Day 3 - Second Opinion

Tuesday morning, I got a call from the Sports-medicine clinic - They could fit me in at 12:30!

Shortly after that, the university hospital called - they had finally scheduled me for an appointment on Wednesday, and had a tentative slot for me on Thursday for surgery (if it turned out to be necessary).

I decided to still go ahead with the sports-medicine appointment - I figured it wouldn’t hurt to see two specialists.

This appointment gave me much more confidence. I was seen by a resident first, who immediately did a Thompson test. Shortly after this, the podiatrist came in and did the same test.

His diagnosis: “It’s at least 90% torn - You should do an MRI to be sure.” Basically he said that there’s a chance that some of the tendon is still ok, in which case surgery would not be necessary, but an MRI would determine the best path.

I had pretty mixed feelings about this diagnosis - On the one hand, I felt vindicated: I had not been completely off target with my self-diagnosis. On the other hand, I was also upset at my primary care physician for being so nonchalant. Finally, I had read enough by now to know the long road toward recovery ahead of me.

I decided that I’d follow up with the university hospital since they already had a surgery slot scheduled for me.

(BTW: I had also read about surgical vs. non-surgical options by that time. My decision was that I’d opt for the procedure that had the best long-term outlook in terms of the tendon. Based on this doctor’s recommendation, and the research that I’ve read, it seems like the non-surgical option’s outcomes are *at best* the same as surgery, in terms of the tendon itself. There’s a significantly higher risk of surgical complications, of course (the majority of which appear to be soft-tissue related, like infection), but I figured that with my generally good health my risk from surgical complications would be lower than typical).

3 Responses to “Day 3 - Second Opinion”

  1. True, I can recall only one test in one study — one of the strength tests in the 2007 New Zealand study, IIRC — where the non-op patients actually demonstrated a result that was statistically-significantly BETTER than the post-op patients. In that study, all the other tests were statistically “not different”. And I think the 2010 UWO study went exactly the other way — all tests statistically “not different” except one, where the post-op patients were statistically-significantly stronger. And a simple review of UWO’s raw results suggests that the statistically “not different” results mostly showed a bias in favor of the post-op crowd.

    I wish I could confirm your conclusion that infections and non-closing wounds and ill-tempered non-dissolving sutures avoid healthy and fit patients, but I’m not convinced it’s so. At the extremes, many diabetic patients and some other sickly folks do have troubles with wound closures, but many infections seem to be “equal opportunity” nasties.

    But surgery is obviously a fine treatment for an ATR, and as you say, the main question is whether or not it’s statistically-significantly superior to a good modern non-op treatment, on average.

    The worst unsubstantiated “fact” in your presentation is your surgeon’s suggestion that non-op treatment is clearly superior for an ATR that’s 90% or 95%, but not if it’s 100%. I am aware of NO studies that have compared op and non-op treatment for partial ATRs — zero. ALL the studies (including my faves, the 2007 and 2010 studies cited above) excluded any patient that clearly has a partial rupture, in favor of total ruptures, often with measurable gaps.

    Your surgeon’s unsubstantiated hunch has a logical wiff to it, and it may turn out to be true, or it may turn out to be total BS — that’s why we do randomized trials. And they very often disprove logical-sounding theories!

    Good luck, and Good Healing!

  2. Thanks for your comments, Norm - I have great respect for all of your contributions to this site!

    Certainly I made a pretty significant “intuitive” leap re: surgical complications and my risk of acquiring them. Still, for me the main criterion was the outcome with respect to the tendon itself, and if I had to go through some extra pain on the way there - so be it.

    I also have a slightly different interpretation of the podiatrist’s “advice” to get an MRI. This particular sports medicine clinic has their own MRI facility, and I think he was using this justification more to convince me to give them the extra revenue from the MRI than that he had any real expectation that surgery would not be required.

    They actually asked me to take an X-ray before he saw me, but after I asked them whether it was necessary, they quickly backed off.

  3. Yes, X-rays of apparent ATRs are a total waste of time maybe 99% of the time. Unfortunately, in the remaining ~1%, the over-stressed tendon has broken off a piece of the heel (calcaneus?) bone at the attachment point. Especially for patients slated for non-op treatment, that complication is important. Whether or not that justifies subjecting all ATR patients to X-rays or not is probably an arguable point.

    And the opinion that partial ATRs respond better to non-op treatment than full ATRs is common, mostly because it has a smidge of logic to it. But in this area of medicine, most of the good evidence we’ve gotten seems to DISprove logical-sounding theories. . .

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