CanuckintheUK on http://www.injuryupdate.com.au
Some interesting info on early weight bearing protocol.
For me it happened while playing soccer at lunch; just standing guarding someone and turned and then felt a tremendous pain in my ankle. This went away after a few minutes but I knew I had done something bad to my ankle while trying to walk. A few minutes of Googling later and I was certain I had ruptured my AT. I went into A&E and they confirmed the diagnosis and sent me away with a cast until I could be seen in the fracture clinic. So, being a scientist by trade, I started reading papers published in scientific journals which dealt with AT ruptures. There are quite a few good ones, though in some cases you need to have access to the journals through a university library account. There was a very good review in 2002 (reference below)
Wong J, Barrass V, Maffulli N. Quantitative review of operative and nonoperative management of achilles tendon ruptures. Am J Sports Med. 2002 Jul-Aug;30(4):565-75.
It describes in detail a review of 5300 AT ruptures, how they were treated and the outcomes. It also describes in some detail the various techniques used for treatment and the pros and cons. Having been able to read through this, I found I was much better prepared to speak to the orthopaedic surgeons at the clinic. The first doctor I spoke to (and in fact most I spoke to) said that there was no big difference between surgery and conservative treatment in terms of outcome. In fact this isn’t really true; it is quite clear that the “functional outcome” of surgery is better in terms of mobility, rate of rerupture, and duration of recover. It is true that not having surgery avoids some risks such as infections, but similar rates of wound/general complications exist for conservatively treated patients as well (clear from the review, but not from talking to the doctor). The problem is that doctors only have so much time to keep up with current research and there are so may specific problems they have to deal with on a daily basis, it’s ultimately unrealistic to expect them to know everything about every aspect of your condition. The senior registrar at the clinic did not know of a study published by his co-worker about the benefits of early weight bearing (discussed below) after AT surgery; had I not done my own research, I might have been stuck wearing a hard cast (and crutches) for 8 weeks, rather than (if all goes well) an air-cast after 10 days. It’s hard to get access to the information, but where possible, you should try and find out and understand all of your options first and then speak to a doctor about what you want to do, not just what the doctor says. As I am a physically active 34 year old, I likely would have been recommended to have surgery regardless, but the first doctor seemed keen to have me in a cast and out the door.
Anyway, having a 2 year old and a new born, I am keen to get walking as soon as possible again, so I was also interested in articles which dealt with early, weight bearing mobilization after surgery. There was recent study published (by a orthopaedic surgeon who coincidentally works at the clinic I went to!) showing that early weight bearing after surgery actually reduces the rate of rerupture and complication rate as compared to surgery and immobilization (this is also clear from the 2002 review). Presumably the increased blood/lymph flow from muscle use helps in recovery, although it’s not specially stated why this is. Although it should not have taken as much effort or convincing as it did, I was able to get the senior registrar to agree that I could follow the early weight bearing protocol; he just needed to talk to the doctor a few doors down and find out exactly what he does. So at the moment, I am 5 days post-op and waiting to get out of my current cast and starting my long road to re-hab! In summary, my advice is to try and be informed as much as possible when talking to a doctor and even then, get second/third opinions until you feel satisfied that you are getting the treatment you want. Whether you are an elite athlete or not, it is just you that has to live with the injury, not the doctor, so make sure you are happy with your decisions.
CanuckintheUK on www.injuryupdate.com.au
Hi there Mumofmany,
You should really speak to your surgeon/GP about your concerns; that may involve being very persistent in calling his office/hospital to try and get another appointment to speak to him. There is no reason that he should not be able to speak to you and most surgeons will want to see their patients after surgery anyway. Anyway, nurses don’t decide on the course of treatment, doctors do, so ask to speak to him in person and ignore the grumpy nurse! Just seems a bit strange.
As you have probably read, there are a wide range of treatments for this sort of injury ranging from complete immobilization for 6-8 weeks to be fitted with a walking boot right away. The decision about how to treat the patient usually seems to rest with the doctor, but you as the patient still have the final say (although it sometimes does not feel this way). For patients immobilized in plaster casts (with or without surgery) the *usual* protocol is to recast the leg every two weeks, gradually moving it from equnius position to neutral. There are some scientific papers that have been published which indicate that there are benefits for early mobilization and weight bearing (the weight bearing is thought to allow the proper orientation of the new collagen fibres across the repaired tendon). Despite this, many doctors (including my own!) would prefer to treat the patient more conservatively by not having them weight bear until they are out of their cast. This works well in theory, but the practical day-to-day considerations do not enter into their decision. It’s all well and good to tell someone to take it easy and stay off their legs if you’re not the one who has to take care of their kids in the morning!
I am 4 weeks post-op now and after 2 weeks in a plaster cast with my foot in gravity equinus, I was fitted with a walking boot (AirCast is the tradename) with 3 - 1.5cm heel wedges (which keeps the tendon from coming under tension). One heel wedge is removed every 2 weeks, allowing the tendon to be stretched back to the neutral position in stages. This treatment regime was one I had to *convince* my doctor to follow as he tends to not use walking boots at this stage. I should also say, I didn’t invent this treatment protocol, it was published in a decent scientific journal of sports medicine and one of the authors was at the same clinic where I am being treated!! This paper, and other similar ones that looked at the benefit of early mobilization and weight bearing, showed that the re-rupture rate drops from ~2% to ~1%, the return to normal walking, stair climbing is much faster than without weight bearing and there is a much lower complication rate compared to surgery and immobilization in a cast. So it seems strange that it would be so much of a hassle to get one doctor to do what another one down the hall does, particularly when there are clear benefits, but doctors tend to get set in their ways. In a 2002 review , ~5300 AT ruptures (from many different locations) were examined in retrospect and ~4000 were treated surgically and of these ~350 had early mobilization, so the meta-analysis had a large sample size (i.e. it’s not just one lucky individual who benefited from early weight bearing) and the differences in outcomes are statistically significant. Having said that, you could always be the very *unlucky* rare case that has serious complications or re-ruptures even when it should be very unlikely to happen. My doctor laughed when I asked him about how nobody seems to do the same thing and agreed that there was a huge range treatment types for this injury; if you have a strong preference for treatment, you just need to understand the implications are of that treatment and ask your doctor to do it; if they refuse ask them to justify why they don’t want to.
In my case, being able to wear the boot (full weight bearing with no crutches) has been a huge advantage as I can shower on a regular basis, I can do 90% of my normal work around the house, I can carry my own coffee to the table and I don’t have to worry about putting a bag over my foot when it rains. On weekends, my wife and kids can go back to going for afternoon walks and outdoor play at the local parks.
I wish more doctors would spend time reading the current literature to try and make their patients lives a little easier but in a way, I suppose they are trying to do whatever they can to try and make sure their patient does not have a re-rupture, even if this means being inconvenienced for a few months at home and having a bit of muscle/bone atrophy in the process…
mumofmany on www.injuryupdate.com.au
Thankyou ‘canuckinttheUK’ - I took your advice and called back the Dr’s receptionist - well I got my husband to and I actually ahve an appointment with the specialist next week. But the receptionist is insisting that he ‘only deals in plaster’. We shall see! I am going armed with some documents that cover other forms of treatment - otherwise it’s like I am being held hostage by him.
Thanks for the sympathy ‘Max’ - I spent yesterday trying to get another specialist to see me, but it seems because I have been operated on already I am ‘off limits’ so to speak and it is deemed inappropriate to see another surgeons patient
I mean my surgery was classed as ‘emergency’ as I was sent by my GP to and ER and then admitted that way, so the most discussion I had with the surgeon was for about 2 minutes before he operated - I spoke to the anaesthetist for longer. I mean really who knows anything about achilles injury and treatment until you are affected by it!
Choz on www.injuryupdate.com.au
I am in a similar situation to you, I am now 2.5 weeks post op, I spent the first two weeks in a half cast (on the front of my shin) that was bandaged on. At the 2 week mark I went and saw the surgeon, he check the wound healed ok and put me into a full fibre glass cast. I had the cast on for one day and it just didn’t feel right, it was digging into me and felt really tight, anyway I decided to action this myself, I went into an emergency department and they ended up loosing up the cast and replastering it for me, Feels so much better. The doctor that replastered me said that any time you have discomfort (well abnormal discomfort like tightness, rubbing etc) with plaster then you are best to get it adjusted. He was adamant that I did the right thing, and no after the plaster re-adjustment I am glad that I went and got it redone. In terms of the debate about the boot or not, it is definitely dependant on who you are seeing. I am in the cast for 6 weeks, then will start my physio etc, this is just the way my surgeon does it, and I think because he has had some good results he is sticking to that way. My personal opinion, is to try and get the best of both worlds, sit in a cast for 4 weeks or so, then move into the walking boot, this way you have had enough immobilisation and can slowly get back into walking etc. I’m happy to stay in my cast for 6 weeks, then I will consult with my physio, surgeon and local GP on their opinions in moving forward after this period. Best of luck with everything, I hope that you reach a full and speedy recovery. By the way I am in a fibre glass cast, weight isnt to bad.
CanuckintheUK on www.injuryupdate.com.au
Glad to hear to were able to actually talk to your doctor! If your doctor “only deals in plaster” then ask to see another one; I understand you were trying to be seen by another specialist and that this was frowned upon (I had a similar experience) but if the surgery has already ben done, there is no reason why the rest of treatment should *have* to be tied to the doctor who operated, although it often is. If your doctor refuses to do anything other than put you in another plaster cast (and you don’t want that option (and it is just one treatment option!)) then ask him to transfer you to the care of another specialist who will treat you according to your wishes. Doctors can tell you what they think is best for you (i.e. which medicine you should take) but the don’t have the right to force you to do what they say. I should say, I’m really not anti-doctor at all!! I have a lot of friends who are doctors actually as we get along fine. I just don’t like doctors who treat patients as though they are ungrateful trouble makers if they question the procedures that doctors prescribe (or suggest different ones).
p.s. If possible go in with your husband for moral support.