all that much. It’ll come, though, I’m sure. We all know it’s a long recovery. But there are definitely benefits if your life comes to a full stop in such a way.

9 Comments »

  1. My doctor said that big lump is a good thing. It shows the tendon is healing. I’m sure that Norm will chime in but I recall reading somewhere that those mop ends of the tendon manage to find each other. (I never had an MRI either and went non-op and it all turned out fine anyway.) The cast came off at four or five weeks and the Dr did a light Thompson test to verify the tendon was healing. I don’t know if an MRI is really necessary unless you fail the Thompson test. I’m envious of your protocol–FWB at two weeks is awesome. That’s what I wanted. Enjoy your down time. It doesn’t last long! Hope you keep up the blog!

    Comment by kellygirl — May 3, 2014 @ 11:04 pm

  2. Pete, hello neighbour! Are you saying that Toronto’s Sunnybrook Hospital fracture clinic insisted that you go non-op? I’m shocked — last I noticed, ATR treatment in Toronto was “all over the block” (some would say “random”).

    The main fear with a big gap is not that the healed AT will be weak. It seems to heal pretty well pretty reliably. But if the gap is not “approximated” during rehab — or if a number of other things happen, many of them post-op and some still mysterious — the tendon can heal longer than pre-ATR, which can mean that either the Gastroc or the Soleus (or both) can run out of ROM before you’ve got normal ankle extension aka plantarflexion. A bit of that can compromise your 1-leg heel raise. More can compromise your running and jumping in sports. Even more can perpetuate the “dip-limp” most of us lived with for weeks after we got into 2 shoes. At that level, it’s often repaired surgically, which starts the whole long rehab again.
    I think you can see a Gastroc example in KellyGirl’s latest photos of her 2-legged heel raise from behind. Just like mine (only much cuter!), her post-ATR calf/Gastroc muscle is more contracted (higher) than her non-ATR one, at identical ankle angles.
    There are a number of relevant studies: One substudy of the UWO (”Western” to us Ontarians) Study looked for a correlation between initial ATR gap (measured by ultrasound) and non-op clinical results, and found NONE. In other words, patients with the largest gaps did as well non-op as those with the smallest. Mind you, only 25 of the ~72 non-op patients in that study had good enough initial ultrasounds to include in this gap-measure study. Still, evidence trumps assumptions.
    There are also a few studies that have tried to figure out the best average ankle angle to approximate a torn tendon. I’ve seen one done on rabbits, and one on human cadavers. (I think they mostly settled on around 20-25 degrees.)
    And finally, there is the recent Wallace study from Belfast, which is so revolutionary, I’m still smacking my head with my hand and saying D’Ohhh! (like Homer Simpson) over it!
    Wallace internalized the simple fact that the ATR gap is usually pretty clearly visible (as a dimple, “dip”, or divot at the back of the leg) and also pretty clearly palpable with a Doctor’s fingers. So he just checked the gap size _WHILE he extended the ankle into “equinus” (= PF)_! When the ends came together, he noted that angle and immobilized the ankle there (initially with a cast, in his study/practice).
    That simple approach — using an immobilization angle that approximates the torn ends of EACH tendon, not just the AVERAGE tendon — seems so obviously correct once it’s explained, that I’m embarrassed that I (and the entire world’s medical establishment apart from Wallace, AFAICS!!) never thought of it!!
    I’m assuming that your experts at Sunnybrook weren’t clever enough to check your gap at the immobilization angle they chose. (I still haven’t heard of ANY patient outside Wallace’s region in Ireland who’s gotten that treatment, and his study has been out for a couple of years already, IIRC!)

    At this point in your rehab, I think the best approach is just to “stay with the program” and see what you get when you finish. (I wish I had more faith in MRIs and Ultrasounds — details on my blog.)
    As you may have seen from my blog, my biggest surprise from my own second ATR rehab (non-op) was that, although I am too weak to do full-height 1-leg heel raises, I notice absolutely NO deficit in my vertical height at the volleyball net, my speed and agility in court defense in volleyball, or anything else I do! In my case (and I’m not alone), I think I’ve healed long in the AT-Gastroc connection, but not in the AT-Soleus connection, so I think my plantarflexion strength is only compromised when my knee is straight. That includes all normal 1-leg heel raises, but relatively few sports “moves”. I’ve also always been a 2-footed jumper (unlike some of my teammates), which probably helps, too.
    And while MOST of us have a “fatter” AT post-ATR than we did before, at least for a couple of years, I think loss of “smoothness” is largely restricted to those post-op patients who suffer from “adhesions”, scar-tissue formations that glue together adjacent layers of tissue that should slide over each other. Non-op folks only have one torn layer, so usually escape without adhesions.
    One little note to you and everybody else who’s using a hinge-ing boot relatively early in rehab: DO NOT walk BACKWARDS!! It is a MUCH bigger challenge to the calf and AT in a hinged boot than normal boot-walking! Eventually, there is a role for that kind of “concentric” exercise, but not for a while.
    Finally, one way to minimize the tension on the AT when changing your boot angle is to make the change at bed-time. That gives your leg ~8 hours of NWB to get comfortable with the new angle, before you load it up.
    OK, one more: I do NOT expect you to have pain when you move to 2 shoes. Frustration, fear, impatience, sure, but not pain. ;-)

    Comment by normofthenorth — May 4, 2014 @ 12:33 am

  3. Hi Kelly and Norm,

    Thank you very much for your quick responses and encouragement. That’s always very welcome.

    @Kelly - no doctor has done the Thompson test on me since the start of the treatment. My PT has done it at around 4-5 weeks and i failed. I guess i am healing, however, as Norm says, I might be healing long.

    @Norm - yep, Sunnybrook didn’t want me to go operative, they didn’t want to discuss it at all. Actually the young doctor (i think Andrew Dold was his name) who saw me was also a little unsure about non-operative because of my big gap and i asked him »hey, shouldn’t we do surgery because of this?«
    He then mumbled something like »maybe… I think so…«, left the room to consult with somebody else (don’t know who) and came back with the aircast boot. That was pretty much it. At the time i didn’t have the knowledge i have now (I’ve also read the irish study a few days ago). I might have gone to UofT, i think they have some excellent foot and ankle experts there. Sunnybrook doesn’t seem to have foot and ankle experts. The head of the department Dr Yee specializes in spine, i think. You can tell. last time i was there i was seen by him (for 90 seconds) and he was clearly not up to date with the latest research. He even wants me to go slower than uwoprotocol, take out one wedge per week over the next 4 weeks and wean off the boot over the next 6-8 weeks. I am in week 7 now. In my opinion that’s bollocks. I should start weaning off in two weeks and at that point I should be at 90 degress (or 0 for that matter) according to uwoprotocol. He also said things like i shouldn’t expect to have my achilles back to where it was and that an achilles tendon rupture usually means the end of a pro sports career. Having said that, he told me to take off my boot but never even looked at my foot. Asked me if i could dorsiflex. Well…

    They’re surgeons. My family background is a fair amount of doctors (there’s one who specializes in Sports medicine for pro athletes and he urged me to have surgery - but he’s 3000 miles away and probably also not too familiar with the latest studies on ATR), some of them surgeons and if the patient is not about to die from their condition it’s just so hard to get them even interested. They’re trained to “remove” the disease. And they’re adrenalin junkies in my experience, so if you can’t provide that adrenalin rush to them by allowing them to save your life, you’ll have a tough time. Sunnybrook fracture clinic felt like that, tons of boring fractures and torn ligaments…

    I’ve seen one more doctor at Athletes Care for a second opinion right after the rupture, but he also said i should try to avoid surgery. I am going to see him again on Monday. I am just a little concerned that nobody ever checked the approximation in my specific case. No two cases are the same, and i just feel i received the »one size fits all« treatment. I am not leaning towards one treatment or the other, i just would have wanted the one that’s best for me. So now i just hope that it’s going to work out.

    I think you are right, even if the initial indication is towards one certain therapy (because of a gap), during this long rehab there are so many other things that can go sideways. In the end, it might not even make a difference. As with so many things in life, you just need to get lucky. You’re right, i won’t just go back to square one. I have a five and seven year old, taught them how to ski over the last 3-4 winters, and being able to ski with them next season is probably my highest priority. I know you went skiing much sooner after your second ATR, so i hope I’ll be fine, too.

    I have read your advice on the hinged boot before. i locked mine now and will let it hinge again once i am closer to getting to two shoes. I still switch back and forth between aircast and vacocast. Vacocast is mostly for when i leave the house and expect to walk more (it’s a lot more easy to make the vacocast snug). The aircast i use for cycling on my spin bike, sometimes for sleeping and quite often when i quickly need to put on a boot (e.g. When i am resting with my foot out of the boot) because the aircast is more simple to strap on.

    Ignoring the advice of my doctor (Dr Yee) i am planning on going to 0 degrees over the next two weeks instead over the next FOUR. I think that’s what uwoprotocol says (i think you, Norm, called it cold turkey because at some point they took out the entire wedge all at once at week 6 - i don’t want to do that). What do you guys think? Should i really drag that out over 4 weeks? Should i go faster than 2 weeks for removing the heel lift?

    Comment by pete0609 — May 5, 2014 @ 6:28 am

  4. What Norm wrote about the Dr physically palpating the gap area is exactly what my Dr did to approximate my initial plantar flexion angle and assess the healing at subsequent visits. He did use an MRI to double check initially. At my third visit, about 6 weeks, he used a quick ultrasound to show me the gap closure and tissue density compared to the surrounding tissue at the repair site. The ultrasound probably wasn’t necessary, but interesting and a nice visual for me.

    I wish I could have got a hinged boot, but I’m in a regular old 20 pound bledsoe boot with heel wedges. Its so ratty looking now, the velcro is not even sticking very well anymore.

    At least my Dr admitted he was conservative, acknowledged the modern studies out there and told me to listen to my body and be more aggressive if that’s the way I wanted to go. So for me, being at the end of week 7 now, I’m going to try to drop from 20 degrees to zero degrees in 10 degree increments by the end of week 8 or 9. My suggestion is to go down one increment over night like Norm suggests and then go down another increment when you feel good about it.

    Comment by Roark — May 6, 2014 @ 2:22 pm

  5. Ok, Roark - when you say regular old 20 pound bledsoe boot - what does it really weigh??

    Comment by sporti — May 6, 2014 @ 10:48 pm

  6. I’ll have to weigh it when I get home, I’m sure its less than what I think it is, still too heavy in my opinion.

    Comment by Roark — May 7, 2014 @ 11:40 am

  7. For what its worth (nothing?) the VACO Achilles boot weighs in at 1.5 kg (under 4 pounds). Definitely there are lighter boots out there, and certainly there are heavier ones too.

    Comment by hillie — May 7, 2014 @ 12:00 pm

  8. Hi Pete,
    Reading this post has filled me with optimism since your 7cm gap in AT is the closest I’ve found so far to my own four finger absence (roughly 7cm, give or take). Hopefully, you’ve made a full recovery…and if you’re still checking this site at all…might have the time to send me a ‘Yep…all’s okay’. I’m currently non op, four weeks in, still in cast but due back in hospital next week to see a physio and potentially get a boot. I’m a strong, sporty, positive person with lots of support at home, so I’m in a good place…but just a tad concerned about the size of the gap. Any reassurance or experiential wisdom would be wonderful. Thank you.

    Comment by Rita — November 30, 2015 @ 6:37 am

  9. Hi Roark, Norm and Pete,

    Thank you so much for the information. My gut says the Irish doctor has it spot on.

    I’m 4,5 weeks in now and I’m in the Netherlands. I have a similar story as yours an I feel like I’m swimming between specialists, protocols and Internet information. Just trying to make sense of it all and wanting the best for my Achilles.

    There was no echo made in the hospital and I was put in a soft cast at 30 degrees for 2 weeks. In the meantime I did my research and when I came back in the hospital they put me in tape. I asked the OS if he could refer me to a specialist who had experience with CAM Walkers and he literally said: “I have no time for that. You didn’t want surgery so we are going to tape you now.” After that I went for a second opinion in an orthopaedic clinic that was a bit more cooperative. They arranged the boot I wanted and planned an ultrasound for me.

    Finally having an ultrasound almost 4 weeks in. After analysis they concluded that I had a 2cm gap and they thought that was quite big and planned another one to see if I would heal as there was no ‘reference ultrasound’ from the moment of rupture. They also speculated that it might be necessary to do surgery if it would not heel (which seems really strange to me).

    At the moment I received the Walker I decided to put in a 2cm heel lift instead of a 3cm heel lift. I read a lot of the information Norm has put on this website and concluded it was the right time to go for 2cm and PWB. When I was back at the OS to discuss the echo he said that it would be better to put in the higher heel and not WB until he could see healing take place.

    Now, here is where I am a bit confused at the moment. After reading the most recent information on recovery I am convinced I should go with PWB and FWB. However about the heel lift I am not so certain. This could depend of the size of the gap I assume? Or was the 2cm in the protocol for all gap sizes? I now decided to change back from 2cm to 3cm after a week of having the 2cm heel lift. Could this interfere with healing or is it wise given the size of the gap?

    I hope someone can help me with this.

    Best of luck to you all. Thanks for all your information. Happy healing!

    Comment by Pieter — May 11, 2016 @ 8:44 am

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