Disappointed and a bit infuriated!

I went to the fracture clinic again today. I was excited because last time I was there (4 weeks ago), I was told that after these 4 weeks in a boot I could move to shoes and start physiotherapy.

When I first got in, I was seen by one doctor who did the Thompson test, which I definitely failed (I think I have that the right way around - anyway it was a very clear *good* result). She felt carefully all along the tendon. Basically all seemed good. She talked about starting swimming now, and when I asked if I was going into shoes she went off to ask the surgeon (or consultant or something). When she came back, the result was different - stay in the boot (day and night) for another 3 weeks! And obviously no swimming.

I accepted this, but after I left the room I started to feel really infuriated. All these doctors have different protocols, and you get a different one each time. They all just start trying to apply their protocol to your situation, and the end result always seems to be that you have to take things slower. So I went back and asked again. The doctor explained that this particular consultant liked people to be casted/booted for 10 weeks, on some 4-3-3 programme. I pointed out that I was casted for 5 weeks, and have now been in the boot for just over 4 weeks - so I am already over 9 weeks - why do I have to wait 3 more weeks before going into shoes?

We reached a sort of compromise, whereby I spend 1 more week in the boot at all times (day and night), and then after one week I carry on with the boot outside, but at home I take off the boot and try walking with shoes with some inserts that they gave me. Then they will see me again in 2 weeks because they ‘need to keep an eye on me’. I am hoping that physiotherapy will start then…

I think the thing that is most annoying is that I am still wearing the boot at night. Can this really be necessary?

11 Responses to “Disappointed and a bit infuriated!”

  1. I don’t blame you for feeling frustrated Snafu, it is very unfair to keep changing your protocol (and not overly professional). The good news is that you have healed! For what its worth I am waiting till 10 weeks before moving out of my boot, unlike you that has been clear from the beginning so I am OK with it (I have been sleeping boot free at night since week 7 though). It is very common to transition out of the boot, and wearing shoes indoors and the boot outdoors initially is a good idea.
    How is your ROM? What have you been up to as far as getting your foot and ankle ready to start walking again? Hang in there!

  2. Are you two post-op or non-op? I love non-op, but it’s much more reliant on a good (fast) protocol, for best results, than post-op is. Also, you can’t just add up the weeks. 9 weeks in casts doesn’t produce the healing and regrowth that weeks of PWB and FWB do. If you try to jump ahead as if they’re the same, you’re at high rerupture risk.
    The old Conservative Casting used around 12 weeks of NWB immobilization - give it lots of time to heal properly, you don’t want to do this twice, do you? - followed by 2 shoes, because everything was healed. 100% wrong, for decades, maybe centuries! ~20% rerupture rates, sometimes higher! No wonder surgery became preferred, despite the pain, scar, and complications!?! In hindsight, the persistence of slow non-op treatment - and of the myth that slower ATR treatment is safer - is a tribute to the persistence of myths, but at the time (and still in many dark corners of the world) it passes for Received Wisdom. So does the preference for surgery - which is definitely preferable if you can’t read and follow a 1-page protocol!
    I am pretty tolerant of ignorance and illogic, but not when it causes real suffering.

  3. One directly relevant PKI t of my rant is this: even among intelligent Doctors, a dispute about rehab speed will usually be won by the stupidest argument, not the smartest. Let’s take an extra few weeks, just to be safe. If it weren’t so harmful, it’d be funny to portray well educated professionals being so oblivious to the evidence.

  4. PKI t = point. Turn on AJAX Editing and some of us will fix our typos.

  5. That does sound like a bit of a rant Norm :)
    I am non-op and following a fast protocol, I think Snafu is also non-op but may not be following any protocol as she is under ever changing care.
    Snafu, I have been thinking about your post. If your OS “needs to keep an eye” on you, why are you moving into shoes for a week on your own before your next app. Doesn’t make sense to me. If you have not been doing any functional rehab yet then this is even more alarming. If you haven’t already done so check out the protocols that are posted here-http://achillesblog.com/cecilia/protocols/ and see if you can identify with modern timelines.

  6. I will edit the linked email to skip moderation!
    That does sound like a bit of a rant Norm :)
    I am non-op and following a fast protocol, I think Snafu is also non-op but may not be following any protocol as she is under ever changing care.
    Snafu, I have been thinking about your post. If your OS “needs to keep an eye” on you, why are you moving into shoes for a week on your own before your next app. Doesn’t make sense to me. If you have not been doing any functional rehab yet then this is even more alarming. If you haven’t already done so check out the protocols that are posted at achillesblog. com cecilia protocols and see if you can identify with modern timelines.

  7. Thank you *normofthenorth* and *herewegoagain* for your replies.

    I am non-op, and have so far had 5 weeks of casts, followed by 4.5 weeks of the boot. I am very comfortably fwb now with no heel raises in the boot.

    “Snafu may not be following any protocol as she is under ever changing care”

    Yes! This is exactly it. Once I definitely was seen by a doctor who was very conservative. He was shocked I had not been offered surgery. I saw him at 3 weeks and he insisted (to the surprise of everyone in the plaster room) that I go back into a cast for 3 more weeks. In the end I got the appointment changed so that I was just in the cast for 2 more weeks. I think all the other doctors I have seen have been following some reasonably modern protocol, but they are all following different ones. When I turn up, I think they consult their own protocol to see where I have got up to, and it nearly always turns out that I am a bit behind where I should be on *their* schedule, and so all this switching of protocols is slowing the process down. I now really wish that I had taken my own protocol everywhere with me and tried to insist that it was followed… if no-one at the hospital can make out a plan and maybe attach it to my notes, then I could have done this form them! I guess I just didn’t realise it would be like this.

    Whenever I have a hospital appointment, I ask about physiotherapy, but the answer is always ‘later’. I think this time some sort of request was made for the physiotherapy department to give me an appointment - so I guess that is a good thing. I have tried to make an private physiotherapy appointment, but I got no reply… maybe I’d better try that again.

    My ROM seems great in that when I have the boot off, I can move the ankle normally I would say. What happens when I try to walk on it (and I have tried very very gingerly - I know, I know) is that I feel scared to move the weight off my heel and onto the balls of my feet, so my walk is a bit funny. If I had the go-ahead I would be happy to try walking normally and see how this goes. But I guess I shouldn’t start just trying to do proper walking without seeing a physiotherapist or anything? Maybe I should not try walking around indoors next week in shoes…?

    Anyway, it’s my birthday today, and I am trying to be happy about it. I think I just imagined that I’d have got into shoes yesterday (and I saw this as the perfect birthday present), and now I’m sulking about it. Very childish…. not what should be expected of a 40 year old!

  8. Happy Birthday Snafu!
    You obviously can’t change what has happened so far, but I think contacting a PT now would be a great idea. Call around and see if you can find one who has experience with ATR and non-op modern protocols. Investing in a few visits could be the best birthday present of all!

  9. Happy Birthday, Snafu
    That link to Cecilia’s 3 best protocols need “slashes” - AchillesBlog.com/Cecilia/ protocols should work. Pay attention, and transition incrementally to one of them.
    That one out-of-touch Doctor has WAY too much influence considering his ignorance. That’s what happens when knowledge changes fast, as it has in our new specialty. IF you believed that non-op ATR treatment had to be slow to work at all, THEN you’d probably notice that it worked pretty badly, AND you’d also notice that surgical treatment works better. QED, except for the more recent evidence from fast non-op treatment that shows that it does as well as surgery. Sorry, but this dangerous Doc deserves a rant!
    Never Do Harm, Doctor!

  10. Happy Birthday Snafu! Try not to let things get you down. I think you are in the UK too and this inconsistency in care doesn’t surprise me. I got a boot after 1 week, but then was told to just come back in 4 weeks - no advice at all about what to do in this time!
    I think herewegoagain’s idea to go see your own PT is good - if you can afford private try to find someone good; it’s not that expensive, about 50 pounds a session. I’m going to go at week 4 and I’m going to start PWB at week 3 and some gentle ankle exercises.
    I had another reply from another expert this weekend - Kevin Willetts at UWO told me where to find his fast rehabilitation protocol online:
    It’s at http://www.fowlerkennedy.com then go to ‘professional protocol’ and then ‘treatment protocols’ - Achilles Tendon Rupture Rehabilitation Protocol - . it may be worth showing to PT/doctor.
    But as others say because you haven’t followed this from the beginning, be careful.

    I’m going to post this on my own blog too but have been too busy doing my day job!

  11. Thank you *Herewegoagain*, *Normofthenorth* and *Heeling*. I would have sought out the private physio, except that the NHS physio phoned me soon after I posted here to schedule my first appointment. Admittedly the appointment is scheduled for after i come out of the boot, which seems a bit odd given what the protocols say, but it seems a bit late now to switch to a private physio, so I’m going to see how the NHS physio goes.
    Having just come out of the boot (2 days ago) and discovered that I can basically walk, I am massively reassured and whatever they are doing is working (at least - working okay).

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