Wednesday, August 4, 2010
Achilles Tendon Ruptures: Surgery or Cast--Which is Better
The MRI above shows a normal achilles tendon attaching into the back of the heel bone. Note that the thickness is uniform as it goes up the leg in its normal state. Cross sectional views will show a well compacted semi-lunar shape of uniform density. It is the most powerful tendon in our marvelously made bodies, able to lift 10 times body weight or more. But an injury to the achilles is devastating. The next 2 images show the tendon partially or completely torn.
This side view of the tendon, where normal tendon is dark colored, shows most of the tendon torn above the heel bone with tendon fibres in a state of major disarray.
This side view shows a complete tear of the achilles with only the side walls of the tendon sheath holding things together. The dense normal achilles tendon can be seen above and below the tear.
So what can be done? The patient whom has been diagnosed with an achilles tendon tear should be offered two choices---a surgical fix and casting. Both methods heal the tendon and by 1 year the results of both techniques are similar. Surgical fixation is intelligently and intuitively the best way. This was how I was trained to treat this injury, but Dr James Garrick, world renowned orthopedist, convinced me to cast patients. And they did great. In rehabilitating 100's of achilles ruptures, both surgically and casting alone, I have no doubt they are equally good techniques. We give our patients the option of surgery or casting. And, no matter what any one says, the rehabilitation to a strong, powerful achilles is 9 months to 2 years, with either technique. The fastest return to begin running was 5 1/2 months in a 66 year old patient who was casted, and no surgery. Casting has a slightly higher rate of re-rupture, surgery has post-operative complications that can be disabling. The re-ruptures in both groups normally occur in the 30 days after the cast comes off for good, and before the tendon is beginning to build decent strength. Contrary to what I read, modern day sophisticated achilles tendon rehab can restrengthen both methods to 100% of normal.
So, what are the major differences. For one, you must find a specialist that will cast you for 3 months, instead of doing surgery. This makes surgery win the popularity. Surgeons feel more comfortable with surgery, but sports medicine doctors, surgeons and non-surgeons tend to have more of an open-mind. The true purpose of this blog is to tell you the technique does work, and should be discussed. I wrote an article in the 1990's in the Journal of the American Podiatric Medical Association which can be found. Some patients are just poor surgical risks for whatever reason and this technique should be done. Casting can be started the day the diagnosis is made. The first 6 weeks the patient is non weight bearing (the big downer) and the foot is plantar flexed maximally (like a ballet dancer on pointe). The second 6 weeks the cast is gradually brought to a 90 degree angle. I personally want to change the cast every two weeks during this 12 week adventure, initially to plantar flex more, and then in the 2nd 6 weeks, to dorsiflex the cast to a 90% angle foot to leg. After the 12 weeks is ended the patient at least deserved an ice cream cone reward, and the removable cast period of 6 weeks begins.
With surgical correction, our surgeons recommend 2 to 6 weeks in a removable cast after 2 weeks in a fluffy compression cast non weight bearing. So the surgical patient begins the removable cast stage, 10 weeks earlier than the cast patients. During the first 4 weeks of the removable cast, the area is vulnerable to re rupture since it is so weak. Once the permanent casts come off, physical therapy begins 2-3 times/week for the next 3 months minimum. The casting group seems behind but has less surgical scarring to deal with. The complications with surgical repair of the achilles can be very difficult with infections, etc, and the cast patients have none of these to deal with.
By 8-9 months, surgical repair or cast repair seem to be on an even pace, with the same percentage running, walking, or still limping. Psychologically, many patients prefer the thought of the tendon having been sown together. Some patients, like me, try to avoid surgery, or their health status does not allow surgery, and casting for complete achilles tendon ruptures can be a very valuable treatment. The treatment of achilles tendon ruptures should be given your full attention for 1 full year so that you can enjoy a great tendon in the years to come. I hope this gives you a viable option to consider.