Non Surgical repair of ruptured Achilles Tendon

[lauren_barnard]

So its been 4 weeks today since my right Achilles Tendon went snap whilst playing football. It is a full rupture and I was advised by the hospital to go for a non surgical repair due to my age (22), i was then promptly placed in a back slab given some crutches and sent home. 10 days later i was back at the hospital for a full cast to be fitted in the equinus position and i would be in this for a further 3 weeks. next week i get this removed and a new cast fitted with my foot placed in a neutral position. This will be on for 3 weeks followed by a walking cast for 3 weeks.

In total i will be in a cast for 10 weeks.

I have been reading up on achilles tears and other peoples blogs, most are advised to have surgery and I haven't found any that have been immobilised in cast for this long. Is this time in a cast normal?

I am a very active person, play football 3 times a week, how long after the cast is removed until i can begin physio?

Is there anything i can do whilst in cast to increse recovery?

Any help and advise would be greatly appriciated!

Lauren.

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[badlybruised]

Hiya

Firstly I would like to reassure you that being immobilised for such a period of time is not unusual. Where I work we do surgical repairs or conservative treatments. Some places use plaster casts, whereas in my Trust we use a special boot, which has a fixed ankle that we slowly increase the range of movement in. There is no definitive evidence on this topic, but you will find some papers suggesting different rates of re-rupture etc. Either way I am afraid due to the nature of the tendon it is a slow process!

I personally would suggest keeping the rest of your body fit and healthy. Unfortunately once you come out of the cast you can start physio straight away, but you will need a good period of time to build up your calf muscle and range of movement. This needs to be done slowly and gently as you dont want to over stress the tendon. But in the mean time lots of work on core stability would be great, as well as cardiovascular work (for example the use of hand cycling).

Hope thats some help
:-)

[physiobob]

For my two cents worth (and not sure on the data if anyone can provide any?) I would have opted for a surgical repair. The UK NHS has been doing along term trial on surgical repair vs non-surgical 'conservative' management. Basically a money saving exercise I would think. Perhaps for me the first question is what is your activity level like. As a footballer I would want this as strong as possible following, hence opting for a surgical approach where they can better approximate the ends of the tear. They do a nice micro repair now and we have a video of that in the video section of this forum.

http://www.physiobob.com/forum/physi...es-repair.html

If you were more of a sedentary individual then a conservative approach may be argued. Overall a non-surgical approach is going be more cautious during the immobilization and rehabilitation phase. Unfortunately that means ruling out any full-on sport for this summer. I should also comment that I had a friend who was given a non-surgical approach, I disagreed and we had a surgeon take off the cast and repair it. 6 weeks later he came out of the case and was rehab'ing really well only to trip down a step in his kitchen and re-rupture (perhaps at a secondary site). So even surgical repairs take time to heal.

[mikee1504]

I snapped mine last week playing basketball, It has separated by about 5 millimeters at 45 degree and about a centimeter at 90 degrees.

I asked for surgery after having researched treatments online and I was refused on the basis that 5 mil or less is treated by non surgical means,

I was a bit miffed by this as I am very active person and wanted the option that had the lowest re-rupture rate. (Although their is some debate about the actual statistics as a lot of past studies used inappropriate sample groups.)

I am stuck in a cast for at least 6 weeks with one change and I have been told that if the tendon is not fusing properly then I will have surgery which annoyed me further as I may as well just have it now!

One thing I did do was to rent a wheel chair so that I could keep my leg up and static to try to aid the repair rather than hopping around and possibly making the separation worse.

Should I have been offered the surgery? I am 29 yo man and as I said very active.

[Dr Damien]

Dear Lauren

Just adding to what has already been said. Decisions for Surgical/non surgical approaches due to age are based on several factors. these include comorbities (other health problems) you come to the hospital with, the extent of tissue damage needing repair, level of function you are hoping to achieve and the risk factors of being immobilized can cause. In general all surgical approaches have many risks e.g infection, nerve damages, blood vessel damages, fatality etc.

So for a surgeon to look at you and think you are young, you have virtually no comorbities that increases the risk of a surgical approach, it is either the extent of tissue needing repair is not that great or he/she thought immobilizing you in a cast would pose no dangers to your health due to general immobility. This is different with the elderly. In addition, younger patients are often immobilized more than elderly clients because they always pose a risk to the repair tissue by being too active. Elderly clients on the other hand are not very active however immobility causes health risks so whatever you can do if the comorbidities allow for it to salvage their ability to move, then do it. These would probably consititute some of the reasons you were managed conservatively. It is probably expected that being young, you should heal quite quickly compared to the older patient.

Even though you are in a cast, there are several issues to consider...i.e the strength of the muscles that are still able to function and the range of movement of the joints still free to move. this should be the focus of your ongoing physiotherapy or in the least, the advice you may have left the hospital with. being a footballer, you need these muscles to stay strong so you should have exercises to do on a daily basis and advice with regards how to progress them while you wait for the cast to be taken off...

Dear Mike1504,
the same reasons go for you too. A good example is seen with that given by Physiobob, younger patients take risks even though they dont know they are taking risks. It is quite possible to keep having ongoing management of a problem due to this level of overactivity.
What I am saying was/is the doctrine of physio101 (orthopeadics), for example you would cast the arm of a younger client after a broken arm but you would sling that of the elderly...
However, based on the level of function you want to achieve perhaps a surgical approach should have been given to you...but no surgeon wants to operate on a problem more than once, maybe if you were in your 40s, fifteis, sixties, he or she wouldnt think twice about this...
I know it sounds stupid to think that the health professional would preempt your likelihood of disrupting the surgically repaird tendon...perhaps a surgical approach with a few weeks in a boot should have been suggested, with strict advice to only take off at night, that way you have the best possibility of union as well as you you still have the partial immobilization...

cheers

[lauren_barnard]

thanks or all the advise so for, i thought I would give an update!

So I am now 7 weeks 4 days (not that i'm counting) post rupture. Spent 10 days in a backslab, 3 weeks in a full equinus cast and 3 weeks in a semi equinus cast. ive now been given an aircast boot for the next 3 weeks. There is obvious signs of major muscle loss in the calf muscle and quads.

Is there anything i can/should be doing to help the my recover?

[physiobob]

With a conservative approach I would wait until your boot is off. That said your hospital, consultant or physio should have provided you a protocol to follow with this approach. We should not undermine that with suggestions to do more

[nwessexian]

Hi Lauren, having hobbled out of hospital this afternoon have had my final cast removed from non surgical interventuion for ruptured ach tendon, got gel wedge in heel of shoe and now waiting for physio to make appointment to come in, seeing as you must be well on the mend with your's what exercises did you get for the early days of recovery, don't worry I am not about to do anything daft as my leg is half the size of the good leg due to muscle wastage and my ankle is stiff as hell. Cheers, Ian, plus I am far older than you too

[nwessexian]

Snapped mine playing paddle tennis in spain on last day of hols, lol, back in June, flew homw straight to A&E, told 9 months to a year to walk as per normal again, surgeon gave me stats to think on for repair, sounded pretty cut and dried to me, have surgery for better non rupture outcome but major risk of infection due to lack of blood supply or non surgery, either way many months in laster? Backslab on told to return in 2 days for full plaster and or decision on surgery.

Returned convinced would risk surgery, new consultant of opposite opinion, no firm evidence from uk, irish and usa reaearch of this year reporting that non surgery results in any higher re-rupture for normal to mild physical use, which is me sort of, and defo not going to operate, but must do as told throughout process or risk snapperoony again.

I simply stopped and bent to hit the ball back, no snap but pain out of this world, felt like flor had disappeared under me foot, had borrowed wrong size bowling green shoes (too big) on astro-turf. Played week before for hour and half with own shoes no problem.

It has now gone bold and cannot turn it off as it just keeps resetting itself, so figure that one?

Been 4 weeks in plaster at equinous, two weeks in acrylic, bastad uncomfortable stuff, at part raised foot position then 2 more weeks in fully level foot position in more acrylic, who invented this terrible stuff for casts, why not fully udjustable boot / leg cast as in germany?

Left hospital today with gel wedge in shoe, one leg half the thickness of the other, cannot feel me foot on the ground, ankle solid as a rock, calf aching, on crutches no can put weight on foot, small amounts of crutch aided walking before start 2 months physio, yet to hear from physio on date to return for that, consultant wants to see me end of october.

Want my advice do not snap your achilles, if you do only do it once.....

Anyone got any mild leg exercises i can do whilst waiting to hear from physio, but gentle mind you as i have been warned this period is when most folk with non surgery snap em again......and that ain't going to be me.......

Ian

[Joseph2724]

Hello sorry to jump on your post but I'm not sure how to create my own...... So I ruptured my Achilles October 22nd at a football(American) combine during a drill.... I was coming out of a backpedal and planted to go into a sprint when I heard what sounded like a gun shot and I fell to the grass. There was excoriating pain for about 5 minutes then it went away almost completely..... The trainer on the field advised me that she believed I ruptured my Achilles and a Thompson's test later confirmed that.... I did not go to the hospital but rather went home iced and elevated and took allot of ibuprofen and called an orthopedic to set an appointment.... I was shocked when I was advised they couldn't get me in until November 8th which was a full 15 days after my injury.... So I researched and purchased a Ossur walking boot and a wedge kit so I could start healing while I waited for my appointment..... When I finally saw by OS (who was very upset with her scheduling secretary who scheduled me so late) she was impressed by the fact that I had started a treatment on my own and decided to go the non operative route since I was already essentially two weeks into recovery.... I never used crutches and was FWB from day one of getting the wedge kit and boot and I was in the gym 4 days after injury working upper body.... I started on the stationary bike after two weeks with the boot on and started with resistance bands after week 5.... I'm currently into week 6 and can walk without my boot without a limp and virtually no pain.... I'm too scared to even attempt a one leg Heel lift as it will feels very tight but I will attempt hopefully soon... Also the divit that I had where I had my rupture is no longer there which is a good sign I think.... Everything I've read on non surgical has had a much slower recovery time so I'm confused as to why I'm healing so fast and I was curious if anyone else has a similar experience with recovery....