POST NON OP (or No Op) PROTOCOL (Provided by Norm)

http://achillesblog.com/normofthenorth/the-non-surgical-protocol-ive-been-following (bit.ly/UWOProtocol)

This is good, but you will also want to view the Exeter 2013 updated protocol, but be careful and patient.

Check out Norm’s, Kellygirl and other No Op ATR blogs.

27 Comments so far

1. Ron on September 19, 2013 10:34 am

   Please let me know what I am missing or if you have any input. I would love to get you input and help me shape this post better for newbees (like self), which Docs don’t really give you much to work with.

   Thanks and I wish everyone a patiently quick recovery.
   Ron

2. kkirk on September 22, 2013 12:04 am

   All of this is great stuff. I’m going to link this to my link page off my blog if you don’t mind. Good luck with your recovery.

3. Ron on September 22, 2013 2:56 am

   Thanks Kkirk,

   I have a lot of time on my hands. LOL. I am also an ex-engineer and like road maps. Talking to the people here and reading a lot of posts was great. Hopefully, I can get some input from others and build the page up for newbees. No problem using anything on here.

   I wish you a patiently quick recovery.

   Have a great day.
   Ron

4. normofthenorth on September 22, 2013 10:04 pm

   Ron, you’ve featured the non-op option prominently throughout, right up there with surgical repair, which I think is fair and sensible. But it’s not in your title. did you mean something like “Non-Op, Post-Op Protocols/Concepts. . .” in your title rather than “OP, Post Op. . .”?

   Also, as much as I love praise and appreciate the great work done in the UWO study, the title of “Best POST NON OP PROTOCOL I’ve seen” might properly belong to the Exeter study now, since it seems to be (a) faster than the UWO protocol and therefore more convenient (and maybe more atrophy-resistant) and (b) more successful than the UWO protocol, at least in terms of reported re-rupture rates. Both studies included post-op and non-op patients, though I’m not sure if Exeter reported their re-rupture rates separately or not. (I think I’ve still only looked at Hillie’s summary of their results on Suddsy’s blog.)

5. normofthenorth on September 22, 2013 11:02 pm

   OK, I’ve finally looked at the abstract of the Devon/Exeter study, including their detailed (though abstracted) results. Here’s the passage:

   “We prospectively collected data on all patients with Achilles tendon ruptures from October 2008 to March 2012. There were 246 patients in total with four lost to follow up. 80 were treated with the Achillon system, 18 had an open repair and 144 were treated conservatively (of which 56 were partial or musculocutaneous junction tears).

   “Three patients sustained re-rupture (1.2%), all initially treated conservatively. There were two operative complications (2%), both wound breakdowns. Two patients suffered PE’s (0.8%), confirmed on VQ scan or CTPA (one operative, one conservative). One non-compliant patient healed functionally long and required a shortening procedure.”

   A coupla notes:
   - “Achillon” is a gizmo that facilitates percutaneous (aka “closed” or “minimally invasive”) surgical repair, so those 80 patients were treated surgically, percutaneously.
   - “Open repair” is conventional “open” surgery.
   - “Conservative” just means “non-op” — and the usage is especially noteworthy here, because “conservative” often means “slow”, but this group went FASTER than any other group that’s reported its results (except one, that went very fast and got bad results — discussed by RyanB and me on one of my blog pages).
   - Unlike the UWO study and the three other modern studies that compared “op” with “non-op” after randomizing a number of full ATRs, this group “streamed” their patients into different treatments depending on their injury, and included partial ATRs, all of which were treated non-op. (It seems logical that partial-ATR patients would experience fewer re-ruptures, so we should adjust the results.)
   - They got follow-up information from 242/246 patients (or ~98.4%), which seems shockingly high to me, even for a short-term study.
   - Also shockingly, among their 98 post-op patients, they seem to have gotten ZERO re-ruptures(!), two wound breakdowns, and one Pulmonary Embolism (PE). If these were all their serious complications, the rate seems to be around 3%, which is nice, esp. no reruptures. (They don’t mention DVT, and all they tell us about the patient who healed long is that (s)he was “non-compliant”.)
   - Among their 144 non-op patients (88 complete ATRs and 56 partial ones and/or “musculocutaneous junction tears”, which I take to mean tears between the calf muscle and the AT), they had 3 re-ruptures and one PE. DVTs and PEs can happen to any ATR patient (complete or partial), but are usually somewhat more likely post-op (and here too). If we assume (arbitrarily) that 40 of those 56 were partial ATRs and the rest were complete, AND if we assume () that all the re-ruptures among the 144 non-op patients happened among the (88+16=104) complete ruptures, then their rerupture rate was just <3%.
   - IIRC, that non-op rerupture rate is statistically identical to UWO’s (2 or 3 of ~75). If so, we’re maybe talking about a faster and more convenient protocol with results “at least as good as” UWO’s, rather than clearly better than UWO’s, on the non-op side.
   - It’s possible that their stunning re-rupture rates on the post-op side are meaningful and reproducible, but it’s also not unlikely that they’re a fluke. Basically, whenever you’re talking about near-zero rerupture rates — or near-zero rates of ANYTHING — it’s easy to have big variations from one (random) sample to another. I personally think that re-rupture rates at or below around 2% are “effectively zero”, since about 1 patient in 50 can be expected to have a serious pratfall on crutches, or be non-compliant, or otherwise re-rupture their ATR despite being treated with an excellent initial treatment and an excellent rehab protocol. Just my $0.02. (E.g., in our current sample of bloggers, we’ve got one who reruptured after the heel wedges in her Aircast boot were installed without being peeled-and-stuck down, and slid under her arch, putting her in DORSIflexion while FWB! That fluke would likely rerupture ANY healing ATR, and would skew the results of any study it was in.)
   - Some of these questions/conclusions might be answered/altered by reading the complete study. But it does seem as if there’s no good reason for any ATR patient — op or non-op — to go any slower than these guys did, since their results are at least as good as anybody else has gotten.
   - One interesting Q might be what, and who, influenced the decisions on initial treatment, between open or closed surgery and non-op. It might have been “informed consent” by the patient — except that most ATR patients who’ve checked in here, in the UK and almost everywhere else, have been pushed hard into one treatment stream without much “informed consent”.

6. normofthenorth on September 22, 2013 11:03 pm

   That full abstract, as posted elsewhere by Hillie, is at bjjprocs.boneandjoint.org.uk/content/95-B/SUPP_18/16.abstract .

7. CliveC on September 23, 2013 4:31 am

   Hi Ron

   About the boot types - do they really all work the same? For example, one, the Vaco doesn’t use internal wedges but al least one of the others does.

   I”m no expert so can you help me out here and give some more guidance please?

   CC

8. Ron on September 23, 2013 4:39 pm

   Hi CC,

   The boot cam was very uncomfortable to me and dug in in areas that created pain. The Air Cast I tried was better, but not the answer either. The boot Cam that a hospital gives you can be bought on Amazon for $40 and the Air Cast costs a bit under $100.

   The Vacocast was more comfortable out of the box and helped relieve pain and swelling. They all work, but it’s just a matter of comfort - especially over the first 4 weeks.

   The VACOCast can adjust to 30 degrees down (Plantar Flexion and 15 degrees up (Dorsi Flexion), and can also be put in ROM mode with the walker.

   Check out this video:
   Go to youtbue and type “P04 VACOcast Pro”
   It will show you how to adjust it to 20 degrees, but you can adjust it to 30 to start.

   You can also send back the VACOcast within 2 weeks if you are not happy.

   With that said, they all work about the same, but some are better than others.
   Since my insurance paid for the Cam Boot, I have that one as well, but I have not tried the others - but
   also bought an Air Cast boot. I hear the Bledsoe is also good.

   You can also contact ken or jeremy@opedusa (.com)

   I hope that helps.
   Ron

9. Ron on September 23, 2013 4:49 pm

   Hi Norm,

   Thanks for the input. I made some changes to some of the titles (non op\OP, etc. from the first post and found that Exeter abstract (Hillie), made a pdf of it, and added it under Suddy’s protocol link.

   I am going with a hybrid of it because my incision is over 6 inches, while Suddsy’s is 3.

   Question….does the size of your gap or severity of your tear, make a difference in the protocol you pick?

   Seems to me that it should?

   Thanks again,
   Ron

10. Ron on September 23, 2013 4:54 pm

    Hi Norm,

    Awesome stuff. I also added a note at the beginning to read your comments and others that follow my post. The more they read and learn, the better it will be to make choices that work.

    Have a great day.
    Ron

11. kellygirl on September 23, 2013 6:55 pm

    You’ve put together some great information. It’s awesome to see it all in one place rather that have to search about here and there. Thanks for compiling it all. Very helpful!

    @CC: The premise of the boots are the same–whether it’s articulating or wedge. I had a Bledsoe boot which came with removable wedges–removed a wedge a week so pretty simple to operate. The velcro straps were secure and it had a rocker heel that made walking very easy. No bells and whistles but it got the job done. I think the Vaco cast has it’s advantages especially if you are planning on getting it wet–swimming, windsurfing, etc. The removable liner is pretty clutch too. I think you can pump it up to get a custom fit too. I have no regrets with Bledsoe though. He was a fine companion for the short time we were together. Good luck!

12. Ron on September 23, 2013 7:30 pm

    Thanks Kellygirl,

    I’m and ex-engineer and I like order. LOL. I just wanted to bring one post together that has almost everything on it. I hope to massage, edit and change things as I receive input from others with more experience.

    Great advice to CC as well. I forgot about the Bledsoe and added it to the options of boots in my comment.

    Have a great day.
    Ron

13. Ron on September 23, 2013 7:43 pm

    PLEASE GIVE ME YOUR 0-6 WEEK EXPERIENCES (first 3 days, week, 2 weeks, pains, difficulties, exercises…going from NWB to PWB to FWB, etc.)

    I am trying to give newbees a feel of what to expect, especially for the first 2 weeks (Post Op and Non Post OP).

    In POST OP, up to when you stitches or staples came out (2-3 weeks).

    For POST AND NO OP, what was PWB and FWB like?

    The goal here is give a what to expect scenario(s)with variations. For example,
    tingling, pains, soreness, precautions, etc. An example would be the first 3 days of
    pain, using crutches, etc.

    My GOAL is to created a collective experience link with pdf that may helps people who are
    Post Op and Post Cast no non op ATR’s, giving them advice on what to expect, avoid, etc.

    Thanks,
    Ron

14. kellygirl on September 23, 2013 8:12 pm

    For non-op, the first four weeks were pretty much the same–I just got better with the crutches and developed better aim when throwing things at my kids to get them to help me. In terms of pain, soreness–it was nothing except for a dull ache at times due to inactivity. The goal was to elevate when sitting around–I tried to keep up with some normal activities to keep the blood flowing. Didn’t really do any kind of real exercise until the boot. My best advice is to keep those toes clean!

    I pretty much went from NWB to FWB at five weeks. It was harder to PWB with the crutches than it was to walk with the boot. Transition was pretty easy. Very little discomfort in the boot except for the initial fitting which felt weird and tight more than anything. Got on the spin bike the next day and haven’t really stopped. Removed the boot for sleeping at night too. Business as usual until two shoes.

15. Ron on September 24, 2013 1:05 am

    Thanks Kellygirl,

    A few questions…

    1. Were you in a cast for 3 weeks and then went to a boot?
    2. When did you try to PWB? Or was it just a try and skip it thing, taking you to FWB at 5 weeks?
    3. When did you start taking the boot off to sleep?
    4. When did you ditch the boot?

    I did check out your entire blog and Norm’s to get a better idea of the Non Surgical approach and trackable results - they both look great!

    Congrats on your recovery.

    That’s funny regarding the kids.
    Thanks again.
    Ron

16. kellygirl on September 24, 2013 1:06 pm

    To clarify:
    1.) I was in a cast, NWB for 4 weeks and transitioned into a FWB boot at week 5. My boot was Bledsoe.
    2.) I tried PWB the first day in a boot but it was awkward. I wasn’t in pain so I just ditched the crutches.
    3.) My doctor said it was fine to sleep without the boot when I got my cast off. I was nervous though so I used an ace bandage loosely wrapped around the half of my cast (like a splint) to keep it protected the first few nights. It was (again) too much work so I ditched it all and just let my leg sleep naked.
    4.) Ditched the boot at week 9. Haven’t looked back

    Thanks again for doing this, Ron!

17. Ron on September 24, 2013 9:05 pm

    Hi Kellygirl,

    Wow, you are brave! I love it, and hope I have the nerves. LOL.

    Thanks and have a great day.
    Ron

18. Steve on October 17, 2013 5:34 pm

    I have a new one….My OS said to “ditch the crutches and walk in the boot” at 7 weeks after surgery. Well, this week is 9 weeks since surgery and my PT tells me he would feel more comfortable if I used at least 1 crutch, if not 2. Bullsh**! I am not going backwards! This recovery is such a mental game! My next appt. with the OS is the 30th of this month and he has already said he expects me to be in shoes! The PT says…”well, that is only the beginning and you should take it slow and use the boot still….I’m starting to get a little cranky with the PT….way too conservative!! I can walk barefoot, although it is not a pretty walk…

19. kellygirl on October 17, 2013 5:46 pm

    @Steve: I agree with your OS. I don’t see why your PT is so cautious. A well fitting boot should keep your achilles secure. Many of us were on similar time lines as your OS has you on. Two shoes, here you come!

20. Ron on October 18, 2013 3:19 pm

    I agree with Kellygirl,

    Although we all have different bodies and our injuries were different in some cases, my gap was 9 and I have DVT’s. With that said, my Ortho told me the quicker I am moving, the better, so he is aggressive and so am I. If he were not, I would leave him behind - and he knows it. I would not go backwards, although there may be times when you are moving too fast and have to pause.

    Good luck
    Ron

21. craiger9er on November 4, 2013 10:45 pm

    Nice post Ron - here’s my timeline. It’s amazing to me that I had to go back and look this stuff back up because I’m starting to forget EXACTLY what I had to do to get where I am.

    Rupture through Surgery -

    Very little pain, laid around until doctor appts / surgery.

    Post op to 1 week.

    Pain meds had a bad effect on me, giving me anxiety. Had to stop taking them. What hurt the most was pain from swelling and pushing against the cast. I had a hard fiberglass cast, with foot pointed down. After 1 week, got a new cast which brought the foot up a bit. Iced through the cast, which did help. I should have done that more.

    1-2 weeks still NWB. Into a boot. I got the Breg CROM boot

    http://www.breg.com/products/foot-ankle-bracing/walker-boots/controlled-range-motion-walker-boot-crom

    From the weight of the boot, it hurt my hip a bit when moving around. Only pain so far, besides the hip, was from swelling against the cast, but very little in the boot, which was much more comfortable.

    2-5 weeks PWB Boot - Stitches desolved from the inside, nothing to come out. Adjusted my boot to 0% / neutral. Also go the go ahead to sleep without it. Putting weight on the heel was pretty painful. Sleeping without boot was scary, but great for the mental aspect after a while. Really realized it isn’t as fragile as I thought. Still had hip problems from the weight of the boot, while rolling over to my side. Pain in calf, sides of ankle and mild soreness in AT area, by heel. Bottom of heel pain - feels like someone put an extension cord in there and kept plugging it in. Started some ROM exercises on my own, writing alphabet with toes, etc.

    5-8 - week 5 - Physical therapy assessment. They also gave me ROM exercises and stretching. Around week 6, FWB Boot. Bought an “EVENUP” shoe balancer. I recommend them, very helpful, especially from the pain and soreness in my hip from the boot.

    ROM exercises out of the boot, stretching with theraband (not pushing against it yet), some leg strenthening with boot on.

    8 + weeks - 2 shoes. No real problems, just soreness and still pain on the bottom of my heel from impact, some hip discomfort still. Lot of therapy, stretching, rehab, etc.

    Some exercises - Theraband strengthening, dorsi,plantar, eversion, inversion. “Nu-Step” machine, Stationary bike, leg presses (weight on heel) standing hip abduction, squats against wall (not full), with exercise ball (weight on heel) Walking. Lots of balance exercises. Balance on one leg, close eyes and balance on one leg. Stand on pillow with ATR leg, balance. PT ended, even though I felt I needed more, wasn’t covered by insurance.

    4.5 months - got the go ahead to start light jogging (basically a couch to 5k program). No jumping or full running.

    Not sure if any of that will help you with anything but I figured I’d add to it. I can probably come up with exercise specifics if needed.

22. normofthenorth on January 25, 2014 2:17 pm

    Ron, back in Sept you asked:
    “Question….does the size of your gap or severity of your tear, make a difference in the protocol you pick?
    Seems to me that it should?”
    And I never answered here. Just in case:
    The key question (for me) is whether those initial differences make surgery more worthwhile, beneficial, or necessary for a good result. E.g. Having a “stale” or neglected ATR almost surely DOES make surgery the best bet.

    For the other indications, logic says they “should” but the evide ce we’ve got so far says they DON’T! Specifically, an analysis of the UWO data showed that non-op patients with LARGE initial gaps (from ultrasound) did just as well non-op as those with SMALL initial gaps! They also found that gap LOCATION had no impact on outcomes non-op (though high gaps make surgical outcomes riskier).

    There are other kinds of “severity”, and some of them seem (logically) to indicate surgery — e.g. If the rupture has pulled a bone chip off the heel. I’ve also heard about ATRs where one torn end has rolled up like a window shade (NOT just a big calf contraction), and it’s hard to imagine non-op fixing that well.

23. Ron on January 25, 2014 5:47 pm

    craiger9er, how are things going? Thanks for the tips, and sorry I just got back to you - I think I left for Bermuda to see family on Nov. 3rd (however, I did read them then, but forgot to reply when I returned to the US). BTW, that boot looked interesting.

    Have a great day.
    Ron

24. Ron on January 25, 2014 6:37 pm

    Norm,

    No worries at all.

    I only asked that in Sept. (before surgery) because I made a mess of my foot AFTER my injury by teaching golf and tennis for 3 days. My ankle was the size of my calf, and my calf was the size of my thigh. LOL. This caused two blot clots, two badly sprained ankles, and to top it off, my surgeon appears to have made 2 incision points. So…It’s funny when I see 3-4 inch post surgery scars, because mine is double that size, and the 22 staples and womb closer mismanagement did not help much, either.

    Thankfully, I had the knowledge to catch a lot of mistakes and correct “the process” on a number of occasions, but it took a lot of research and effort.

    The lucky part was having this blog, yourself, and others to fill in the gaps. Man, are we all lucky! IMHO. With that said, it’s never to late or often to donate to Achillesblog.com.

    Thanks again, Norm. You are still the man.
    Ron
    Moving Patiently Forward

25. anniel on March 27, 2014 3:26 pm

    Hi,
    What sort of exercises were you doing from around week 5 onwards (I tried some of your links but they came up with a not found message)?
    My physio seems fairly conservative with just massage so far and doesn’t want to see me for another 10 days! And my personal trainer at the gym maybe is a bit too fast as was making me go flat on the floor when I still have a couple of wedges (approx 2cm) in my boot (and I was able to do it, but with a certain amount of trepidation)! From all I have read here about the best results I know I need to be doing something to get motion/strength back but I don’t want to overdo it (am going through a bit of a fearful stage at the moment worrying about re-rupture or atrophy!)…
    Oh and I am non-op, and in my 5th week since ATR.
    Thanks,
    Anna.

26. normofthenorth on March 28, 2014 10:31 am

    bit.ly/UWOProtocol should work, Anniel. I think you may be right about BOTH of your pros! You’re allowed to switch PTs - and to say No to your trainer!

27. anniel on March 30, 2014 6:10 pm

    Hi Norm - I think you are right - I am going to tell my personal trainer that I want to stick to upper body work for a while (or things that I can do in my boot - seems that several people did stationary bike with little/no resistance etc) - and will try and have a chat with the physios at the gym that other people have used with Achilles injuries and see what they have to say for this stage in process. Thanks