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Saturday, August 25, 2012

Day 4: Conservative Treatment of Complete Achilles Tendon Ruptures

Day 4: Conservative Management of Complete Achilles Tendon Ruptures

     Even though a complete tear of the Achilles Tendon is typically managed by surgical repair, it can be managed well with below knee casting and physical therapy. The literature and my experience point to equal successes and failures with both techniques. Re- rupture rates are slightly higher with conservative treatment, but do exist with surgery. The other complications of serious note all involve surgical problems--excessive scarring, post op infections, and wound healing issues. We always give my patients both options, and the majority go for surgery. Given a good rehabilitation with physical therapy, both types of patients are at the same point one year after injury. All of my patients who have conservative care are at risk for re-rupture in the 45 days following cast removal. If re- rupture occurs, surgery is normally chosen to fix it. With modern day physical therapy, my patients get to 110% strength of their good side. The fastest patient to begin running post rupture with conservative treatment was at 6 and 1/2 months post injury. Since this technique needs the full teamwork between physician, patient, and therapist, there are only certain situations that this perfect storm will gel.

Email Received by Dr Blake

Dear Dr. Blake,

I am a 38 year old adjunct professor of occupational therapy/integrative health at and I recently sustained a right Achilles Tendon Rupture on the evening of August 13th. I went to the ER where my right foot was placed in a posterior cast and was told to see a doctor. I was able to see the doctor on August 15th where I was told that he recommends surgery for all of his Achilles Tendon rupture patients. He was not interested in supporting me through a nonoperative treatment approach. No ultrasound or MRI imaging was ordered.

After having done an extensive literature search on the topic so far and the fact that I have worked in physical rehabilitation for over 20 years I feel comfortable with choosing the nonoperative approach to my Achilles rupture treatment.

I came across an abstract of your article titled Achilles tendon rupture. A protocol for conservative management and I was hoping you might share the protocol with me.

I currently do not have a doctor following me and am willing to to pay out of pocket for a physical therapist that would be interested and open to supporting me through an Accelerated Functional Rehabilitation and/or the protocol you recommend. Do you feel this is an appropriate path to take?

Thank you for your time and consideration. I look forward to hearing from you.

Kind regards,
Sarah (name changed)

Dr Blake's Response:

Sarah, thanks for the email. My approach has worked well, but requires 3 months of cast immobilization, normally done by a doctor. The first 6 weeks are crucial to be non weight bearing with your foot maximally planantarflexed at the ankle. I actually change the cast every 2 weeks to gain more plantarflexion with each cast. Due to various reasons, I have started the process up to 5 weeks post tear with no noticeable change in outcome. At 6 weeks, I begin to change the direction towards a more and more dorsiflexed position. These next 6 weeks are weight bearing, although initially not much due to the size of the cast. I carefully measure the amount of ankle joint dorsiflexion with each cast change. The last two weeks of weight bearing casting must be at 0 degrees of dorsiflexion to be on schedule to remove the cast at 12 weeks. I love to use a muscle stimulator under the cast from 6 to 12 weeks. From 12 to 18 weeks, you are still being protected in a removable cast as you begin the re-strengthening process. Here is where the physical therapist becomes the most important part of the team. Keeping the activity below the fatigue/re-rupture level of strength, and keeping the strength/flexibility ratio perfect, and gradually increasing power/endurance/ cardio takes a skilled PT. With the uniqueness/unfamiliarity of this conservative approach, I find that most patients and therapists go naturally slower than need be, but there is no rush. Let me know if you want more info, and good luck! Rich

Sarah's Response:

Dear Dr. Blake,

Thank you so much for your prompt and thorough reply!

I have a particularly unstable lower back and I have found the cast to be quite cumbersome. I ruptured a disc when I had an ACL reconstruction in 2000 and I have trepidations about potentially doing the same thing in this situation.

Would a cast boot system such as the VacoCast ( set at maximum degrees of plantar flexion be appropriate for me to use now with the continued non-weight bearing status for 6 weeks as you mention? It seems the VacoCast would put a much less load on my spine over these next several weeks.

Thank you for sharing your wisdom!
Kind regards,

Dr Blake's response:

Sarah, Could not get a stong feel from their website pro or con removable vs permanent cast. Normally, patients must be at 15 to 25 degrees of ankle plantarflexion in the first 2 to 4 weeks. This says it only goes to -10. Could you check with them on Monday if it can be adjusted but to -20 at least. Thanks. Rich This is important to bring the ends of the tear into as close proximity as possible!!!

Sarah's response:

Hi Dr. Blake,

After looking at another non-op study protocol it appears that they put a 2cm heal lift in the VACO cast boot system and gradually reduced the height of the heal lift (1.5cm then 1cm) every 2 weeks after the 6 week mark. Would this be satisfactory to achieve the 15-20 degrees of plantar flexion?

Thank you!

Dr Blake's Response: 

Sarah, The acid test if it is enough lift is that when you walk you feel no pull on the calf. So, all theory aside, I guess we will have to see when you try on the Vaco Boot if you feel no tension. I also remembered two patients last night that needed crutches for the longest time with their achilles. One had an opposite knee problem, and the other was back issues. With crutches you have 3 or 4 feet inside of 1 or 2 to balance on and protect your spine. Also, for the next 6 to 12 weeks you probably want to look into renting a Roll A Bout. They are also a way to stay non weightbearing with a stable back. I love them. Rich

Sarah's Response:

Great recommendation Dr. Blake. I will rent a Roll A Bout! :)

I will make sure there is noooo tension on the Achilles. Thank you!

1 comment:

  1. Wow, this is great stuff! I will never forget the day my best friend tore his Achilles. I was close by and could actually hear it. Thank goodness for PT and relaxing ways to recover! :)


Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.