Achilles Tendon Rupture – Pre-Op Researches

By Press on June 28, 2016 in Achilles Rehab Journey
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Background

[Note: This is not medical advice, it’s a record of my thought process during my research on achilles tendon rupture injury, treatment and rehab)

I am writing this post to record my journey on the achilles tendon rupture recovery.  I am planning to update it on a daily basis at the beginning and scale off to weekly, bi-weekly then monthly updates.  The reason I am recording this is because I found it hard to find achilles tendon rupture recovery resources I can relate to on the web.  There are plenty of post on achillesblog.com, but the posts are pretty random and doesn’t show progress images or videos.  I was worried to see some of the people saying they are recovering well but their YouTube videos show them limping at 1 year mark.

Don’t get me wrong, I know everybody is different pre-injury, so the levels they get back to post injury are not really a good gauge for my own progress.

 

How did it Happen?

I ruptured my right achilles tendon while playing a NTRP 4.0 tennis match in the annual Burnaby Tennis Open tournament on June 23, 2016.  I don’t have a clip of how it happened to me.  However, the following are some achilles tendon rupture caught on tape:

Famous Athletes:

David Beckham

Kobe Bryant

 

Average Joes

 

 

Surgical or Non Surgical?

I only trust track record.  I don’t trust randomized studies.  While recent studies shows surgical and non surgical treatments yield the same result at the 1 year mark, there are a lot of voodoo sciences in collecting, evaluating and interpreting the results.  Let me explain why:

1. Prevalent Wisdom Bias:

Before they conducted and published this study, the prevalent wisdom is if you are a young athlete intending to compete at your pre-injury level, surgical treatment is the way to go.  Which mean no young athlete in their right mind would go with the non-surgical option, therefore, the non-surgical group most likely have a sedentary lifestyle.

2. Performance Evaluation Bias:

The result are compared by questionnaires regarding how the patient feels, range of motion measurement and some other such non-sense.  A 1% performance difference for an athlete like Kobe Bryant and David Beckham means very different thing than a 1% performance difference from an average joe who torn his achilles tendon hiking.  Range of motion comparison doesn’t mean much either, since even if you have the same range of motion, it doesn’t mean you have the same power and reaction time.

3. Voodoo Science:

As an engineer, I would consider most if not all medical reports a failure.  Having read so many of them during my achilles tendon rupture research, I accept that it’s simply how the medical world conduct researches.

In the engineering world, an meaningful experiment criteria should be at least:

  1. Has the same pre-condition
  2. Repeatable
  3. Measurable

In the medical world, it’s more like a survey than anything else:

  1. Pre-condition are usually different (How people rupture their Achilles tendon, degree of rupture, age, fitness, body type are all different)
  2. I don’t think anyone would want to rupture or re-rupture their Achilles tendon in the name of science.
  3. The effectiveness of a protocol is based on a super simplistic survey like the one below.  I have seen only one study on rat that actually put dye in two points of the achilles tendon and measure the distance between the two points as it heals.

I understand that there is simply to no way to collect achilles tendon performance data before a patient rupture his/her tendon, so there is no way to compare the before and after.

4. Re-rupture Rate

In some of the latest studies, it was indicated that the re-rupture rate between surgical and non-surgical is “insignificant”.  How insignificant you ask?  The re-rupture rate was 3% for surgical and 6% for non-surgical treatment.  WTF?  How is that insignificant!?!  It means, it’s 100% more likely to re-rupture your achilles tendon if you go the non-surgical route.

However, don’t get despaired if you have already chosen the non-surgical route.  They did provide the statistics but they didn’t exactly tell you the causes of the re-rupture.  Little did they tell you the actual rupture cause probably has more to do with the carelessness of the patient than the option itself.  Here are some of the re-rupture causes:

1. Slipped and fell on stairs.

At 6 week post op Read more

At 8 week post op Read more

2. Car door slammed on the bad foot.

3. Bike ride accident on the beach landed on the bad foot.

At 6 weeks post op Read more

4. One legged head raise (tip toe) with the OK from doctor

At 6 week post op  Read more

5. Walk on tip toes with OK from physiotherapist

AT 18 weeks post op Read more

6. Going straight from Non-Weight-Bearing (NWB) to Full Weight Bearing (FWB) in shoes (At 7 week post op) Read more

I have read a study on open re-rupture, meaning the re-rupture includes ripping apart the wound.  The two cases re-ruptured at exactly the same place.  It has something to do with the surgical procedure, the suture technique used during surgery.  So, it begs the questions, why didn’t all the studies include the suture technique used by the surgeons.

5. Suture Techniques

I read somewhere that a certain suture pattern can only withstand a certain force.  There was comparison table show the amount of force the suture can hold up vs the amount of force some common activities demand.

Comparison of Achilles Tendon Suture Repair Techniques: Krackow vs. Modified Mason-Allen Under Cyclic Loading in an In-Vitro Bovine Mode

Suture techniques for tendon repair; a comparative review

Achilles Tendon Repair Using Nonabsorbable Suture Loop for Modified Giftbox Technique

Looking at the re-rupture cause 6 and 7, it appears that nobody really know the healing progress of the tendon other than “if it hurts”.  My problem with this approach is, it didn’t hurt before I snapped my tendon, and it didn’t hurt much during or after I snapped it.  So how do I know if I have fully recovered?  It also appears that for most people, their activities levels are purely based on the strength of the suture pattern used during surgery and how bad their calf muscle atrophy is during the casting phase.

 

The Reasons I Choose Surgery?

1. Sports Stars who have Multi-Millions Dollar career on the line chose Surgery.

All sports stars who have achilles tendon rupture choose the surgical route.  Most of them came back with lower than pre-injury performance.  One oddity stands out from the following NBA players suffering from achilles tendon ruptures – Dominique Wilkins.  cbssport

Sources: http://www.cbssports.com/fantasy/basketball/news/history-not-kind-for-ruptured-achilles-recovery/

2.  All Achilles Tendon Rupture YouTuber updates are still limping at 1 year mark.

So, while sports stars usually recovered by 6 months and went back to play competitively by 8 months, most average joes are still limping at 1 year mark.  Why is that?  I spent an ungodly amount of time researching as many achilles tendon rupture blogs and youtube.  One common theme among the average joes is that they don’t weight train.  None of them seems to have a clue on basic weight training concept and rely entirely on what the surgeon and physiotherapist said.  While most people have trouble doing single leg calf raise, the pros are back on the court dunking and scoring.  It’s glaringly obvious that the “secret” lies in the rehab program.

What is a Meaningful Rehab Plan?

Here is a clip on how tendon heals.  From what I understand, the first 2 weeks in cast is pretty much for the incision wound to heal.  2 weeks Non Weight Bearing is plenty of muscle atrophy to recover from.  The main dish, the achilles tendon is going to take 12 to 16 months to heal.  Along the way, range of motion, eccentric exercises are necessary to break down scar tissue formed in the wrong direction.  There is no magic.  If you do anything that exceed your half baked tendon can withstand, it’s going to snap again.

1. How long should you stay in cast?

Studies show patients using walking boots starting as early as 24 hours to 2 weeks post op has the best result.  The cast is pretty much just for protecting the incision wound, you have achieve the same benefit with a walking boot.

2. How to avoid calf muscle atrophy when you are in cast?

This is the least talked about in any studies and barely mentioned in achilleblog.com. Most patients reported weakness on the injured leg, often limping or having difficulty performing single legged toe raises.

Muscle Atrophy from NASA

“Without regular use and exercise our muscles weaken and deteriorate. It’s a process called atrophy. Studies have shown that astronauts experience up to a 20 percent loss of muscle mass on spaceflights lasting five to 11 days.”

a. Electrical Massager – One early-recoverer mentioned using a electric massager on the calf muscle or tendon for 20 minutes or more a day.  A study show the use of electrical massager on the achilles tendon of rate 5 minutes a day show significant reduction on calf muscle atrophy.

Influence of brief daily tendon vibration on rat soleus muscle in non-weight-bearing situation

b. Electrical Muscle Simulator (EMS) – One study shows the use of EMS that significantly reduce muscle atrophy.

The effect of electrical muscle stimulation on the prevention of disuse muscle atrophy in patients with consciousness disturbance in the intensive care unit

“In the control group, the decrease in cross-sectional area progressed in all compartments every week (P < .0001). Cross-sectional areas of all compartments at day 14 were significantly decreased in the control group compared with those in the EMS group at day 7 (P < .001). We were able to limit the rate of muscle atrophy as measured in the cross-sectional areas to within 4% during the period of EMS (days 7-42) in 5 patients. The difference between the control and the EMS groups was statistically significant (P < .001).”

Effect of early implementation of electrical muscle stimulation to prevent muscle atrophy and weakness in patients after anterior cruciate ligament reconstruction

“Muscle thickness of vastus lateralis and calf increased significantly 4 weeks after surgery in the EMS group, while it decreased significantly in the CON group. The decline of knee extension strength was significantly less in the EMS group than in the CON group at 4 weeks after the surgery, and the EMS group showed greater recovery of knee extension strength at 3 months after surgery.”

 

 

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