Looking for more info on treatment protocols

Hi Folks. I’m aware that there’s lots of info on this site and around the internet about the surgical v. non-surgical approach to ATR. I already had surgery and I’m looking for information on different approaches post-surgery.

As best as I can tell thus far there’s wide disagreement on how long to stay in the boot, position of the wedges, and how aggressive PT should be. Most articles that I’ve read that examine these issues do so in the context of surgical v. non-surgical question. Does anyone know studies that look at what’s best for those who’ve had surgery?

The best I’m come-up with so far is the Kearney Physiotherapy 98(1):24-32, 2012 study and even that one examined the issue within the surgery v. no-surg context. That study was basically inconclusive.

I have my next meeting with the doc on Thursday. I’m thing that she’ll move in to FWB now that I’m 4 weeks post-surgery. I’d love to have some info when I see her so that I can talk about treatment for the coming weeks. Thus far she’s been pretty unenthusiastic about PT, which I find somewhat surprising. I’m certainly not afraid to be pushy, but want goof info at my hands.

11 Responses to “Looking for more info on treatment protocols”

  1. 1 hillie October 21, 2013 at 1:11 pm

    You’ve mentioned one of the studies carried out by Rebecca Kearney at the University of Warwick in the UK. This was a study about previous studies, and early mobilisation which as we should all know by now (!) is key to a smart recovery.

    The Exeter findings (see my blog over past couple of days, together with the treatment protocol) were published directly by the clinicians and based on their treatment of surgical and non-op patients over an almost 4 year period, using a Vaco boot on a pretty fast moving protocol which was exactly the same for these two ‘options’ - you simply don’t need to distinguish between them. I was non-op and Suddsy (see blog) was surgical and had basically the same treatment.

    So, surgery or not, you want early mobilisation - by now, on Exeter’s protocol (and UWO?) you should, all being well, just about be fwb by now, weaning off crutches or whatever, leaving the boot off when in bed (from end week 4) and doing some gentle, basic exercises. Your physio should be able to tell you what to do, and you should have a written plan of action for the next 3 -4 months. Also at end of week 4 I had a range of movement (i.e. not fixed) in my non-wedge boot of between 30º and 15º PF - this was expanded further a fortnight at a time ending with rom pf to df, and made the transition into 2 shoes dead easy, although some here do debate whether this rom is all that necessary.

    Enjoy a good recovery and don’t sit still for long…

  2. 2 reasonsformoving October 21, 2013 at 1:34 pm

    Thanks Hillie. Unfortunately the Exeter article is not on medline and therefore isn’t available through my university.

    Nonetheless, thank you very much for the info!

  3. 3 hillie October 21, 2013 at 1:41 pm

    Click on http://www.bjjprocs.boneandjoint.org.uk/content/95-B/SUPP_18/16.abstract and http://achillesblog.com/suddsy/2013/06/24/end-of-wk-2-wow-progress/.

    Or do you have a bar that is topping you? If so, read at home if you can. MTH

  4. 4 normofthenorth October 22, 2013 at 5:52 am

    What Hillie said. In the “Studies and Protocols” page on this site, you’ll see some older articles that tested the benefits of fast rehab post-op. i think the more recent studies have gone faster and done even better. If the surgical patients in UWO or Exeter did great, why do you care that they also had a bunch of non-op patients (who also did great)? Just emulate the happy post-op patients!

  5. 5 Beng October 22, 2013 at 7:56 am

    I had surgery myself. My surgeon advised me switch from cast to boot at week 2 and also to transition to PWB at week 2 and FWB by week 3-4 and wean off boot wedges till neutral by week 8-10. However, he advised no ROM or PT till week around week 8. The reason he gave was the tendon needs to bind and heal fully with as little stress as possible up to approx week 8. This reduces risk of re rupture and healing long but not starting PT till week 8 makes no difference to making a full recovery. I wanted to start PT sooner so saw my PT at week 4 but he advised the same. He was not too worried about my ROM as he said this can be worked on post week 8. I followed this advice and I am now at 10 months post op. ROM on my ATR foot is now about same as my non ATR side. Calf strength and bulk is still not equal with my good leg but progressed from no single heel raises at 5 months to doing 3 sets of 15 at 10 months.

    Looking back now, the protocol my OS prescribed was aggressive toward PWB to FWB but ROM and strengthening only from week 8. I would say that whichever approach is taken, follow it as a guide only and listen to what your body is telling you because every ATR is unique. Also, I found maintaining and incrementally increasing your calf strength once you are in 2 shoes and walking relatively easily is critical. It’s at this point where motivation to keep working at it can be hard because you feel back to normal. For me this was at approx 4-5 months.

  6. 6 hillie October 22, 2013 at 9:00 am

    My reply yesterday to ‘reasonsformoving’ (this blog) has web links it but is currently awaiting moderation - or go to my blog here at /hili.

    Why have I mentioned the Exeter study and protocol? Because it is the regime that I worked with, and the report was compiled by the very practitioners who developed the protocol. I know that it works, and works well, it isn’t just something that I am reporting on second-hand. Side effects or residual weakness in that leg now - none.

    I wonder how often a specialist, on being presented with these stories of how others do it, contacts the authors of the reports - Exeter’s are clearly listed at the top of the paper.

  7. 7 normofthenorth October 22, 2013 at 2:00 pm

    Hillie, I love your recommendations, studies, links, and results, BUT… Your preference for anecdotal evidence (with one data point) over the “second-hand” evidence from large randomized trials like UWO (~150 data points) is anti-scientific. That’s where I get off the bus.

    I think the Exeter data is not randomized-controlled, but I think it’s still meaningful, and it suggests that the next step after bit.ly/UWOProtocol — going to PWB even faster than 2 weeks in (op or non-op) — is clinically helpful, or at worst harmless. So I think smart patients and practitioners should follow it.

  8. 8 sallycolella October 22, 2013 at 8:21 pm

    Hi - I will be 11 weeks post surgery Thursday.

    First Two weeks - I was in splint and no weight bearing.

    Weeks Two - Four - Traditional ortho boot (not even remotely fashionable like Vaco) with giant wedge(I always slept without boot and OS said I could gently point and flex my foot at this point).

    Weeks 5 - That huge annoying wedge went into the trash at OS office with a huge clunk and was left only a very small heel in the boot. I was told to move toward FWB as I could tolerate. I weaned off crutches during this period.I could have started PT at this point but I was traveling for work (love those airport wheel chairs) and PT who had been recommended to me was booked. I did lots of pointing and stretching of my healing foot — gently.

    Week 6-8 Walked in boot with no wedge and no crutches. Started PT week 6. At first very gentle - stretching with bands up,down, side to side, Scar massage and heat prior cooling after. I have been absolutely rigorous every day with home PT. Many weeks I only go to PT office one day a week due to my schedule.

    Week 8-11 Now in two shoes. PT is picking up. Last week I started heel raises, standing on one foot, for a few week I have been doing a bunch of exercises to build up gluts/hamstrings and quads on healing leg. I am now going to PT twice a week and this week started walking in the Alter G treadmill that reduces my weight to 70%.

    My results are mostly great. I can flex,point and rotate my healing foot almost as much as the strong one. I have minimal scar tissue. I am strong. The final frontier is heel lifts and walking without a limp. How can it be so hard to remember how to walk??? I can go up and down stairs step over step versus the 1-2 step catch up move I have been using going down steps.

    I know this is anecdotal but we hear plenty of distressing anecdotes and my experience has been very positive so far.

    In addition to PT I do a fair amount of fitness on my own - I have kept going to CrossFit - lots of push ups, sit ups, overhead lifts with dumb bells and rowing biking on my heels for past few weeks. This overall fitness really helps my head and my healing.

  9. 9 Ron October 22, 2013 at 9:35 pm
  10. 10 hillie October 23, 2013 at 12:49 pm


    I had to read your post a couple of times to really get what you are saying - maybe you could have done the same with mine. I said “why have I mentioned…”, not why would I recommend my individual experience over the findings of the scientists of course I don’t. I did think that the whole point of the blog was to mention our individual experiences, and not solely our knowledge of the work being done out there to help atr patients. I had the best treatment from leaders in orthopaedics, wasn’t I fortunate?

    My posts have been simple and straightforward, no mention of randomised-controlled (what does that mean?), data points and anti-scientific, but each to his own and there is plenty of room here for both styles of contribution.

  11. 11 normofthenorth October 23, 2013 at 1:22 pm

    Hillie, I find myself wishing I’d posted ~98% of what you post — and frequently posting “+1″ or “What Hillie said” soon afterwards. Maybe it’s not helpful to focus on the other 2%, as I did above. Instead, let’s both continue focusing on helping as many ATR patients get as good info as possible. (You even hit 100% with your first posts above! :-) )

Leave a Reply

To prove you're a person (not a spam script), type the security word shown in the picture.
Anti-Spam Image

Powered by WP Hashcash

ATR Timeline

  • Name: reasonsformoving
    Which Leg: R
    Status: FWB

    251 wks  6 days Post-ATR
    251 wks  2 days
       Since start of treatment

  • reasonsformoving has completed the grueling 26.2 ATR miles to full recovery!
    Goal: 365 days from the surgery date.
    Achilles NYC Marathon Course Sidebar Image

    Click here for the Group Marathon Tracker