Achilles Rupture: Conservative treatment vs operative management. What is best? CP podcast

okay so this is the next episode of the complete podcast um my name is chris myers clinical director at complete physio and i'm very pleased to say that we've been joined by somebody that i've known for a very long time mr sam singh welcome thank you chris thank you for having me no problem and sam's been um operating on feet at ankles for 16 years as a consultant right and then another probably five years as a trainee and then a fellow as well cool so a long time yeah so we've been working together for for many years and we've seen lots of mutual patience and the reason we thought we'd get you on today sam is because we've been having lots of conversations and whatsapp messages about achilles ruptures yeah and i think it's very important i mean uh the thing about the achilles tendon is the rupture rate has gone up so if you look at the data you look for example the instance of ruptures in the 1970s a substantial increase now and and it's shocking how much has gone up and and we see it i think basically the reason is that people are doing more competitive sports at a later age yeah okay so the big trends that we've seen even i've seen in my own career over 20 years uh uh from back home already strong my uh consulting time is uh i've seen them in very much younger patients sometimes shockingly young patients in their 20s you've seen you know well it was a good premiership football in the last two years there's been a 22 year old that's ruptured there's been a lot so we have the president that's an elite that's going to keep him in that age why is that and i think i think it's to do with the nature of the training yeah and the the level that they're competing at remember i mean the amount of force they're pulling through like this they're just the the fitness levels are different yeah the amount they're pushing it is different there's also a link i think genetically as well yep there seems to be quite a few ruptures in afro-caribbean players in certain areas um so i think there is a genetic we know sometimes that tendon problems well first of all as you say age is the biggest risk factor isn't it of getting a tendon problem yeah and if people are doing exercise till they're older now and then maybe that's different but also not just exercise i mean people are doing doing a lot more yeah at a later age than they used to so if you look at if you look at including yourself a little bit not as much as i should is the answer yeah thank you yeah cheers chris no uh absolutely correct though the one thing is look we do um you know you see people push themselves hard so you see people playing football quite happily on clapham common yeah when they're in their 50s yeah and you would you wouldn't see that before people hang their boots up there when they're 34 years old yeah so you're seeing people doing the kind of sports where you have a problem racket sports football you don't get it from running you don't get it from running you don't get that's true you don't get it from doing the park run okay because you're not doing that sudden bounce that sudden explosive force a sudden sort of step back eccentric activity and then yeah well you're sitting there you know i mean the japanese say veterans football like yeah playing i was in goal yeah obviously not but he's still playing you know he's 53 or four years old yeah and but at the same time the benefits of the exercise the general population is they're massively out there but there is a distinct chance just like you know i say people might get plantar fasciitis one time in their life yeah there is a good chance that you know even either you one day might have trophies and the problem the problem with achilles ruptures is that there's there's often not that warning sign yes and so i always find it amazing and people find it amazing that actually you're just as likely if not more likely to have an achilles rupture if you've never had pain in your achilles before and and then we always ask them if you had a bad achilles have you uh got a a degenerate achilles yeah and and one of the other missiles i think i could answer for you while i'm here is just because you have a really fat ugly achilles tendon when when you see your physio and he goes well that's a bit swollen it doesn't mean you rupture it okay the number of those actually going to rock i think it's almost protective it's almost protective i think the pain is the most protective thicker and it hurts so you don't need explosive yeah activity so actually most people who basically have a pristine tendon and they woke up one day it's popped it's crazy isn't it just no warning signs but you can't live in fear either so no you can't yeah you can't live in fear and you shouldn't stop doing things but i think i'm sure you'll agree i mean when something i'd like your opinion what should they be doing to warm up before these activities to minimize the chance of problems yeah what do you think chris so i definitely see a group of i'm not sure it's just warming up is really important so don't just suddenly you know you're five minutes late to get to the fiverr side which is classics and at five side or squash is the big one and you're a bit late and you don't really do anything you just go straight into it there's no doubt that that is probably increasing your risk of a rupture so it is important to get there increase your heart rate run around a little bit do some dynamics movements dynamic stretches not just hanging your foot over the edge of the curb pushing up against the lamp post and so i mean just going up the escalator on the tube on the way there's no that doesn't work and the uber the uber on the way there isn't a warm-up either but but the other thing we see a lot in and this is the other thing i was gonna bring up is we've with covid people have changed their uh lifestyles their activity levels we've seen so many more achilles ruptures in the last two years and there's something that i have i've seen i've seen a big surge in the number i'm seeing including but also it's because you've been relatively mobile you're suddenly ramping up and you see it is it it's not the seasoned athlete who ruptures the kidney center you don't see underneath season yeah yeah yeah yeah and that's what i was going to say is often not you know warm-ups are important and that sort of thing building up your exercise tolerance slowly is important um but actually the ones we see it in is oh i went and played five aside football for the first time in two years no and i don't i don't want to do them chris yeah it doesn't happen the first time they play all right second time the second half okay for the first time they're cautious yeah yeah yeah yeah yeah second time how many times the second time i've been after how many years 15 years yeah that's true okay now i want to get into the the one of the reasons we really wanted to do this is because we are getting so many emails so many people worried about how they should manage an achilles rupture there's lots of conversations around should you have it surgically repaired if you're a premiership footballer there is no doubt you're having it surgically repaired so why is there don't answer this yet we'll come on to it why is there such a push now particularly in the nhs to manage all of these non-surgically and conservatively now let's go right back to the beginning because i think the other thing that we've talked about is how important that first few days of management correct and how this whole process doesn't matter if you do it surgically or conservatively the whole process can go wrong from the beginning so imagine sam you're playing squash do you play squash uh yes i have done okay you you you and let's say real life story tonight you play squash for the first time or second time you feel or you hear something pop at the back of your achilles or someone else the one thing about it is someone else comments that they heard it right if you break a bone other people in the room don't unless you really hear it probably people don't hear it but the achilles tendon the person playing with you hears it the person on the sideline hears it because you get this explosive back yeah okay and they feel it and they feel and the best line i always love is it's always you feel like you were kicked in the back of the leg yeah there's a great case kind of told you about this one where there was a tourist who ruptures the achilles tendon i don't know why he was running on ultra street maybe his next song was maybe it was a big pocket or something but as he as he as he was when he robbed his achilles tendon he turned around and he thought that someone kicked him so his first reaction was to turn around and kick the person behind him who happened to be a copper okay so that's just one of those anecdotal stories it's a great one but it shows exactly what happens so you feel it and someone's kicked you and you're looking around you're going hey mate i'm in goal there's no one behind me i'm the last guy here how the hell have i managed to return my please so everyone assumes well they must assume they sprained their ankle these are the terrible things okay and actually the i shouldn't say this sorry chris i know you know physio something but it says from by the by the tv who happens to be sitting on the sideline and just turn up they it's all sometimes awful yeah just look at them and go oh it's all right mate it doesn't look like he's also doing a terrible examination examination and you're going guys it's not if you think so that i think look if you think you've popped your achilles tendon you have popped it okay still proven otherwise i think that's a good way of doing it and the other thing is don't be put off by pain and what i mean by that is this is not always the most it's like shocking it's shocking when it happens you look at david beckham if you just put youtube david beckham he just looks behind him he's ruptures achilles david beckham he i he knew what he'd done yeah and i saw the face it's facial expression on him and the scene on youtube and i could see the tears he knew because he knows this yeah but if it's not really painful in a way that's that even though it makes it even more likely people think he must be acting you know it is or not how could a tendon snapping it doesn't hurt it's less sore than if the tendon just absolutely medical professional yeah before saying oh i think it's okay so the world i think the key thing to all to our listeners is that you must until proven otherwise if you think you've rubbed your kidneys tendon yeah okay and this is the important thing okay now when you then you need to get to a medical facility fairly soon where there is a facility to be put into a position that we call aquinas okay now what we'll do is just for the for those on the thing aquinas basically means your foot should be pointing downwards so that your tendon can now get closer together so if you imagine your achilles is there this is called dorsiflexion that would stretch it that is literally the worst thing you could do because what you're doing is you're pulling the two ends apart yes and so it's not going to heal whereas if you point your toe it comes together so the two ends oppose and you need to be in that position for the first minute absolutely yeah or the first you need to walk around with your like that with your limping around like that and get some help getting a good stretch on it doesn't help no tuba grip won't help no so you need something now the facility to keep that is either they put a plaster on your leg and often they're interesting they'll put the plastic at the front to stop it bending upwards yeah you call it an anterior slab yeah or they put you in a boot and you can do the same thing so if for example you'd have a heel boot or lots of hair and really that should be done straight straight away but within 48 hours yeah okay and the reason is is is is very is very simple and i think the simplest way i look at it is uh is your tendon lives within the sheath okay uh so that the sheet is like a like a out outer bit of the of a sausage you know yeah and the meat is the only inside okay that's your tendency so yeah why the skin of the sausage give us a sausage okay yeah so the skin of sausages so the tendency within that but if you then if you pop your tendon and the two ends migrate far apart you will bleed yeah and when we see these and you see them on ultrasound i've seen if we ever open them and opera when they bleed when that blood gets congealed so initially it's watery blood so if you push the foot into the so-called ballerina let's say ballerina position okay yeah yeah yeah yeah totally getting down yeah okay okay yeah if you push then the tendon will slide within the sheath and the engines will come together yeah but after 48 hours that blood has condued and congealed blood forms like a scar tissue and the ends no longer slide together so it's going to be a sub-optimal repair okay straight away yeah so yeah yeah so so you know so the problem then is the debate is is which you're going to come to the treatment yeah yeah but the debate for treatment really is only if you've presented early to a e so yes if you go within the first 48 hours then you can actually get a good outcome yeah yeah with or without surgery yeah depending on what we'll come to in a minute but but if you have turned up at five days yeah then you're gonna get a poor result from surgery and i know there are people that say well you can ultrasound them they don't come together they'll never come together because that stuff is conducive yeah you always have a permanent well on ultrasound it would be hard to differentiate the good stuff from the bad stuff so so let's when we talk about an achilles rupture the majority of the ruptures we see would be in the mid portion so like five centimeters up from the yeah and that is your typical that's your typical one and that's but you can also rupture them down at the heel and further up and essentially they are treated very simple very similarly but but they are different and rarer versions now that i i personally think that the ones that happen further up yeah is actually a bit of a pat on the back and you feel a bit happy because you got a few they heal because they're a bit like a serious bit more muscle muscular good we know that the problem with the achilles chris as you know it is is the the blood supply is so poor yeah that's why they rupture yeah yeah because they have a little bit of disease they can't heal yeah and they rupture yeah and also when you operate on them or you treat them with or without surgery their healing times are slow yeah and they take so long everything about this i suppose it's just slow but yeah you know you said why was david beckham crying because he's thinking this is slow burn this is my this is one here you know he just knows it's happened tell me how many muscle tears take that long to you yeah there's no other muscle tear if you tear your calf muscle i'm pretty much by six seven days question saying you have to like yeah well tendons are definitely a different ball game they take a lot longer and also you know there's lots of stuff out there you know this treatment speeds up healing and that and at the end of the day it just takes you down it takes time you have to respect that decision yeah and the more you dick about with it yeah the more complications you have yeah yeah okay yeah no i totally agree okay so you've been to a e they've said it's a rupture um and and that's the other thing is at this point you don't actually have to have any imaging do you so a lot of people we see is like oh i need a scan i need to scan well actually the first thing intelligent doctor is getting them into that and achilles yeah the worst diagnosis and this is this is the one thing that i i always think is you and i will say i know i do talk to gps yeah the partial tech yeah okay oh they give you a nice power oh it's really good mate you very much aren't you lucky you will always have something in that gap chris yeah you will always have something in that gap and the reason is you remember so what you were saying is that let's be clear so and this is a really important point so if you feel that sudden pop and there's been a cute tr not even a trauma but an acute episode yes and you get that pop what we're saying is this is these don't harshly tear they don't wash it and and why do people say oh really good news i can feel a partial tear because remember we talked about the analogy the skin of the sausage yeah the skin is still there yeah okay or the plantarity or the plant parasite which you all have this horrible fat tender next to it which only causes pain in life doesn't do anything good for us that can sometimes be felt in the gap okay and but the other thing is chris when you rupture even complete rupture what happens in reality and when you see these when we open them because we do opposite of surgery obviously is you'll get 80 percent of the tendon will have completely ruptured but 20 percent just stretched a bit and it's something that can be used but there is something in the gap yeah so to say that there's an absolute gap now so the mistake is the partial tear it isn't i have a picture of hormone symptoms on a slide i have of homer simpson and i say you know it's the idiot's diagnosis okay to make a partially clean standard option unless you are so this so the key thing there and this is also a very important thing you know if you if you're if you're if you're a physiotherapist yeah i know the advice is dump the problem on someone else yeah okay which is either a e yeah or they've got that classic history achilles rupture it's not your call to make it completely proven you have it's just not your place to call it a partial day yeah yeah fine okay that's really good advice so you've been to a e you've got your your foot in an aquinas position um and it's gonna have to be like that for a long time a long time let's just establish that whatever happens yeah yeah whatever happens it's gonna be roughly like that for about 10 weeks yeah yeah okay your life has now yes stopped then what happens or we see a big group of patients that start going they start googling like everybody does these days and they go well hang on or often what happens is well that chelsea player ruptured last week he's had surgery why am i not having surgery so people start looking there's lots of information out there about whether you should manage this conservatively with a boot without surgery or with surgery so what we want to get onto now is i was going to ask you sam in fact let's start with this if you ruptured your achilles which we've already said you had last night or tonight playing squash fine which luckily you don't play so hopefully it's not going to happen i haven't tempted fate would you have surgery or would you go for conservative treatment that's a straightening at the deep end certainly it's a question yeah so as we discussed earlier return to support and at how much exercise i do is not being great yeah so actually i would treat mine conservatively but i'll tell you why yeah chris because i don't play tennis i don't play really play squash football i haven't played for years yeah i'm might be running yeah i cycle quite a lot yeah okay but those are not activities that puts my tendon at risk of re-rupture yeah okay all right so that's something uh that that's why i would go so because because you're not doing any high impact sports uh absolutely you feel like conservative treatment will give you the opportunity to get back to hiking walking the things that you do that i can do and i enjoy i can actually doing fine yeah okay yeah and i probably will keep doing fine yeah but that does not mean that that's but i have patients looking at me and saying i'm the same as you i've i'll treat yours with surgery yeah yeah and why because it depends what you want to do yeah and what you expect to do right yeah and i think that's a lot of it yeah yeah there's also an element i mean i'm not i'm self i'm partly self-employed yeah yeah and and the facts are really important and that's important because i need to be able to i can still operate with the boot on yeah but i can't if i've had surgery i know i have to rest it to get the wound here yeah i have got that you know i've got to give myself that period to get the wounding okay so you know it could that could be a factor yeah and i think the other thing as well as and there's lots of evidence that's being done on this now uh maybe in the past people thought the conservative treatment so non-surgical treatment had slightly higher re-rupture rates but i think there's enough evidence now to say that the re-rupture rates across the board are quite similar to whether it's conservative and i think and i think i think i i think that's something we need to stress okay yeah and we do need to stress that they are quite similar so if i wanted to put you off conservative treatment i could say you know roughly so different data is lots of different but in my overall reading everything and looking at all the studies there's a lot of studies that claim they're the solutions problem there is we can never have a big enough study yeah for this for this information the standardized enough because when you read the small print they've taken out the really elite sportsman already yeah straight away sure you must forget that they're taking they're just not and i'm sorry but probably in swansea people are not as active as they are in common yeah okay so we're talking about the swansea because there's a smart trial oh yeah which they took the same population that we see that you see and look after you know that but this is the problem with research isn't it if they've got i think they had around 300 people in the smart trial yeah and that is 40 year olds 50 year old 60 year old 70 year old it's yeah it's fine yeah but if it's the guy who's still playing rugby veterans rugby if it's a guy who's still you know playing in the squash league yeah we have to treat the different patients differently yeah yeah and i suppose just thinking aloud let's say that your conservative treatment doesn't work you've still then got the opposite you've got the surgery so firstly you still got the opposite absolutely failed conservative treatment yeah so surgery absolute indications are if you re-rupture a conservative unless you've got a a a doctor who's really avoiding the job you've got to prepare okay right so re-rupture has a re-rupture of any type it has to be repaired right okay and if you present late i still feel you have to have a repair so if you come to me at five days then it's i'm not going to be talking to you unless you've got a lot of medical issues yeah or you're very for example very ill dude you do see as well yeah or you really want to cope with so if there are other personal reasons i would really assist that stage you have to think about depression but if you come to me day one day two or even week two but you've been in some form of equine this position remember your ballerina position where your toes pointing downwards with either a slab or a boot then i can talk to you about both options it doesn't matter right okay yeah yeah so let's say that we have opted for conservative treatment can you just run through the sort of rough guidelines or protocol that you use with your your very individual i think going into a boot day one is quite harsh yeah a because the leg is quite swollen b because you're worried okay and at that point forcing you to start weight bearing etc is difficult yeah plus the boots need a little bit of specialist fitting as well okay either it doesn't have to be done by the consultant or so but it does require that someone living within a hospital and sometimes i don't think any is the best place for boots to be fitted okay well i think it depends what time you go in the day if you're seeing someone's never put one on and it's reading the book then you know it's sometimes safer to go into a cast and then in a planned system either in the fracture clinic or if you're seeing a prior expression he will take the cast off at some point and say now we put you to a booth and that's normally after i would say so with a conservative i'd say after after about 10 days to two weeks i think that's the time to go in the boot because the swelling is coming down your leg you're confident at that point because you also got used to the crutches you've got used to getting around yeah and as i said crutches the first two weeks you're really not doing much weight-bearing okay and that's i think a fair protocol because one what one says and some people we really think oh we we diagnose it we wait and bear them the second it happens but the problem is you're also in a way then negating the seriousness of the condition of the patient right yeah yeah yeah yeah yeah you need to people need to know that this is a serious thing whereas if we were talking about earlier if you've had the operation you take it seriously you protect it take it seriously you protect it yeah okay and the similarly if you but if you've been stuck shoved in a boot by the a show one at 11 o'clock at night yeah and they said get on with it i mean i've had the patience to take the boot off you know well i've i've had patients where they haven't put the heel raises into the booth so they're actually flat they're not in the ballerina position no option there and that's that unfortunately means that they've made the decision for you yeah exactly so so so actually so just keeping it calm getting over the issue learning how to cope with the crutches learning how to slow down in life because remember planning work yeah you know who's looking after the kids because this is very debilitating it's all very important people forget that people forget that you know you don't want someone to underplay how serious the interest you want to start thinking hey i can't do everything yeah i can't get into work now yeah i need to change back to working for home from home for a while yeah you know that kind of thing put those measures in place yeah so two weeks i'd say roughly 10 days two weeks some form of cast um then it comes with a great debate about ultrasound you know so so do i that's a good question isn't it so when should you get some imaging uh so first thing is a do you need imaging yeah and b so number one is it is not vital okay there is no there is you know if you if if you have a competent clinician diagnosing it can be your physio it can be yeah it can be uh the a need some someone call it can be a speedy dog someone competent probably disney's like no i must confess i don't i very rarely imagine yeah yeah and it's very interesting the ones i'll pronounce the ones i don't image almost right because i know that i'm going to be in there so i'll see oh okay well that's fine i know i'm i'm going to disagree with you sam because i'm just thinking if i ruptured my achilles and i'm going to go conservative fine i am not going to sit around for eight weeks hopefully that those two are together so i agree with you yeah so i would expect if i'm going to treat them conservatively yeah partly because of that because by about the week three i've mentioned coming out why about weekly they do say sam you should have had an ultrasound so yeah yeah i get this like crazy yeah i always get an email that should have had so i i i so absolutely correct with conservative ones i will i do watch stuff yeah yeah but i don't think it's like i have to do that minute i don't want to say okay fine look we're going to treat you conservatively in the next when there's the next slot available yeah yeah just to check that we're going we're not barking up the wrong because it would just be a nightmare to come out of the boot and you do need some time to see problems because yeah yeah you've seen them where yeah you get fat they've torn their they're skin yeah yeah they've torn the sausage skin yeah and the fat's popped into the gap yeah yeah so then you pick those ones up and go all the way different maybe revert plan yeah okay so you've got two weeks in a sort of last cast roughly speaking and then what another six weeks conservative i will tend to go for the full ten weeks yeah yeah okay i go for 10 weeks of immobilization and just to be clear that does mean you've got a boot on you're wearing it at night you're wearing it outside at least for the first time take it off to clean it pick up a cleaning and you're taking it off with your foot dylan we love remember ballerina position yeah yeah so you can have a shower take it off for a shower yeah yeah but you're sitting on a stool and your foot's in there yeah battery position okay yeah yeah ballerina puts this in that position and then as you go through that period of six weeks or eight weeks you start taking that you change the angle yeah so that you don't need to be quite pointing down like a ballerina we slowly bring you up in a controlled manner yeah and the game plan is and and the game plan and this what people this is why i say this is like a sponge cake okay when your sponge cakes whatever you put into it when you take out your sponge cake at at the right time it should not be too moist it should not be too dry and it should have risen what happens between week 0 and week 10 if you're treating conservatively doesn't matter everyone changes everyone varies yeah but i have to have a week 10 a tendon that is not excessively over stretched okay because the worst thing is that and has the correct tension on it so that it feels like a uh it is right yeah and i don't care what it was like at six weeks so then when people say well i gotta do this i gotta do this can i push me harder on it it doesn't matter just come out ten weeks if you deliver if i get delivered attendant ten weeks with the regime we're using a conservative treatment that is got the right tension that's the right thickness that isn't too lacks it isn't too tight at ten weeks they're gonna have a perfect action yeah and from a physio point of view we see that you know it's it i always and one of the reasons i wanted to do this is because we do see such a variation in not overall outcome i think they all generally do pretty well at around that six months i mean return to sport is that six to nine months if it all goes smoothly which it doesn't always but we see loads in the clinic and you'll get one person walking past and you know they are at three months and then you've got another one at six months who's still limping and there's a lot of variation a lot of variation and there's a lot of skill because we see so many of them in the clinic it's really important that you're seeing a physiotherapist that basically knows what they're doing and has loads of experience of seeing them because it does vary and as you say it doesn't really matter where you are at six weeks i had a patient the other day where we've had to put them in a boot for sorry at 10 weeks we've actually put them back in a boot for a couple of weeks because things aren't going you know the cake's not rising as it should yeah and actually delaying that we know that that means that they're going to be able to push on after that now the other thing i was going to talk about is from a physio point of view and lots of people say when should i start physio when when shouldn't i the sort of key things i like is i want them putting full weight through their tendon once they're in the boot so around that three or four weeks so and i think that really because if you're if you're just if you're limping around there's no stimulus for the tendon to get strong but we have to remember if you're put stuck in a boot like a ballerina yeah yeah you can't put full weight because you fall over okay it's difficult you can load you're not walking normally but you can still and that's the way that you can yeah yeah so i totally agree and you all know for tendon healing some and those are slam bones the key thing they said actually is you've got to load yeah attendant early on to get good bugs i think we get people we get better healing better scars but the practicalities and i get patience you know in the last minute but you know but but can i really start walking and i look at it make good luck walking in the boot with your foot at 30 degrees but the principle of getting the toe something down yeah so you're not hopping if at five weeks or six weeks i've got a patient that's hopping in on a boot i know that that is going to take a long period of time for the tendon to get stronger and to remodel if i've got a patient that three or four weeks might still have crutches but he's getting a nice bit of weight through the tendon and i think they're going to be easier and also a lot of like getting back to support sport is about confidence yes there's a lot of fear and there's that situational fear so if you've ruptured playing squash you have that real situational fear about going back to squash you might actually be fine going off yeah start telling you um rupture the other one yeah and so i think it's really important that you get some early weight going through it and also from a physio point of view we do want people to start doing some simple exercises uh three or four weeks so actually take probably more like four or five six weeks taking the boot off and just doing some simple seated car phrase but that has to be done under the supervision absolutely because the worst thing you can do and it's probably worth us mentioning it again now is this tendon elongation so if you stretch the tendon it's like an elastic band isn't it yeah if you stretch an elastic pan there's a point where it either snaps or it doesn't return to its um starting to position so you're losing that spring and you can never compensate you can never get it back so so so it has to come out right and and the supervision is important yeah yeah so there are various protocols so obviously our patients that come to you they have they have a access to a good physio yeah they just say someone's listening to this who's got a uh who's on um who's nhs basically being pushed a little bit to the side yeah and that's happening unfortunately a lot a lot no they're not they're getting a bit of online physio one session and stuff and yeah which has a phone you know don't get me started on that but yeah yeah so but then there are a lot of protocols and the great key there is the patient is you can find the protocols and you can safely do them yeah yeah so you know we know what the issue so they're all public you know publicly so there are some simple stuff you can start doing and starting but the the other thing we'll forget about the first three or four weeks it's a bit cruel to start people on hard bridges because it hurts yeah yeah yeah yeah they're not used to even the basically being suddenly being independent yeah suddenly we love this giant boot device that we've put on them yeah or this car smooth one yeah yeah and just on that point just just to recap chris you know some sensors do put them in a in a in a in a cast yeah in aquinas for five weeks and to be honest there's no real difference in that sure absolutely fine okay yeah in some factors it's sometimes nicer because yeah then you know patients feel reassured that they're not going to accidentally take it off and fall over yeah of course it's a careful balance it's getting between yeah you can easily overdo it and those are the ones yeah just because there's a lot of promotion from different boot manufacturers that yeah this is the backup this is one we have to be using it doesn't mean that actually that's the only way no of course just because they're you know there's industry sponsors yeah push for things you know it doesn't mean that if you're not a sports person you're not interested in getting back to running but these generally do really well don't they and they take time and you don't need to rush it but the people that we see a lot of the ones that like how do i get back quicker how do i make sure i'm running six months and you know so we can optimize it but at the end of the day you it's still going to take time it doesn't matter why is cost it doesn't matter so if we go back to david beckham's story yeah so when that happened um i was a young consultant then i remember the story happened and it came out and i and i was thinking who's going to fix it is going to fix it and then they found some clown from finland okay who declared that he's going to have him back playing football at six weeks okay i really yeah and he was on tv and i saw he goes we have a technique we're gonna have him back at six weeks it doesn't happen he didn't he didn't play he didn't play competitively for 15 months no and he never played at the same level now i'm not saying that people won't play africa because what the level he's expected to play is very different yeah you know yeah yeah you know but you know but um it's just and even in premiership football is where they've got all the medical staff around absolutely there's six people that come back at you yeah you've got you've got people that are getting back you know even before that six month mark and then there's people in the same team that are getting back after a year and it's because there's no fault of complications yeah and i've never said the other thing i observe i don't know how quickly people lose their calf varies i mean some people they come at 48 hours their coughs tripled yeah and that's another thing that from a physio point of view i want to mention is that when you look at your calf after you've been in a boot for 12 weeks i mean it looks it's shriveled up and even after two years you can um the chicken wing versus the chicken drumsticks yeah yeah and even after two years it's shown that you are going to have less heart strength yeah you're probably not going to be able to lift your heel up quite as high so you're never actually going to get it right versus let's talk about you just show that what you meant by that on the just just show us what you meant chris is going to demonstrate so this is called single heel raise um chris you do a double heel race for us first that's a double heel raise and that we expect is uh that patience can do quite early on but what chris is going to demonstrate now is a single heel raise and i actually do not panic even if a patient can't do that for about nine months post surgery that is a very hard maneuver now what chris is saying is that when you go on single heel raise uh there patients heals are when they've ruptured eclipse tendon their single heel raise height tends to be a bit lower like you're seeing now it doesn't quite go as high but it's it we encourage it it's a good parameter but if i say to them at the outset chris nine months of single heel raise because because i've seen patients take that long yeah and you and chris is saying to me well they it's usually quicker and i say it's good but at nine months after that i panicked because it could then could be a problem with the achilles yourself but actually until i was and then those guys are young one year about playing all their sports so it's a little bit delayed but they're back doing everything just a bit yeah i mean i if if a patient can't do that in nine months i would i would take that personally okay so but but at the same time if it depends doesn't it if you want to get back to football we need to get that but actually you don't have to be at a single leg heel raise to walk without a limp or at least you don't need to have a full heel and i get the sense and then i get i actually get patience is the same thing oh you know i want to do a bit of a short run but i can't because i can't single heroes i said mate you can you didn't even know you could do that before the actual yeah i do find something we'll come on to operations now but i do find sometimes that if they're operated sometimes you can get that back a little bit with and the patient feels a bit more confident but i i would want to get a single heel raise between four and six months i would i i've had them at three months and yeah and i've seen them but it varies but it does vary so what i'm trying to say is do i get massively panicked no sure about no i don't and i just think some people are different some of them yeah someone may have been a little bit more over immobilized at the beginning they may have had a lot of cardboard right at the beginning yeah you know those are the kind so let's say we've gone through conservatives so actually from a physio point of view conservative versus surgical there's not a huge amount of difference from the rehab protocols that we use absolutely but just talk to me about what do you actually do in surgery like fine yeah that's a brilliant question and i know you're seeing a client of mine this afternoon uh this afternoon tomorrow for surgery so what will you be doing to her fine so so so i'll talk to you about what we went through with her okay yeah yeah sure with with the discussion okay yeah so so this patient who you know well so she's a and i told you we might discuss her in this podcast okay he's very happy for us to talk about so she is um about 44 years old yeah but she still is active very and her main passions are horse riding and netball okay and she loves netball okay and she plays her pretty good and that's pretty good still and she says she's older than a lot of players on the team but she still is as good as them and wants to keep playing yeah her worry is that she injured the achilles playing nipple yeah so saturday i think it was set that yeah so she's worried you know will like what's my chance of re-rupture is what she asked me and i spoke to her yeah and what do you think i said i said are you in an aquinas position and she said before we even started talking about certainly yes she was immediately she had gone to a e yeah and she had been put in the in the car she's got the options absolutely yeah so what did i what did i worry what do i worry about her there so number one is she plays um netball uh and has no intention to stop it yeah okay and that ball is a sport that people do play even veterans there's got no she's got that is a really key thing she's got no intention of stopping whereas if she went i was thinking about stopping netball in six months anyway and this is sort of sped up it might change your decision might absolutely yeah but but it's interesting the other sport that she does she right horse rides competition and actually the horse riding is one of the most unpredictable sports you could do yeah and i can i don't even know what happens in that sort of thing on a horse and imagine losing control or eruption in ten on a horse so her paranoia is about that which i think is reasonable yeah so we went through the options and i said look i will i'll give you exact options and i even said possibly slightly higher erupted rate treated conservatively yeah versus surgery but surgery has got risks okay so now let's talk through those risks yeah so so so first so you can send someone that's what we're saying right it's very difficult because actually it's one of the hardest consensus we do because you know in a court of law someone could say we should treat this conservatively based on the right interesting yeah yeah but the thing is we still do operate and even as you said correctly still most elite sportsmen in the world are operating on yeah and that's not just habit that's because they're expectations so what are the what are the benefits of operating versus conservative yeah yeah well the risk what's the risk so the risk the risks of surgery are there there is one risk that is extra so if you're in a period of in a boot for ten weeks you've got the same risk really of dbt yeah thrombosis which is something he's a definite blood clot he says and that's a definite risk for the police injuries okay yeah so one thing you must be sure of that you're unblocking it yeah so whether you've got a red hot swollen calf you need to go to any immediate yeah yeah okay that's because of all the bleeding in the area but but also but you are it's because your calf muscle you know is the main thing that works and you can't use a calf muscle because you've stopped it with the boot or you turn your uh your calf or your achilles complex what so dv you lose that muscle muscle the so whether you operate or don't operate the risk of dvds is still is high so you have to be on blood thinners other risks will you you'll be in a cast or boot either way correct okay i said be on blood thinners is that if obviously after surgery no but no everyone has to be whether you're really even a conservative and that's very is that done routinely it is you should be done routinely and it's interesting the if it's if the patients have gone to any then it's usually done okay so they what would they give them generally injections in the style right same you know low molecular weight heparin injections and it is it is mandatory it's almost marriage because it's known to be killing you is a high risk injury 25 yeah carb tears so yeah along with it so it's a definite risk okay yeah so we do have to treat them aggressively okay yeah so that's that was same so what are the additional risks of operation the main risk is wound healing problems okay and why do we say that so we know that the achilles tendon there's no flesh okay so if you look at the achilles tendon and we showed this earlier there's it's the tendon is just under the skin yeah yeah so there's no fat there's no muscle sheath this is the other even if you get a superficial infection it's going to infect the tenderness yeah that's the problem and also you're putting foreign material in like stitches you know so they are sniders for infection the blood supply to the area is terrible hey that's why you're here because you've probably attended because it doesn't have any propensity to heal itself so you know it's a it's one of the most a vascular areas in the body there is very little natural looking so that's why and if you get an infection you're going to be put on antibiotics you're going to have you might even have difficult clothing yeah but it is not common and the problem that we have is that many of the things literature we see is based on the operation being done by whoever is available because having been a trainee and i know uh you know that it's a kind of nice operation you need to registrar to do yeah yeah you know in the evening go you do it you know you've got the time you can do it tonight because it's a good training one had learned how to attend repair but obviously the quality of repair by consult yeah and i suppose obviously in the nhs you don't you don't you don't know who's going to use it and it may not be done by the consultant of number junior hence you're not comparing you're not comparing the like for like yeah yeah yeah yeah so you know is my infection rate nil no it's not okay but is it is it uh is it like some studies just fifty percent god no i shouldn't you know i meant to wash my hands before and operationally not fifty percent it's probably about five to ten percent yeah and usually you can manage it sometimes it can be very difficult yeah and you have to get involved classes etc so that's the one that's the real risk yeah yeah i mean you can't say general anaesthetics because you know it's not yeah yeah all right so infection yeah yeah so why do i sometimes operate okay yeah is what you're going to say why do i have some disorders but no i think i i understand why you operate them because i i think from a physio point of view we i think one of the key things is the serious not the serious this thing's not going to kill you let's be clear but the seriousness of the injury so if you've had an operation done and you you've you've gone you've had a general anaesthetic you've re you've had to change your whole life for a week you know you take that injury pretty seriously don't you and you follow the protocol sometimes with conservative treatment people can be a little bit blase um and so so i and also in elites and and the patient we're talking about i i just i just gut feeling i just think she'll do really well with an operation and you're right it's you know it's difficult but at the end of the day what i did this is this is for me this is why i referred her to you because i knew she was a potential candidate yes all we can do as clinicians is provide the correct up-to-date information to the patient at the end of the day they have to make the decision you know and that's difficult isn't it but you know we we have to be careful and we have to make sure we give all the information so they can say actually i feel like i've been given all the information required to make an informed decision the problem i find is obviously through the nhs everything or most is done conservatively now and actually maybe not even being given the option of surgery yeah so that was my main reason was go and see sam and have a conversation and it sounds like you know as you said in the consultation you were two and a half years she's made the decision yeah because because you know there are people who walk in and i said you do great with concern you know the next question i saw he's a bit older he says how did you do it i was playing goal in veterans football yeah said what he goes um i don't know well then do that again don't do that again yeah fine conservatively also he's 10 days down the line already yeah so i'm thinking well yes you're only another seven weeks from the whole thing finishing yeah yeah go downstream let's go down that route so i think i think but the surgery so you ask what we do at surgery so the aim of surgery is basically to bring the tendon ends together yeah okay now what what there is a satisfaction about knowing that this tendon and has been brought together there's a stitch in there and the stitch is strong so what is it made of it's it's a so we use a strong it's a basically kind of it's almost like a metallic stitch yeah it's not i don't want people it's not a stitch like you stitch your head up no no it's just i do i see them on ultrasound they're really they look very strong they're very very strong i mean this did you you know i could hang you you know with that thread and it would yeah and you would it wouldn't repair if i hang it from there if that's this stitches and you do see that in physio sometimes that they they sometimes when they've been operated they do feel a little bit more confident i think they do feel more always and the tinder and that can be a yeah okay but the nice thing i have is that when i then one of the i love the fact that if you're okay two weeks you're going to be fine i don't need to ever worry about because you know you've got the tendency got the attention back so unless somebody does something similar in their rehab if he slips on a banana or something but even if he slips on the banana the bit protects that's just holding him yeah okay and i've even seen pastes have i seen patients i've seen patients tear above the yeah but the key thing is that he just what what the reassurance is that the enemies i'm not worried at two weeks time and need patience well you're almost reflecting what they're thinking they're thinking fine the wounds okay this tendon's together now it's not gonna elongate it's not gonna be too stiff actually i can really push your rehab part now yeah yeah you know and also it might not be going you have to remember chris then might be going to you they might be going to someone who's who really is who's who doesn't see who they need one year or one every two years you know and actually just he's just doing you know a bit of cough massage you know so then these guys can do themselves yeah it's just it kind of goes into hinterland without worry yeah okay yeah absolutely so two things i want to just come on to before we finish one is return to sport um and uh we'll start with that so just from a physio point of view i think people always say oh when can i go back to sport you when you see him at three weeks and they ask you that you've no idea you know you know roughly it could be what five months to two years absolutely an average six probably nine months as an average i would say yeah um but it's very hard and we just take them through the process of rehab we get their calf strong and then we start adding in sort of more dynamic stuff so we'll go into different hopping tests and that's i you guys are so confident putting them on the little trampoline and stuff yeah yeah and i honestly haven't i i can't imagine someone bouncing on their leg after i've done their kids what they do i'm not sure what they do and i'm like gosh but we build it up but it's lovely and then people and then we will do a proper over a period of time we'll return them to sport we'll give them we'll go through a barrage of tests so we know there's that confidence and then we build them up slowly it's a very slow you don't go from like doing a few heel raises to playing football there's a very much a return to the sort of sport um uh program that we do um and with a lot of success i must say the other thing i wanted to talk about is um one thing that we've had recently and we've talked about it and people forget about it is the potential to re-rupture whether it's surgical or whether it's conservative that if you're gonna re-rupture it seems to always happen as you start to get more confident and come out of the boot so around that 8 to 12 week so you start walking around the house with your socks on and it's always like a slip or something like that so you have to be really cautious between eight to 12 weeks and there's no harm in that time uh you know we're based in london there's no harm i say to patients for the first two weeks i know you're out of the boot but just wear the boot on the tube yeah oh you've been at like 10 to 12 weeks yeah yeah yeah even 12 to 14 weeks doesn't matter you get a seat you get a seat and also you just you just you're not going to sleep on the pavement yeah you're not going to be knocked over you know when you get to work you can walk around that when you get home take everything off yeah but when you're in uncontrollable being cautious is not a bad thing yeah and it i think the other thing is i think as the public can relate to a broken bone takes six weeks it heals generally but tendons you come out at 10 weeks this thing is not healed it's not it's healing it's a process but it's a prototype and we know that it takes a couple of years for this thing to absolutely remodel absolutely it's a process it's just mature enough now that it doesn't need the extra support of boot yeah yeah okay but it hasn't healed okay it hasn't healed it's a process not even so throughout this podcast as we come to the end i've been thinking if i ruptured my achilles let's say i was absent no that's unless i was playing football five aside um and i ruptured my achilles i would also go for conservative treatment that's right because i don't play five a side i run a bit but i believe i can get back to running um and i'm not going to play football i'm not going to play rugby i am also self-employed um and so i would probably treat this conservatively um however if i had any concern i would ultrasound it and just probably every day just check it all together if i had any sign of elongation so we haven't talked about the angle of the dangle yeah um if there was any sign when i was lying on my front that my my foot was not plantar flexed then i would i would seriously think about maybe even having surgery at that point but i think because i know i would get aquinas literally within 10 seconds of that injury and i wouldn't leave it yeah then i think i would do well and you'd be confusing with the protocol and i think the same and and therefore it is it is still my my default for any patient who comes to my clinic is to say treat it conservatively yeah unless they can either feel that they're only going to be reassured with surgery which is a which is actually changing and i've had that before yeah i've had a patient say i am not i'm not leaving until you stitch it yeah yeah you know because i can't imagine charlie down the road at it i can't imagine how this will ever come together yeah and i'll even i'm like he doesn't need to you guys know and that was the high tech i said he doesn't easy no no you just have to do it yeah and then the minute you stitch it he's back his life is going on it's heavy but he's different everyone's different it's different and that's the whole thing and that's why a protocol is not is yeah the protocol is not the answer protocol is a guy yeah yeah to have been turned that needs to be adapted but you know what to do with a lady who goes horse riding no no no you know who competitively horse rides you know i don't we don't know what happens no one really knows how involved the achilles tendon is you know in that we don't know we might know what happens to joggers we might happens to marathon runners yeah you know maybe football players but we don't really know absolutely no no it's very individual yeah so we do have to think of it cool okay well i think we've come to an end sam thank you very much so really uh really enjoyed it good luck with the squash game tonight yeah exactly i'll go there yeah i'll be there yeah brilliant and um if anybody's got any questions i'm sure both myself or sam are more than happy to answer it um and um thanks very much for hopefully getting to the end and listening to the whole thing thanks a lot cheers

Channel: Complete Physio

Views: 57,390

Keywords: Complete Physio, Physiotherapy, How to stretch

Id: zHfPpUMPFao

Length: 54min 46sec (3286 seconds)

Published: Wed Mar 23 2022