Achilles Tendon Ruptures: Excellent Article on Your Choices

https://podiatry.com/news/241/Residency-Insight-Can-Patients-with-Achilles-Tendon-Ruptures-Start-Immediate-Protected-Weight-Bearing-and-Accelerated-Rehab-Protocol

Achilles Tendon Rupture: Make Sure To Check Flexibility at each Visit

I saw a patient yesterday that is now 5 and one half months post achilles tendon rupture. We decided to treat her without surgery and she is doing great. The purpose of this post is to mention the very important point to make sure the achilles flexibility is measured at each visit. With conservative treatment of achilles tendon ruptures, you have to err on the side of tightness initially. You tend to see however a good improvement with walking outside the removable boot between 4 to 6 months with the goal being 10 degrees ankle dorsiflexion with the knee straight, and 15 degrees with the knee bent. So, I was a little surprised when she had -4 degrees straight and 6 degrees bent yesterday. I have attached my video below on this measurement. Last time I measured her 3 weeks ago she was at 2 degrees and 5 degrees. So, there was a little soleal gain. Since the tightness can lead to re-tearing, I immediately put her on pain free stretching of both parts of the achilles 4 times a day with a quick check next week while she is in physical therapy. She is one of the patients that develops strength quickly, but tightness can develop even faster. I have a video on the blog on appropriate achilles stretching, and in this vulnerable state do not recommend negative stretching where the heel falls off a stair or ledge of some kind. 

https://youtu.be/hh4wC0RJqjY

Achilles Tendon Ruptures: Abstract on Surgical vs Non-Surgical Approaches

http://ajs.sagepub.com/content/35/12/2033.abstract

Achilles Tendon Ruptures: There is a Place for No Surgery

In our clinic, when the patient sees me, I give them a choice between surgery and non-surgical repair of achilles tendon injuries. I have not heard a lecture on conservative treatment of achilles ruptures in 20 years, but it is still an important consideration for many patients. 

http://www.ncbi.nlm.nih.gov/pubmed/26537241

http://www.drblakeshealingsole.com/2010/08/achilles-tendon-ruptures-surgery-or.html

Achilles Tendon Ruptures: Conservative Treatment with Casting

When I treat Achilles Tendon Complete Ruptures without surgery, prolonged casting is necessary. This article implies that weight bearing casting is probably actually better than the dreaded 6 weeks of non-weight bearing casting I presently use. See the link to my blog below the article. 

http://lermagazine.com/news/in-the-moment-op/weight-bearing-casts-for-achilles-tear-keep-pace-with-nonweight-bearing

http://www.drblakeshealingsole.com/2010/08/achilles-tendon-ruptures-surgery-or.html

Achilles Tendon Rupture

As an avid Basketball, I am watching my beloved Golden State Warriors attempt to beat the Los Angeles Lakers with the magical Kobe Bryant in the game. Harrison Barnes is guarding Kobe as he collapses. The first thing he asks Harrison is "did you kick me"? When he found out that he was not kicked he knew he had torn his achilles. All basketball fans were saddened because a great basketball player, even though our present enemy in battle, had gone down to injury. This simple, but beautifully illustrated video, shows the mechanism of tearing and then the repair. After the repair, the real hard work comes into the picture, as you attempt to regain that power in that tendon. From start to finish, in a recreational and dedicated athlete, 2 years, with return to sports 9 to 12 months in a moderate program. 

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

Partial Rupture Achilles Tendon

View of cross section of the achilles tendon showing small tear with fluid accummulation. The tendon itself is 1/3 larger than it should be typical in a injured tendon that is trying to heal with scar tissue and chronic inflammation

Side View of the same achilles belonging to the patient below. The 3/8th inch tear in length is more easily seen. The area around the tear is thicker than normal as the body attempts to heal. 

Dear Dr. Blake:

I received your voice-mail message yesterday.  Thank you.  I have the following questions:


You said there is a tear in the left achilles.  What is the size and extent of the tear?  Can you ascertain from the MRI how long it has been there, and if there are signs of healing?
Dr Blake's comment: The tear is one inch long and is 10% of the total tendon. No, cannot determine how long it has been there. In 6 months, we can get a new MRI to assess the healing status. 


The worst of the achilles was after a long hike in November, 2011.  I did use a boot for approximately 3 weeks in December, which did seem to help.  Since then I have been getting some physical therapy.  
You did say that you didn't think that physical therapy would be useful, although it seems to me that the deep tissue work along with the ultrasound which I have been getting has been helpful.
Dr Blake's comment: PT can be helpful, just unpredictable, and will not heal the tear. I do know patients whose tear remained, but their symptoms resolved. Unsure why?


  Although much better, the injury is still problematic, especially in going up and down stairs and up and down an incline.  Hiking is one way I try keep in shape, keep my weight down and work off stress, but I have been unable to hike for many months.  Can you tell me your prognosis for this injury?
Dr Blake's comment: People get better with this injury, but it is approached in many ways. One of the main questions is "Can you coexist with the injury without surgically fixing it?" I had mentioned to the patient that there were many options including 3 month removable boot to rest the tendon, PRP injection(s) (Plasma Rich Proteins), Topaz surgical welding of the good parts of the tendon together, more traditional open incision with exploration and fixing what find, and deep tissue work with the boot. 

Of the treatment options you mentioned, I am most inclined toward the most conservative treatment which seems to be immobilizing the foot in a boot for a period of time.  I am concerned that walking in a boot may cause other problems with my back, hips, ect, as I have had those problems in the past.  What is your opinion regarding this potential side effect? 

Dr Blake's comment: For the other side you will use an EvenUp which helps protect your back.
Regarding the X-rays of my right foot, you indicated that there is no sign of fracture.  That's great, however I do still have a lot of pain in the joint of the second toe.  If it is not fractured, what is causing the pain?  I am using the toe brace you prescribed which does give me some relief.  I have been getting physical therapy for that as well, but it is too painful to do much manipulation of the joint.  Do you think a Cortisone injection be helpful in any way?
Dr Blake's comment:  Regarding second toe, stay away from cortisone shot since it would
weaken ligament.  Probably should get  MRI of this. No fracture seen
on xray, but still
could exist. 


How does the injury of the left achilles effect the injury of the right, second toe, and visa versa?  (It seems to me that a shoe with a slight heal relieves the left achilles, but aggravates the right, second toe; and a flat shoe relieves the right, second toe but aggravates the left achilles.)
Dr Blake's comment: Yes, why a boot with Even Up is best.

Thank you for your willingness to communicate with me via email.  It is so much easier and more efficient for me.  I look forward to your reply.

Very truly yours,


Dr Blake's Comment: I would be remiss not to mention BRISS, the acronym for the management of all tendinitis conditions like you have. Please see the link to my original post on this. Rich


http://www.drblakeshealingsole.com/2010/06/briss-principle-of-tendinitis-treatment.html

Achilles Tendon Ruptures: Don't Forget about Non-Surgical Options

http://www.htrnews.com/article/20110503/MAN04/105030567/Treatments-Achilles-tendon-tear?odyssey=nav%7Chead

I want to thank Dr Carl DiRaimondo for pointing out that Achilles Tendon Ruptures can be treated non-surgically. I have rehabed about 100 complete achilles tendon ruptures without surgery and another 50 or so surgically repaired. Both have there pros and cons, but both types of repair can be rehabed to 100%+ strength. Both groups seem to start running between 6 and 9 months. Both groups can have failures requiring further surgery. The failures in the surgical group are much more dramatic due to surgical complications. The main complications in the nonsurgical group are re-rupture and inadequate reattachment. Both can be fixed with the surgery in the future.

There is quite a bias in the world  when achilles are ruptured to fix them surgically. They are sent to surgeons from the primary care docs or from the ERs. Only the articles like these can make someone stop and say maybe I could treat this injury without surgery. After one year, whether the tendon was surgically or nonsurgerically fixed, there really is no difference in function. If you are surgically averse like me, and unfortunately you have a problem like this, consider a non-surgical approach. I would be happy to send our protocol to anyone on the non surgical rehab of achilles injuries.

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.