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 (http://www.vacocast.com/pro/) 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,
Sarah

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!

Sarah

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!

Sarah

Day 3: Bone Stimulators

Day 3: Bone Stimulators

     I have used bone stimulators to help heal fractures that are notorious for slow healing for the last 25 plus years. The early versions had to be embedded initially under your skin with a minor surgery. But then happily came the external ones which could be used as long as you had a cast on (they were embedded into the cast). These ran for 24/7 sending an electrical impulse across the fracture. If you know that in electricity like dating that opposites attract, these bone stims placed a negative charge on 1/2 of the fracture, and a positive charge on the other 1/2. These units still exist, but send the current from a patch into the skin. For the last 10 years or so, I have used the Exogen unit from Smith and Nephew. It actually uses ultrasound to merely increase circulation to the bone directly. You apply a patch connected to some wires to your skin and twice daily for 20 minutes while you multitask stimulate your bone. I use this on many types of fractures, but particularly the 3 most stubborn fractures in the foot: Sesamoid, Jones Fifth Metatarsal, and Navicular.

     To drive home the importance of bone stimulators, there is the first paragraph from an email I received today.

Dear Dr. Blake,

I am writing to first update you to say my sesamoid is now healed!!! Actually as of a few months after my April 2011 email below to you :)) After being quite upset with my progress the Doctor finally recommended we try to get me a bone growth stimulator. My insurance wouldn't pay for it ($3500) but FORTUNATELY the company that had them offered me one for free based on my situation. IT WAS A MIRACLE! To this day I am so thankful for that that company and that device. After just a few days of use I noticed "something" different. After two weeks it felt better and by May/June I was surfing again. I still remained ginger with it for the next several months. When walking, popping up on my board or doing yoga related sequences where flexion is called for. The tenderness remained for a throughout 2011 but very light which I think was simply from not using the tendon/muscles for so long. So by winter 2011/12 which was well over a year from the injury, I was finally doing most things I never thought I'd be able to do again! I highly recommend the bone growth stimulator. I also thank you so much for your words of encouragement along my healing progess. Without you I may have lost it.

Day 2: Accessory Navicular Syndrome

Day 2: Accessory Navicular Syndrome (A Discussion of Samantha's Dilemma)

     Less than 5% of us are born with an extra arch bone which can give us fits at times. This extra bone is right where the most important tendon that supports the arch attaches, so it can cause pain, arch collapse, or just an obnoxious bump. The tendon is called the posterior tibial tendon. This accessory navicular is commonly called Os Navicularis, Os Tibial Externum, or The Second Ankle Bone. I have many patients who come for second opinions when they become painful, and someone justifiably wants to remove it. Some do need to be removed, but many can become asymptomatic thus avoiding the surgery.

     Like any injury, there are phases the patients must go through to get well. Patients can be in 1 or more phases at a time. But, it is important to recognize what phase you are in, so you do not get too frustrated. The phaseYs of injury rehabilitation are: Immobilization/Anti-Inflammatory Phase, Re-Strengthening Phase, and Return To Activity Phase. Each phase should be individually orchestrated for that patient. Normally, you are 80% better when you begin the Return To Activity Phase. You are 100% better when you are back doing everything you want.

      In this email from Samantha, the doctor did the right things-- arch supports for the Immobilzation Phase, and exercises to begin the Re-Strengthening Phase.

Email from Samantha

Dear Dr. Blake,

Thank you for posting up helpful tips about foot and ankle problems. Recently I have been for a consultation with an orthopedic surgeon ( which cost me so much), and he has diagnosed me with Accessory Navicular Syndrome ( attached herewith is an X-Ray of my foot), my left foot collapses inwards to an extreme and I have extremely flat feet. He has advised me to go for physio therapy to strengthen the posterior tibial tendon, as well as to constantly wear arch supports.

My problem is here, the reason why the pain has flared up is because I have recently picked up the sport of running, which I really like to do. However, sometimes when I run, it always reaches a point where there is a sharp pain at that area and I have to stop. It then goes away after a while, but then comes back again when I start running. I am determined to not have to give up running.

I have followed his advice and got special insoles with arch support for my running shoes (https://secure.yoursole.com/us/footbeds/thin-sport/ -these are the ones particularly), however due to the insoles I keep getting blisters on my heels which puts me in a different painful situation all together. I always feel very frustrated with my feet, because they restrict me in so many different ways. The insoles do help to a certain extent, but the pain is still there. I fear I may not be wearing the proper type.  I was thinking of getting custom running shoes, but I am not too sure what is the right type and what properties should the shoe have. Was hoping you could give me some advice on this, or what should the proper insole should be and how can I over come the blisters?

I have been also wanting to go for physio therapy to strengthen the tendon, however it is just so costly here in my country that I keep putting off. Do you have any tips on how I can strengthen it for my certain condition?

Thank you so much in advance for your help Dr. Blake, I really hope to hear from you soon.

Kindest Regards,
Samantha (from Malaysia) name changed

Dr Blake's Response

Samantha,thanks for the email. If you bought the Sole arch supports you can oven heat them for a better custom fit which may help. You can buy a roll of 1/8 inch adhesive felt from Moore Medical to pad areas for support or protection. You can use Body Glide before running in the areas you get blisters. Buy Kinesiotape or Rocktape and see my post on arch taping. You may need to go to a custom device via a sports podiatrist at some point. Without knowing your biomechanics makes it hard for an exact shoe rec, but go to good running shoe store that sells Brooks Ariel, Brooks Addiction, or Brooks Adrenaline. Ice the side of your foot for 10 minutes 3 times daily for the next month whether you run or not, and see how that works. Hope this helps and keep me in the loop. Rich
Samantha's Response

Dear Dr.Blake,

Thank you so very much for your advice. You are awesome!

As soon as I saw your post I went out to get Rocktape and followed your post on arch taping, we don't have body glide here in Malaysia,so I looked for alternatives online and tried Vaseline, which worked really good, I also decided to purchase anti-blistering socks.I also heated up my soles for a custom fit.And the results, my pain was reduced tremendously during my run today, to a point it was almost non existent ,but of course it was still a lil there =) In fact, I don't seem to have that pain at the bone area I usually feel after running.

I really can't thank you enough.But thank you so much for your advice. My next step will be to check out the Brooks shoes or a custom shoe.

Thank you so much.

Kind Regards,
Samantha

Dr Blake's Response

You are welcome. Right now try to find an every other day running distance that does not seem to push it too far and cause pain. Stay at that distance for 10 runs and if all works out increase by 10% the next 10 runs, and so on. Good luck. Rich

     Each of these case histories is packed with truths that I call The Golden Rules of Foot. Golden Rule of Foot:  Ice for 2 Weeks longer than you think you need to ice.

Day 1: Hallux Limitus/Rigidus

     Day 1: Hallux Limitus/Rigidus (A Discussion of Cindy's Predictament)

     Hallux Limitus is a stiffening of the big toe joint. We normally need 60 degrees of upward motion in that joint to move properly for day to day activity. Various sporting activities require more motion than 60. By definition, Hallux Limitus is less than 60 degrees, and Hallux Rigidus less than 30 degrees. When should you treat this problem? Always if it gives you pain. Will Hallux Limitus always become a surgical problem? Definitely No! Years I have treated patients with this problem and only a few require surgery any given year, emphasis on a few unluckly ones. Some patients put up with more pain, some patients don't need to wear heels, yet many patients with severe Hallux Limitus/Rigidus do no have pain that is unmanageable. I believe it is best to treat all of these as a sore joint, get the soreness calmed down, and then gradually develop a program around keeping the joint in the 0 to 2 pain range.

     This brings us to an email via my blog of a patient complaining of joint stiffness who then underwent the basic of surgeries for this problem called a joint cleanout or arthroplasty or cheilectomy. These joint cleanouts, much like knee arthroscopies, can last forever in alleviating pain, or not work at all. Joint cleanouts need a year to two to heal since the joint surfaces are scraped and cartilage involved. Any time you have a surgery that involves cartilage and the potential for slow healing, be ready for a slow going. MRIs are the best way at track the healing process of cartilage, but it is best to wait 3-6 months between MRIs. Golden Rule of Foot: The disability of the patient must match the disability of the first 6 months post surgery to make it a reasonable option.

Email from Cindy

     Hi dr blake, been reading your blog for quite some time, especially the HR posts. Used it to make what I thought was a good decision to have surgery March 7th of this year (she is 5 months post op at the time of the email). I had been told i had HR 2 years ago, after living with what i thought was bunions for many years. went to the podiatrist because of pain under my 3 and 4th toes, and much stiffness in the big toe. I love to hike and that was becoming increasingly difficult. even biking was painful because my toes would go numb.  I work retail, and have been wearing dansko shoes for several years, had a carbon plate made to put in some other shoes, also wore "rocking" sneakers - all of which helped a little.

      Anyway, decided i wanted to try and make life easier (ha!) so went for surgery. I had a chilectomy and first mtp joint (big toe joint) shortening.  All seemed to heal very slowly - i was told not to go for physical therapy by the podiatrist, but after several months I could not walk properly and thought pt might help.  I have a great pt who is very specialised in feet (wish i had found her before the surgery - she would have told me not to bother). she fixed the adhesion and helped me learn to walk again with the aid of hiking poles. I am back in my dansko shoes with a limp but am now having pain in my big toe joint where i never had it before.


     I am despairing now of being able to walk properly without pain.  All the podiatrist could suggest was surgery again to fuse the joint completely - would that be a solution or should i leave well alone for another 12 months or so? I still have quite a bit of swelling -another thing that my pt works on with a laser and massage. I do use ice and elevation after a day at work, but am pretty depressed about the outcome. I know that the rest of my body is affected from years of walking incorrectly, my ankles are pretty rigid, my knees are out of alignment and my hips and back suffer because of my odd walking habit. I am only 54 years old, played tennis and walked several miles a day until last year.


     My other foot is going in the same general direction, so am trying to get a sense of what i can do to help avoid this situation all over again!  would very much appreciate any thoughts on the situation.
       thank you so much, Cindy (name changed)

Dr Blake's Responses

Cindy, so sorry you are on this plateau between surgery and health. After a cheilectomy, it can take awhile for the bone swelling and pain to go down, so it is way to early to talk fusion. Cheilectomy is normally done when there is joint pain to begin with so those patients are more prepared mentally for this soreness. For right now you need to daily strengthen your foot, ice the top of the joint 3 times a day, learn to spica tape and see when you need to do that, get orthotics with dancer's pads to off weight the area, follow the smart advice of your PT, make sure you find the most comfortable shoes, and select activities that do not irritate. Remember one month at a time. Because I am short on time right now, please respond to this with further questions, comments. Rich

Cindy, some other thoughts, also remember that we must create a pain free environment. At times, I will place patients for part of the day in a removable cast like an Anklizer, until the taping, orthos, icing, Meds, PT, can calm the joint down enough! Tell me what helps you now alleviate pain. Rich

Cindy's Response

I dont take any pain relievers, ice helps when the swelling is bad. Often it feels as if there is a pin sticking under my big toe! this sensation is actually rather new.
 I try to be very concious of how i am walking, I do glute clenches which make me walk more evenly and "spread" my toes and try to keep my foot even as i put it down (sorry if that isnt too clear - my pt calls it "squishing the bug under my joint!).  I also often have a kinesio tape "splint" and various tapings which are somewhat helpful.  Discomfort is only present when i am walking, and occasionally when i bike (i have to be careful where i place my foot on the pedal).
My pt at first thought that the heads of the pins from the joint shortening were perhaps in the joint space on looking at my followup xrays, she sent me back to the podiatrist after we pondered that. He took more xrays and i looked at them with him, it didnt look like that but its pretty darn close! He told me that as my rom was bad before, what i have now was as good as it would get.  On relaying that to the pt, we did change tactics a little and stopped working on rom as much, just concentrating on my walking more "normally".
I am so very appreciative of your taking the time to read my email!
Cindy



Dr Blake's Response

Walking is the easiest to alleviate pain. Is the pain from bending the joint or putting pressure on it or both? Definitely review on self mob for HR and begin to do daily. Ice three times daily whether or not you think you need to. If I could show you the bone swelling, you would understand. Rich

Cindy's Response

Pain is from putting pressure on it, on the upward motion doing rom there is discomfort but it's doable. My walking is such a mess because I can't toe off.
I will do ice and keep on walking,  I'm grateful for the encouragement.

Dr Blake's Response

Cindy,  definitely buy 1/8 th inch adhesive felt from www.mooremedical.com and put as much dancer's pads in all your shoes and sandals. Various shoes will take various sizes and shapes. Golden Rule of Foot: With a Dancer's Pad, you should like you are taking pressure off the joint, not falling into the hole. They are easy to make. Rich

1 Year in Podiatry: An Introduction

1 Year in Podiatry

by Dr Richard Blake



     This will be a fun year, although not without it's problems. This is purely educational, yet my personal biases will be apparent. I will take one patient a day from my practice, change their names for privacy, and discuss some aspect of their situation. Through them, we will learn some truth, some treatment plan, some story.

     I have been in practice for 31 years, have taught hundreds of podiatrists, tried and failed to write a book twice, and getting worn out by the business of medicine. Yet, I started my podiatry blog two plus years ago, and my readers have re-energized me. I see I must try to get out information that is being lost. When I say I practice the KISS (Keep It Simple Stupid) principle, most students run the other way.

     The year will not take a year, but it will have 365 patients involved. Since, one day will their day, and no other, I will be adding to their experiences when appropriate until the book is complete. This book will get published in written form, but not until I am complete, so it will be a weekly addition to my blog.

     I went into the field of podiatry because of it's exceptional treatment of athletes. The 1970's were the early days of sports medicine. I was able to study under Dr James Garrick, orthopedic surgeon, one of the founders of the sports medicine field. The truths that he taught me are spread throughout this text.

     My number one bias that will resound in these pages is what type of treatment is best for the patient at that time. Sounds simple, but trying to deliver care that is the best for every patient, every day, with sometimes little information to go on, can be very tough to do. But, every day this is what must be attempted.

     I will be emphasizing the truths I have found in medicine. I call them The Golden Rules of Foot. I say them over and over, to patient after patient, in situation after situation. I rarely find exceptions to these, so they are more than just generalizations. An example? Golden Rule of Foot: Begin to re-strengthen your injury almost as soon as the injury takes place.