My Road back to CrossFit
I did my Achilles 10 days ago and I can honestly say I’m confussed on what is the best road back for me! I have seen a specialist on 1 occassion and I had to push for that to happen, I was advised in hermind non surgery was best with an early exit from a cast and into a moonboot to start PT? This however goes against everything I have read and heard that surgery offers the strongest possible repair.
I visit her again for an ultrasound on Thursday and think I will push for this after reading Dave’s blog today, unless someone can tell me how this type of rehab programme has worked for themselves or others?
In terms of the injury it was done doing box jumps, I was just about to finish my workout which was 21,18,15,12,9,6,3 reps of box jumps, kettlebell swings 28kg and sit ups, I was in the doing the 6th rep in the round of 6 when it happened, no pain at all just my foot wouldn’t work.
I feel down about the fact that in my eyes there has been a lack of action to get me on the road to recovery!!! so I am expecting more to happen on Thursday when I go for my ultrasound, I will let you know how it all goes 
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Yep not sure what happened had a whole heap lot typed out but nothing got posted?
I love CF! I only started this year and never had so much fun working out. I just started to get into the swing of things when I injured myself doing DUs barefoot (while on vacation and not during a CF class). Just one of those freaky things. I am nervous about a possible re-reupture or have it happen to my other leg. I never want to go through something like this ever again.
How long since you did it? Did you have surgery?
I have been CF for 14 months and did mine doing box jumps, I’m totally not gutted about it!!! I had made it into our box team to do a couple of big national comps in the next 2 months and was training the house down.
I just want the strongest possible recovery for my Achilles, as I turn 40 next year and in 2016 I want to give the masters a good shake and possibly go to the games.
Hi Peter,
It may seem counterintuitive that non-op can be the best route, but before you decide to go surgery you may want to read the 2011 Wallace et. al paper. It clearly shows that for most patients the fast non operative route is similar, or even better than op. It was a large study of 945 patients.
I was going to refer you to Cecilia’s page where I originally downloaded the paper, but the link is not working for me today so I uploaded it to my blog. You can find the paper here: achillesblog.com/goldman/files/2014/07/the-non-operative-functional-management-of-patients-with-a-rupture-of-the-tendo-achillis-leads-to-low-rates-of-re-rupture-by-wallace-et-al.pdf
My personal experience was that I ruptured in Feb of this year and went operative in March. I had not read the Wallace paper before deciding. I live in the U.S. and wanted to go non-op initially, but then large gap in ruptured tendon, and surgeons here who tend toward the operative route, convinced me to go under the knife. Operative has been a pain, literally: surgery very painful for a couple days; annoying side effects. Suffered a blood clot - now dissolved and healed but was scary at the time and added significant extra expense; Recovery time: just as slow as non-op; Expense: high - about $13,000 for the procedure (you can read my blog for operative report).
Well, good luck with your decision,
-Jon
This sounds just like my story!! I was doing “Fight Gone Bad” bleave it or not it was bad and same thing box jumps and snap. I went and got put in plaster straight away, I then had to wait a week to go back and see specialists who confirmed that I had rupture it, they said no scan was needed and it was up to me if I wanted surgery but they said there was no gains in surgery and healing on its own was just as good so I opted for no surgery. I was in a cast for 4 weeks then put into a boot with the heel reduced every 2 weeks. I am now into my 7th week after rupture and after I went back last week they said doesnt seem like it is healing so I am fuming that I have never had a scan in the first place and seen three different doctors so how do they know how its healing, so I was sent back out with my boot on saying have to wait now for 12 weeks to see if I need op. Then today I have had a call off them to now go in for a scan. My mind is just all over the place to be honest I want to get back to crossfit asap and have the best possible outcome, i have also just started competing
r first: Goldman nailed it. Believe it or not, the newest and best evidence - not old myths or popular opinion, but evidence from large scientific studies - shows either zero benefits from ATR surgery (and lots of costs and risks) or virtually none, compared to a modern fast non-op treatment.
E.g. Wallace’s 945 non-op patients had a great low rerupture rate (lower than most surgical studies without the scars, pain, infections, etc.) and 100% return to sports.
/Cecilia/protocols shows the 3 best protocols and studies, and Goldman’s got Wallace if Cecilia’s link is broken.
The protocols are important because old-fashioned slow non-op treatment is NOT as effective as surgery, but modern fast non-op is. It’s all counterintuitive and pretty new too, which helps explain why so many “experts” haven’t caught up to the evidence yet.
One ankle angle fits all non-op - like UWO and Exeter - works well for the vast majority, but the individual best angle for each patient - Wallace - is even better. Not hard, no scans needed, but most experts haven’t figured it out yet. Some sad regions force patients to choose between surgery and old slow non-op. No excuse in 2014, except incompetence and inadvertence, but nonfatal boring conditions like ATRs breed those.
And Peter, if you’ve been immobilized nwb in equinus, you haven’t been wasting time, you’ve been healing non-op. Maybe not at the perfect angle, but that can still be checked (gently!) if you can find a cooperative health professional with a few spare minutes.
Karen it’s not possible to diagnose you from here. Every cure has a few % of failures, and you may be in that few % - or not. Your protocol hasn’t followed the Best Practices (see Cecilia’s summary), and that increases risk as well as PITA nuisance for non-op patients. Old-fashioned slow casting (bad non-op) does have high failure / rerupture rates, in the 15-20% range.
Remarkably, Wallace got great non-op results with ATRs that had been neglected or maltreated, so you could still escape the knife and get great results, but maybe not where you are being treated now.
Karen, there are patients here who have chosen surgery just because their local doctors were familiar with that, but couldn’t handle the better modern non-op treatments that work as well or better. That’s ironic or even crazy, since a smart non-MD could likely get results as great as Wallace’s non-op, while nobody would choose surgery by a non-MD! But ignorance or denial of the best evidence is still rampant in ATR care, alas!
I went the surgical route - I’ve read about the benefits of both surgical and nonsurgical and agree that the new nonsurgical method COULD be the way to go but I wanted more LONG TERM studies before committing to the nonsurgical route. I’m not entirely convinced of the low rerupture rate (yet). These studies are still too new for my comfort, in a few more years a new study might reveal that their studies were all wrong. There are way too many conflicting studies out there for everything (not just ATR). Look at all the hype for vaccinations and Autism. Now we are finding out that there is no direct link which is why I am glad my kids were vaccinated. Not the same thing, I know but just wanted to give my perspective on why I hesitate with new(er) research studies.
atr2014
For piece of mind it is important that you had the treatment that you believed was the best for you, especially as surgery is not without significant risks and discomfort.
The “newer” nonsurgical methods quoted on achillesblog mostly began before 2008 and have been very successful. I am not personally aware that any studies have shown in recent years that surgery gives a sustainably superior and stronger repair. There are conflicting studies out there but they mostly seem to be from different times.
I guess that I was just lucky - treated at Exeter for a full atr. Early mobility and physio, Vaco Achilles hingeable boot, a dedicated AT clinic with immediate advice on the end of the line. These factors applied to surgical and non-op patients - no difference in rehab schedule.
I use Crossfit as a background strength conditioning regime. The good news is that once you’re able to walk in the boot, there’s a decent number of core and upper body exercises you can manage — and they can be stitched together into a little workout. The trainers at my gym have been terrific about helping me make a training plan that accommodates my restrictions. So while it’s an awfully long road back to box jumps and double-unders and all that, one can get back into the gym well before then.
@atr2014, what Hillie said! The first non-op study I call “modern” — showing no significant difference in strength, ROM, or rerupture rate between op and non-op — was published in NZ in 2007 by Twaddle et al. I assume the research was done a year or two earlier. And most of the post-2007 results have been quite similar, making scientific fraud (as in vaccines and autism) unlikely.
The UWO-study folks followed up for ~2 years, but I’ve never seen a study that followed up ATR patients longer than that, op or non-op. Either “cure” could have problems popping up long afterwards, but they ones I’ve heard about are usually relatively minor, relatively rare, and largely unreported. E.g., about 10 years post-op from my own first ATR (surgically repaired, unlike the second), I developed a “trick knee” which my Podiatrist, my Sports-Med MD guru, and my PT all attribute to that surgical ATR repair. As my OS told me in early 2002, when I told him my post-op right ankle had less Dorsiflexion ROM than my then uninjured left ankle, “Good, that’s what I was aiming for!” He was worried about what we call “Healing Long”, which can compromise strength and power, and I escaped that completely, because he repaired my right AT short!
But my “artificially tight” right calf-and-AT, combined with my naturally tight quad muscles on both sides, pulls my knee out of alignment frequently, unless I stretch them both frequently. My LEFT quads are reportedly even tighter than my right quads, but they’ve never caused a knee problem, and my experts and I all attribute the difference to that ATR surgery. (No knee problems so far after my left-ATR non-op cure, touch wood!)
The frequency of same-leg reruptures drops pretty quickly to ~0 starting around 12 weeks post-either, so I’m not sure what long-term consequences you’re waiting for — or whether the medical-scientific community will even notice them if they do exist!
You’re definitely right about one thing: It’s too soon to take any expert’s 2014 understanding of “the ATR truth” as definitive, because the situation is still quite fluid. But most of the movement since 2007 has been in the direction of homing in on optimal non-op care and quantifying just how consistently excellent its results can be when it’s done right. (Me, I suspect that Wallace’s “approximation” technique will produce even better results than Wallace’s when combined a slightly faster rehab protocol, more like Exeter or UWO.)
Surgery hasn’t stood still either (mostly with some apparently attractive less-invasive techniques — including the Achillon — that may be able to avoid the higher incidence of sural nerve damage that characterized earlier “closed” repairs), but its improvements have been dwarfed, IMHO, by the results from the latest studies and meta-studies that included non-op treatment. I also report (on my blog) on an incredibly promising small Japanese report on a new open-surgery technique that demonstrated blisteringly fast returns to FWB, 2 shoes, full activity, and full-on sports — but I haven’t heard any more about it after that report on the first few dozen patients.
From what I see, I don’t think we’re waiting for much new evidence or studies, though having more than a single meta-study that can see the difference between modern successful non-op treatment and old slow UNsuccessful conservative casting would be nice. (Are you listening, Cochrane Group?!?)
What we ARE waiting for, IMO, is for the Old Guard to retire or die off, so future ATR patients can be treated with Best Evidence-Based Practices by a new crop of practitioners who are willing to look at the evidence with clear eyes. And that may be more revolutionary than any common practice today, anywhere. For example, the non-op “magic” that Wallace did (or better) could probably be done by a smart specialist nurse, PT, or nurse-practitioner, no MD needed! If so, it’s maybe not too surprising that so many OSs (and Med Schools) are defending the good ol’ ways. . .
Just to clarify, I’m not opposed to the nonsurgical method - it seems to be the least risky method and anytime surgery can be avoided, that’s all good in my eyes. My issue is the rerupture rate. I am looking beyond the 12 week timeframe. I’m thinking what are the likelihood of a rerupture during a person’s lifetime? To me, I can’t help but think that having it sewn back together would make my tendon stronger. It’s just something I personally believe (right now).
Also, when I did my research, most of the info I discovered had better results with the surgical method. I only discovered this blog the day before my surgery and through this blog was I made aware of the huge strides in the new(er) nonsurgical method. Trust me, I think it has a lot of merit and something I would give considerable consideration had I found out sooner. I’m still happy with my decision as it was what provided ME with peace of mind that I chose what I felt was best for me in my situation. That’s not to say that I would not consider going the alternate route should I ever (god forbid) rupture my other leg. I just know I NEVER want to go through this again. Just the thought of going through this twice … can’t fathom.
atr2014
I meant it when I said that you had the treatment that you felt was good for you personally.
When I was injured I had not even seen this website and when I received my diagnosis, then told we would be trying a non-op route first, I scoured the internet because I wondered (naively) if my OS was correct! Little did I know then that I was already dealing with one of the world-leading clinics, and I’ve had no regrets or doubts since - but I did feel that I had to satisfy myself at the time.
Three years later my AT is still there performing better I think than before my rupture. You should do a deal with yourself - if you are unfortunate enough to rupture the other leg, go non-op and you can observe your own findings, so long as you follow one of the modern (although they been out there some time now) protocols.
Are you on a progressive rehab schedule? Sorry if you’ve already talked about this somewhere.
H
hillie
I am not on the progressive rehab schedule - I am in a cast (was put in one 8 days postop) and have a total of three weeks in it before going to the boot. I was told that I will go to PWB when the cast gets off. I will be talking to my OS when I get my cast off and will seek his advice on PT’s. I am definitely going to push for the progressive rehab - that is something I definitely agree with 100%. I’m going to research for a good therapist who specializes in this method.
atr2014 (sounds so impersonal!)
Interestingly, after my diagnosis, I only ever saw physiotherapists - for boot fitting and adjustment, exercises and massage of the leg, and finally certifying me as ready to go but only after authorising external physio near to my workplace. This took me to week 14ish after which I went to a sports physio for 8 weeks.
Where non-op and surgical cases go wrong is when patients are cast for too long, don’t get mobile early (as in 2-3 weeks max), don’t do even the smallest of exercises, and don’t receive good information from the practitioners. Its a fact, out there and in this blog for all to read. Oh, and of course all failure is not down to bad practice, far from it.
We slip, we take chances, sometimes we think we are experts and it goes horribly wrong.
Find a very good rehab schedule and follow it - it won’t be slow, and it won’t be easy, but stick with it.
Check out suddsy’s blog and especially suddsy/2013/06/24/end-of-wk-2-wow-progress/
Atr2014, I hope you stay happy with your personal choice, now that it’s made. But there is virtually zero evidence of long delayed reruptures of ATRs following ANY kind of treatment, even the worst, so I wonder if your fear is based on anything at all. Old slow conservative casting has been practiced for maybe centuries, and is still happening in low-IQ pockets of the planet. The early rerupture rate is unacceptably high (sometimes even >20%!), but those who successfully heal don’t seem to blow up years later. On the contrary, there are many reports of people who were plagued with tendonitis or -osis who were cured by the experience.
Furthermore, most operating OSs - even those who do NOT use dissolving sutures, as many do - only claim suture-strength benefits in the early weeks, not years later.
It’s always conceivable that there’s a huge conspiracy to publish fraudulent data in peer-reviewed journals, but I don’t see any other threats to the evidence to date - though I’m confident that future studies will improve ATR Best Practice.
BTW, 8 years after surviving a super slow surgical cure with a super-conservative OS for ATR #1, I was mostly pleasantly surprised by my progress for ATR #2, non-op, following UWO. Faster, pain-free, scar free, no time off work (from home on the PC), and evidence-based, unlike #1, which was arbitrarily responsive to my OS’s false belief that slower was safer! (”After all, you don’t want to go through this again!”)
Good guy, good with scalpel and needle and disinfectants, but no time to read scientific studies. He didn’t get 100% in school or on the job, just like the rest of us don’t…
hillie - sorry that my username isn’t very original. I drew a complete blank when I signed up. Thanks for all the info too. Very interesting. I’m a little nervous about my rehab to be honest. I do hate the fact that I will be essentially 4 weeks from the operation before being placed in a boot. The lack of movement in the early stages is really starting to concern me. My leg has atrophied and when it isn’t swollen, I have quite a bit of wiggle room in my cast and doing as much stretching and rotating as possible.
Norm - have read your story and can’t believe you’ve ruptured both your Achilles! That is my worst nightmare. As for rerupture, I wasn’t aware that most reruptures occur within the first 12 weeks (other than a result of a fluke accident). I can’t help but be concerned with post op rehab - it seems that is the key for best results. I keep finding more and more on this site and don’t understand why more doctors aren’t pushing for the non-op route with the progressive rehab. What I still don’t understand is how can one not have surgery if their tendon snaps and is far up their calf? How could it possibly heal? So confusing!
atr2014
Didn’t meant that your username was unoriginal. What some here do if their usernames aren’t very inspiring, is they add their real(?) first name, but that’s personal choice.
By the way, my rupture was so far up that my GP and doctor at local small hospital thought that I had ruptured a calf muscle. My specialist when he diagnosed the rupture wanted to try non-op first - it worked, and I’m now 3 years on with the tendon fully healed and de-atrophied (is there such a word?) for ages now.
While you have time on your hands (and my lunch break is almost over), research how collagen, 2 types I seem to remember, works to re-join the damaged AT ends - very clever stuff.
Atr2014, it is puzzling magic that can reconstruct a good correct length AT without surgery. But the first law of science is “If it exists, it must be possible!” And the 3 studies listed by Cecilia clearly show that a reliably successful and quick non-op cure definitely exists.
I think there are many reasons why OSs are slow to stop operating. My guy did exactly that, but he’s a rare bird - and he had too many patients waiting anyway because he’s a superstar, so no complaints from his practice partners or his bank mgr. But even without professional or $ pressure, confirmation bias alone keeps most of us from concluding that we’ve long been doing something that’s essentially useless. My rare bird just said “I didn’t become a surgeon to do surgery without any benefit, so I stopped!”
BTW, many surgeons tell their post-op ATR patients that it was really lucky they had the op, because of their specifics - huge gap, muscle rolled up like a window shade, etc. But in 945 acute (prompt) ATRs, Wallace found NONE that wouldn’t approximate (and none among the reruptures and only a few among the neglected ATRs)!! And his success rate non-op was better than most surgical studies!
Surgeon bedside puffery, I think. If your surgeon tells you that your problem was unusually tricky but he cured it, then you feel great about yourself, your painful rehab, and your surgeon, too - win-win, harmless puffery. Except most of it is BS, so we shouldn’t rely on it the way we rely on peer-reviewed published evidence.
peterg: don’t stress. The non-operative option can work out great even as treatment after a post-operative rerupture for a sports active fit man in his early forties.