The Achilles rupture: Surgery or no surgery?
After my injury, I learned there is another route besides surgery. Working with a skilled physiotherapist, I am ahead of schedule in returning to the strength and flexibility I had before.
By Glenn Faltenhine
I always thought that if you sustained an injury that was bad enough for the doctor to suggest surgery, you were going to get the surgery. However that is not always the case as I found out last July. I was volunteering with a junior tennis team as their fitness trainer. The program had kids that ranged in age from 10 to 18. I was there to give them fitness and agility drills.
Two weeks into the program I suffered an injury. While demonstrating a pylon drill at half speed, I planted my foot to change direction and suddenly there was a loud popping noise. I also felt the snap behind my right leg. The kids immediately asked what the noise was. I bowed my head and said, “That was my Achilles” Just to be sure I reached down and felt behind my leg and there was no tendon to be felt. The only bonus at that moment was I didn’t have any pain. Once in a while the rupture is quick and clean and painless. Lucky me.
Before heading to the hospital I called a friend who happens to be one of the best orthopedic surgeons in the country and an ankle specialist. He told me to get right to emergency and get my foot set in a cast.
I won’t go into the long wait at emergency as that goes without saying. When I finally got to see a doctor he performed the Thompson test (squeezing your calf muscle to see if it will contract and move your foot). I had no movement in my foot so the diagnosis was full rupture.
Then he told me a local orthopedic surgeon was doing a study on the benefits of non-operative repair to the Achilles and wanted to know if I would be willing to take part. There would be lots of work and physio either way, but much more work with the non-operative. However, I would avoid all the risks that go with surgery, including the 18% risk of infection and increased complications down the road. Mind you, with surgery I would probably be more active sooner. Then I discovered the doctor doing the study was my friend. Decision made. No surgery.
What surprised me the most about not needing surgery was that I thought when your Achilles ruptured it recoiled up your leg. In fact, it is more like mop ends and there are usually strands that remain connected, so there is no retraction. The two pieces don’t usually end up that far apart. This is why the Achilles can begin to reattach. That is why they cast you right away and they actually point your toe as much as possible. This brings the two pieces of the Achilles as close as possible by moving the heel toward the calf.
Cast and crutches
You are in the plaster cast and on crutches for two weeks. You are not allowed to do much; in fact, they don’t want you to do anything. The one thing you need to do is source your physiotherapist. You are going to be spending a lot of time with this person over the next 6-8 months.
Your surgeon will probably have a recommendation. You can also use physiotherapists at the hospital (if you don’t have medical insurance). I suggest doing your homework and not only finding a therapist that is familiar with your injury but also your lifestyle. If you are an active person and want to get back to your lifestyle, you should find a therapist that deals with athletes and understands your training or sport. I was lucky to have two friends who owned Nova Physiotherapy in Dartmouth, NS. They would be instrumental in my recovery. Robbie MacDonald was my therapist.
After two weeks in a plaster cast you go in and they fit you with a boot-like walking cast. It almost goes to your knee and has multiple Velcro straps. There are also heel inserts that give you a 4 cm lift in the back. This keeps your foot pointed and is very important for the healing process.
The most amazing thing was that when the cast came off I could move my foot. The healing had already started! You will be in this boot for about 12 weeks and you will use crutches for about half that time. Over the six weeks you have the crutches you are gradually increasing the amount of weight you are putting on the injured leg.
Physio starts the first week you are in the boot cast. No weight bearing at all. You will use a lot of ice to control swelling. The physio will also use acupuncture and TENS (transcutaneous electrical nerve stimulation); I ended up really liking the TENS unit. Ultrasound plays a big part in your rehab; you will get this on every visit.
Be prepared for total muscle atrophy in your bad leg. I was amazed at how much strength I lost. It was a while before I could do a heel raise, and I was mostly sitting down. As long as you don’t have too much pain they will also get you to do seated calf raises and use EMS on the calf to stimulate the muscle. This goes on for about 10 weeks. How much you do will depend on the pain and how well you progress. Bring a book because you will have lots of down time to read.
When you hit the 6 week mark you will have started on the stationary bike and you will be doing some resistance exercises. It is very important to do all the exercises when you are in physio and also when you are not in physio. You want to build up the strength in that leg–this is key to a strong recovery.
You will also start to do some assisted dorsiflexion stretching with a belt. This is moving your toes up toward the ceiling, but you will not get close to neutral and it will be months before they let you go past neutral. Too much stretching can create too much play in the Achilles and this will cause you problems down the road. Listen to your physio and never push unless they tell you. It is so important to follow all instructions. You will also be doing a lot of exercises to help strengthen the hip and the rest of your leg. You do not want to have the rest of your leg go as weak as your calf. During this time they will also begin to take out the heel lifts in your boot and you will end up in the neutral position.
During the 8-12 week period they will start to look at getting you out of the boot. They will warn you that this is a very scary time. You will feel good. You won’t have a lot of strength, however you will be able to walk pretty well and it will feel like you can do more.
Again, listen to your therapist. Robbie MacDonald made sure to tell me all the stories of the people who thought they were fine and did more than they should. One guy went to a movie without the boot and stepped on another person’s foot and was re-injured. I put my boot on when I was in public up until almost the 12 weeks; when home I was out of the boot and working on my gait and strength.
By the 16 week mark you are doing a lot more resistance training and also getting in to more dynamic movements. For me this is when I really started appreciating Robbie. I have a very athletic background and love training in the gym and also do agility training outside. Robbie made sure to incorporate many of the things I loved to do into my rehab. This made me work harder to get that goal of being 100% again.
At the 6 month point they used to say you could go back to full sporting ability; however, that has been extended to a year after they had a few cases of re rupture. This made more sense as all research says that by the 12 month mark the surgical patient and the non-surgical patient are now equal. Both have healed 100% and you should be at full strength and able to compete once again.
It is a very long year and it takes a lot of work to get back to 100%, whether you choose surgery or not. An Achilles rupture is a big deal; this is the strongest tendon in your body. So if you want to compete again and get back to what you love to do, follow instructions and work hard. It is truly amazing what the human body is capable of. You cannot recover from this on your own. Physiotherapy is a must. If you are not willing to work hard at the physio, then choose surgery.
I would like to say again how much I appreciate Robbie and all the staff at Nova Physio. I am ahead of the curve and well on my way to being 100%. I owe it all to them.
Glenn Faltenhine is a marketer for OptiMYz Magazine and the co-founder of HealthyHFX, a blog to help educate and motivate you to live a healthy realistic lifestyle healthyhfx.com