Surgery For Achilles Tendon May Not Improve Recovery
Thursday, March 25, 2010
Jolie Bookspan, M.Ed, PhD, FAWM
Readers have been asking about fixing Achilles tendon tears. They ask if tears can heal without surgery. Tears, even complete tears, can heal with the right rehab therapy even without surgery. A recent study of 92 patients made news when it concluded, "Surgical and nonsurgical treatment were equally effective for patients with acute rupture of the Achilles tendon."
Dr. Katarina Nilsson Helander, MD, of Kungsbacka Hospital in Sweden reported at the March 2010 American Academy of Orthopaedic Surgeons meeting, that outcomes and rates of re-rupture did not differ significantly through 12 months between patients getting surgery and those with physical rehab alone. Within 72 hours of injury, the 97 patients were randomized to surgery (48 patients) or no surgery (49 patients), followed by two weeks in a firm cast, then six weeks in an adjustable brace that allowed some movement of the foot. Both groups reported increased physical activity over time. All underwent identical rehabilitation programs. Complications in the surgical group included one contracture of the tendon, two wound infections (one deep and one superficial), and two nerve disturbances. Thirteen patients had concerns about the scar, 10 for cosmetic reasons and three for scar contracture and pain. Both groups were still below pre-injury levels at one year.
Primary source: American Academy of Orthopaedic Surgeons. Nilsson Helander K, et al., "Acute Achilles tendon rupture: an RCT comparing surgical and nonsurgical treatments" AAOS 2010; Abstract 712.
There is currently no consensus whether surgery plus physical rehab, or physical rehab alone is the favorable approach. That means, if you go to a doctor with your Achilles tear, you may be told that surgery is the only way, even though you may get the same results without the surgery. Many people hope to have surgery and be done with their problem, not knowing they will need the same physical therapy either way. Complications such as incision-healing difficulties, infection, contractures, re-rupture of the tendon, atrophy, complications and illness from anesthesia, bleeding, clots, scar pain, nerve pain, can arise from surgery. Drugs required during and after surgery can create new illnesses and further drug prescriptions. Surgical and healing outcomes vary with the skill, luck, and patient load of the operating team that day.
It is not new information that surgery may not always be required. Several studies conclude that non-surgical treatment yields similar results:
- Fruensgaard S, Helmig P, Riis J, Stovring JO. Conservative treatment for acute rupture of the Achilles tendon. Int Orthop. 1992;16(1):33-5.
- McComis GP, Nawoczenski DA, DeHaven KE. Functional bracing for rupture of the Achilles tendon. Clinical results and analysis of ground-reaction forces and temporal data. J Bone Joint Surg Am. 1997;79(12):1799–808.
- van der Linden-van der Zwaag HM, Nelissen RG, Sintenie JB. Results of surgical versus non-surgical treatment of Achilles tendon rupture. Int Orthop. 2004;28(6):370–3.
You have choices if surgery is not right for you.
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Read success stories and send your own.
See if your answers are already here - click Fitness Fixer labels, links, archives, and Index.
For personal medical questions - Replies to Medical Questions.
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Labels: achilles stretch, drugs, injury, surgery
3 Comments:
At Saturday, March 27, 2010 3:17:00 PM,
Fred said…
I suffered a complete tear of my Achilles tendon some 15 years ago at age 40 when playing basketball. In the emergency room the orthopedic surgeon cited similar statistics that you have in your post and recommended that I take the conservative non-surgical route. This involved being in a cast for several months and during this time you are not allowed to bear weight on the leg so that the two ruptured ends can heal together. I took his advice and took the non-surgical option.
The positives in this option for me were that I avoided the potential complications that can arise in any surgery. I also was able to return to long distance running after about 10 months and continue to do so to this day.
The negatives for me was after 2 months of being in a non -weight bearing cast I had very significant atrophy of the calf muscle. This muscle never came back to pre-injury size and to this day this leg is significantly weaker than my non-affected leg... The calf is a very difficult muscle to target to increase size, particularly if you have the added factor of a previously ruptured Achilles. I was aware of the surgical risks, but this risk of the non-weight bearing option was not told me to by the surgeon when I was weighing my options. I think after weighing the risks of both options I may have taken the surgical option if this risk was put forth to me. I follow professional sports closely and I believe in every case I have read about when a pro athlete suffers this injury they take the surgical option. I suspect this is done because they will be able to bear weight on the leg much sooner and not run the risk of enduring significant muscle atrophy.
At Monday, March 29, 2010 6:37:00 PM,
Jolie Bookspan, M.Ed, PhD, FAWM said…
Dear Fred, You had rehab from 15 years ago - far less than what could have been done. Note in the article above that both the surgical and non-surgical study groups had identical rehab. Same non-weightbearing as with surgery.
Surgery and after-care 15 years ago were also less effective than now; it may not have improved outcome. Calf atrophy and weakness can occur from surgery, both from the period of disuse, and from surgical injury, which is worse. If you had undergone surgery then, you might also have had the inadequate rehab that was common then, with the same weakness and atrophy now.
Have they checked if there is any other reason for the weakness and atrophy? Something from the injury, rather than the rehab or lack? Someone with surgical injury will have a harder time rehabbing than someone who avoided it, as you did. You still can have surgery if you want - to recut and lengthen the tendon if necessary, and improve whatever is impeding rebuilding.
Professional athletes, like soldiers, are steered to surgery to get them back doing their job sooner, not because it is better for them, their long-term ability to exercise, or even their health. The short term is the decision-maker. Their job tenure is short, then new blood takes their place. Many old former pros are pretty beat up now from their surgeries then. I see the biased sample - all the sad people with failed surgeries coming to me years later to fix what others did to them. You returned to long distance running and continued 15 years. Not everyone having surgery can say that.
Instead of wishing to have had surgery, you can wish for better rehab. Distance running isn't known to build size. There is still much you can do. The calf is not difficult to "target" in real life function. If you can tell me some things, we can tell what could help next. Can you do healthy bending using the half-squat with both heels down and get a good Achilles tendon stretch? Do you use it for the hundreds of daily bends? It is a built-in strengthener and stretch. Can/do you full squat for any real life activity? Can you add lower leg challenge using Fast Fitness - Better Back and Backside Muscles.
Have you had your cholesterol checked? Plaque build up in vessels is not just around the heart. Cholesterol is a factor in some Achilles tears.
Don't beat yourself up that you didn't have surgery of 15 years ago, when things were even more dicey. It's tough either way, and you may have dodged a bullet.
At Tuesday, March 30, 2010 12:32:00 PM,
Fred said…
Thank you Jolie for taking the time to address this issue. You make some good points in regards to both a possibly inadequate PT rehab. program and to the quick use of the knife for professional athletes.
I actually am one of the "choir" on the over use of surgery for many pro athletes. I see it particularly in the almost routine use of arthroscopic meniscus repairs for pro athletes. Sometimes the media discusses these as if the athlete took 2 aspirin. I think we would agree in the vast majority of those cases a change in performance techniques and physical/muscle development would be the correct course of action. I think if surgery really was the correct option in a specific case, given the young age of these athletes, that meniscus replacement versus removal would be the correct choice, but that would mean months out of action versus weeks. Short term results over ride the better long term option.
I only brought up the other side in Achilles rupture cases because I assumed weight bearing could occur at a much earlier stage in the rehab process with the surgical option and this would reduce the risk of considerable atrophy. But as you point out it is possible with the correct rehab. program I could have overcame that problem. I also did not want to minimize the surgical risks.
One thing that stands out in my mind at the time of my injury, the surgeon informed me that the Achilles area does not receive great blood flow and this heightens the risk of infection. In the end, being told by a orthopedic surgeon at a prominent Boston Academic Medical Center that he did not want to "cut" when all the incentives to do so were there for him was enough for me to take his advice.
As to your specific questions about my current abilities:
1) I can do full squats with both heels on the floor. I can also do this with light to moderate weights.
2) Do I do this regularly for the 100s of activities of daily living? - I plead guilty and do not don't employ this position regularly
3)I looked at the lower leg challenge with the photo of the baseball pitcher and I can get into that "T" stretching position.
4)Cholesterol is normal
In terms of muscle inbalance - if I were to raise up on my toes one leg at a time the distance I could lift my heel on my affected leg would be about 1/2 as I could on my good leg. The calf is shorter and about 75% the size of my good leg. I theorize this muscle inbalance has contributed to various other running injuries through the years post rupture.
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