Sheffield Regime for Conservative treatment

[RoystonV]

Below is the regime that my hospital uses for treatment of non-operative ruptures. They call it the Sheffield regime as I believe it was developed from research done at Sheffield University.

My first impression is that it is fairly ambitious/aggressive (e.g walking on toes after 12 weeks!). I will be very cautious about some of the steps and won't be doing things if they feel uncomfortable.

Anyway I thought I'd post it for information/comments.


Week 1-3
Below Knee full equinus cast
No weight bearing (NWB)

Week 3-6
Change to below knee removable cast at 15 degrees equinus with heel block to allow WBAT (Weight Bearing As Tolerated) using crutches
Refer to Physio
Active Dorsiflexion, inversion and eversion exercises (NWB)
Progress to active Plantarflexion exercises
Specific Soft Tissue Mobilisations (SSTM) to tendon

Week 6-7
Cast off into Samson Boot +/- heel raise if plantigrade not achievable
WBAT in boot, gait re-education, wean off crutches
Toe & Heel raises in sitting
Active ankle ROM exercises
Passive DF stretches, PWB in sitting, e.g Heel slides
SSTM
Basic Proprioceptive exercises as appropriate

Week 7-9
Wean out of boot once DF past neutral and able to FWB in boot without crutches
Gait re education out of boot +/- heel raise in shoe, FWB no crutches
DF stretches in standing
Heel raises in standing 80/20, 50/50, 20/80
Resisted theraband exercises for all movements
Progress proprioceptive exercises

Week 9-12
Aim towards single leg heel raises
Refer to Ankle class
Eccentric and concentric loading exercises

Week 12 onwards
Single leg heel raises
Walking on toes
Jogging on toes
Running
Return to sport

Use your clinical judgement to progress each stage, e.g pain, stretch, strength.

[wafto]

WHAAAAAAAAAT, they are surely taking the p**s, in my opinion if you follow this regime you WILL re-rupture. I am at nearly 8 months, conservative method, and only had the courage to rise up on tip-toes using both feet and transfer the weight onto my injured leg and walk 2 weeks ago, and then it showed how weak my calf muscle was. I was told by my physio to never stress test the repair, the exercises you have listed, especially from week 9 onwards all stress the repair. Like John (Lambertcar), I am very focused on getting back to normal and seem to live in the gym, but all the work I carry out is agreed in advance with the physio and not once has he told me to do any of what you have listed, especially from week 12 onwards. This injury is going to take at least 12 months to recover from, listen to what Simon says and he should know, take it easy, slowly, slowly is the only way. You will have setbacks, my AT is as sore as hell today, but I had a good workout last night and probably overdid it, my limp is back so I will have to take it easy over the next few days.

Please take care.



Steve

[smacsor]

This scares the s**t out of me!!!

I tripped yesterday in work getting up from my desk and put my full weight on my bad leg. I felt a stabbing pain in my tendon and this remained for the rest of the day. I woke up this morning and the pain is still there (but reduced) so I'm having a quiet day at home today.

I'm sure I haven't done any damage and I'm virtually back to normal now but it just shows that even after 12 weeks (and this is with surgery, not conservative), you still need to be really careful.

I'm having private physio at a clinic that deals with professional sports people and they are still not even considering heel raises.

I know you have to place a certain degree of trust in healthcare professionals but there are a few of us who have suffered the consequences and now have a healthy degree of cynicism.

As Steve and Paul have commented, why test your tendon strength at such an early stage? Surely it's better to take things slow and have a higher chance of a successful outcome. I don't care if it takes me another 12 months to get back to full fitness but I have no idea how I would cope psychologically if I ruptured again.

I really don't want to appear negative and you have to make your own mind up but this group is here to share experiences so if reading our stories prevents you rerupturing then that's got to be a good thing.

Take care,

Simon

[RoystonV]

Thanks for the comments and words of caution. Since the nightmare of the ruptured achilles started for me (only 3 weeks now but feels like a lifetime!) I have been expecting a long, slow recovery to some sort of normality. I've got a lot of useful information from people who have been through this nightmare and I can't ignore those experiences.

Thats why I was surpised/anxious about my visit to the hospital yesterday when they outlined the regime they follow and wanted to get some comments from those that have been there and got the T-shirt.

The hospital is a big, renowned hospital and I am registered with the Trauma Unit which again is supposed to be very good. As you say, you have to place a certain amount of trust in the professionals. They are telling me that there is much clinical evidence to show that early controlled mobilisation is beneficial and their results are very good (they are treating injuries like me all the time). What I am to do? Ultimately, I guess its up to me to make an informed decision on what the doctors are saying, what information I can pick up here, by listening to my body, by being careful, etc.

Doing a quick search on t'internet does find a number of references to the benefits of early controlled mobilisation. One of the papers suggest that the "physiology of tendon healing would suggest that a certain amount of movement and stress during healing is beneficial". I assume thats why its been suggested that I do some small amounts of weight bearing? Some of the other links I found along these lines are:

http://www.physsportsmed.com/issues/2000/03_00/kannu.htm
http://journal.ajsm.org/cgi/content/full/31/5/685#R22
http://www.renaissancept.com/rpt_newsletter_summer_2001.html
http://www.fqresearch.org/spontaneous_8.htm

Anyway, I'm confused now

Keep the comments coming

Neil

[smacsor]

Neil,

I think everyone agrees that early mobilisation and a certain degree of stress during healing is beneficial but when you are doing heel raises and going on to your toes, all your weight is transferring through a newly healed tendon.

Paul did this during physiotherapy and his snapped. I did this on the advice of a physiotherapist and mine snapped as well.

Early exercising to get flexibility back into the joint is definately universally recommended. The differences of opinion are around when do start the more agressive and strengthening exercises.

Sorry it's so confusing, I'm afraid there's no easy answers but I certianly founf other peoples experiences a great help both in respect of knowing when to be cautious and for encouragement.

Regards,

Simon

[gerry k]

Hi guys. Did mine a year ago playing badminton. When my cast came off after 9 weeks the doctor asked me to go up on my toes then and there !!!! I nearly hit him. I didnt even attempt it and my physio was gobsmacked when I told her about it. Obviously the person who wrote that exercise system has never ruptured their tendon. !!!
It was weeks after my cast came off before I had the nerve to even try to go up on my toes never mind actually being able to do it. Its a slow process and a cautious one as you are building confidence as well as strength and suppleness. I was running after about 5 months but I really did spend a lot of time on my exercises and stretching during those first months of rehabilitation. It is fine now but still dont have the confidence to play badminton. You take your time, be careful, watch those kerbs and bikes. One thing though happened to me. Wearing my shoes for the first time going down the hall way I stepped on my shoelace which had come undone. The pain and the terror that it had gone again !!!!
Luckily it only stretched it a little but it was bloody sore and put back my
healing by about 10days so be warned !!!!!

[Bernie]

I found this thread most informative but frightening,

I'm 75 and at week 6. With the wind in the right direction, when do you think I will be able to drive again?

Regards Bernie

[RoystonV]

If I remember correctly (it was 3 years ago now ) I think I was driving just after Christmas so didn't drive for just under 4 months. It was my right foot though so didn't want to risk any problems due to braking. This regime worked fine for me. From what I recall I started riding my bike at about the same time.

[nobleduke]

No way one should attempt one heel raises at the 9th week or even the 12ht week mark...I tried two heel raises after 12 weeks...one single heel raise only after 20 weeks...couldnt do it till the 25th week...

[WDB]

Yeah, that chart sounds pretty insane to me. Whoever thought of that must have been smoking some serious crack!

[bogstandard]

There is little doubt that such a regime can work and indeed can encourage positive healing and mitigate damage caused by long term inactivity. However it is entirely dependent on the individual's injury. The progress must be monitored continuously by ones specialist - ultra sounds etc.- something that appears not to happen in the shambles of the UK's health system some of the kindest thing one can say about some of the consultants/registrars/ is that they have a pulse Oh and they earn several times more than their slipshod slovenly French or German colleagues with moonlighting privileges thrown in for good measure!
So if you are "young" have a hands on specialist seen every few days or week you definitely have a singular advantage over most of us in the UK who have been forced to take a safe fit all sizes recovery plan ie medicine more as practiced cheaply in 1907 than in the developed World in 2007. If you aint so blessed then be mighty careful! Don't do any body weight heel lifts before walking without a limp - there is nothing to be gained by so doing! The absolute best place to start lifts etc is in water at a suitable depth!

[Rah]

Hello there

I find it all very confusing, I haven't had surgery but 4 weeks in a cast and am on week 3 of 8 of my aircast boot. I have been told not to do any exercises at all as its to early and the tendon could rupture again. When i asked about physio I was told that it wasnt reccomended as this could again cause another rupture if not done gently enough! So, I am doing nothing at all, apart from trying to walk as normally as poss with the aircast on.

Anyway, time for another chocolate hob-nob........

Rah.

[normofthenorth]

I agree that this protocol seems very aggressive -- especially the timing of one-legged calf raises. I'm now an "expert", since I'm partway through the rehab of my SECOND ATRupture. Both from competitive volleyball, both from doing the same "move", eccentric, switching from back-pedaling to lunging forward.

I started with the right side, 8 yrs ago, recovered very well with surgery. I'm now working on the right side, without surgery, following the protocol of a careful randomized study (surgery vs. non-) done recently at Univ. of Western Ontario in Canada (not far from here -- I'm in Toronto).

You can find that protocol online -- I posted a link in my first (bottom) blog post at http://achillesblog.com/normofthenorth/ . There are TWO versions of the protocol, at http://clinicaltrials.gov/ct2/show/NCT00284648 and http://www.medscape.com/viewarticle/588904 . (They really followed the slightly less aggressive one, second link.)

After my first ATR, I progressed slowly ("conservative" surgeon) but steadily, until I could finally walk normally in bare feet. It was almost exactly 4 months (16+ weeks) after the surgery. That day, my physio told me to do one-legged heel lifts (calf raises, whatever) on my "bad" side. I refused, because I told her I couldn't do anywhere near 8, so it was too hard. She said "just do as many as you can". Like a fool, I did just that -- and I couldn't walk again in bare feet for a MONTH!

More details, and current progress, at http://achillesblog.com/normofthenorth/ .