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Can a hinge joint technically allow rotatory motion?

Can a hinge joint technically allow rotatory motion?



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Let's use a hinge joint and pivot joint as examples.

When talking about the difference between them in terms of movements permitted, I see that on any websites and textbooks, the term 'rotation' is applied to pivot joint only rather than hinge joint.

For example, according to Moore Clinically Oriented Anatomy 10th edition.

Hinge joints permit flexion and extension only, movements that occur in one plane (sagittal) around a single axis that runs transversely; thus, hinge joints are uniaxial joints.

Pivot joints permit rotation around a central axis; thus, they are uniaxial. In these joints, a rounded process of bone rotates within a sleeve or ring.

I never see the word 'rotation' being used to describe hinge joints' motion, however, doesn't hinge joint technically allow rotation, just that the rotation for hinge and for pivot joints are over a different axis? For example, at the anatomical position, flexion in the elbow's hinge joint involves rotating the joint along the tranverse axis.

So my question is, can a hinge joint technically allow rotatory motion? If not, am I misunderstanding what is meant by 'rotation'/'rotatory motion'?


It is about the movement of the bone along its major axis of movement. A hinge joint moves like a lever while a pivot joint involves rotation side to side like an axle.

It helps if you look at a example of a bone that has both types of joints. The radial head is part of both a pivot and hinge joint, with the ulna it rotates allowing the hand to pronate and is a pivot joint, while with the humerus it is a hinge allowing the arm to swing through an arc.

Keep in mind these are biological terms and not strict engineering descriptions, biology is more interested in how tissues move relative to each other. Biological terms are not interchangeable with geometry and engineering, nor are they designed to be perfectly rigorous, they are descriptive in nature. In biology rotation is a term reserved for more wheel and axle type motion where a bone is revolving around its own axis.

Find more help here.


6 Types of Freely Movable Joints

The human body has 206 individual bones. These bones come together at connections called joints. While some joints do not move freely, such as those in the skull, chest and pelvis, others have a range of motion, enabling mobility and the ability to complete tasks without much thought. While they seem simple, joints are complicated body parts with abilities that vary based on their structure.

Simply defined, a joint is a place where two bones join. Joints fall into two basic categories: fibrous and cartilaginous joints, which contain connecting tissue and are mostly fixed in place, and synovial joints, which contain synovial fluid that enables movement as one bone smoothly slides over another. The joints that move are the ones most commonly studied.

The bones in synovial joints are covered with a thin layer of cartilage. Thin-walled sacs, called bursas, provide a cushion between the cartilage, allowing the bones to freely and smoothly move without rubbing against each other. Certain joints also have specialized cartilage such as the disks of the spine or meniscus in the knee that further cushion where the bones meet. Ligaments and tendons serve as connectors for these joined bones and are important to the proper functioning of joints. Ligaments connect bone to bone, tendons connect muscle to bone. Ligaments are essential to joint health a stretch or tear to a ligament is usually called a sprain, while damage to a muscle or tendon is a strain. There are six types of synovial joints, each allowing its own type of movement.


Hinge Supports

The hinge support is capable of resisting forces acting in any direction of the plane. This support does not provide any resistance to rotation. The horizontal and vertical component of reaction can be determined using equation of equilibrium. Hinge support may also be used in three hinged arched bridges at the banks supports while at the center internal hinge is introduced. It is also used in doors to produce only rotation in a door. Hinge support reduces sensitivity to earthquake.


Ligaments

There are two main sets of ligaments, which originate from each malleolus.

Medial Ligament

The medial ligament (or deltoid ligament) is attached to the medial malleolus (a bony prominence projecting from the medial aspect of the distal tibia).

It consists of four ligaments, which fan out from the malleolus, attaching to the talus, calcaneus and navicular bones. The primary action of the medial ligament is to resist over-eversion of the foot.

Lateral Ligament

The lateral ligament originates from the lateral malleolus (a bony prominence projecting from the lateral aspect of the distal fibula).

It resists over-inversion of the foot, and is comprised of three distinct and separate ligaments:

  • Anterior talofibular – spans between the lateral malleolus and lateral aspect of the talus.
  • Posterior talofibular – spans between the lateral malleolus and the posterior aspect of the talus.
  • Calcaneofibular – spans between the lateral malleolus and the calcaneus.

Fig 4 – Ligaments of the ankle joint.

Clinical Relevance: The Ankle ‘Ring’

The ankle joint and associated ligaments can be visualised as a ring in the coronal plane:

  • The upper part of the ring is formed by the articular surfaces of the tibia and fibula.
  • The lower part of the ring is formed by the subtalar joint (between the talus and the calcaneus).
  • The sides of the ring are formed by the medial and lateral ligaments.

A ring, when broken, usually breaks in two places (the best way of illustrating this is with a polo mint – it is very difficult to break one side without breaking the other).

When dealing with an injury to the ankle joint, a clinician must bear this in mind. For example, a fracture of the ankle joint may occur in association with ligament damage (which would not be apparent on x-ray).


Cartilaginous Joints: Symphyses

A symphysis is a secondary cartilaginous joint that is permanent and slightly movable.

Learning Objectives

Differentiate among the types of symphyses between two bones

Key Takeaways

Key Points

  • Symphyses include the pubic symphysis and the intervertebral disc between two vertebrae, among others.
  • The pubic symphysis or symphysis pubis is the midline cartilaginous joint uniting the superior rami of the left and right pubic bones. It widens slightly whenever the legs are stretched far apart and can become dislocated.
  • Intervertebral discs lie between adjacent vertebrae in the spine. Each disc forms a cartilaginous joint to allow slight movement of the vertebrae and acts as a ligament to hold the vertebrae together.

Key Terms

  • annulus fibrosus: Fibrous ring of intervertebral disk.
  • nucleus pulposus: Inner gel-like center of the vertebral disc.
  • sciatica: Pain that travels down the leg from the lower back region.
  • symphysis: The cartilaginous material that adjoins and facilitates the junction of such bones, with or without synovia.
  • intervertebral disc: A cartilaginous joint that allows slight movement of the vertebrae by lying between adjacent vertebrae in the spine. It also acts as a ligament to hold the vertebrae together.

A symphysis, a type of secondary cartilaginous joint, is a fibrocartilaginous fusion between two bones. It is an amphiarthrosis (slightly movable) joint, and an area where two parts or structures grow together. Unlike synchondroses, symphyses are permanent. The more prominent symphyses are the pubic symphysis the symphyses between the bones of the skull, most notably the mandible (symphysis menti) sacrococcygeal symphysis the intervertebral disc between two vertebrae and in the sternum, between the manubrium and body, and between the body and xiphoid process.

Pubic Symphysis

The pubic symphysis or symphysis pubis is the midline cartilaginous joint (secondary cartilaginous) uniting the superior rami of the left and right pubic bones. It is a nonsynovial amphiarthrodial joint connected by fibrocartilage, and may contain a fluid-filled cavity. The ends of both pubic bones are covered by a thin layer of hyaline cartilage attached to the fibrocartilage.

Symphyses: Diagrammatic section of a symphysis including the ligament, disc of fibrocartilage, and articular cartilage.

The pubic symphysis is located anterior to the urinary bladder and superior to the external genitalia, above the vulva in females and above the penis in males. The suspensory ligament of the penis attaches to the pubic symphysis. In females, the pubic symphysis is intimately close to the clitoris. In normal adults, it can be moved roughly two mm and with one degree of rotation. Mobility of this joint increases for women at the time of childbirth.

During birth, the pubic symphysis of relaxes to slightly widen the birth canal. This movement is minimal, but along with the compression of the unfused fetal skull generally allows an infant to be born vaginally.

The pubic symphysis widens slightly whenever the legs are stretched far apart. In sports in which this movement is frequent, the risk of a pubic symphysis blockage is high. This injury occurs when the bones at the symphysis do not realign correctly after completion of the movement and get jammed in a dislocated position. The resulting pain can be quite severe, especially if further strain is put upon the affected joint. In most cases, the joint can only be successfully reduced into its normal position by a trained medical professional.

Pubic symphyses have importance in the field of forensic anthropology, as they can be used to estimate the age of adult skeletons. Throughout life, the surfaces become worn at a more or less predictable rate. By examining the wear of the pubic symphysis, it is possible to estimate the age of the person at death.

Mandible

The external surface of the mandible is marked in the median line by a faint ridge, indicating the symphysis menti, mandibular symphysis, or line of junction. This line delineates the two pieces of bone that compose the mandible during the first years of life.

Intervertebral Discs

Intervertebral discs (or intervertebral fibrocartilage) lie between adjacent vertebrae in the spine. Each disc forms a cartilaginous joint to allow slight movement of the vertebrae and acts as a ligament to hold the vertebrae together. The discs consist of an outer annulus fibrosus that surrounds the inner nucleus pulposus. The annulus fibrosus and the nucleus pulposus distribute pressure evenly across the disc.

The nucleus pulposus contains loose fibers suspended in a mucoprotein gel with the consistency of jelly. The nucleus of the disc acts as a shock absorber, absorbing the impact of the body’s daily activities and keeping the two vertebrae separated. The disc can be likened to a jelly doughnut with the annulus fibrosis as the dough and the nucleus pulposis as the jelly. If one presses down on the front of the doughnut, the jelly moves posteriorly. When one develops a prolapsed disc, the jelly (the nucleus pulposus) is forced out of the doughnut (the disc) and may put pressure on the nerve located near the disc, potentially causing symptoms of sciatica.

Diagram of Invertebral Disc: The lateral and superior view of an invertebral disc, including the vertebral body, intervertebral foramen, anulus fibrosis, and nucleus pulposus.

Aging causes disc degeneration, in which the nucleus pulposus begins to dehydrate and the concentration of proteoglycans in the matrix decreases, limiting the ability of the disc to absorb shock. This general shrinking of disc size is partially responsible for the common decrease in height as humans age.


Legs and Arms

Types of Joints in the Skeletal System

The legs and arms have ball and socket joints that allow the limbs to move in any direction to include pivoting. The glenohumeral joint articulates the humerus to the space in the shoulder known as the glenoid fossa. The glenohumeral, or shoulder, joint is not a true pivot joint, but the ball and socket connection allows this joint to appear to pivot when it is actually medially and laterally rotating. The same is true of the iliofemoral joint, the femur joining the hip at the ilium that attaches the femur, or thigh, to the ball and socket joint in the hip. The femur appears to pivot because it rolls into a pivot position. In order for the joints of the legs and arms to be true pivot joints, they would need to have a stationary axis on which to pivot.

  • The legs and arms have ball and socket joints that allow the limbs to move in any direction to include pivoting.
  • The glenohumeral, or shoulder, joint is not a true pivot joint, but the ball and socket connection allows this joint to appear to pivot when it is actually medially and laterally rotating.

Five Tips for Training the V-Sit

When I attended my first Progressive Calisthenics Certification, learning to hold an L-sit was one of my goals. It’s a tough move, but I surprised myself and was able to nail it for a few seconds that weekend. Of course once I got the L-sit, I needed a new challenge.

This was how I began my journey toward the V-sit, a move which progresses the L-sit by lifting the legs and hips higher, changing the shape of the body from a position resembling the letter “L” to one that looks like a “V.” Due to the shift in balance and leverage, it’s also a lot harder.

It’s been almost 3 years since I went to my first PCC, and I’m just finally starting to get comfortable holding a proper V-sit. Like many advanced calisthenics exercises, training for this move requires a lot of patience. It also forced me to reassess several aspects of my training that I did not realize had been lacking.

Here are 5 things I learned along the way that helped me achieve this difficult feat:

1 – Make A Good “Compression”
Before I started working toward the V-sit, I thought I already had a very powerful core. Whereas conquering the L-sit bolstered my confidence, starting over with the V-sit was a humbling reality check. The two moves may not look substantially different, but the amount of abdominal strength required to perform a V-sit is exponentially greater.

Transitioning from an L-sit into a V-sit is not just about lifting your legs higher – you also need to bring your hips farther forward. This means compressing your trunk by drawing your pelvis toward your sternum, and that requires significant abdominal activation, particularly when your legs are above you in the air. It can help to practice other exercises that involve this type of abdominal compression, like “toes-to-bar” hanging leg raises, to better get a feel for this.

I also recommend the “boat pose” from yoga, as it mimics the V-sit, while allowing you to stay seated on the ground. This makes the exercise considerably less difficult while still letting you get a feel for the body alignment needed for the V-sit.

2 – Elevate Your Training
Practicing this move with your hands elevated on parallettes or yoga blocks can be helpful during your journey to the V-sit. Not only does holding onto something make it less brutal on your wrists, but it also gives you extra room for your hips and legs.

When I first started toying with the V-sit, I would begin by holding a bent-knee L-sit on my parallel bars. From there I started experimenting with sliding my hips forward in front of my hands. This helped me figure out that I needed to shift my weight back in order to move my hips into the proper position. From there I could practice leg extensions, gradually reaching my legs farther in the air each time.

3 – Stretch Your Way to Success
Though many people tend to skip this portion of their training, if a V-Sit is one of your goals then you will probably need to improve your hamstring flexibility.

The classic toe touch or forward fold is a great way to loosen the backs of your legs in preparation for the V-sit, and there are several ways in which you can approach it: You can bend over from a standing position, practice the gym-class style “sit and reach” while on the ground, or even try it hanging with your legs raised and feet hooked beneath the bar. I recommend spending some time in all of these positions as a warm-up for your V-sit practice, as well as throughout the day.

In the beginning, these moves can be practiced with a slight bend in your knees, or with your legs slightly apart. As your flexibility increases (where you can touch your toes without overly rounding your back), you can start to slowly straighten your knees and/or bring your legs together until you are in the full expression of each pose. You may find it helpful to exhale fully as you fold forward. When you reach your “edge,” focus on drawing your abdominal muscles inward to go deeper. It may be helpful to repeat this process several times.

4 – Use Helping Hands
When performing this move, proper hand positioning is important for success. If your hands are placed too far away from your body it will be difficult to generate tension between your arms and your torso. Furthermore, turning your hands out and pointing your fingers to the sides (or behind you) can allow you better leverage to lean back farther without tipping over. You can also practice “tenting” your hands to help you find a little extra clearance when you begin practicing the V-sit on the floor.

5 – Don’t Forget to “Tri”
There is an immense amount of triceps strength needed in order to do any type of L or V-Sit. You also need strong lats, a powerful chest and iron forearms. One of the best pieces of advice I’m continually reminded of every time I’m at a PCC event is to “get great at the basics.”

This means you need to do your push-ups, pull-ups, squats and knee raises. Anytime you find yourself at a plateau with a new skill, you can always return to these foundational exercises. Yes, you need proper technique and training to conquer the V-sit, but that journey begins with perfecting the basics.

The V-sit takes practice and patience to achieve, but you’ll never get there if you don’t try!

Grace Kavadlo is a PCC Team Leader, personal trainer and group exercise instructor located in New York City. She is a columnist for Bodybuilding.com and can be seen in several Dragon Door books, including Al Kavadlo’s Zen Mind, Strong Body and Paul “Coach” Wade’s Explosive Calisthenics. For more information about Grace, check out her website, www.DieselGrace.com.


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Library of Congress Cataloging-in-Publication Data

Creating games with Unity and Maya : creating games with Unity and Maya : how to develop fun and marketable 3D games / Adam Watkins.

1. Computer games--Programming. 2. Video games--Design. 3. Unity (Electronic resource) 4. Maya (Computer file) 5. Three-dimensional display systems. I. Title.

QA76.76.C672W322 2012 794.8'1526--dc23

British Library Cataloguing-in-Publication Data

A catalogue record for this book is available from the British Library.

For information on all Focal Press publications visit our website at www.elsevierdirect.com

Books like this are the results of a lot of work by a lot of people. It is important to point them out.

First, many thanks to Kelly Michel and the team at the Los Alamos National Laboratory that made working on this book possible. The opportunities to learn and grow have been exciting to me professionally, and I've personally very much enjoyed my time working with my teammates Brian Dickens, Elise Elfman, Jake Green, and Birch Hayes.

Also, thanks to the tireless efforts of my tech editor, Anson Call the book is more accurate, and tighter conceptually than it would have been without his meticulous work.

Thanks also, of course, to the editors at Focal with whom I have worked on the project: Sara Scott, Laura Lewin, Katy Spencer, and Lauren Mattos.

Acknowledgments . . . . vi

Chapter 1: Game Production Process . . . .1

The Tools and Unity . . . . 4

Teams of Teams and Pipelines . . . . 4

Technology Assets (Scripts) . . . . 5

Order of Operations . . . . 6

Conclusion and Introduction to Incursion . . . . 6

Chapter 2: Asset Creation: Maya Scenography Modeling . . . .9

Scenography Modeling within the Game Design Pipeline . . . . 9

Limitations and Optimizations for Games . . . .13

Rules of 3D Game Modeling . . . .14

Tutorial 2 .1: Game Level Modeling: The Entryway . . . .17

Cleaning or Deleting History . . . .27

Homework and Challenges . . . .34

Chapter 3: Asset Creation: Maya Scenography UV Mapping . . . . 37

Scenography UV Layout within the Game Design Pipeline . . . .37

Exploring the UV Texture Editor . . . .39

Tutorial 3 .1: Game Level UV Layout, Tools, and Techniques . . . .40

Mapping Beginning with Automatic Mapping . . . .42

Further Optimization . . . .49

Maya's Unfold UV via Smooth UV Tool . . . .50

Homework and Challenges . . . .62

Chapter 4: Asset Creation: Maya Scenography Texturing . . . . 63

Textures, Materials, and Shaders . . . .63

Nature of Effective Textures . . . .64

Tutorial 4 .1: Seamless Tiled Textures . . . .66

Select and Prepare a Raw Texture Image . . . .68

Offset and Clone Stamp . . . .68

Unify the Color Balance . . . .70

Tutorial 4 .2: Nontiled Textures and Their Dirt . . . .74

Preparing the UV Snapshot for Painting in Photoshop . . . .76

Painting the Texture . . . .77

Saving Multiple Files . . . .82

Application in Maya . . . .82

Chapter 5: Asset Creation: Unity Scenography Importing . . . . 89

Tutorial 5 .1: Creating a Unity Project . . . .90

About the New Project File . . . .92

Tutorial 5 .2: Exporting from Maya . . . .97

Unity Nomenclature . . . .101

Tutorial 5 .3: Importing, Tweaking, and Placing Scenography Assets into Unity . . . .102

Inspector Breakdown . . . .108

Homework and Challenges . . . .112

Chapter 6: Asset Creation: Unity Scenography Creation Tools . . . . 113

Asset Creation in Unity . . . .113

Tutorial 6 .1: Adding and Manipulating Unity Water, Sky, and Fog . . . .114

Importing Packages . . . .114

Tutorial 6 .2: Terrain Creation . . . .121

Terrain Editing Tools . . . .125

Tutorial 6 .3: Primitives and Particles . . . .136

Tweaking Terrain Settings . . . .143

Chapter 7: Asset Creation: Advanced Shading, Lighting, and Baking . . . . . 145

Baking in Unity (aka Unity Lightmapping) . . . .146

Limitations to Unity Lightmapping . . . .147

Tutorial 7 .1: Normal Maps . . . .148

Tutorial 7 .2: Lighting and Baking in Unity . . . .159

Unity's Lighting Instruments . . . .160

Homework and Challenges . . . .178

Chapter 8: Asset Creation: Maya Character Creation . . . . 179

Considerations of Style Sheets . . . .181

Tutorial 8 .1: Game Character Modeling: Aegis Chung . . . .182

Chapter 9: Asset Creation: Maya Character UV Mapping and Texturing . . . . 233

Tutorial 9 .1: Character UV Mapping . . . .234

Mesh Inspection and Cleanup . . . .234

Tutorial 9 .2: Character Texture Painting . . . .262

Ambient Occlusion Pass . . . .264

Chapter 10: Asset Creation: Maya Rigging and Skinning and

Unity Animated Character Importing and Implementation . . . . 275

Tutorial 10 .1: Rigging . . . .276

Joints and Rigging . . . .280

Tutorial 10 .2: Maya Skinning . . . .302

Binding Rigid Body Parts . . . .303

Painting Skin Weights . . . .305

Tutorial 10 .3: Maya Animation . . . .310

General Notes on Game Animation . . . .310

Tutorial 10 .4: Getting Animated Characters to Unity . . . .314

Tutorial 10 .5: Animating in Unity . . . .319

Homework and Challenges . . . .322

Chapter 11: Unity Sound . . . . 323

Sound Listener and Sound Source Paradigm . . . .325

Tutorial 11 .1: Placing Sound in Unity . . . .325

Audio Reverb Zones . . . .327

Homework and Challenges . . . .332

Chapter 12: Introduction to Unity Scripting Basics and Graphical User Interface . . . . 333

Unity's Scripting Languages . . . .334

A Note about This Approach . . . .336

Tutorial 12 .1: Graphical User Interfaces . . . .340

Homework and Challenges . . . .354

Chapter 13: Unity Triggers . . . . 355

Designating Triggers . . . .356

Tutorial 13 .1: Activating and Changing Screen Hints with Triggers . . . .356

Scripting the GUIText . . . .359

Scripting Triggers . . . .361

Triggers to Swap Levels . . . .364

Tutorial 13 .2: Triggers and Doors . . . .367

Cleaning Up with Destroy and Booleans . . . .373

Homework and Challenges . . . .377

Chapter 14: Unity Raycasting . . . . 379

But First . . . A Few Notes on Scripting and Help . . . .381

Commenting Blocks of Script with /* . . . .382

Accessing the Documentation . . . .383

Decoding a Help Page . . . .384

Tutorial 14 .1: Highlighting Actionable Objects with Raycasting . . . .386

Homework and Challenges . . . .402

Chapter 15: Unity Prefabs and Instantiation . . . . 403

Prefabs versus Prefab Connections . . . .404

Tutorial 15 .1: The Power of Prefabs . . . .407

Tutorial 15 .2: Setting Up the Armed Arms . . . .414

Tutorial 15 .3: Firing a Gun . . . .417

A Few Notes about Pistol Sparks . . . .419

Quick Note about Detonator and Explosion Framework . . . .420

Tutorial 15 .4: Sound Revisited . . . .423

Scope and Optimizing Script . . . .425

Tutorial 15 .5: The EMP Mines . . . .427

Make the EMP Effective . . . .437

Chapter 16: Unity: Creating Inventory Systems . . . . 441

State Engine and How Many Scripts? . . . .441

Tutorial 16 .1: Setting Up Inventory GUI and Script . . . .443

Refresher on Interscript Communication . . . .446

Firing Animations in Script . . . .448

Hiding and Showing Weapons . . . .453

Bulking up the GUI System . . . .457

Create a GUIElements Prefab . . . .458

Animate the Inventory to Show and Hide . . . .459

Tutorial 16 .2: Keys . . . .464

Accessing the State Engine . . . .465

Building upon the Raycasting Mechanism . . . .465

Creating a Smart Trigger . . . .467

Homework and Challenges . . . .472

Chapter 17: Health Systems, Winning, and Losing the Game . . . . 473

Tutorial 17 .1: Winning . . . .474

The Endgame Trigger . . . .476

Tutorial 17 .2: Health Systems . . . .478

Creating Health Display . . . .479

Creating the Damage Triggers . . . .482

Particles Doing Damage (Steam) . . . .487

Homework and Challenges . . . .494

Chapter 18: Unity Debugging, Optimization, and Builds . . . . 495

Finding What Needs to Be Optimized . . . .496

Optimizing with Textures . . . .498

Optimizing with Scripts . . . .500

Preparing Player Settings . . . .501

Outputting the Final Build . . . .506

Why This Book?

The Unity Game Engine has been shaking things up. The engine is only a little over five years old now and in 2010 they have earned Develop Magazine's Grand Prix Award and surpassed 170,000 developers. The user base of consuming Unity products has grown dynamically as well. There are over 30 million total Unity Web Player installations, and the base continues to expand at over 2 million installs per month.

Part of this success undoubtedly comes from their 2009 bold move to give away a free version of Unity Indie. Suddenly, everyone could get their hands on a game engine and anyone with the will to learn could start making games. Unity further empowered the masses by making Unity a viable development platform for iDevices (iPhone, iPod Touch, iPad), Mac, PC, Xbox 360, Wii, and now Android and PlayStation 3. Web deployment further democratized the 3D development and distribution process. At conferences and online Unity is generating quite the buzz. Since I have been using the software, conversations among faculty at training institutions and game developers alike have gone from, “Unity? No, I've never heard of that. Is it new?” to “Yeah, we're using Unity in three of our courses coming up this semester,” and Skype tags that say, “I want Unity 3.0.”

But with all this buzz, and the rapid development and deployment cycle that the Unity 3D team has undergone, there has been a distinct lack of introductory documentation, especially documentation aimed at the entire process of game development. In recent months there have been some new (and really nice) books released to get people into Unity and it is true that Unity provides some nice downloadable projects and some tutorials attached to those projects (which you should grab for free if you haven't yet), but often while my students (who are trained as 3D artists) have worked through these, although they have become familiar with Unity's interface and with what does what, they are simply unable to extrapolate this knowledge into a new “authored from scratch” game. Further, most of the Unity 3D provided tutorials are focused on Unity and provide prebuilt assets that the reader simply plugs into his or her Unity project. This misses some of the vital creative processes and tricks of getting these assets into Unity.

Who's It For?

My professional background recently has been developing training games for inspectors in pursuit of nonproliferation efforts at the Los Alamos National Laboratory. But this is a temporary assignment and part of a one-year research sabbatical. I am on sabbatical from a position as head of 3D Animation at the University of the Incarnate Word in San Antonio, TX where I have taught 3D animation for over 10 years. With this background, as I use tools, I am always thinking of how this particular tool or technique can be taught, and how it can be taught differently to different demographics.

In the construction of this book, there are three main groups of learners in mind:

Game Enthusiasts: The biggest group of students we have coming

into our university are those with the idea, “I love to play video games, therefore, I'll be great at making them.” Unfortunately this is often not the case—consuming is much different than creating—but, this sort of enthusiasm is important to maintain through the long learning arcs that are required for making 3D games. This book assumes that, at the very least, you love games. And that you are passionate enough about them that you want to create your own games.

This volume is for you. Equipped with a free version of Unity and a copy of Maya, this book will provide you with the necessary steps and ideas to empower your own game creation. The book is organized into manageable tutorials coupled with theory discussions so you can see measurable progress quickly that you can bridge into your own development. In a few days, or weeks, you could have your first tutorial-driven game developed, and the scripts to begin your own.

Students: Ten years ago, developing 3D animation programs was all the

rage at colleges and universities. This enthusiasm has crept into high schools and even middle schools. With this 3D curriculum—of which you may be a part—has come the natural desire to expand into game development. This book has been specifically structured with you in mind. The tutorials are structured so that they can be tackled in class or as part of a homework assignment. The pacing has been carefully considered to allow for bite-sized chunks of knowledge that are still delivered at a brisk pace. Most importantly, each chapter builds on the next and allows for real progress really quickly.

Teachers: I have done a lot of training for teachers at colleges, universities,

Included in the appendices for this book (on the supporting website

(http://www.Creating3DGames.com) are some suggested curricula for using this book in a classroom setting. It will help in being able to plug this book into your work flow and class plans. Although it will be critical that you follow the tutorials yourself to understand the questions that the students will undoubtedly have, this volume will provide some tutorials for in class or homework that will help to provide a lot of instruction in learning the 3D-to-game publication process.

Structure

Although presently I am also a game developer, my long-term passion is teaching. I know how people learn 3D and game engines. There is an unfortunate trend for many early learners to pick up a tutorial and immediately start working through the steps without any consideration to why that tutorial was written, and what the basic concepts are behind the steps they are following. At the end of the tutorial, readers have the sense of accomplishment that they have finished the tutorial, but suddenly come to the crushing reality that they can't create their own project, and they couldn't even replicate this project unless the tutorial was in front of them again. Essentially, they have become recipe followers—they can only cook if the book is open in front of them, and if someone else has figured out the steps. They certainly aren't chefs. The goal of this book is to make master game chefs. To do this, there are some specific conventions this book will follow.

First, every chapter and every tutorial will be prefaced with some theory— some explanations of the method behind the madness of what they are about to embark on. This theory will cover not only the reasoning of the tutorial and its goals but also the reasoning behind Maya or Unity and their particular implementation of 3D technique. Avoid the temptation to skip the theory and smash into the tutorial you will be much more enriched by understanding the reason behind the steps.

Every chapter will also include tutorials, some longer than others, but each with a very specific learning objective in mind. Each tutorial will build upon the last and move us closer to completing the game that will be playable at the end of this book. However, this book is a novel, not a collection of short stories, and if you skip too far ahead too quickly, you will miss vital information that make later chapters seem logical. So even if you know the technique covered and you have no need to follow a given tutorial, be sure you skim through it to see what is being covered there.

they are an important self-assessment tool to check if you have really gotten the core concepts presented in the chapter. You will get the most out of this book if you tackle those challenges. They will cement ideas and strengthen technique before you move on.

Book Paradigm and Assumptions

Although Creating Unity3D Games is meant to be holistic, it is not comprehensive of everything involved in creating 3D games. It is assumed that you have the following things:

Unity and Maya: At the publication of this book, the latest versions of this

software will be Maya 2011 and Unity 3.2. The Unity 3.2 Indie license is free (downloadable at www.unity3d.com), and if you are a student, Maya 2011 can be had for free for one year at http://students.autodesk.com/ if you sign up at the Autodesk Education Community. For a registered student, your biggest expense of the process will be this book.

Basic Knowledge of Maya: This knowledge can indeed be basic, but this

book will not take a huge amount of time to work through Maya interface, or basic tools. You should know how to navigate the camera controls and how to conduct basic functions of moving, rotating, and scaling objects. This book will be focusing on very game-specific techniques to modelling, texturing, and animating, and so some general knowledge of Maya will be of great help, although not critical.

Love and Knowledge of Games: No need to be a game geek. But,

knowing the basics of how games work and what makes them fun will be important to making games. The game in this book will be a first-person and third-first-person hybrid with both first-first-person shooter and puzzle elements. These are carefully designed to help you grasp some important concepts. But always be referencing past knowledge and looking for ways to expand the ideas covered in these pages to your own blockbuster title.

Book Conventions

Throughout this volume, I will be making use of several conventions to assist you in understanding what I'm talking about, and where.

When we are tackling a tutorial, each step will be numbered:

Step 1: Do this and then,

Step 2: Do this. When you're finished, Step 3: Try this.

Usually, these instructions will be tied closely to screenshots to help illustrate the step, or the results of a step.

finishing this tome, there will be frequent “breaks” in the tutorials to do some explaining. Watch for:

Tips and Tricks Warnings and Pitfalls Why?

These will be the important notes that get you beyond the confines of the tutorials, and on to your own million-dollar games.

Finally, navigating through the programs can be tricky (especially in Maya with its multiple nodes). Drop-down menus will be indicated with the following format:

This is shorthand for, “In Modeling mode, go to the Mesh drop-down menu and look for Combine, and choose the Options box.”

In Unity, this will be a little simpler since there are no disappearing drop-down menus like there are in Maya. However, it will be important that we are aware of what things need to be typed—as in code. Any script we type will be listed and formatted like this:

Occasionally, there will be some salient information within the code that is important to notice. When this is needed, the text will be bolded (you, however, would not need to use bold text when writing the script):

Similarly, new ideas, concepts, or keywords will be bolded within the body of the text.

A Note about the Approach

include some information that might be too basic for those approaching this from a programming background. Not to worry though, the first part of the book is 3D focused, and so there should be plenty of new material for those coming from the scripting world.

Creating Games with Unity and Maya

Game Production Process

Describing the game production process is actually a bit tricky, partly because it is different for every team and different for every budget. But also, the reality is that a team might be, well, you. Indeed, sometimes games are produced by very small groups of people, and occasionally by a team of one.

However, whether you are a team of fifty working on the next AAA blockbuster or a team of one creating a student project that you hope will get you on that team of fifty, there are some specific steps that need to happen to create a playable game. How successful you or your team are at these steps, and completing the steps in a timely manner, will play a big role in how efficiently the project comes together and how successful the game ultimately appears and plays.

The specifics of team management and money management and even time management are really out of the scope of this book (along with marketing your game and getting funding). However, understanding what needs to happen in what order will help you as you assemble your team or build your project.

The Team

of these are important for a profitable game, the focus of this book is learning the technology, so the production of the game will be the focus.

Generally most game production teams (or development teams) contain people in the following roles:

Designer: The Game Designer is the head of the creative vision. He or she

must be artistically able and technically proficient. He is able to straddle the aesthetic and programming ends of the spectrum. More importantly, he understands and often has authored the goals of the game, the genre of the game, the game play, the rules and structure of the game, and any other game mechanics. The game designer typically communicates these goals through a document called a Game Design Document.

The Game Design Document is often predicated by a Game Proposal Document before it can be created. Usually, a game designer has substantial writing skills to be able to communicate the vision of a game. This Game Design Document becomes the bible upon which the other designers reference as the game production goes on.

The structure of this document is out of the scope of what we are covering here, but there are multiple references and examples online of such documents. Further, Game Design Documents should be specific to an organization, financial structure, and even work culture. However, although we might not cover the details of what this document is, what it

Now a Game Design Document is rarely set in stone. The scope of a game and the features of a game often have to be adjusted due to time, talent, or budget reasons. However, as the production cycle grinds on, effective management and distribution of this document becomes important to keeping the team on task. I have personally witnessed many times where days and even weeks of labor were wasted because team members failed to reference—and managers failed to confirm—that they were referencing a Game Design Document.

Even if you are working as an expansive team of one, developing an internal Game Design Document (even if it is a bulleted list, or a flowchart sketch on your whiteboard, or a list on the back of a napkin) can help you keep an eye on the prize and avoid pitfalls like feature creep, where new options forever find their way into a game and keeps it from ever being released.

Mechanics Engineer: Games have mechanics. Mechanics are the rules

A quick note on this: The academic community has been studying the issue of game play and game mechanics fairly rigorously in recent years. It is still a developing field of study, and is a bit of a moving target as the rules of engagement with your game continue to change. However, if you want to get serious about understanding what makes games fun and how game mechanics can help this, there is an ever-increasing library of research that explores this. In the long run, researching this literature will be worth your while if you want to be a successful game designer or mechanics engineer.

Level Designer: Justifiably, this position has become more and more

prominent in the game production process. This designer creates the environment in which the gameplay takes place. He works carefully with the Game Designer and Mechanics Engineer to ensure that the space he is designing both remains true to the vision of the designer and allows the space for effective game mechanics. These designs are carefully considered and designed and almost always begin with conceptual sketches or paintings and detailed floor plans that lay out where puzzles, challenges, pitfalls, and enemies appear or are interacted with.

Character Designer: This is often one of the sexiest roles because this

person designs the characters. These characters are based upon the goals defined in the Game Design Document, and almost always start on paper with drawings. Conceptual sketches provide quick communication devices before the considerable modeling time is undertaken. These sketches also can provide a visceral response to a concept that often a T-pose-modeled character lacks.

Animator or Motion Designer: Animation is incredibly important in

games since it seems to be the thing that draws our attention. Ironically, even complex games have a fairly limited collection of animations that are cycled as the game is played. Some characters have as many as 100 different moves, but most have much, much less. The animator will create in-game animations that are cycled, but will also often be responsible for cut scenes and more “meaty” assignments where traditional noncycled animation is used. Very large studios often will have separate cinematic (cut scenes and intro animations) departments that are creating higher-rez, prerendered animations.

Writer: Due to strikes in recent years, there has been a migration (at least

Sound Designer: Playing a game with the sound off has its charms,

but anyone who has played a game on a big screen TV, with the lights off, and the sound pumped way up (or on headphones) knows how an effective sound design creates perhaps more ambiance than any visual elements of a game. Too often in all aspects of 3D animation, students or beginners treat sound and music as an afterthought, but it never is in big-budget games.

Sometimes for students there are budget restrictions that prevent custom soundtracks from being used. However, thinking early of sound effects and music will allow for proper timing and can even influence visual choices.

The Tools and Unity

Now that we have generally looked at who is on a team, it is important to talk through what the tools of that team are, and specifically how Unity fits within that tool box.

Unity is classed as a game engine. What this means is that it is the technology that drives a game. The way to think about it in production terms though is as an “assembler.” Unity itself is generally not used to create assets (although there are some things like particles that are created within Unity itself). Almost all the art assets are created outside of Unity itself—the 3D models are created in a 3D application (Maya, Cinema4D, Blender, modo, 3DS Max, Lightwave, etc.), the texture assets are made in Photoshop or BodyPaint, and even the scripts are actually written in some other application (UniSCTE on a PC, Unitron on the Mac, or some other scripting tool all together). All these assets are imported in Unity through a quite painless process where you are then able to combine these assets to create the game.

So, you assemble games in Unity, but most games—and all games with any level of visual complexity—make heavy use of lots of other applications in the process. Just as there are lots of different ways to create 3D assets (some will choose Maya, others 3DS Max, for instance), there are multiple game engines as well. Unity is particularly flexible and accessible that is why it is the tool of choice in this book. But be aware that there are lots of other methods of creating games (Unreal Engine, CryEngine, Source, etc.).

Teams of Teams and Pipelines

Often, a production team will be broken into two teams, an art team (sometimes called “Creative”) and a technology team. The work of both is critical for a successful game, and communication between the two teams better ensures a smooth process.

Often, technology is being developed and has been developed when the creative team delivers certain assets that are then plugged directly into the game.

However, if you are working alone (and the assumption is that most readers of this book are doing just that) creation of assets in an appropriate order will make the development process much more efficient. So to begin, let's look at the assets needed for the game produced in this book.

Assets

Once the Game Design Document is completed, the lead designer will need to start working out what assets need to be created and when they need to be done. Assets can be a lot of things: 2D elements like GUI and interface designs, texture files, 3D models, sound files, animation clips, as well as things like scripts and other mechanisms that drive the game. For this book, we will focus on two categories of assets: art assets and scripting assets.

Art Assets

For the tutorials covered in this game we will need three art-based assets: models, textures, and animations. The models and animations will be created in Maya while the textures will be created in Photoshop, but linked to the models within Maya. Other visual elements like lighting will take place in both Maya and Unity (depending on which version of Unity you are using).

Technology Assets (Scripts)

Unity allows for mechanics to be built with a variety of scripting mechanisms. Most reference or discussion you will find will be in either Unity's implementation of JavaScript or C#. These scripts are attached to an object or objects within your Unity scene and drive the interaction between the player and the game.

There are many approaches for tackling the scripting problem. My software engineer colleagues that I work with extensively here make heavy use of C# and drive nearly everything in the game (including creation and placement of assets) with these scripts. They understand the structure of the game when they can see the script that is doing it.

forums uses Unity's version of JavaScript as the vernacular. We will hang the scripts off of objects (rather than allowing the script to do this for us) because it is a more visual approach and often easier for artists to understand what's controlling what within the scene.

In either case, the technology assets are just little pieces of ASCII text that harness the power of Unity and allow interaction to be created and controlled.

Order of Operations

In this book, we will be creating all of our art assets first, importing them into Unity as we go, and then we spend the last part of the book creating the tech assets. However, it is important to note that this process of art first, script second is certainly not a rigid one. Unity is very good at allowing art assets to be updated and changed along the way. Sometimes it takes a little bit of reattaching scripts to new objects, but with careful naming, even this is minimized. I find in my own development process, the back and forth between my 3D application and Unity is frequent and important. So in this way, the process outlined in this book is quite unlike a studio's workflow. In a studio, although the scripters will do most of the bug squashing and wrapping up, they will start on developing scripts and programming solutions long before the artists have finished their work. Further, in your own development process, you will find that spaces you thought would work well for a particular challenge or battle don't work quite as planned. Or that a character doesn't quite convey what you had planned. So you go back and rework in 3D in the middle of your scripting process. So while our linear process here lends itself to learning Unity well, it likely will not be the way you work on your own projects.

Conclusion and Introduction to

Incursion

premises. You must bypass these security systems through whatever means necessary (espionage, alternate paths, hacking, explosives) to gain entry to the inner lab where the device is stored. Along the way, all your training (both physical and mental) will be tested (Figure 1.1).

For you as the game development team, this will provide opportunities to model a character, a level design, and various instrumentation. As the scripting team, this game will allow for extensive mini-games as you get a chance to build in the puzzles that are the security devices the player must bypass. All in all, there are a lot of learning opportunities with this game. Note to teachers and students: To make sure that the game stays appropriate for larger audiences, although we will use a gun to defeat certain obstacles, there will be no shooting of people.

A Note on Research

Often people like to pretend that they can sit down and create beautiful environments or characters that flow beautifully out of their minds, through their pencils onto the paper. I suppose there are some character designers who can do exactly this, but only after years of study and observation of anatomy, people, animals, and other designer's work. For most of us mortals, before great work can emerge, we have to research similar locations, feelings, and styles.

The space on which we will be basing our game's style is really an abandoned Soviet nuclear submarine base. The base is in Balaklava, Ukraine and has some really fine reference photos online. Because I don't own the rights to these images, they can't be included in the book however, before we get started, be

sure you do a quick Internet search for “balaklava ukraine submarine” and you will be led to a great collection of web sites with background information, and loads and loads of great photographs.

It will be worth your while to collect images of the space, as you'll recognize them coming together in the book, and these additional reference photos will be valuable. In any case, good research provides information about spaces that most people simply won't include if they are “building it from their head.” There's no need to copy directly from your research, but let your research inform your choices as you build any space. Research, if followed, is guaranteed to bring an added level of sophistication and believability to any project. When you move on to create your own game from scratch, be sure you are providing some real visual meat to your project by doing appropriate research.

And on We Go…

Creating Games with Unity and Maya

Asset Creation: Maya

Scenography Modeling

Scenography Modeling within the Game

Design Pipeline

The game pipeline—specifically, the Unity game development pipeline— can be a fairly flexible thing. There are not that many elements that must be done in a sequential order. Many can be done concurrently, and often the order of steps can be leapfrogged and rearranged. While the art team is developing models, textures, and animations, the tech team (i.e., scripters and programmers) can be developing the technology and mechanics that drive the game. So the things that happen in the following three scenography chapters do not need to be complete before the programmers do their thing (or before you do the programming thing).

doesn't work quite as well as you had hoped when laying it out on paper. Once you walk a space, or try playing the mechanics, you may find that the space you had planned may not be the best. If you've just got quick mock-ups, you can quickly adjust before investing all the time into the scenography asset creation.

However, in a book setting we need to work largely in a linear progression. So for these tutorials we want to imagine that the prototypes have yielded results that have cemented the level and character design. And so, with the approval of the game designer, we are moving forward with our art asset creations.

Why Maya Tutorials?

Unity is the last step in the chain of technologies that creates the game. Without it, an effective game can't be made. But the success of the game will also rely heavily on the effectiveness of the assets that go into it. No matter how well the chef knows the tools and the oven when baking, if he or she uses poor quality ingredients, the cake is not edible.

I've had many students who, when working in Unity, are unable to create the game they envisioned because of poor choices or techniques in their 3D application of choice. General 3D techniques are not necessarily the same as 3D game techniques. Creating economic and correctly structured 3D assets and textures is an absolutely critical part of creating games in Unity.

Why Maya? Well, Maya isn't even my favorite 3D package. However, it does have an amazing market penetration and without a doubt is one of the most powerful 3D tools out there. Ironically, modeling is not one of its strongest points, but for our purposes its polygonal modeling tools will do just fine. Among other parallels, the default camera manipulation and object manipulation tools in Unity have identical keyboard shortcuts to Maya. Additionally, Maya has some very powerful character animation tools, which we will use, that import via FBX very easily into Unity. Ultimately, I chose to create our assets in Maya because the large base means there are lots of people who know how to use the software and you will have lots of options to further your skill set beyond this book once you are done reading it.

Even if you are not a Maya user and are capable in some other 3D app, take a quick look at these chapters to make sure you make note of topology and texture creation and how to extrapolate those techniques into your own application. It will make your game assets stronger, tighter, and better to work within Unity.

tutorials, the assumption is that you are familiar with the basic Maya tools (Move, Scale, Rotate) as well as how to select component parts (vertices, edges, faces). If you don't understand these concepts, it will be worth your while at least to watch the introductory videos that are included with your Maya installation.

A Bit of 3D Theory

Although we assume you know something about Maya's tools, it will be vital that the basic theory of 3D is understood. Without this baseline understanding of how digital 3D works, it will be impossible to appropriately construct assets to be used in a game framework.

Figure 2.1 shows the anatomy of the polygon—the building block of 3D. The main form that we think of as a polygon is referred to in Maya as a face. The face is what the video card (and thus we) “see.” The face's shape is editable by the components that surround it. The face is surrounded by edges that are joined by vertices (singular form is vertex). Most of these sorts of concepts are covered in some form of junior high geometry the one other important concept and part of a polygon is the normal. The normal defines the front of the polygon. In Figure 2.1, this is indicated by the green line coming right out of the middle of the face. Understanding that faces have normals is important since most game engines save processing power by only drawing the front of a polygon. If the camera is behind the polygons (if the normal is facing away from the camera), the polygon is invisible.

Three-dimensional forms in a 3D application are created when collections of polygons are put together. Think of polygons as unbending sheets of metal. Where the sheets of metal connect can hinge, but the polygon itself cannot. This means that the more polygons present, the more places the mesh can bend, and thus the more complex the form can be. Take a look at Figure 2.2 to see how a form goes from six polygons to 32 polygons to 100 polygons, and the resulting forms that are possible.

Forms that are seen in a 3D environment are drawn by the video card in your computer via a rendering engine of some sort. The rendering engines see shapes by recognizing polygons. To be more specific, most rendering engines actually see only triangular polygons (sometimes called tris). There are several ways to construct these tris Maya's techniques include NURBS, Subdivs, and straight polygonal modeling. All of these are different methodologies of

constructing forms of assembling polygons. Some methods are derived from curves others work along the line of creating polygons directly. But at the end of the process, all the methods' results are turned into triangles by a process called tessellation, so that the engine can see them and the video card can draw them.

Rendering

This drawing of polygons and the textures and lighting associated with them is called rendering. There are two kinds of rendering: software and hardware rendering. Software rendering is what commonly is used in television and film projects. The scene is built within a 3D application including lights and textures, and then the CPU is engaged to draw the complex interaction of the objects, colors, and lights in the scene. Because the results are displayed later (not in real time), if it takes a second for a frame to be rendered, or a minute, or even an hour per frame, this is acceptable. The sequential stills that are the output of this process are put together via a video editing package, and watched as a moving image.

Hardware rendering is much different. Games are in this category because the video card renders the polygons within the digital space to represent 3D space. The hardware draws what is on the screen (including all the objects, textures, and light) and needs to do so at many times per second. Generally, if players are getting much below 30 frames per second, they notice the choppiness of the game.

So how does a computer draw 30 frames per second of one project, but one frame every 30 minutes of another? The answer is simply the size of the data set and the hardware dedicated to handle that set. For projects that will not be rendered in real time, the amount of data can be much higher. The number of polygons can be much more, the size and number of textures bigger, and the complex calculations of light more sophisticated. In real-time situations (hardware rendering, with dedicated hardware chugging away on this data set), the amount of data the video card deals with is much, much smaller.

Video Cards

Video cards are a big part of the “hardware” in “hardware rendering.” Video cards come in lots of different configurations and power combinations. The intricacies of how a video card works are varied and cards that seem the same (share the same amount of video RAM) may not actually be identical in their ability to draw assets. However, for our purposes we will oversimplify and say that “bigger” cards (cards with more video RAM) are able to draw more information. “More information” can include a lot of things: more polygons, more textures, or larger textures. It can also mean dynamic lighting visualization. In all cases, a video card being able to render more information means that the complexity of a scene can increase as the video card gets larger.

At this point it is worth noting that the cost of gamer's video cards have become a very manageable cost in most computers. And in fact, when students come to me complaining about slow working conditions on their home computer, the first suggestion I almost always make is to upgrade the video card. One GB video cards can easily be had for less than $100 and it's a quick and easy way to empower a computer to show more polygons more quickly.

The technology embedded in video cards evolves so quickly it would be foolish to try and explain it all in a book—as soon as it was published the specs would be outdated. However, generally, there's no need to buy a workstation card—the gamer's cards usually do quite reasonably and come with a substantially cheaper price tag.

In my 10-plus years of using Maya, I generally have had better experiences with NVidia cards. Either ATI or NVidia seem to get along well with Unity but NVidia has provided the most predictable experience in authoring 3D elements when using Maya. This is based largely upon anecdotal evidence of my systems and the systems of a few hundred students, but when buying or upgrading a card to work with Maya, NVidia has worked better for me.

Limitations and Optimizations for Games

drawn twice, essentially doubling the number of polygons in the scene), and new visual effects like particles and complex shaders became used and expected by gamers. As the hardware got more powerful, we simply asked more of it.

Rules of 3D Game Modeling

So now that we've established that there are indeed limitations to what computers can show, it's easy to see that limits or rules need to be heeded when creating assets for unity. We will visit new rules with each step (there are specific considerations for texturing, for instance, that we won't cover until later). For this first tutorial, the two rules are:

2. Topology is critical (quads are best).

Polycount Matters

All the dynamic rise in hardware means that the visual sophistication of games continues to rise at an exciting pace. It also means that carefully creating our assets to allow for room to create these great effects remains the reality. Ultimately, effective use of the number of polygons in a scene (polycount) will be critical to both the immersive impact of the game and conversely, the performance in frame rate at which the game will play. Now, with most recent machines, polycount is much less of an issue than it once was. And frankly, usually if a game is dog-slow, it isn't a case of the sheer number of polys—it's usually related to other texture problems or other issues related to draw calls (more on this later). However, keeping an eye on the number of polys in your scene remains one of the pressures on a video card, and keeping a reasonable poly-budget is important (especially if ultimately developing for any mobile devices).

This can sometimes be a tricky balance. Figure 2.3 shows two sphere-like objects. The one on the right has 1000 polygons and the one on the left has 20. Sure enough, the 20-polygon model will require less video card power to draw, but it really doesn't appear to be a sphere anymore. Carefully dialing the details up to effectively communicate the shape while keeping the number of polygons low enough to draw quickly is part of the art that is game asset creation.

For our uses we will be focusing primarily on polygonal modeling techniques (the techniques using the tools in Maya's Polygons mode). The other methods of NURBS (non-uniform rational b-splines) and Subdivs are too indirect in their creation of polygons, and thus we lose control over polygon placement and count.

Topology

Topology refers to the structure or organization of polygons on a surface. Topology matters. Correctly structuring polygons makes a huge difference in how the mesh can be deformed later (with things like joints), how the form interprets collisions in Unity, and how easy it is to lay out UV maps. Much of topology concern centers around the tessellation process—the process of converting the form into three-sided polygons (tris) when it comes time to render.

Maya, like most 3D software, allows the user to create polygons of any number of sides (usually called n-gons). This is relatively new in the 3D production history. Not many years ago, 3D software would allow polygons to be constructed only as tris or quads (four-sided polygons). Tris are pretty hard to work with and manipulate quickly, so quads became the preferred method of organizing polygons. To allow artists to more fluidly create forms, most 3D apps began allowing the user to pay no attention to the number of sides of a polygon as the form was built. However, woe be the modeler who doesn't pay attention to the construction of his polygons. Five- (and more) sided polygons cause all sorts of problems down the road.

The issue is in the tessellation process. When the 3D software (or game engine, like Unity) converts a 3D form into all tris (which it must for the video cards to draw them), there are some shapes that are easier to tessellate. A quad is relatively easy, since it just splits it in half from vertex to vertex (Figure 2.4). However, the tessellation of the n-gon is often unpredictable, especially from a game asset creation standpoint. It does it for sure, but the resulting mesh is a mess (Figure 2.5). This messy tessellation that can be seen in Figure 2.5 may not seem to be a big deal here, but when these polygons are subjected to distortion techniques (like bending a mesh with joints), suddenly the edges where things can actually bend end up being in unpredictable places and result in

unpredictable distortion, and even worse pinching of the mesh. Additionally, when we get to creating UV maps, quads are much easier to work with than any other form.

So the first consideration we need to always keep in mind when modeling is to work with quads. Quadrangles will always make for easier modeling and for the most predictable results as we go. Don't succumb to Maya's temptation to allow for the creation of n-gons they are nothing but trouble.

On to the Tools

Now that we've established the reason for our two rules of game modeling and discussed the importance of them, we can start to use them in action. In this chapter we will complete four tutorials that will culminate with a completed level (none of the mini-puzzles, just the architecture) in which our game will be set. At the end of this chapter, the player will be able to walk through the unlit halls of the Soviet facility. The tutorials will allow us to model, UV, and texture our asset. Finally, the last tutorial will bring the completed model into Unity. Before we get started, make sure to set up a new Maya project called “Incursion–Maya.” If you are unfamiliar with setting up projects (a vital part of creating assets with Maya, be sure to check out Appendix A, “Creating and Setting Maya Projects” that is housed on the supporting website (http://www. Creating3dGames.com).). Then move on to the tutorial.

The facility we are about to model is large. It was used to service nuclear submarines during the Cold War, and includes multiple levels and many, many hallways. In the following tutorials, we will not be modeling the entire complex or even the entire level that we will be using in the game. Instead, we will be targeting a few specific sections of the facility that are either indicative of the aesthetic style of the level, or that help illustrate a particular technique of modeling that is important to understand.

Do note that we will be using a much larger version of the facility in the construction of the game. We will be building parts of the game in these tutorials with challenges to create the rest included at the end of the chapter. If you're confident with your modeling skills, and don't want to have to create the

remaining parts of the level, you can simply use the versions that are included on the web site (http://www.Creating3dGames.com). However, if you're looking to make sure your game modeling skills are tight, be sure to attempt the challenges at the end of the chapter and complete the entire level by yourself.

Tutorial 2.1: Game Level Modeling:

The Entryway

The entry of the Balaklava facility is a great place to start. First, the parts that make up the entry are largely rectilinear. Anything man-made and rectilinear is easily created in 3D applications. Second, all these rectilinear forms are a perfect trap for beginning modelers—a trap to create shapes that neither produce the appropriate sense of age or dirt. Over the course of the tutorials, we will look at taking a simple geometric space and making it look like it's been around for a while (Figure 2.6).

Step 1: Double-check you've got a project set up called “Incursion–Maya.”

If you don't, or don't know how, check out Appendix A.

Step 2: Choose File>Save Scene (Options).

Step 3: Check Incremental Save and click Save Scene.

Why?

Incremental Saves are insurance policies. What happens is that each time a scene is saved, Maya makes a copy of the scene from the last time it was saved and saves it to a folder called incrementalSaves. This does mean that there are lots of copies of your file, but it makes sure that in the catastrophic case of corrupted files you have a backup. Even if you run out of Undo's, an incrementalSaves folder means you can go back in time to what you wanted or needed. Every single semester I have taught, incremental saves have saved at least one student's project.

Step 4: In File Name: enter EntryWay and click the Save button. Note that if the project has been defined correctly, you are in the Incursion–Maya scenes folder.

Warnings and Pitfalls

I know it's tempting to skip this step since you're anxious to get started. Worse, I see lots of students who don't quite understand this step and skip it because it doesn't seem important. But keeping track of your assets is critical to success in projects as diverse as games. Create and Set your project in Maya. You must know that your texture files are in the sourceimages folder, and that your scene files are in your scenes folder.

Columns Base Shape

Step 5: Create the base shape of the cement columns with a polygonal

cube (Create>Polygon Primitives>Cube). Using the Channel box, make the cube Width = 1, Height = 16, Depth = 1 units by adjusting the polyCube1 INPUTS (Figure 2.7). Make sure the Subdivision Width, Height, and Depth is set to 1. In the Outline (Window>Outliner), double-click this new pCube and rename it EntryWayColumn.

Why?

X = 1 Y = 16 and Z = 1? How come? Well, no reason actually, except that it's a nice round number. Scale between apps and Unity is always a little tough and something that we will tackle more specifically in Unity. In Maya, absolute sizes are frustratingly difficult to keep track of, so we will focus on relative sizes. However, it is clear from the research that the pillar's cross-sections are square, and so numerically ensuring that this is so is much more accurate than eyeballing the thing. The Subdivision settings are set to 1 because we only need one subdivision to describe the shape, and any more is a waste of polys.

Step 6: Create a base using the Extrude tool to widen the base and give

it depth (Figure 2.8). As a review, right-click on the object and select Face. Select the bottom face, choose Polygons>Edit Mesh>Extrude, and use the manipulator handles to scale out the first extrusion. Repeat the process and use the manipulator handles to add depth.

Why?

The shape here is really a long cube on top of a short squatty one, so why not just create two cubes? There are several reasons for this. First, when we create textures for this object, it will be much easier if we have one solid mesh (more on this later). Second, and more importantly, if we have one object that defines the base and shaft of the column, we have half as many objects to define the same shape. Less objects mean less Draw Calls and thus a faster game (more on this later too).

Step 7: Delete the bottom face.

Why?

We will never see that bottom polygon. But, this polygon will take up texture space (which is at a premium in games) and add to the overall polycount. Yes, it's only one quad (two tris), and doesn't seem like it would be a big deal in the scheme of a big game, but if there are going to be many duplicates of any object, cleaning up faces that absolutely won't be seen can pay dividends for over 100 duplicates. Taking time to keep it clean now will save optimization time later.

Step 8: Repeat similar process to create column capital (Figure 2.9).

Figure 2.8 Creating column base.

Dock Creation

Step 9: Begin creation of the cement dock area in similar fashion. Start

with a cube (renamed in the Outliner to EntryWayDock) that is X = 20, Y = 4, Z = 60 (this can be adjusted later as we build), and extrude the faces as shown in Figure 2.10.

Step 10: Continue working around the dock making sure to make

extrusions at locations that will allow new extrusions that will allow for holes (Figure 2.11).

Tips and Tricks

Deciding when to make extrusions is a skill you build up over time and with experience. I find that sketching out the shape I want to make on a sheet of paper, and then sketching out the places that extrusions would need to be made, helps me quite a bit when it comes time to do it digitally.

Figure 2.10 Beginning to lay out dock.

Step 11: Here's where things might get a bit tricky. What we want to do is

make sure we have new locations to build outcroppings of the dock. Look carefully at how extrusions are made to allow for future extrusions that make the stepping out. Notice that this creates some pretty inefficient topology (geometry where there needn't be), but we will clean that up in a bit (Figure 2.12).

Tips and Tricks

This part of the process is really about roughing out the shape. It won't be perfect right away, so don't worry too much about being exact. When creating this tutorial, I ended up with lots and lots of Undo's to get back to a place that would allow me to more efficiently create the form. 3D creation is a process of stops and starts to be certain.

Step 12: Create a stepped section by deleting faces and filling them in

with the Append to Polygon tool. Select the faces on the far corner (as shown in Figure 2.13) and delete them. This will leave a hole in the mesh that needs to be filled. One way to fill this is the Append to Polygon tool. To use this tool, be sure to be in Object Mode (right-click the object and select Polygons>Edit Mesh>Append to Polygon Tool) and then click an edge of the hole. Purple arrows will appear that show the path of the new polygon that will be created. Click these arrows until the face is filled and press Enter. Repeat for the other plane that needs to be filled.

Figure 2.12 Dock continuation.

Tips and Tricks

When using the Append to Polygon tool, usually there is no need to go all around the outside of the shape that is being filled. It is faster to click one edge, and then click the edge opposite that edge and press Enter. This fills the hole quickly as it figures out the other edges are included in the function.

Tips and Tricks

Notice that after filling the hole, there will be some black chunks across the new planes that have been made. This is happening because the new polygon has soft normals, which are great for organic shapes, but not so great with rigid forms like this dock. To get rid of these, select the object and choose Polygons>Normals>Harden Edge.

Step 13: Rotate the front of the dock. Right-click the dock and choose Vertex from the hotbox menu. Marquee select the vertices across the front of the docs as shown in Figure 2.14. Choose the Rotate tool (keyboard shortcut is the E key), and then (to move the axis of rotation) press and hold the D key on the keyboard. Move the manipulator handles back to the back corner of the collection of vertices that have been selected. Release the D key and rotate the vertices from this new axis just defined.

Tips and Tricks

This rotation trick or moving the axis of rotation (via holding down the D key or by pressing the Insert key) works in Object mode too. The axis of rotation can be moved to wherever it needs to be for a given object. In our case, it's temporary for a selection of components (vertices in this example), but when done while in Object mode, the object will “remember” this new axis location.

Dock Optimization

Step 14: Optimize the mesh. In the process of outlining this shape, we

have quickly made some shapes that could be optimized. As pointed out earlier, polycount is rarely the problem with slow games, but it is certainly one of them. Especially if you are developing for iOS (iPad, iPhone, iPod Touch) or Android, keeping a tight grasp on polycount will be critical.

To optimize what we've created, we will be deleting edges that aren't needed and rearranging some of the edges that exist. Figure 2.15 shows one such edge that we should delete. Double-click the edge that will attempt to select an edge loop and then either press Delete on the keyboard (and then select and delete the vertices it leaves behind), or Ctrl-right-click and choose Edge Loop Utilities > To Edge Loop and Delete (which will automatically delete the left-behind points).

Step 15: Adjust topology to ensure four-sided polygons. Look carefully at

Figure 2.16. Note that this top polygon is actually a five-sided polygon. It's deceptive as sides 4 and 5 at first blush appear to be one edge, but there is a vertex in the middle where that other edge comes out. In a case like this, where all the polygons on the top of the deck are on the same plane, this five-sided poly would likely not cause any trouble to be sure we will use another new tool, the Split Polygon tool.

In Object Mode, choose Polygons>Edit Mesh>Split Polygons Tool. This tool works by clicking and dragging on an edge to establish where to split the polygon. Usually click an edge and drag along that edge to a point (Figure 2.17). Click again on the opposite edge and drag to the point opposite the first. This will create two polygons (a four-sided one and a three-sided one) where there was once one five-sided polygon.

Step 16: Clean corners. Now that we've used the Split Polygon tool, we can further optimize our polycount in places that make right corners.

Figure 2.18 shows the result of using the Split Polygon tool to make a new cut from corner to corner. After this diagonal cut is made, the two straight edges that used to make the corner can be deleted.

Figure 2.16 Deceptive five-sided polygon. Figure 2.15 Edge that isn't needed and should be

deleted. Make sure you delete the points it leaves behind.

Figure 2.17 Using the Split Polygon tool.

Tips and Tricks

Be sure that when getting rid of the edges that are no longer needed that those edges as they continue down the size and bottom of the shape are deleted as well. Additionally, watch for left-over vertices that should be selected and deleted as well.

Step 17: Repeat and optimize throughout right corners (Figure 2.19).

Why?

Looking at Figure 2.19, you can count four four-sided polygons that were involved in the three right angle turns the shape made. This makes for eight tris. Compare that with the seven four-sided polys that were there before (14 tris), and you can see how this sort of optimization can whittle down a polycount in a hurry. Ultimately there are some tradeoffs you have to make. It takes a bit of time to optimize, and if you're taking too much time out to optimize you're eating into your creation time. However, I find that if I do a bit of obvious optimizing as I go, it saves me from hours of painful optimization later.

Step 18: Delete the polygons along the bottom. We don't see them, we

don't need them, get rid of them.

There is certainly some other optimization that can be done here, but we have looked at the basic techniques that are used to make a lean, mean mesh. Feel free to further optimize, but for now we'll move on.

Step 19: Add the lip to inside of the channel. Select the faces as shown

in Figure 2.20 (the faces that are along the inside of the channel into the mountain), and use the Extrude tool to extrude them out just a small bit. This will create a new collection of faces along the dock top. Select these and extrude up to create the lip.

Step 20: Duplicate and place the column roughly as shown in Figure 2.21. Yes, I realize it would be better to UV map the column first before duplicating it. And in fact, these columns we are placing now will undoubtedly be deleted and replaced by duplicates that are UV mapped. However, placing these here allow for some important placement of items in the upcoming steps.


30 Random Thoughts

I apologize for the really long blogpost – I intended to post a random thoughts blog last week but didn’t get around to it. As time went on I thought of more and more stuff, hence the long post. Anyway, this is definitely the most random post I’ve ever written.

1. If the Blog is Rockin’, Don’t Come Knockin’!

Last Thursday my blog had 5,969 views. I started this blog last November and had 119 total views that month. A year later I’m averaging over 4,000 views per day. As of a few minutes ago I had over 110,000 views for the month of October and there are four days left in the month. I’ve worked very hard on this blog and am very proud that it seems to be one of the most popular blogs in strength & conditioning. Below is a chart that shows the blog’s rise in viewership.

2. Epic Conversation in “Training Women” Blog

Following my “ Training Women ” blog, I had some amazing dialogue with several people but most notably from my friend Karla. I’m glad she had the guts to call me out as it led to an amazing discussion. I felt like I threw down some serious knowledge in the comments portion so I recommend you read through it if you have time.

3. Raise the Bar for the Glutes!

I don’t want to sound like an asshole, but we really need to raise the bar for the glutes. It’s very important to get clients and athletes moving well with their own bodyweight. Many times I have to regress exercises as far back as possible in order to start them off with an appropriate exercise variation.

Hell, I had a female client several years ago who was very tall, uncoordinated, top-heavy, and weak. It took me an entire year to get her to do a bodyweight full squat. Believe me, I understand the vast range of fitness between sedentary and athletic individuals.

But we need to raise the bar for the glutes and have high-standards if we want to see nice butts, fast runners, and reduced low-back pain. Bodyweight movements just don’t cut it.

Barbell squats, barbell deadlifts, barbell hip thrusts, barbell Bulgarian split squats, etc. are where it’s at for the glutes. Dumbbells, cables, bands, and kettlebells can be used to but we have to progress past bodyweight (unless the client is sprinting, cutting, jumping, etc.).

I think I could do 10 straight minutes of bodyweight glute bridges, low step ups, or clamshells. For me bodyweight glute bridges are like jogging – pure endurance work. Bodyweight glute bridges activate my 20% of glute MVC for me. Conversely, 600 lb barbell glute bridges activate well over 100% of glute MVC (this is possible because MVC is an isometric measurement) for me. I realize that I have strong glutes but every grown man should be able to glute bridge at least 225 lbs.

I bet if we found a frozen Neanderthal and unfroze him he’d lay down and bust out 30 reps with 225 on the glute bridge without even warming up.

In our glute articles we can’t be satisfied with bodyweight movements…we have to keep showing pictures of barbell movements so people know where to aim. Of course we can tell them to master their bodyweight before loading up, but if all we ever show in the articles are pictures of someone doing bodyweight glute bridges, low step ups, and clamshells, then we set the bar way too low and don’t give people something for which to strive. (I hate that I’m not supposed to end a sentence in a preposition – that sounded strange)

4. Barbell 1-Leg SLDL

I have never really pushed the barbell 1-Leg SLDL to see how much I could lift. Last Wednesday I busted out 2 reps with 225 and 1 rep with 275. I felt slightly unbalanced and uncoordinated, but I know if I kept at it I’d quickly be able to use 315 or so.

This is important because it indicates that there may be a considerable bilateral deficit with deadlifting. My max deadlift is around 565 right now. I’m hoping to get it to 600 one of these days (although 585 which is 6 plates per side sound really cool too). Here’s a vid of the bb sl sldl (I don’t really keep the leg straight but I keep the hips high and do down until the bar touches the floor while focusing on sitting back and keeping the chest up).

Whenever I see pet owners with fat pets it diminishes my faith in humanity. Seriously, we’ve gotten pretty damn pathetic. Here’s what I tell people in that situation.

1. Stop feeding Junior table scraps.
2. Stop filling his entire bowl full of food every day.
3. Start out with half a bowl per day and see if he loses weight.
4. Just keep tinkering with the amount until you reach an equilibrium and you’re happy with your dog’s (or other pet) weight.
5. Then just keep it at that level.

If your pet is fat, it’s your fault, not the pet’s! This pisses me off very much. The dog deserves more competent owners.

6. Ultimate Fighter on Spike

I’ve been watching the Ultimate Fighter this year and wanted to say three quick things.

1. Josh Koscheck is just too immature for my liking. I used to really like him (I still think he’s a great and exciting fighter) but now I’m a little annoyed. Cocky fighters need to get humbled.
2. GSP is a class act.
3. I’m very glad that the UFC and MMA trainers in general seems to be improving in their strength & conditioning. It’s not uncommon now to see guys doing trap bar deadlifts, inverted rows, using the battleropes, etc.

7. Back Extension Instructional Video

Here is how I teach back extensions at my garage:

This needs to be watched by everyone! Back extensions are an amazing glute exercise if done correctly.

8. Professor Richard Hinrichs Drops Some Knowledge

A couple of weeks ago I posted a video on ACL Biomechanics. In case you missed it, here was the video:

I showed my professor the video and he dropped some serious knowledge on me. Here was his response:

The first error was a time 3:02. You said that the larger moment arm for the quads (than the hamstrings) allowed the quads to produce more force. The word you wanted was torque here. The same force with a larger moment arm produces a greater moment or torque, not more force. And torque is what is important when trying to extend the knees. The second error you made is at time 4:16. I think you must have misunderstood one point I made when comparing males and females in the timing of the coactivation of the hamstrings and quads in landing. Contrary to what you might expect, females turn on their hamstrings significantly sooner in the landing process (not later) compared to males–as if to recognize that their hamstrings are weak. It is the quads to hamstrings strength ratio that is so much higher in females than males that seems to be the risk factor for ACL injuries.

Rick is a brilliant man and I am very happy to be learning from him. He’s exceptionally knowledgeable about the ACL and swimming biomechanics. I still get an A for effort!

I’m curious as to what my readers will think about this video. Check it out:

10. Creatine on the Nose

I’ve taken creatine for so long that I don’t mix it anymore. I just put the scoop in my mouth and then wash it down with some liquid. The other day I got some on my nose when the scoop touched it. Later that day, about five minutes prior to having to train a client I noticed in the mirror that I had a bunch of white powder on my nose.

I’ve never used cocaine in my entire life but I was thinking about how funny it would have been if my client showed up and saw the white powder on my nose. What else could they possibly assume? Thank God I noticed it!

11. Anthropometry & Attachment Points as it Relates to Big Lifts

I get a lot of questions from people who ask me stuff like, “Why can I deadlift so much more than I can squat?” Actually I should expound upon this in an “ABC: Ask Bret Contreras” post but for people in this situation, know that it’s perfectly normal.

Most women can deadlift much more than they can squat (at least in my experience). The main reason why some men can squat more than they can deadlift is because they aren’t proficient in the deadlift. With practice they almost always deadlift more than they can squat real quickly. Over the years I would say that on average I put 50-80 lbs on a typical guy’s deadlift “instantly” just by teaching them the correct starting position. Most try to deadlift like a squat, and when they learn how to maximize their leverage in their hips they set an instant PR (not because they got stronger, but because they never learned how to deadlift).

I’m talking raw lifting, not geared powerliting. Wearing gear changes things a bit as the squat briefs and suits add some serious spring to the squat…but the deadlift suits don’t do much for the deadlift.

Furthermore, it’s quite common for a taller lifter to be able to deadlift way more than he or she can squat. For example, a 5𔄂″ female lifter may be full squatting with 65 lbs but deadlifting with 175 lbs. This is not uncommon and has everything to do with human Anatomy. More specifically, it has to do with anthropometry (the relationship between body segment lengths) and the where the tendons attach on the bones.

Leverage is huge for lifting and people don’t quite understand from a biomechanical perspective how critical “leverage” is….just by taking a couple of inches off or putting a couple of inches on a particular bone or moving the tendon insertion a couple of centimeters out can lead to much higher abilities of the muscles to move some serious weight.

Those who are well-versed in Biomechanics are able to create equations using Anatomy, Physics, and Mathematics to solve for muscle forces required to move resistance based on the moment of the resistance arm (resistance times lever distance). All you need to know are bone lengths, tendon attachment points, amount of resistance, and joint angles. Can you see why I freakin’ love Biomechanics?!

12. What’s a G6?

There’s a popular song on right now called “Like a G6” by Far East Movement.

I didn’t know what a G6 was so I had to look it up. It’s a reference to a jet airplane that Gulfstream Aerospace makes called the G650. So technically the song-writer’s are off – there’s no G6, just a G650.

13. TC Luoma is the Real-Deal

A few weeks ago I met with TC Luoma, the editor-in-chief of T-Nation. I love writing for T-Nation and I’ve always wanted to meet TC. His Atomic Dog column was a riot and I bought 4 copies of his book back in the day – one for me and one for each of my brothers. My brothers all loved the book so much that when I told them I was meeting with him they acted like I was meeting an A-List Celebrity. We had some good conversation.

Here’s a video of him talking about his book (which is called Atomic Dog – Testosterone Principles).

I believe that every grown man should own this book.

14. Isoholds

Isoholds are a good thing to toss into a workout from time to time. They’re not too CNS demanding, they can increase flexibility and add stability to new mobility gains, and they can increase muscle activation by awakening dormant muscles. Plus, variety is always nice.

Good choices of Isoholds that can all be done with bodyweight are static lunge holds, Bulgarian split squat holds, good morning holds, chin up holds, push up holds, inverted row holds, glute ham raise holds, back extension holds, and reverse hyper holds.

A sixty second Bulgarian squat hold might be the most grueling exercise in the entire world. Sounds easy but it’s not!

Try this variation I learned from Jeremy Frisch! It’s tough!

15. Smart Blog Readers

I want to give a shout-out to my blog-readers. I think I have some of the smartest blog readers on the web. Often there are very good conversations following some of my blogposts. I appreciate all of the comments that my readers leave very much.

16. Weak Point Training

I’m often amazed at how many lifters assume that you can bring up a weak point in a matter of days. For example, I get lots of emails from people asking me whether they can get a great butt by next month.

This leads me to a funny story. A couple years ago at my training studio Lifts, my trainer Jordan and I trained this 19 year old girl (we’ll call her Leslie) and her mother at the same time. Leslie had a great body to begin with and a beautiful face, but she didn’t have much of a butt.

Within six workouts that spanned over the course of two weeks, all of a sudden her butt was amazing. Seriously it was one of the greatest butts imaginable. Round, perky, etc. It went from completely flat to perfect in two weeks!

One day Jordan asked me if I noticed how great Leslie’s butt was looking and I replied to him saying, “Yeah, I don’t want to feel like a pervert or anything but I’ve never seen such rapid results in my entire life as a trainer.”

Later on that day we were training Leslie and her mom and her mom said to us, “Can you believe how great Leslie’s butt is looking? It’s remarkable.”

Both of us looked at each other and replied with something like, “Um, yeah, I guess so. I hadn’t really noticed.” We were both too chicken to tell the mom that we had noticed!

On the other end of the spectrum, I had another client who was a bit frustrated with her lack of positive results in her glute region. I tried everything with her. She got much stronger but didn’t improve much in her glutes. We did plenty of hip stretching, low load glute activation, and glute strengthening from every angle with every major glute exercise, and still it seemed like she was going no where in this regard (well, her body got much better – she lost fat and gained muscle, but her butt didn’t seem to change much).

But she kept training hard, week in and week out. After she’d been with me for a year, I dug up her “before” picture and was blown away. Her butt had improved markedly we just didn’t realize it because the adaptations occurred so slowly.

The moral of the story is that with hard work, everyone can improve the shape of their butt. For some people it takes a few weeks, whereas with others it can take a year or two. But with hard work and consistency you can overcome poor genetics and dramatically improve the shape of a particular body part. Just don’t give up.

There are plenty of bodybuilders who have “reversed” a weak bodypart and turned it into a great bodypart but it often takes them years to do so.

17. Kinematics vs. Kinetics

Most people don’t know the difference between Kinematics and Kinetics.

Kinematics describes motion without considering the forces that cause the motion. Kinematics just describes things like joint angles, range of motion, velocity, vectors, etc.

Kinetics is concerned with the relationship between motion and its causes. Kinetics looks at things like forces and torque.

Kinematic variables (translations, rotations, etc.) are related to their respective kinetic variables (forces, moments/torques, etc.).

18. Getting Stronger by Using Steriods and Gaining a Ton of Weight

This “random thought” is probably going to piss some people off. Years ago I remember scanning through a T-Nation thread by Mark Bell (known as “Jackass” on this thread and in the movie “Bigger, Stronger, Faster” he’s known as “Smelly”). This thread started in 2004 and Jackass looked really good (see below). He looked strong, athletic, and was a great looking guy. Here’s a collage from his early years.

Several years later, the thread was still going (in 2008) and he looked like this:

He looks fat, unathletic, and disgusting. But very strong! As the years went on his strength went up but his looks went down.

Right now I am 6𔃾″, I weigh 225 lbs, and I am natural. I don’t wear any gear when I train and I don’t take any anabolic steroids. I can full squat 365 lbs, bench press 300 lbs, and sumo deadlift 565 lbs. By powerlifting standards this is laughable.

I remember talking to Dave Tate a while back and I asked him how much I’d need to weight to “balance out my leverages” for powerlifting. At my height, he told me I’d have to weigh 350 to ever amount to anything.

I have no doubt that Mark Bell is a kind dude. I shook hands with him at this year’s Mr. Olympia convention. His brother’s movie was one of the coolest movies I’ve ever watched. Mark is ten times stronger than me, but I try to think of him when I’m fighting the urge to get stronger at the expense of staying lean.

I’ve always wanted to get my bench up to 500 lbs. I’ve always wanted a 500 lb squat. Deadlifting 600 lbs would be awesome too.

I bet if I learned how to squat in briefs and a suit, and learned how to use a bench shirt, and trained specifically for powerlifting while taking anabolic steroids and eating like a horse for 3 years, I would probably get to an 1,800 lb total in powerlifting. Big deal? There are guys totalling 1,000 lbs over that.

It would be really fun to move that kind of weight, but what’s the point? I’m not genetically gifted to set powerlifting records. I’ll never be an elite lifter. And I would end up looking just like Jackass. He has made the choice to go down that route and I respect him for it. Sometimes I think it would be fun to open my own powerlifting gym, hang out and train with huge beasts all day long, and enter competitions several times per year. I know that Mark has his own powerlifting gym in Sacremento (Team Supertraining) and has tons of friends in the sport, and I believe he and his wife started up their own powerlifting magazine called Power. My hat is off to Mark.

But at the end of the day I don’t want to go down that road. I have a decent looking face and I intend to keep it. While Mark chose to let his looks slide in efforts to raise his powerlifting total, I choose to keep my looks and never be that strong. This doesn’t mean that I’m complacent with my strength, as I’m still trying to get stronger and reach my strength goals (especially a 600 lb deadlift). It just means that I have to keep reminding myself that I train for strength and aesthetics and that I want to build solely muscle, not muscle and a ton of fat. To each their own.

19. Joe Kenn Quote

I heard a Joe Kenn quote a couple of weeks ago. He said,

If he means that he’s doing great things in his “lab,” then I’m all for the quote. In my humble little garage in Scottsdale I’m doing some good things that I’m very proud of. I know for certain that I’m “ahead of the research.”

By the way, I really enjoyed Joe’s “ The Coach’s Strength Training Playbook ” and definitely recommend it.

20. The Social Network

For those of you who have not yet seen the movie “Social Media,” go see it. I don’t think I’ve ever been so captivated by a movie in my entire life. It was so intriguing! I’m usually only that impressed by movies like “Braveheart,” “Gladiator,” “The Last Samurai,” “Heat,” “American Gangster,” etc., but this movie was awesome.

21. Conversation with a Drunk Girl – Contreras is Dumber than a Box of Rocks!

Three weekends ago I was at a wedding in San Diego and I was approached by a drunk girl at the reception at the end of the night. She wanted me to go back to her hotel and go skinny dipping with her in the ocean. I was not attracted to her at all, so this was not an option.

She was getting really frisky and started feeling my pecs, then she said, “I’m ready to take my clothes off!” I said, “Why wait for the beach when there’s a fountain right over there?” She wasn’t phased by my comment and then said, “You’re coming home with me, right?” To get her off my back I told her that I had to go to the restroom, and then ran off to find the groom to say goodbye.

Apparently I pissed her off because as I was leaving the reception I overheard her telling her friends about me. She said, “Yeah, he’s totally hot but he’s dumber than a box of rocks.” Hell hath no fury like a woman scorn!

22. Quad Dominance

The other day I was watching a friend’s soccer game and I was able to “see” which athletes effectively used their glutes and which ones relied mostly on their quads. After training people for so many years you develop a s
sense for watching movement on the field. The glutes are hip extensors, hip abductors, and hip external rotators. So important for running, jumping, cutting, throwing, and swinging.

23. Glute Ham Raises Don’t Work Much Glute!

Why do people think the glute ham raise works a ton of glute? Why, why, why? The glute ham raise is primarily a hamstring exercise!

I can hold onto a 30 lb dumbbell and do a glute ham raise and it only gets my mean glute activation up to 18% of MVC. However, it does get my mean hamstring activation up to 82% of MVC.

All the glutes have to do in a glute ham raise is keep the torso erect and hips extended via isometric contraction. It’s not that hard. The hard part of a glute ham raise is controlling the descent which is eccentric knee flexion and then raising the body which is concentric knee flexion.

Here are a couple of different ways to do glute ham raises (also called Russian leans, Russian leg curls, Nordic leg curls, manual glute ham raises, manual leg curls, etc.)

24. Men’s Health: GET FIT RULE

I saw this in Men’s Health and completely agree!

“The best exercise program in the world is the one you enjoy doing.”

25. Soreness

Most people think you need to get sore to see results. I try my hardest to prevent soreness in my clients, as I train them frequently and am always having them strive for PR’s.

I was reading in Muscular Development Magazine the other day that Jay Cutler (current Mr. Olympia) rarely gets sore from his workouts and he said that Ronnie Coleman (former Mr. Olympia) rarely got sore as well.

Some places are a little more prone to soreness than others – like the pecs and quads. The point is that you shouldn’t “try” to get sore. It shouldn’t be a goal of yours. If it happens or doesn’t, so be it. What matters is that you’re consistently going up over time, moving well, and engaging in intelligent training. If Ronnie and Jay aren’t getting sore and they’re annihilating a specific bodypart with 30 sets in a single session, then you don’t need to get sore either for max strength or size gains.

26. Speed & Agility Revolution

A colleague of mine named Jim Kielbaso wrote an amazing book a few years ago that I don’t think many people in Strength & Conditioning have heard of. It’s called “Speed & Agility Revolution” and it’s an amazing book. I don’t think I’ve read another book like it it breaks down the mechanics involved in speed and agility training and is very comprehensive.

27. Chalk One Up for Personal Trainers!

Personal trainers help people get stronger! Even trained athletes see better results when there’s a coach or trainer motivating them. Check it out here and here.

28. Female Strength Coaches

As many of you know, I’m currently taking a graduate level Biomechanics course at ASU. I think there are 25 guys and 5 girls in the class. I’ve heard many in the S & C field discuss how more women need to get involved in strength & conditioning, but it’s not happening. It’s a male-driven field and men are much more drawn to the profession than women.

There are plenty of women becoming Physical Therapists, Registered Dietitians, and even Personal Trainers, but not many becoming Strength Coaches.

Congratulations to the women out there who are trainers and strength coaches. The world needs you! Men, we need to go out of our way to mentor and empower women who are interested in the profession.

29. Heavy Half Squats for Valgus Collapse

While I believe that valgus collapse is a full-range phenomenon and that individuals need strong hip abductors and external rotators (mainly glute medius strength as it has the best moment arm for this purpose) through the entire range of hip flexion/extension, I’ve been having some success with prescribing heavy half squats and cueing my clients to make sure they keep their knees out.

This strategy, in combination with hip abduction/hip transverse abduction isolation movements and squats with a mini-band around the knees, seems to be helpful in this regard.

30. Conversation with Dr. Carl DeRosa

Last week I drove to Flagstaff to have a discussion with Dr. Carl DeRosa, one of the world’s most intelligent spinal experts. I learned a lot of interesting things from him and found him to be extremely intelligent and surprisingly well-versed in strength training. His two sons were both involved in Olympic lifting, plus he’s a Physical Therapist, Professor, Researcher, Lecturer, Author, and an all-around good guy!

I was in such a good mood on my drive back home that I was rocking out in my car while flipping through the stations. I hadn’t heard Billy Idol’s “Mony Mony” in ages and was singing up a storm while driving home. I felt like Tom Cruise singing to Tom Petty’s “Free Fallin'” in “Jerry MacGuire.”

If someone had a hidden camera on the drive home they could have blackmailed me for a lot of money.


197 Responses to “The case for skipping ATR surgery”

By normofthenorth on Oct 23, 2010 | Reply

I referred to the Wikipedia links to the four new studies. But those can be changed at any moment, so here they are, just in case:

Bruce C. Twaddle, FRACS†,* and Peter Poon, FRACS, Am J Sports Med December 2007 vol. 35 no. 12 2033-2038, “Early Motion for Achilles Tendon Ruptures: Is Surgery Important?: A Randomized, Prospective Study”, ajs.sagepub.com/content/35/12/2033.abstract

http://www.ncbi.nlm.nih.gov/pubmed/19825777?dopt=Abstract — Netherlands: Metz R, et al, Foot Ankle Spec. 2009 Oct2(5):219-26. Epub 2009 Sep 4. “Recovery of calf muscle strength following acute achilles tendon rupture treatment: a comparison between minimally invasive surgery and conservative treatment.” (In this study, there actually was one result in which the two treatment groups differed statistically significantly: In isokinetic strength at 90 degrees per second after 6 months, the NON-surgical patients were significantly stronger!)

Gothenburg, Sweden, May 2009: http://www.physorg.com/news161516132.html (”Surgery may not be necessary for Achilles tendon rupture”)
[This study is also discussed in more detail at www3.aaos.org/education/anmeet/anmt2010/podium/podium.cfm?Pevent=712 . I've discussed the findings elsewhere, and they're not quite as strong a proof of the benefits of non-op at the text suggests.]

http://www.medscape.com/viewarticle/588904 — Canada: Kevin Willits, March 2009 paper at AAOS 2009: “Nonsurgical Rehab After Achilles Tendon Rupture Better Than Surgery”. (formal publication forthcoming).

It’s also probably worth mentioning that an earlier blog page of mine — quick-linked at bit.ly/achillesstudies — has a much longer and denser discussion of the studies I’d found online back then. Dennis has linked that from his own summary of protocols and studies. This page is more intended for the “So you’ve just ruptured your Achilles” folks, and the “What to do without insurance” folks, too.

normofthenorth - I just want to be clear that the main theme of AchillesBlog is to provide community support for all people recovering from ATR. I prefer to move the topic of debating pros/cons of surgical/non-surgical elsewhere.

I am all for individuals making informed decisions about choosing their protocol for ATR recovery, but I feel that sometimes people are overstepping their boundaries, and turning people way from AchillesBlog in the process.

I do not want to see people advocating one protocol over another on AchillesBlog since I feel that’s not why AchillesBlog exists.

The literature is there if people want to search for themselves and decide for themselves, and I don’t see that there is such an overwhelming evidence for one protocol over another to warrant such a strong endorsement on AchilesBlog.

You may argue that there is indeed overwhelming evidence for one protocol over another, but I don’t want AchillesBlog to be the platform where people argue over that.

By normofthenorth on Oct 24, 2010 | Reply

Dennis, of course you’re right that the main theme of AchillesBlog is to provide community support for all people recovering from ATR, and I hope I’ve made a contribution to providing that support. One small part of that support (and of my contribution) is helping to inform the key decisions that an ATR patient has to make, and this page is dedicated to informing the first key decision.

In addition, I didn’t mean to suggest that there isn’t also a case for HAVING ATR-repair surgery. Indeed, I think that case — the flip side of the coin — is still usually made very forcefully to most ATR patients, judging by the questions and comments that constantly show up throughout this website, including this week (and probably even today!).

Indeed, most of the studies I love and recommend above, begin by saying that the choice of ATR treatment is still controversial and under active debate, and I would never deny that. (I also know that you and I have both read extremely vitriolic statements in favor of surgery here — some of them old, but some of them quite recent, and many of them much more strongly worded than anything I would ever write on the subject.)

In the past, I’ve participated in discussions and debates on this topic that ranged throughout this great web-site, but now I’m trying to keep these discussions here, in my own corner of the site. I don’t imagine that my posting these views in this corner would turn anybody away from the whole web-site, do you?

After Rafael asked for info by e-mail on the benefits of non-surgery (and Ifixteeth referred him to my blog), I gladly complied, and sent Rafael the above summary of “the case” by e-mail. Then it seemed silly NOT to share that summary of “the case” with anybody else on AchillesBlog.com who wanted to read it, so I posted it here.

For every minute I spend presenting this “case” — and extolling the benefits of faster protocols, both post-op and post-NON-op — I bet I spend 2 or 3 minutes giving tips to “both kinds” of ATR folks, on how to walk down stairs, or use (and modify) crutches, or balance shoes to match boots or casts, or help a fellow ATR patient predict what’s coming next, etc., etc. Those tips are directed at both post-op and non-op patients, and are largely based on what I’ve learned from the collective wisdom on the site. I’m doing all those things throughout the site, while trying to keep “the case” here.

Dennis, have you found an online forum that is actually debating the pros/cons of surgical/non-surgical treatment of ATRs? I haven’t, and I think your site here is the “go to” place where any new ATR patient would naturally turn for help in making the important decisions we all had to make soon after we felt that fateful “pop”.

You’ve already got two discussions of the first decision (”op” vs. “non-op”) linked from your “Just ruptured your Achilles?” page, and I was just trying to add another one, that reflects the latest (post-2007) studies on the subject. Nothing here is presented as the official position of AchillesBlog.com, nor is it. It’s all coming from me, and I’m just an informed and opinionated 2-time ATR patient.

normofthenorth - Although I don’t think you mean to, you have offended several people with your overzealous endorsement of the UWO, non-op protocol. “Op” vs. “non-op” has become a divisive topic on the site in a large part due to your comments. where people have taken sides, etc.

I’ve read many comments from people who were offended, and some personally emailed me to complain and have chosen to stop participating in AchillesBlog as a result.

In the past, I had been interested in reading constructive discussions on “op” vs. “non-op”, as I felt that it would be informative for some. But at this point, some of the discussions that you’ve been part of have polarized this topic to the point that we almost have to choose between a support community for ATR and a battle ground for “op” vs “non-op”.

I prefer the ATR support community for everyone, regardless of which recovery protocol people choose. I know that you have been a bit better recently, but please take “op” vs “non-op” discussions elsewhere. I have been patient and accommodating so far, but this is a final warning.

By normofthenorth on Oct 27, 2010 | Reply

Dennis, I put this item here — in a corner of my “normofthenorth” blog, and not (e.g.) as a direct response to Rafael’s cry for help on your Medical Care for the Uninsured page — precisely to address those concerns. Nobody has to read this unless they’re interested, and they have to go out of their way to find it. If they are searching for info on this topic, they’ll find your 2008 links under “Surgery vs. Non operative treatment (conservative treatment)”, and this page.

Whether or not the past discussions have been a Good thing or a Bad, I don’t see anybody posting here other than you and me, so there’s not much of an “op” vs “non-op” discussion — just a copy of my response to Rafael’s urgent plea. And if a discussion starts, it will be here, far removed from the Main Page and the pages linked from it. Isn’t that what you asked me to do, and does it still try your patience?

I’m sure you’re happy that I responded to Rafael, and I’m sure we’re both frustrated that he seems to be getting one-sided un-responsive advice from his Doc. Am I wrong?
As you say in your intro:
“The operative word is Recovery, and the site’s purpose is to make the recovery better.”

I am still worried about Rafael’s recovery, because it’s already been 3 weeks since his ATR, and I’m not sure his ankle has been immobilized or NWB yet. We’re exchanging e-mails, out of sight of anybody else (whether they’re interested or not).

In his last e-mail to me, Rafael wrote “Anyhow, I really appreciate your response. Is the one thing that has been positive in this experience. I feel that at least now I know a little bit more of what happened to me and about what my options are.”

That appreciation isn’t just due to me, of course, because I couldn’t have done it without you and AB.com. Together, I hope we’ve helped Rafael’s recovery. We’ve tried.

I’ve been pleased to read many such “appreciations” aimed in my (and your) direction sprinkled throughout AB.com. I guess if people DISlike my comments, they’re more likely to complain to you privately than to post, and if my info or tips or experience makes their day, or helps them walk down stairs better or balance on one foot more safely, they would never e-mail you about it, they’d either just smile, or say thanks in a post. But you’re making me glad that eBay’s “feedback” does a NET calculation, where they count the positives as well as the negatives!

Dennis, the vast majority of my references to the UWO protocol — and almost all of them in the past month or two — have NOT been to the “op” vs. “non-op” part of it.

The UWO study produced a great recovery in BOTH kinds of patients — “op” and “non-op” — so it’s a reasonable benchmark for a good modern protocol for ALL ATR patients. You’ve already posted a bunch of links to studies showing benefits from early WB and early mobility, and boots vs. casts, etc. You naturally didn’t include the latest studies (like UWO) because they weren’t available in 2008 when you tore your AT. But we can see the results now, and they reinforce the message from the earlier studies you cited.

I just did a quick search for “UWO” here, and the discussions are mostly about the protocol AFTER the initial treatment (op or non-op), and not about the choice of that initial treatment. If I mention the fact that UWO produced great results even NON-op, it’s usually to stress the fact that the UWO results seem to prove there’s no scientific reason to go any slower, especially post-op (since everybody knows that the surgical sutures make the AT stronger in the first few weeks).

Many of the search “hits” involve discussions between patients and their Docs (or PTs), where they discuss their Doc’s plans in the context of the UWO Protocol. The vast majority of them are empowered and pleased with the results. Some get to follow that protocol, some get theirs modified in that (faster) direction, and some GET a protocol from their Doc for the first time. I’m sure we are both proud and happy to be part of all those discussions and results, right?

Most of the discussions on this whole site touch on the topics of rehab and recovery speed, and there are very few benchmarks, and lots of posts and comments looking for benchmarks. Is this normal, am I going too fast, am I going too slow, where should I be now, etc. All those frequent questions can be answered with one anecdote after another, and/or with the results of the studies you link on faster rehab protocols, and with the results of studies, including UWO.

According to the comments at AAOS 2009, it’s no ordinary study:
“”This is a great study and a landmark paper, and it’s a model of how to perform a randomized controlled trial,” commented Paul Fortin, MD, director of foot and ankle surgery at the William Beaumont Hospital, in Royal Oak, Michigan, who moderated the session at which the paper was presented.”

Its protocol isn’t the ultimate perfect one, but it’s one of the good ones that’s been proven to produce good results, so I think it’s a useful benchmark for discussions between patients and professionals. Most people here seem to agree, though not everybody. (Some have also been annoyed that my “addiction” to this great site means I turn up everywhere. Guilty, and trying to reform.)

Would you be happier if I stopped steering people — both post-op and post-non-op people — toward the UWO protocol, as a benchmark or as a topic for discussion with their Doc?

From my POV, this site, and this community, are great because of two things: the sharing of emotional support, and the sharing of info. The emotional support is extremely helpful and important — I’ve been there, it gets better, hang in there, and “these details and experiences are interesting to me, even if they bore your friends and associates to death!” I don’t specialize in it, though I certainly do some of it.

But the info part is also extremely helpful and important, too. It’s not a warm hug, but it’s also “support”. That’s why you’ve posted so much of it yourself, and I’m sure it’s helped draw a lot of people here. (I hope that’s a Good Thing, and not just something that raises your web-hosting bill!)

Most bloggers here are long past their initial-treatment decision, so the info is mostly about “tips and tricks”, or how to deal with your health professionals, or about rehab choices (including speed), or about whether or not your current symptoms mean you should DO something about them. Much of it is necessarily anecdotal and “logical”, because we have no solid evidence.

“Rehab choices (including speed)” is an exception, because we do have some solid evidence. Your linked studies and “my” 4 post-2007 studies (including UWO) all provide some good evidence to support modern fast rehab protocols for ALL patients.

Are those discussions about protocols part of this “final warning”, or am I OK if keep the “op” vs “non-op” discussions here on this page? Or do you want AB.com to turn away from answering the urgent questions of future “Rafaels” (and Gunners, and Mikek753s, and Johannas [aka FirstDayOfSummer], and northranchers. . .) — or ask them to send us their e-mail addresses, so some of us can advise them off-line?

I really don’t want to try your patience, Dennis — far from it! But I think that you and I both, together, have added a bunch of value to the RECOVERY of a number of good people who’ve come here looking for help, and I don’t want to eliminate any more of that than I have to. Helping to support and inform the (rare) people who come here early, looking for guidance about their urgent “op” vs “non-op” decision, has been a small part of that for me, but it’s added enormous value for some of them, IMHO. I hope it can stay here, as long as it’s confined to a little corner of the site, like this one. I haven’t found another website anything like this one.

By dancingdoug on Oct 28, 2010 | Reply

I can’t leave Dennis haning by himself so, not to offend anyone, but I agree wholeheartedly that this site has become a soap box for some on the surgical v. non-surgical question.

I am a recovering achilles patient and have frankly stopped checking the site or posting because all I see is this tired debate about surgical v. non. Personally I had surgery and it couldn’t have turned out better. I was golfing 3.5 months after the rupture and have no ill effects over 1 year later.

This site was very helpful after my rupture and was a comfort to know others were going through the same things as I was. Most of the comments back then were somewhat lighthearted and a few were very helpful to keep my sanity. This contiuning bloviating about the surgical v. non-surgical procedure is a huge turn off. I think we all know where we all stand on this point, so let’s move on.

Hi Doug, haven’t seen you around in a while. I don’t disagree with you that carrying on about something just for the sake of it is ridiculous and really fairly inane after a certain point, but I do have one question. Are you saying that if someone posts that they just ruptured their Achilles, don’t know if they should have surgery or not and asks for advice or opinions, nobody should say anything? I have seen this question in the past here and expect it will happen again. Like you I had surgery, actually 4 of them, but you were a lot luckier than I was so from your perspective surgery is the way to go. From my perspective it was not such a good deal.

By dancingdoug on Oct 28, 2010 | Reply

Hi Gerry. Long time no contact. From looking at old posts it’s good to hear you are doing well for the most part. Your initial situation from last year scared the ba-jesus out of me, but like most things, time heals all wounds (literally). For what it’s worth, I think there is a place for this question and both alternatives are legitimate courses of action. In fact I had the same question in one of my first blogs last year, so you know this questions will come up again, as it should. Norm’s comments and research are helpful and should give folks some ammunition when talking to their Dr’s. The alternatives should be discussed, but what appeared to be the strong advocacy of one approach over the other is what I found objectionable. Pointing out all alternatives is good and helpful. At some point one has to trust their Dr’s opinion given their situation. Frankly, the way this site has looked over the last several months it appeared to be the Achilles Non-Surgical Recovery Blog.

Keep truckin’ Gerry! BTW are you skiing this winter. How did your heel feel? I skied a bit last winter and found putting my foot in the boot was the most difficult part. Didn’t stop me though.

“BTW are you skiing this winter?” Does a bear s**t in the woods? I even skied last winter when I probably should not have been doing that. It was quite a site at the ski school last year as another instructor was recovering from a broken neck. He and I would give the ski school director grief by limping around. This year I have new skis, Icelantic Shamans, waiting for the bindings to arrive at the ski shop, reservations at Big Sky for Dec 10-12 for the divisional season training meet and I’m trying to line up some Full Tilt boots to try out that weekend. I now what you mean about difficulty putting on the boots. There were days when it took me a couple tries to get it on my bad foot. Sometimes I would go into one of the little offices that has a heater and put them in front of the heater and turn it up to high. In about 5 minutes the buckles would give you second degree burns but even my bad foot would slide right in like it was a shoe. There were even days when it was so painful to have the boot on I sort of hid from the director when he was assigning people to classes so I could just go take them off and go home. But I’ve had them on several time recently walking around the house and no pain this year.

By normofthenorth on Oct 28, 2010 | Reply

Doug, please accept my apologies for my part in the bloviating and the turn-off! I think (I hope!) that I’ve finally learned the difference between giving my advice on “that topic” where it’s wanted, and giving it where it isn’t. I’m embarrassed about how long that lesson took, but I think I’ve got it now.

It’s been a LONG while since I’ve harped on the subject to somebody who’s already had surgery, and I’m EVEN lightening up on people who are just HEADING for surgery — partly prompted by Dennis commenting by e-mail, and partly by a couple of irate bloggers commenting publicly.

There’s been a slow-but-steady stream of bloggers struggling to make an informed-but-urgent decision on this very topic. Top of mind include mikek753, johanna, bradannarbour, bronny, and now Rafael, and several others who made informed decisions FOR surgery (Rougemac and others — why am I forgetting their IDs?).

But other than those cry-for-help responses (which I think Dennis does not want to stop, right?), I have not seen much on this topic since Kaston and I debated “the 4 new studies” in some detail. Wasn’t that a few months ago already?

By firstdayofsummer on Oct 28, 2010 | Reply

Doug and Norm,
I do not want to get into your discussion, and as a matter of fact am even too tired right now to read the whole thread. However, I did read a bit of Norm’s response and do just want to emphasize how Norm’s entries helped me when I needed to make a decision. He at this time was not even aware of me or my situation (I only started posting after I found a doctor who supported my choice of non surgical treatment).
My point being is, yes everybody is different and people do choose different treatments (which will equally work because they believe in it), however in my case (one severe complication in the past with anesthesia) it is just nice to realize that there are other choices.
So to wrap it up…can Norm appear annoying at times? Hell yes (to somebody that has had or just decided on the surgical treatment at least). But at the end of the day we all went thru the same ‘unpleasant’ experience, choose different treatments, go thru physical therapy, all hope not to re-rupture, and trying to get our lifes back.
Norm and this blog has helped me thru one of the most humbling experiences in my life and I am thankful and happy that he was willing to share all his experience and inside.
This blog should not become a ’surgical’ versus ‘non-surgical’ front. We can read the information out there but at the end of the day we all have to choose what we feel is right for us (though for us non-surgical people the choice seems pretty clear )……just busting your balls now.
happy healing and relax guys, we are all in the same (sinking at times) boat

By dancingdoug on Oct 29, 2010 | Reply

“Icelantic Shamans” that sounds pretty exotic, compared to my old Atomic Ski’s and Nordica boots. Anyone remember the old Nordica Grand Prix boots. Uncomfortable and cold, but really good boots.

Anyhow, no hard feelings, good points brought up by all. I guess I’ve been stewing for a while and needed to blow a little steam. It is kind of nice to be back on this site (wheather you want me back or not). Maybe I’ll even update my actual blog. I know everyone has been waiting with abaited breath to hear how I’m doing.

My wife skis on Atomic ST11’s and I wish she would either trade them to me for my Volkl Supersport Allstars or give up skiing so I can have them. They are just amazingly quick race skis, the closest I will ever get to world cup skis. I remember those boots but never owned them. Icelantic is an indie company in Denver that makes some very wide skis with very short turning radii. The Shaman has an 11m turning radius, the same as my wife’s Atomics. They also have some wild graphics and change them every year. http://www.icelanticboards.com

And update your blog, we’d all love to hear what you’re been doing.

By normofthenorth on Oct 30, 2010 | Reply

Sorry to interrupt, but. . . I just discovered that my fave study was just finally formally published yesterday, in The Journal of Bone and Joint Surgery (American). The abstract is at http://www.ejbjs.org/cgi/content/abstract/JBJS.I.01401v1 , with links to the Full Text (which I’m too cheap to spring for, at least right now!).

I’d be interesting in discussing the pros and cons, but that obviously shouldn’t happen here, after a final warning. “The literature is there” for people to read.

The other unpublished study among my “fave four”, by Katarina Nilsson-Helander et al, has also finally been published, in The American Journal of Sports Medicine, November 2010. The abstract & link are at ajs.sagepub.com/content/38/11/2186.abstract .

(If anybody with University access wants to share a copy of the full-text studies with me, I’ll take them!)

Regardless of anybody’s op-non-op conclusions, both studies and the critical Commentary all speak the praise of rapid rehab — as do a number of earlier studies linked from near the Main Page here.

By thisdogcanthunt on Nov 16, 2010 | Reply

I gotta say thank you for the information. The night of my rupture i immediately stummbled on this site while looking into treatment options. There is SUBSTANTIALLY more information on why surgery is the only way to go. My ortho here in Chicago told me to forego surgery and that the tides have turned on the pros v cons. Regardless, this site is amazing and has brought me comfort knowing that there are people dealing with the same issues i am…

By normofthenorth on Nov 16, 2010 | Reply

Thanks for the comment, thisdogcanthunt, and good luck with the healing and rehab. If you have the time and interest, start a blog and share your story, too. This is an amazing site, for sure!

I’m tickled by your use of the “tide” analogy on this topic. I grew up on boats, near Boston, so I used to think about tides a fair amount. They are remarkably local, surprisingly variable from one harbour town to the next. And the way health professionals “push” ATR patients toward one treatment or the other is also remarkably local. Heck, if you read Johanna’s firstdayofsummer blog, you can see the way she basically “turned the tide” in Stamford CT, from a rigid “non-op takes forever and doesn’t work well” to something very different — something more balanced and evidence-based and patient-empowering, I hope!

It’d be too bad if this tide went all the way from one extreme to the opposite, like a real tide. Many experts like to overstate their case, and their confidence, and sweep uncertainties under the rug. Surgeons are no exception — heck, I think they’re probably the rule!

So I can imagine the surgeons in Stamford doing a U-turn, from bullying ATR patients into getting surgery, to bullying them OUT of getting surgery. I’ve probably done some of that myself on a bad day, but I regret it, and it’s not my dream of how the health system will work once we get it right. I think there’s a strong case for skipping ATR surgery, and I’ve tried to summarize it here. But the judge and jury have to be the patient, and they have to hear BOTH cases before deciding.

By normofthenorth on Dec 23, 2010 | Reply

garyf just posted this query on a neighbouring page, and I’m “porting” it here:

Norm, I’m new to this site and have probably clicked on the wrong ‘thread’ to get in touch with you so apologies in advance!! I’ve been reading your posts regarding taking the non surgical route and I’m really interested in what you’ve had to say and the links to papers that have been published to back up the theory that non surgical has the same benefits as surgery. Now to my point!! I ruptured my AT in my right leg on Fri 17th Dec 2010. I was dancing at my office Christmas party. I went to A&E (UK) on 19th Dec and was fitted with a holding cast until I saw a ‘consultant’ the following day. I was offered options of surgery or just a cast and I took cast option as I was worried about infections etc. The problem I have is my consultant has put a cast on and told me he’ll see me in 6 weeks. Looking at the stuff you’ve posted this looks to be the worst thing he could do as my calf will weaken, meaning re-rupture more likely!! In the UK we get healthcare free so I don’t know if I can go back to my consultant and demand a more aggressive rehab - any clues what I do now?? Thanks. Gary.

First off, Gary, I’m no expert on the NHS. Sometimes the medical system in Ontario still surprises me, and I’ve been living here 36 years. . .

But we’ve got a LOT of bloggers here from the UK, many of whom have tried to get treated with a modern non-op protocol like bit.ly/UWOProtocol . Some succeeded, some not so much. Luck of the draw, specific doctors, hospitals, days of the week, willingness to become “the patient from Hell”, it’s hard to prove what made the difference. Many who succeeded just bought their own boot and got it fitted. Others got boots provided by NHS, and still others were just slapped into a series of casts, no matter what, “that’s what we do here”. With luck, some of the Brits who are posting now will have some suggestions for you to make the system work for you.

It should be win/win, since following the UWO protocol is way cheap medicine, probably 1/15 the total cost of surgery (which NHS offers for some), and doubtlessly cheaper than repetitive “conservative casting” — and that’s not even counting the patient-side costs to society of all the down-time from work, etc. But institutional momentum and featherbedding are way more powerful forces than logic or even economics, alas!

It would be great to get you into a good boot — the VacoPed (aka VacoCast) is currently by far “the people’s choice” hereabouts, though not the cheapest — in time for you to start (GENTLE!) physio and exercises 2 weeks into your immobilization, as the UWO study did. But if you’re stuck in a cast for 6 weeks, I don’t think that puts you into the “bad old days” of your father’s “conservative casting” with the high re-rupture rates. I suspect that — especially if you can find ways of applying some weight to your cast without breaking it — you can still reap MOST of the benefits of the newer protocols by escaping from the plaster at 6 weeks. But that’s IF you can escape from the plaster at 6 weeks!

It’s not ideal by a big margin, because you’ll be missing a bunch of exercise that is spiritually uplifting as well as physically helpful, a bunch of PT that is ditto, and ESPECIALLY the PWB from 2 weeks and especially the FWB as tolerated from 4 weeks. Keeping your ankle angle unchanged for 6 weeks is slower than many protocols, but it’s ironically EXACTLY what the UWO folks did, and what we “UWO followers” also did, so no harm done there.

I’m in no position to advise you of how to proceed, but I’d guess that winning “the 6-weeks battle” — for a boot, exercise, and physio — might be worth 60-odd percent of the value of convincing them to put you into a boot in a few days.

In all cases, there are no guarantees, it’s all percentages, stats, risks, etc., and way more than half come out quite well with some pretty bad-risk protocols. But it’s still a shame to see whole nations of ATR patients (and fellow members of the Commonwealth!) so badly served by what just looks like fuddy-duddy-ism from here.

You can also look at (e.g.) achillesblog.com/atrpt.php and pick out your neighbours and check out their blogs (though not everybody on that list started a blog). Some will be surgical, and some non-op, and many of the non-ops would have gotten the standard “same old same old”. But you may find a few role models who’ve broken through to a better standard of care.

Good luck! I’ve been quite a wimp in my recent open-heart surgery (valve replacement), though I’m just now bumping into some second-rate medicine in my post-op care. . . But when it comes to ATR treatment, and ESPECIALLY non-op ATR treatment, I think EVERYBODY should be “the patient from Hell”!! After all, you don’t have to go to Med School, or even know where to FIND one, to be able to follow a top tested non-op protocol, so how embarrassing is it that your Doc DID go to Med School and STILL can’t do it! Hello. Is it me, or is it DUMB in here? [end of rant, thanks and sorry ]

As I’ve suggested to many people here, print out the “recipe” from bit.ly/UWOProtocol (or the fancy version posted at ejbjs.org/cgi/data/92/17/2767/DC1/1), and print out the “proof of the pudding” from bit.ly/UWOStudyPub, and take them both to your doctor. You’re presenting excellent non-op results, HUGELY better than those from traditional “conservative casting”, especially in re-rupture rates, AND the road-map that produced those great results. And the argument for following a very different road-map — one with no documented results or much poorer ones — is WHAT, exactly. If your first Doc can’t or won’t read, try another one, or roll up the two printouts and start swinging — in the nicest possible way, of course!

It may be a tough slog, and an uphill battle, but if you can succeed, you’ll make life way better for maybe HUNDREDS of future ATR patients that go through that hospital! We’ve had a few tough patients do exactly that, and document their experiences here, too!

By rmb4 on Mar 28, 2012 | Reply

i also had a non-op procedure and i’m on my week 20 now. i can’t still walk down the stairs as what normal people would do and i’m trying to use both legs sometimes but am afraid that i might hurt my bad leg again.
is that normal?

By normofthenorth on Mar 28, 2012 | Reply

Rmb4, you sound “behind the curve”, as if you’ve gone very slowly, but we’ve got very few details. Best would be to start your own blog page here, and share the who, what, when, where, why. If you’re recently out of a cast and WB, then it’s natural to be weak and awkward, no matter the calendar week. My usual rec is to read the UWO protocol and gradually catch up to that schedule. But gradually, no rushing or jumping ahead, because long NWB & immobilization seem to extend the vulnerability to reinjury.
There is a simple trick to walking downstairs normally when you’re just barely FWB, either booted or in 2 shoes. I’ve posted it many times, incl on one of my own blog pages. Try it, it works well.

By normofthenorth on Mar 28, 2012 | Reply

Here’s one version of the stair-walking trick, from 2010:
“Good luck. Casts are a pain. You’ll have a much better time going down stairs in two shoes if you’ve gotten good at rolling over the edge of the step in your walking cast. The same technique works in a walking cast, a boot, or a shoe.

Basically, you step down onto your healing foot so the foot is straight, but only half on the step, with the toe half over the air. Then as you step down onto your uninjured foot (down 1 more step), your healing foot rolls over the edge of that step, while your ankle stays at roughly neutral flex angle, without any unusual loading of the AT and calf. Once you get good at it, it’s fast, it looks and feels pretty normal, and it’s quite safe as long as you do it right, and consistently so. No distractions, and Watch Your Step!

If your cast is strong enough and well enough fitted, you should be able to get it (and your shin) to take all the strain while you’re walking, with no strain at all on your calf and AT. Or only as much as feels comfy and safe, as you choose. Walking boots work just the same, only they’re more easily adjusted — plus the exercise, physio, and hygiene benefits, of course!”

That trick also works in 2 shoes, as long as you’re FWB. By avoiding FWB on a sharply flexed ankle (which is difficult, painful, dangerous, and often impossible during ATR recovery), this trick lets you LOOK LIKE you’re going downstairs the way you did pre-ATR (& get downstairs just as fast), but without the dorsiflexion, risk, and pain.

Edit (03/2015): I’ve just created the short-link http://bit.ly/downthestairs to point back to this Comment.

By sheena on May 27, 2012 | Reply

Norm,
my name is Sheena and I’m urgently writing because I did my tendon last Thursday. I’m in the UK and went to our A and E (ER) They felt it. Didn’t know if it was a full tear so put a front cast on in ballerina position. I don’t have an appointment with the OS until Tuesday.I am 47 on the 4th July, very active but not too sporty although I did it playing badminton which is very new to me and this is why I guess it happened. I was however a good snow boarder once. Of course I will take advice from the surgeon but real advice from sufferers is far more important in some ways I think.I have read Dennis’s point of view and frankly have chosen to ignore him. My concern is that if my surgeon does reccommend surgery it could be well over a week since the injury before it is done on the UK’s NHS which is a lottery re service I’m afraid. Any thoughts re that time lag? And by far yours is the most informative of all blogs I have read and don’t let someone like Dennis put you off! I am completely new to this but have read all weekend none stop and YOU have helped me lots.I feel if the body can heal without cutting then let it. I have had poor results with a certain surgery in the past…….many thanks in advance.
Sheena.

By normofthenorth on May 27, 2012 | Reply

Sheena, I’m delighted to have helped, but none of us could help anybody without Dennis and this great site.

The most successful studies (incl UWO) used ATRs between 0 and 14 days old. Most OSs prefer those, too — though mine from my 2009 (2d) ATR unusually used to prefer repairing ATRs slightly older than 14d (becore he switched to non-op ATR treatment). At any rate “well over a week” shouldn’t be a problem.

Many Docs and medical systems leave the op/non-op choice to the patient, though often with strong or weak recommendations. You know my fave, but either path usually gives excellent results, esp with a good protocol. Some Docs rule out surgery on very high ATRs, but the only ones that can’t be treated non-op are those with rare complications, like a break in the calcaneous (heel) bone at the base of the AT.

Good luck, and keep us posted!

By ryanb on May 27, 2012 | Reply

I’ll chime in too Sheena - from the perspective of a guy (10 days younger than you) who has been happy going the surgical route. My recommendation would simply be to go with what you’re most comfortable with (sounds like non-op for you). If you’ve kept it immobilized, well then you haven’t waited more than a week- you started (non-op) as soon as you got it supported. Hopefully, you’ve got some plantar-flexion in your splint/cast/boot (whatever you’re in now) to promote the re-attachment process starting.

There are people who do well with surgery, and people who have complications/problems. Likewise, there are people who do well going non-op, and people who have problems with it. It’s a bit of a gamble- and I think you’ve got to pick what you’re comfortable with and rehab accordingly. Find a doc who is willing to work with you, on the path you want. Don’t let a doctor strong-arm you either way. Remember, when talking to a surgeon, there is a good chance he’ll suggest surgery - if all you have is a hammer, everything looks like a nail.

All that said, as Norm points out, there is a possibility that your specific injury (location, type of tear, additional damage) may dictate the course you should take - one way or the other. I’m a very strong proponent of being your own advocate but do listen carefully and objectively to what the doctors have to say, and try to go in with an open mind.

By normofthenorth on May 27, 2012 | Reply

+1 to Ryan’s comments. On another blog I frequent — valvereplacement.org — there are lots of strongly-felt discussions by and for people who’ve recently discovered that they need a replacement heart valve, and have to choose between a mechanical valve and a tissue valve, usually taken from a pig or made from cow tissue. Each comes with its own potential advantages and disadvantages, and each also comes with risks that things will go badly — including the possibility that the promised “potential advantages” will never actually materialize!

In that context, I often add a perspective that is usually absent: In addition to choosing the option that you expect to produce better results (or the best possible results), imagine for a few minutes that you’ve chosen one option and it goes badly. Then imagine you’ve chosen the other and it goes badly. Which possibility makes you feel less rotten?

To me, this admittedly unpleasant exercise is part of honestly discovering “what you’re comfortable with”.

By sheena on May 28, 2012 | Reply

Hi guys,
firstly, thanks for responding and secondly apologies to Dennis…is this his site? I just didn’t like his tone in the email he wrote to you Norm and so what if you advocate non surgical that’s what blogs are for are they not. People should read and make up their own mind. I think that your blog is intelligent, in depth and the most helpful I have read and I have done nothing but read since last Thursday night. Thank you Ryan, you both have been impartial and given me insight. I feel easier now that I wasn’t given surgery the next day as I still have a choice which is good. I understand that my foot being in plaster, pointed down like ballerina is the start of the non op process but i wll listen very very carefully to my OS when I see him tomorrow. Thank you for writing back and taking the time to write these blogs. They have helped me so so much.
I’ll keep you posted on my progress. I have never written before, am I writing in the right place?
Thanks again x

By normofthenorth on May 28, 2012 | Reply

Yes, Sheena, Dennis created this remarkably helpful forum, and he naturally hates getting angry e-mails from old pals upset with recent posts — often mine in the past.

Your posts have been well placed on the site, but a blog of your own (which D will set up for you — see Main Page) will let you share all the details about your injury, treatment, rehab, and recovery. I’d send the e-mail soon, and start filling in the blog blanks when you get some time — or get bored holding your leg up!

By sheena on May 28, 2012 | Reply

By sheena on Jun 7, 2012 | Reply

Norm,
can I ask you a question please? I have been in plaster since 24th in full equinis position.I was ultra sounded and said to go back in two weeks to see if healing. I’d like to go non op. The doc told me to do some excercises and to PWB from day one. this morning I was doing some leg lifts back wards and my calf went into a cramp in the same position your leg would be if you were NWB. I immdiately stopped and tried to relax and put my hand into my cast to stretch out the muscle. I was and am really concerned that the cramp could have pulled the tendon up into the calf. My calf muscle ached for a while and for the first time but only for a very short while the injury area tweaked a bit. Has anyone got any thoughts on this? I’m now worried that when I go back for ultra sound on Monday I won’t have healed at all or maybe re tracted up and have to have surgery. That will be after spending 18 days in a cast.The injury site had a very slite dull ache which it didn’t have before.

By normofthenorth on Jun 7, 2012 | Reply

Sheena, you posted this in 2 places, and I think RyanB nailed the answer in the other place. A calf cramp pulls on your weak-&-healing AT, and could possibly rerupture it. When people slip on crutches and rerupture, I think most of the tears are caused by instinctive calf contractions rather than from the impact itself. (Casts and boots are pretty protective against impact.)

Being boot-less while having a calf cramp might (as Ryan suggests) give some protection by letting the ankle flex. Alas, our ankles are already flexed almost as far (PF = toe down) as they go, so there isn’t a lot there. The good news is that most of us DID experience some calf cramping during ATR rehab, without rerupturing (& probably without doing any damage, tho that’s hard to prove). The longer we’re immobilized, the more chance for our calf to get “bored”, but it’s a lot of hours to stay still even in a fast rehab. In serious cases, Docs will prescribe anti-spasmodic or muscle-relaxant pills.

Offhand, I can’t remember anybody here rerupturing from a spasm, without slipping and falling, tho many of us worried about it. Good luck!

By sheena on Jun 7, 2012 | Reply

Hi Norm,
not being sure how blogs work and who sees which posts I wanted to ask you because I think you seem so well versed. I know you’re not a doc but I trust your judgement. Maybe I should set up my own blog. do I just email Dennis? I usually just post on the UK site. If I do that will you see it? I wasn’t sure if you’d see it so I posted twice. I also have a constant dull ache behind my knee but a bit lower down. sorry about posting twice. won’t do that again.

By normofthenorth on Jun 7, 2012 | Reply

No worries, Sheena. The main page lists all the latest posts, in order, so we only miss stuff if we stay away for several days. (I wish! )

Yes, it’s Dennis who’ll set up your blog page after you e-mail him, as outlined on the Main Page. Do it! And good luck with that cramp.

By sheena on Jun 7, 2012 | Reply

Ha ha. I know you’re addicted. Thanks for the tips. I’m worried I must say becasue I did understand that the muscle cramping will pull that tendon. Fingers crossed.

Hi sheena, I’ve setup your blog, and sent you emails on how to login, etc. Everyone is very helpful on the site so feel free to ask if you have any questions. happy healing!

By brokenbride on Oct 3, 2012 | Reply

Hi Norm, thanks for your post on the non-surgical route to healing. I ruptured my achilles 6 days ago and opted not to have surgery. Despite three doctors telling me the non-operative way is the best thing for me, I’m tortured by my decision.

It seems everything I read online suggests surgery is the only way to a fast recovery and returning to an active lifestyle. Doubting my decision in the ER I immediately booked in with an ortho so I could insist on surgery. The orthopaedic surgeon spent a lot of time with me going over the pros and cons of each option. What resonated with me most was his statement “if it was me, a triathlete and a surgeon, I would not go with surgery”. I left feeling confident that non-surgery was the right decision.

But after a sleepless night, I called the surgeon back in the morning with a change of heart. Turns out he left town for two weeks and surgery is no longer an option.

Reading your post has calmed my anxieties. It’s comforting to know you’ve been through both routes of treatment and have had success with both. Funny, but I was really having a tough time mentally accepting my achilles would heal without sutures. Biology was never my best subject.

I’m getting married in two weeks so the timing couldn’t be worse. But your post and experience is helping me move on with the knowledge that I’m going to be okay. Achillesblog is proving to be very valuable on my road to recovery. Looking back on some of the blog exchanges, it looks like you were getting a bit of grief for presenting a case for non-surgery. I personally found it a huge relief to find out I wasn’t alone by going non-surgical and that there is research to back this approach. I think it’s important for people to learn as much as they can to make informed decisions.

By normofthenorth on Oct 3, 2012 | Reply

Thanks, brokenbride, you made my day! Dennis and I did seem to be at loggerheads for a while, partly because I infuriated a few of the early bloggers here, who had become his pals — as so many of us do here who’ve stuck around. But I’m eternally grateful to him for creating this “home” for us all, and we both want to help as many people as possible, including people in your spot — so there’s no real conflict, IMO. (I’m also a BIT less absolute and outrageous now than I was a year or so ago!)

You’re definitely not alone, and many of us have had successful non-op treatment and returned to aggressive explosive sports afterwards.

Now make sure you get on a proven fast modern protocol (like bit.ly/UWOProtocol ), and stick with it religiously and carefully! With or without surgery, you’re heading for a few months of high vulnerability to (re-)injury, and you’ll be scary-walking on crutches for

4 weeks of it, and later wobbling around in two shoes with a weak and “rusty” leg. So hang in, good luck, and have a wonderful wedding, too!

If you have a chance (busy time, I’m sure!), start a blog and keep us posted, too. You seem to be in Canada — whereabouts? If it’s not London, ON (home of UWO), I’m pleased that so many different experts are familiar with the recent evidence supporting non-op treatment.

Be warned that your torture-like anxieties may return. The “mental game” in this rehab is a challenge, and post-op patients (even if bothered by their wound and/or scar tissue or whatever) have the extra psychological “crutch” of knowing that they put themselves through an invasive and painful and expensive repair. By contrast, those of us who follow a modern non-op rehab can easily feel like we haven’t done much, we’re just trusting to the “magic” of natural healing.

If we had an UltraSound or an MRI machine in the basement, most of us would probably check our progress every day or so, and the non-op patients would be elbowing the post-op patients out of the way!

Do your best not to succumb to those irrational fears. You’re going to be (I hope) following a well-tested, proven-successful evidence-based approach. There are still no guarantees (again, with or without the op), but odds are you’ll be happy with the results.

But next time (kidding!), try to do the ATR more than FOUR weeks before the wedding, so you’ll at least be walking down the aisle without crutches!

By hendrenville on Dec 28, 2012 | Reply

Hey Norm, big fan of your blog. Deciding to take matters into my own hands here and order a VACOcast boot. Have you heard of where you can order them from in Canada? I’m 5 days into the ATR and want to get better ASAP.
Thx Ryan

By normofthenorth on Dec 28, 2012 | Reply

Sorry, Ryan, I’ve never checked into the Vaco boots in Canada, but I’m sure their website or their US agent could steer you. While you’re tracking it down, if you’re planning to go non-op, make sure you get “with the program” ASAP — NWB, and immobilized securely (or be so careful that “securely” isn’t important!) at something close to the right angle. UWO used a flat/neutral AirCast boot with 2cm of firm rubber wedges under the heel, and got great results. Others seem to use a bit more plantarflexion = equinus = ballerina, like 20-30 degrees. (I calculated the equivalency once, but not recently. You good at trigonometry?)

I like a hinged boot (like the Vaco) for much later in your rehab, but for now, NWB, almost anything will do — at the extreme, a bent hunk of alumimum held to your leg with an Ace bandage — that holds your ankle at the right angle, immobile. The boot adds some security if you slip or lose your balance, and is good for walking once you start PWB and FWB, but the healing should be starting now, while you’re NWB. As I’ve told several people (including you elsewhere, I think!), if you lose the mad-healing period of the first week-ish, I think the prospects of a good non-op recovery drop, and surgery starts coming out ahead. (The surgery — slicing and stitching — re-starts the mad-healing clock. Unfortunately, surgery also injures layers of tissue that are UNinjured in a normal ATR, and those adjacent layers of tissue often madly heal to each other, forming harmful “adhesions”.)

Nobody has tested that timing theory of mine, tho’ I’ve invited the UWO authors to mine their data to see if non-op outcomes are as dependent on a quick start as I think they are. Maybe I should try contacting them again. . .

[WORDPRESS HASHCASH] The poster sent us 𔃰 which is not a hashcash value.

By hendrenville on Dec 28, 2012 | Reply

I went to sports clinic the next day and my doc suggested I go non-op, but he was a little short in not giving me much info about the specifics of my ATR other than its ruptured and its a long recovery.
I’m in a splint/cast toes in neutral downward position and have been from the first day. Will be like that till Jan 9th. Then I expect a boot. I just want to make sure I’m using whatever will give me the best results and not just whatever they have available (boot wise).
I’m hoping my PT will use an ambitious rehab protocol (UWO), if he doesn’t I’m planning to suggest it. We’ll see how that goes)
Also I had a trip to Hawaii planned Jan 10th. Still going as I figure if I need to be off my feet, what better place than Hawaii - a lot less snow.

By normofthenorth on Dec 28, 2012 | Reply

Sounds good. Any boot that fits well should give you good results. Most people here who’ve used the Vaco love it a lot. But even a fixed boot will do the trick, at least until

7 weeks in, when I enjoyed letting the hinged boot hinge. It’s also maybe not too early to start thinking about how to build up your other shoe/foot to the same height as your injured-and-booted one.

[WORDPRESS HASHCASH] The poster sent us 𔃰 which is not a hashcash value.

By normofthenorth on Dec 28, 2012 | Reply

AAARGH! Even comments to my own blog page are held up, “awaiting moderation”!! Dennis, any ideas or suggestions? You haven’t put me on a “black list”, have you? (I think I’ve been pretty good lately/. . .)

[WORDPRESS HASHCASH] The poster sent us 𔃰 which is not a hashcash value.

By Lisa on Dec 29, 2012 | Reply

What browser are you using, Norm?

By normofthenorth on Dec 29, 2012 | Reply

I’ve been using Chrome recently. I prefer Opera (which I’m on right now), but mine is working slowly. MAYBE it’s the 40 or 50 tabs I leave open. . . NAAAH!
My last post (with Opera) went through without being held up, so either this site doesn’t like my Chrome, or the problem is fixed, or I just got lucky. (Here goes! Yup, it seems to be working. )

No, I have no blacklist for users.. Norm, if I had a list, you would be on the whitelist, not blacklist. happy new year.

By normofthenorth on Dec 30, 2012 | Reply

Oh, phew, and yay! And happy new year to you and yours, too, Dennis.

And hey, folks, how about a bunch of click on the donation button on the Main Page and send D a few bucks to keep this amazing resource alive!

By normofthenorth on Mar 5, 2013 | Reply

OK, I just heard a CBC Radio news story about the Cochrane Library (aka “Cochrane Review”), whose Canadian wing has just made plain-text summaries available free online. So I wondered — and checked — what Cochrane says about ATR treatments. I found that answer and A LOT MORE, new analyses and meta-analyses from the past few years.
I don’t have time today to get to the bottom of all of it, but here’s what I think I know so far:
1) There have been a number of new meta-studies, trying to combine numerous “good” individual studies to come up with greater “statistical power” and certainty about the key questions, including the relative benefits of op vs. non-op.
2) I KNOW that most of these studies have found a lot more than 2 or 4 studies to include, and I THINK that means that they’ve included a number of studies that (IMHO) “don’t ask the right question” — i.e., they don’t use the fastest and best modern protocols in their non-op patients. I keep referring to the 4 modern randomized trials of op vs. non-op, 2007-2010, and especially the two that seem the most impressive (2007 from NZ, 2010 “UWO” from Canada). There’s no dispute that non-op rehab with a bad old slow rehab works badly — much worse than most surgeries — but that doesn’t prove that surgery produces a benefit compared to the best non-op rehab. In fact, unless you’ve got BAD non-op rehab as your only non-op choice, those bad results are irrelevant to an intelligent choice between treatments.
3) Cochrane published a meta-analysis in mid-2010 which concluded that op is way better than non-op for rerupture rates etc., but way worse than non-op for complications. (Several other of the meta-studies have similar conclusions, including one from China.) I think the Cochrane study was published before the UWO study (late 2010), so I assume UWO was excluded. But if they included enough early “wrong-question” studies, even including UWO wouldn’t come up with smart and relevant results.
4) The symbols on the Cochrane listing page indicate that their “latest issue” has revised conclusions and also a call for more data. . . I haven’t free-joined Cochrane yet, and I have no institutional “in”, so what I’ve seen so far is very limited, no details on the above yet, though it sounds hopeful to me.
5) One recent meta-analysis, from Canada, found no benefit from surgery and led the authors to recommend non-op treatment as worthy of serious consideration. (I haven’t read it yet, either.) It’s Soroceanu A, Sidhwa F, Arabi S, et al. Surgical vs. Non-surgical treatment of acute Achilles ruptures: a meta-analysis of randomized trials. Presented at annual meeting of the American Academy of Orthopaedic Surgeons, San Diego, February 2011.
6) There is a nice easy-to-read summary of the current debate (especially in the US) at http://lowerextremityreview.com/cover_story/battles-of-achilles-the-operative-vs-nonoperative-treatment-debate , entitled “BATTLES OF ACHILLES: The operative vs nonoperative treatment debate”. I find some of it infuriating, because it demonstrates the “Eminence-Based Medicine” and inertia and “If you go to a carpenter, he’ll recommend wood” bias I’ve come to expect from senior (esp. old-senior) American Orthopedic Surgeons when it comes to this issue. Surgery is way better, all athletes especially should get surgery if they care about results, yadda yadda.

But if you read it through and read critically, it’s all there, including what I call the “truth”.
Here’s a nice nugget, quoting Mark Glazebrook, who’s described as the “mentor and coathor” of the chief author of the Canadian meta-study:

Mark Glazebrook emphasized that up-to-date research, not conventional wisdom, should provide the basis for patients’ informed consent.

“We want to make sure that patients are given an option for both operative and nonoperative treatment, and that a surgeon presents those options based on available evidence, not on what they think,” he said. “Often what we think is wrong, and there are many examples of that in history.”

Glazebrook noted that in the first six years of his surgical practice, he treated 95% of Achilles ruptures operatively. In the past six months, he’s treated all 20 cases nonoperatively and has been equally happy with the outcomes.

Unfortunately, the article — reporting a recent (Feb. 2011) meeting of the American Academy of Orthopaedic Surgeons — shows lots of what Glazebrook is complaining about. It also demonstrates that most of the surgeons really prefer surgery, and

80% of them are actually unfamiliar with non-op protocols! (When a carpenter recommends wood, that does NOT prove that the carpenter is evil or greedy, just that he or she is human!)

With luck, I’ll get to review some of this info in the next while, and see what if anything it changes (including any part of my own mind). When I Googled “Operative versus nonoperative management of acute Achilles tendon ruptures”, I got 107,000-odd results, quite a few of which seem to be from 2010 or later. . .

By normofthenorth on Mar 24, 2013 | Reply

The article referenced just above is a nice summary of the debate, IMHO, including the 2011 meta-study by Soroceanu et al. That meta-study reinforces the gist of this blog post and the “pitch” I’ve generally been making on this site: Non-op produces results as good as surgery with much less pain and hassle and cost and risk of side-effects, PROVIDED the non-op treatmemt follows a modern aggressive protocol, like bit.ly/UWOProtocol . But old-style slow “conservative” non-op treatment produces significantly inferior results, especially a rerupture rate that is much higher — average 8.5 extra reruptures per 100 patients according to this meta-study.
There are some special cases where I’m hesitant to push non-op. Having a large ATR gap is NOT one of them (based on the only evidence I’ve seen answering that question), but having a long delay pre-treatment (hobbling around for weeks without being immobilized and NWB) definitely IS.
The logic behind that exception also has made me wonder whether there’s an especial urgency to starting non-op care — e.g. whether ATR patients who start non-op after 1 or 2 days do better, on average, than those who start a week later. Finding the answer to this important question would be a simple and cheap matter, by “mining” data that’s already been gathered — e.g. through the UWO study. Its

75 non-op ATR patients started treatment at different times post-ATR, but all 1-14 days post-ATR. And they either did, or did not, demonstrate that relationship between ATR “age” and clinical results. EITHER result would be interesting, IMO, and worth the tiny trouble to analyze the data to find out.

I’ve already posted that I’ve emailed one or two of the UWO Study’s authors to suggest that they do (& publish) that sub-study, but they haven’t even responded to this “random layman”. WELL, it’s possible that we’ll see some progress on that front! Friday, the DW and I drove our rental car from mid-FL a few hours south to Sanibel FL to visit with some Canadian friends. Also there was our friends’ 30-yr-old MD daughter, and one of her young MD girlfriends. Both of them got their MDs at UWO Med School. We discussed many issues over our 2-day visit, including many medical issues, some involving ATR care — after all, I’m Norm, right. And I mentioned this specific research gap, and the friend — who still practices in London (ON), home of UWO — thought she knew which of their MD pals might be the best one to get this to happen. She sent him an email while we were all still together. Fingers crossed, folks!!

By jdrg on Mar 25, 2013 | Reply

What a lucky connection Norm. I’m interested to hear what will come of this. As a librarian, I also enjoy investigating the literature and am frequently curious how some of these studies come about. I am non-op, and was diagnosed and treated within 24hrs of injury (though as you are already aware I’m having to push my way along for a UWO-ish rehab).

Something else I’ve been curious about is hydration levels. You’ve noted that there’s no convincing evidence that stretching plays a role in prevention of/causing an ATR. I’m curious if dehydration is an issue (more common at certain times of year with more time spent indoors, dry heated air, cooler temp so consuming less water/fresh fruit & veg, etc.? or in intense heat/dry climates in summer months?). Tough to measure with existing data I suppose, and folks are all coming from different climates on this site, but if hydration levels were measured at time of injury, I’m curious what data/patterns one would find. Can you tell I’m sitting around with too much time to mull things over these days?

Good luck with the sub-study.

By ripraproar on Mar 25, 2013 | Reply

Hey norm, Ben reading this thread, thank God you and Dennis made up, I dont know what state I would of been in without your informed guidance, and big plaudits to Dennis for have the ware with all to set up this great site.
I’ve mailed Dennis to start my blog just waiting for confirmation.Hope to be a fellow blogger soon
Thanks guys

By normofthenorth on Mar 25, 2013 | Reply

Thanks for the thanks, ripraproar!

Jdrg, you’re thinking that dehydration would increase the risk of an ATR? Maybe. There was a widely held theory that ATRs mostly happen at a “watershed” area, where two blood supplies meet and stagnate. Loss of blood volume via dehydration could exacerbate that effect. Last study i saw on the “watershed” suggested that the effect was overblown or even non-existent, though I forget all the details. Anecdotally, I generally hydrate well between v-ball games, and probamly did so when I did my two ATRs, too.

Just heard a good quote, from O. W. Holmes, IIRC: “One page of history [I'd prefer "facts"] is worth more than a volume of theory.”

By jacqui on Apr 23, 2013 | Reply

Hi Norm,
Thanks for all the insightful info. that you have posted on this site. You have helped so many including this newbie who was searching for info. about my ATR injury last week when I came across this blog. My ATR rupture happened 3 weeks ago when I was warming up on the tennis court in the Bahamas,where I was visiting from TO. The loud pop, excruciating pain & collapse to the court is indelibly printed in my mind. I had to go the hospital in the Bahamas & pay $1000 USD Out of pocket (willl be reimbursed from extended health insurance thank God) within 2 hours & thankfully it was a good hospital where an orthopaedic Dr. made a right angle half cast for me supported by bandages to ensure that I could travel safely back to TO the very next day. I had an xray & ultrasound 3 days after the injury & was referred to an orthopaedic specialist 4 days after the injury where he discussed both surgical & non-surgical options with me and cited the UWO study and recommended based on my medical history (had wound issues with a previous surgery) that I go the non-surgical route which he felt would give me just as good results within a year as the surgical route. I agreed to go the non-surgical route & was fitted with a Nextep contour walker with heel lifts toes pointed down & given the UWO rehab protocol similar to what you posted (although yours is much more detailed)so I will take yours to my physiotherapist who specializes in sports injury rehab. today.
I will see the Orthopaedic Dr. in a week’s time for 1 month follow up. I started to do the UWO rehab protocol last week (week 3) and will step it up today ( start of week 4) with a more experienced sports injury physiotherapist today which I am looking forward to.
So far so good except:
1) It is very important to get the right boot since we have to wear it almost 24/7 for quite some time. I had to go back to the orthopaedic clinic twice after my initial visit with the specialist because the foam walker which they gave me initially was “no air” and it was unbearable!! When I went back the 2nd time I told them I wanted an air boot however they said they didn’t have any (although I saw someone leaving with one on) so they tried to pad mine with sponges and I said I would try it for a week and if it wasn’t comfortable I would be back. I asked them to order an air boot model for me. Unfortunately the week was again very difficult because I felt the plastic rubbing my foot all the time, so I went back in & literally demanded an air boot which they miraculously were able to find after initially saying that they didn’t have one. This is Canada but I did pay $160 for the boot (not covered by OHIP but will be reimbursed 80% through extended health ins.) so I felt entitled to get the most comfortable boot which I was finally able to achieve with the addition of the air component with the Nextep air contour walker, plus the technician padded it with sponges as well. So lesson to others- make sure you get an air boot so that you can pump up the air to provide more comfort & support & it helps with swelling. The difference is night & day!!
2) I have started the weight bearing with crutches but don’t understand how to do that without a little hop on my “good leg” which has been talking a beating even though I use crutches only when I absolutely have to. Otherwise I use a wheelchair that I can propel in the house & outdoors to save my “good” leg.
Not sure I understand the partial weight bearing. Is it like walking with crutches no hopping or will there still be a little hop on the “good” foot?
Norm, I noticed that in one of your posts above you mentioned “thinking about a way of building up other shoe/foot to the height of the other one”. Is this the trick to make the PWB work better with crutches or even when FWB no crutches with boot? Do you have any ideas you can share to achieve this? I thought about using my husband’s running shoe since he wears one size more than I do and adding sponges similar to what they have put in my air boot.
Thanks again for the WEALTH of information you have shared. I really appreciate it!! I plan to start a blog but after signing up, couldn’t see how to easily get going. I’ll keep looking for info. regarding this. Do you know if Wordpress is compatible with IPad? I know some things don’t work on my iPad.
Thanks eh! Cheers!!

By jacqui on Apr 23, 2013 | Reply

I tried to add this to very long post above but couldn’t…
3) Safest way for me to go up and down stairs is on my butt. That has been interesting. My husband lowers me down to sit on my butt then I do a baby crawl down the stairs in the morning and do the crawl up on my butt at night. I am very afraid to use crutches on 1 foot to climb up & down stairs. I also have 4 steps out to the garage so the down on butt thing happens there too.
Not sure if you know if anybody had a better idea on navigating stairs.
Thanks again!

By normofthenorth on Apr 23, 2013 | Reply

Lots of Qs, Jacqui! I’ll try to hit ‘em all, but please re-ask if I miss 1 or 2.

No problem using an iPad. I’m on an iPod now!

Building up your uninjured-side shoe is vital when you’re FWB, but not a huge deal when you’re still on crutches. No problem doing it early, though! Your way would likely work fine. Anything that balances the height and is comfy enough for walking.

It sounds like you never got good basic training on crutches. It’s way easier in person than in words, though I’m sure YouTube is good at it. Once you get good at crutch-walking NWB with your boot in the air, the next step (2 weeks in following the UWO schedule) is just to rest your boot gently on the floor just as your crutches hit the floor, then crutch-swing forward past the boot ’til your weight is all on your uninjured foot again. (There’s no hopping involved, unless you’re watching someone use invisible crutches.) Gradually you can shift some weight from the crutches to the boot, and eventually (UWO: @

4 wks) you’ll shift all of your weight to it, which is FWB, and you can start ditching the crutches.

Me, I got good at crutches after my first ATR (& surgery and a VERY slow rehab), so I’ve never gone anywhere on my bum, not stairs, not going to the garage, not ever. If your other foot was OK for normal walking (not to mention TENNIS!), then normal crutch-walking shouldn’t be hard on it. Many of us do too many things while standing on one foot, but a few padded stools or wheeled chairs (e.g. at each sink) solves that problem.

“A baby crawl down the stairs”. You go down the stairs head first on all fours, but without banging your boot on the steps. I didn’t find crutch-walking down stairs relaxing, but crawling down sounds scary to me! Sliding down on your bum feet first sounds much safer.

In addition to the normal way of crutch-walking on stairs (which does take a
bit of instruction and practice to master), RyanB has posted some videos of an alternative technique that looks good for relatively fit people (like tennis players!).

I agree 100% that getting a good-fitting boot and adjusting it ’til it’s comfy and supportive is very important. Me, I disliked the feeling of the plastic air bladders in my AirCast boot pressing against my socked foot, so I stopped inflating them. But if they help you, use them, of course. Once you’re FWB, you should be walking full speed in the boot — and while carrying stuff in your hands, too!
Good luck and good healing! If you’ve got a login here and you’ve emailed Dennis to set up a blog for you, you should soon see a new “Hello World!” blog on the Main Page from you. Sign in and go to it, and you’ll see that you have The Power to edit the text and change settings etc. because it’s yours. Even on an iPad — though my eyes and thumbs are getting tired now from this iPod!

By jacqui on Apr 23, 2013 | Reply

Thanks for all the great info. Norm!
At physio today I learned how to WB with crutches as you described very well.
They also taught me how to go upstairs with crutches. Going down they agree will be challenging so I will continue down on my bum. I meant to say bum crawl (not baby crawl). which is the same as sliding down on my bum at a snail’s pace,
I will check out Ryan B’s videos for other techniques.
I will email Dennis to start blog & provide more details there.
Happy that I can use my iPad to blog.
How did you build up your uninjured side shoe?
How many times per week does the UWO protocol suggest. Didn’t see that.
You should get the iPad mini at least to ease your eyes & thumbs
Thanks again!

By trin74 on Apr 23, 2013 | Reply

Hi Jacqui. I have quite narrow, steep and curved stairs - and I went up and down on my butt until I was getting close to FWB. Living by oneself I had to be extra cautious. Stairs at work and about I would use the crutches - but the ones at home are also wooden, and so was worried that the crutches might slip out. Oh - and it does get quicker after awhile! I used an even up from Vacocast/Vacoped that really helped. That, and a small heel wedge when the rocker sole was in really helped.. Got pretty sick of wearing the same shoe all the time though..

By jacqui on Apr 23, 2013 | Reply

Ok good to know I’m not the only one that navigated stairs on my bum.I am looking at getting a prescription for the Vacocast and ordering one….anything to make life easier.
Thanks Norm!

By normofthenorth on Apr 23, 2013 | Reply

No, you’re far from the only “bum-walker” hereabouts, Jacqui!

I actually “faked” an “Even Up”. I’d saved the gear from my first ATR, 8 years earlier (what, me a packrat. ), including a simple cheap Velcro “cast shoe” that was designed to be strapped around a fiberglass “walking cast” to add a rubber sole underneath. OK, it’s not very different from the Vaco Even-Up, but it’s available at most surgical supply houses, or the shops attached to sports-med clinics and surgical offices and hospitals. I strapped mine around a little flip-flop for indoor walking in the house. For outside, I slipped several footbeds into my biggest and thickest-soled hiking boot. Both were very close to the same height as my boot.

I did find crutch-walking DOWN stairs a bit scarier than UP, but when I lost my balance and had to catch myself, it was about 50-50 in both directions. I’ve written out some tricks that make both directions much less scary. . . SOMEwhere here. . .

The basic trick is to shift your center of gravity up or down (depending on which way you’re going) BEFORE you take the step to the next stair. So if you’re going (say) down, you put both crutches on the next step down. Then you DON’T step down onto the next step, at least not directly. Instead, you bend your knee and “crouch” down enough that you’re already at the same height as you will be when you’re on the next step down. THEN you step forward onto that next step down. Similarly on the way up, you stand up extra tall, maybe up on the ball of your foot, first, and THEN step straight ahead onto the next step up. (You can also step INTO a bent-kneed crouch, again, so you separate the “step forward” move from the “step up” move. At least for me, that seemed to make crutch-walking on stairs much more manageable and predictable and reliable. Still not relaxing, I admit — and a GREAT reason to follow a good modern protocol that gets you FWB ASAP, so you can stop DOING that!!

By jacqui on Apr 24, 2013 | Reply

THANKS for the info. Norm!
I think I’ll chicken out of the crutches on the stairs (wooden) and bum walk until i am FWB. I reckon that the exercise in the glutes, legs & arms is doing me some good in light of all the sitting and elevating that I’m doing. Good news
is that physio thought that the swelling was not bad (3 1/2 weeks post ATR).
I had a trip booked (by air- 3hrs.flight from here) before all this for 2 weeks from now when I will be at 6 weeks since injury. I am working hard to be able to be FWB by then. I’ll take my crutches & wheelchair with me for any longer periods of walking. I hope to have my Vacocast boot by then. Is the Vacocast boot with Vacuum relief any cooler (temperature-wise ) than the Air boot? (I have the nextep countour walker with air). I’m looking for something cooler for the warmer since I’ll need to wear a boot for at least another 2 months.

Any tips for early travel?

By normofthenorth on Apr 24, 2013 | Reply

I’ve never seen a Vaco boot in person, Jacqui. I just know that almost everybody here who has, raves about it. The idea of the vacuum-based adjustment is very similar to the air bladder, namely to make the liner conform closely to the countour of your foot. Especially if the surface of the liner is something like plastic — which I think it has to be to contain the vacuum or the air — I’d expect to find it sweat-inducing. But some people don’t perspire nearly as much as I do. . .
Search this site for “travel” or “airplane” or “airport” (or all 3) and I’m sure you’ll get a bunch of good tips.

By ekiaer on Apr 25, 2013 | Reply

Norm, your posts as well as ryanb’s are extremely helpful - thank you for being so generous with your time and insight.

I am finding that the more I learn, the more I worry about, however…so here goes: following surgery, my surgeon but me in the padded cast (open in front, but wrapped in an elastic bandage) and my foot is neutral in the cast. As swelling goes down and muscle mass decreases, I find I have a fair amount of room to move my foot around in (less than it feels like, I know) so have been doing simpleexercises since about day two or three, just moving the foot around. The foot feel great. But now, I’m starting to worry that I will be healing long! I felt little or no pain following surgery except for the incision, so don’t feel like the foot was forced to a neutral position, but I haven’t seen anyone else be placed at 90 degrees following surgery. Have you seen this before? I’m getting the cast off on Tuesday, and will raise it then, but wanted to see if you have seen this anywhere on the site.

Thank you again for sharing your experience and knowledge.

By ryanb on Apr 25, 2013 | Reply

My immediate post surgery cast was a giant clam-shell, so covered with gauze, padding, wrapping, etc., that I can’t even say what angle my foot was placed at. I only had this cast for 5 days or so.

Next, I got something more like what you’re describing - a back “L” splint, wrapped with an ace bandage. I took this off frequently to move my foot around. The best picture I have of it is probably this one:

You can see that it’s probably

15 degrees plantar flexion. This was the angle my foot naturally hung at. There was no effort made to push the range of motion when fitting that splint. That didn’t start happening until I was PWB in the boot.

I am guessing you’re still in week 1, or maybe early into week 2. At this point, I would be cautious about doing too much. I do not think you’re going to hurt yourself just moving the foot around inside the constraints of the post surgical cast. As you say, you’re probably not moving it as much as it feels like :-). Just don’t flex your calf - don’t press the ball of your foot down into the structure of the cast - as this will load the still very fragile Achilles repair. I’d actually feel better about you moving your foot around without the constraint of the cast - just doing passive motion to keep it mobile… without anything to “push against”.

I do think it’s a little unusual if you’re at 90 degrees post surgery. I would ask your surgeon what made that possible. I also think you’ve identified the potential risk - if you’re already comfortable at 90 degrees, hopefully this isn’t a indication that you’re tendon is “long”. On the flip side, I think almost all surgical repairs end up a little short- the frayed ends have to be trimmed, there’s just not enough material to join them “long”. I think healing long - for surgery folks - is almsot always caused by something that happens later in the recovery process (too much stretching, or too early weight bearing, or who know what else). So long as you’re careful with it, you should be OK.

By normofthenorth on Apr 26, 2013 | Reply

As usual, I find myself agreeing with Ryan! But I do recall several people here whose surgeons put them straight into neutral position post-op. Certainly a minority, or even a very small minority, but there have been a few. If I recall right, all the patients in the small and amazingly fast Japanese study I cited in my (first? both?) blogs on the studies and evidence. . . went straight to neutral. It does stretch out the calf muscle more than “equinus”, and puts a tiny smidge more resting tension on the repaired AT (try it on a “good” foot), and puts it all closer to a position or situation where there could be too much tension.

One of the main advantages of the surgical path, IMHO, is that it seems way less sensitive to the details of rehab than non-op, where the evidence is clear that (e.g.) going too slow and going too fast both produce lousy results. In both those cases and many other “creative” ways, variations on post-op care don’t usually produce results as lousy as sub-optimal non-op care does.

So do be gentle and careful in these early times, and don’t even dream of taking a “no pain no gain” approach to your rehab. bit.ly/UWOProtocol can provide a good benchmark for your rehab schedule, but if your Doc pushes you a bit faster or a bit slower, you’ll probably end up OK. (I get much pushier with non-op patients who are going too slow — or taking big chances going too fast, though that’s rare.)

Worrying seems to be part of the process!

By ekiaer on Apr 26, 2013 | Reply

Ryan and Norm - thank you for your input - very helpful! I’m now exactly at two-weeks since surgery, looking forward to seeing what the foot looks like when I go in on Tuesday. As I said, it feels great and I will bring the UWO protocol with me and inquire what my doctor’s protocol is. I also like Ryan’s philosophy of Rom before strength, and will be keeping that in mind. The main thing, as you both point out, is to be patient.

I think I freaked the doctor out a bit when I asked him just prior to surgery if he had practiced his Krackow technique - he should be clued in to me being actively engaged!

My blog is now activated so I’ll try to keep up as my rehab progresses and let everyone know how it goes. And I will certainly check out the Japanese study and find some new ways to worry…-)

By normofthenorth on Apr 26, 2013 | Reply

Erik, you’ve got lots of time and opportunity for worry, if you’re into it! In addition to that Japanese study, I’ve linked (above?) to a recent Chinese study that repaired rabbit ATs with 4 or 5 different sutures then tested them. One of them soundly beat the Krackow suture! Maybe the parachute stitch? My blog knows, somewhere.
Do keep in mind that the vast majority of ATR patients recover very well, with and without surgery…

By bambam on May 8, 2013 | Reply

Hi norm,
I apologise for posting here but can’t seem to fathom how to start my thread off. I’d love to hear from anyone who is in the same situation as me.
I was diagnosed with a full AT rupture on my left leg on 17th feb 2013 at Sunderland Royal Hospital in the UK. A similar story to others in the UK on our NHS actually.
I ruptured it playing squash and although I’ve never done it before (so didn’t know what it felt like) the position of the pain when it snapped immediately made me think it was my AT.
I turned up at Accident & Emergency 2 hours after (as an ambulance wouldn’t take me because I was still conscious!) and waited for 4 hours with no pain relief to see the consultant on call. (I was climbing the walls by this stage).
Th consultant came in and did a quick Thompson test and said “yep, that’s an Achilles Tendon rupture. We’ll book you an appointment tomorrow to see an orthopaedic consultant. They’ll ultrasound it and tell you if it’s a full or partial rupture.”
I was then sent on my way with under arm crutches that were set at different heights and told to take pain killers.
Next day i was seen by the consultant’s registrar who did the Thompson test again (ouuuuch!) and confirmed it was a full rupture of my AT. He said that as I had ruptured it so far up (virtually where the calf muscle joins the tendon) that surgery would be difficult “as it’s very hard to stitch muscle to the tendon” he said. He then went on to outline my treatment plan as 12 weeks of NWB with crutches and foot in a plaster cast. Toes pointing slightly down for 4 weeks then another cast with toes at 45degrees for 4 weeks then finally at 90 degrees for another 4 weeks. He then went and consulted with his boss (the consultant) and he concurred. I had the first cast fitted and was sent on my way.
I then started reading all the info on the web and started getting myself worried about
a) why they didn’t operate
and b) was my foot at the correct angle to allow a full repair.
Anyway I managed to get another appointment to see the consultant (2weeks after) to put my fears to him. The plaster cast was removed and the consultant asked my concerns. When I told him about the angle of my foot he said it was fine and not to worry. When I told him I understood why they couldn’t operate his exact words were “it’s not the fact it can’t be operated on, it’s just that the position of your rupture tends to heal better without surgery.”
I thought as he’s the expert he must know what he’s talking about. My foot was re-cast and I was told to come back in 2 weeks.
I returned on the 18th March 2013 to have the cast number 1 (4 weeks in) removed and my rupture assessed. My consultant was so happy with my progress (no pain and decent flex) that he was fitting a ‘moon boot’ and he’d see me in two months time. He then put me in the care of the NHS physiotherapists. I saw a physio that day (4 weeks post rupture) and she gave me 3 exercises to do every 2 hours (toes pointed down and then up x10 and circular motions clockwise and anti-clockwise x5) with the boot off. She also told me that I needed to start putting weight on my boot but still needed crutches although she did give me elbow crutches.
I then didn’t get another physio appointment for another 3 weeks (7 weeks post rupture).
I was astounded. They got me in, asked me how I was, asked what exercises I was doing and said “great, that’s it then, keep doing those 3 times per day. Book another appointment and we’ll see you in 8 weeks!!”
That’s why now reading about the UWO studies I’m worried I’m not being active enough.
I do hobble around without the crutches (doing little jobs at home) but my good leg aches after a while.
I’m terrified of a re-rupture because my AT isn’t strong enough.
Anybody else had non op treatment on the NHS?
Thanks, Chris.

By normofthenorth on Jun 13, 2013 | Reply

I just posted this on loumar747’s blog, and it seems to make an important point or two, so I’ll copy it here:

“I’ve never seen a study that split the patients between a PT track and a “No PT” track, so there’s only more circumstantial evidence. But as you’ve seen, UWO and the other most successful modern non-op studies all seem to have used PT, usually early on. I’d talk to your PT neighbour. Obviously, the first few PT sessions are very gentle, then they gradually get more aggressive. The painful sessions are usually only for post-op patients, to try to break up inappropriate scar tissue, especially “attachments” or “adhesions” that glue together adjacent tissue layers that should slide over each other.

It’s important to realize that most of the Post-Op studies on fast-vs-slow (like early WB) show that you “may As well” go fast, because the results are comparable or maybe a smidge better with fast rehab. And going faster is obviously WAY more convenient.

But the NON-OP evidence clearly shows that a non-op ATR patient MUST go fast — e.g., at the speed of bit.ly/UWOProtocol — in order to have the best chance of the best clinical results, and the lowest risk of rerupture. It seems so logical that suffering longer will yield long-term benefits, that many “experts” can’t wrap their brains (or their “hearts”) around all the clear evidence that points in exactly the opposite direction.

It doesn’t help that nobody’s ever done a randomized trial that split non-op patients between a fast modern track and a slow “conservative” track — and given the evidence from the other recent studies, most good hospital’s Ethics Committees probably wouldn’t approve one, because it’s unfair to the “conservative” patients. The evidence is technically indirect, because we’re comparing the wonderful non-op results from a few modern fast studies with the unacceptable non-op results from a big number of old slow studies. And comparing one study’s results with another’s is not as “scientific” as comparing one randomized cohort of patients with another in a single study. But the evidence is so clear and consistent that no intelligent person — trained scientist or not — can reasonably doubt the results.

One excellent recent meta-study, combining all the studies that compared surgery with non-op, highlights this little “scientific blind spot”. The authors clearly saw that fast non-op patients did WAY better than slow non-op patients, but they ALSO saw that those two kinds of patients were never treated in the same study. So they never actually said that fast non-op knocks the socks off slow non-op! Instead, they said that fast non-op gives comparable results to surgery without all the risks and complications, and that slow non-op avoids the risks and complications, but has significantly worse clinical outcomes (like rerupture rates)!!

Now, I was raised and trained to be a scientist, and I learned in math class that if A=B and A>C, then B>C. Period. EVERY time!! But these trained researchers can’t bring themselves to make that leap. So we technically have to read between the lines to conclude the obvious: that no sane Doctor should treat any ATR patients with a slow “conservative” non-op protocol, ever again, and that every Doctor should explain to every ATR patient that fast modern non-op treatment seems to produce comparable strength, ROM, rerupture rates and recovery times as surgery, with much lower risks and complications.

By bribur on Oct 10, 2013 | Reply

I love that you have aggregated all of the evidence of the non-operative approach. I tore my ATR this Saturday (10/05/2013) while playing basketball. I am 38, have two small kids, a house-full of stairs, and want to get back to as close to pre-injury levels as I can. I have now been a boot since Saturday with either 20% or 30% of equinous position (not sure which).

I have seen three specialists at this point - two of which advised surgery claiming that non-operative approach works better for getting the right strength and tension in the tendon and citing a risk of re-rupture. I saw another specialist at the University of Washington that said that was baloney and gave me Bruce Twaddle’s regimen.

I have SCHEDULED SURGERY FOR TOMORROW - 10/11 (as a result of the first specialist strongly suggesting it was the better outcome) and before I had seen your wonderful blog and the data on outcomes. Both specialists that quoted the surgery said that there is a higher risk of re-rupture which is not-accurrate and infuriating.

I am thinking of canceling my surgery (assuming I can and not be personally charged $8000 dollars because of a 72 hour cancellation policy issue). Before I do, I am really concerned about the heal rise and strength deficiency issue resulting from not having surgery. How big an issue is that? What does that mean in terms of my ability to jump or play sports afterwards? Is that a big deficiency? I am equally concerned about risk of surgery but don’t know how to compare the two - because as you said I do see the difference in strength that was measured in all but Twaddle’s study.

I am also concerned that now, if I choose the non-operative approach the doc still wants to put me in a cast for two weeks (even though I have been in a boot for nearly a week) - and that effectively being in a cast for three weeks instead of two will impact my outcome.

Anyhow, I don’t know if this message will find you quickly enough or not but I need to decide this morning Pacific Time. If you do get this, I would love your thoughts and anyone else on this blog that has gone with the non-operative approach.

By steve01 on Oct 10, 2013 | Reply

I wish I’d seen this info before I had my surgery but ultimately think I would have still made the choice to have it. There is no question that surgery (which is to say recovery) is difficult but based on everything I’ve read it still seems the better choice once there’s been a rupture.

I lived with achilles tendonosis in my right foot for almost 18 months before I partially tore it. While I believe I know how the tendonosis started, I am not certain when it tore. For me there was no sudden “pop.” However, in late July I was walking around New York and was in pain, stopping to stretch often, when I suddenly found I could walk no more. Not one more step. A subsequent MRI showed the tear (partial rupture).

Brian, like you I also went to several doctors before deciding on surgery. One doctor, a podiatrist who treated me for a year, initially sent me to physical therapy, then put me in a boot for eight weeks, then more PT. He told me on several occasions that his goal was “to keep me out of surgery” but I’m not sure that was the right goal. This was prior to me actually tearing the tendon and I think his treatment was faulty because he never sent me for an MRI. Once I realized my tendon was worse (not knowing it ruptured but feeling more pain) I dropped him, went to a doc who ordered an MRI, and had it repaired by the best orthopedic surgeon i could find.

I can tell you this: my first month out of surgery (it will be one month in a few days) has been difficult but there’s satisfaction in knowing I am on my road to recovery, albeit a long road. Though I’ve read others have gotten better with a non-surgical approach, it did not work for me and that was prior to a my partial rupture.

If you do go the surgical route, use extreme caution on those stairs. I’ve found that kneeing my way up them and scooting down on my butt is the safest way. I’ve almost fallen once or twice with crutches on the stairs and it is way scary.

Best of luck in your decision and recovery.

By joinaine on Oct 10, 2013 | Reply

I was also weighing the pros and cons of surgery and decided to go ahead and get the operation. That was ten days ago. As it turned out, during the surgery the orthopedist discovered that my injury consisted of the tendon tearing off of the heal bone, and not a straight rupture per se. He said it was definitely better for me that I had the surgery under this situation. He said this version of the injury would not have healed as well non-surgically. Of course, he’s a surgeon, so he must have some bias. I have not been able to find any research to confirm his comment, but it makes a certain amount of sense to a layman. Just thought I would mention this. Good luck whichever path you take.

By normofthenorth on Oct 10, 2013 | Reply

Jonaine, if the report is true — and I think many surgeons tend to tell all their patients that they’re exceptional — then I suspect that the conclusion is true. I’ve never seen any scientific evidence to support it, but it may well be true that ATRs where the AT separates from the heel bone don’t respond well to non-op treatment. Maybe.

I’ve never even seen guesstimates of how many ATRs are like that — or even worse, break off a piece of heel bone, which also happens (though an X-Ray should catch that). OT1H, we’ve had a few of these during the

3 yrs I’ve been hanging out here, so you’re not unique. OTOH, if it were common AND if my assumptions above (& your surgeon’s) are right, you’d expect randomized trials like UWO and Exeter to find inferior results in the non-op cohort (which would include some of those “bad” cases), but they don’t.

One of the paradoxes (or myths?) in ATR treatment is that most patients are convinced they’re getting personalized care that’s designed to match their particular situation and response — but most OSs treat all their ATR patients virtually identically (and the best ones hand out a standard written protocol). Both claims can’t be true.

My ATR surgeons (1 op, 2 surgeons) told me my ATR was the most frayed and messy — “like 2 horses’ tails” — they’d seen. My heart surgeon told me that my native (& failing) Aortic valve was in about as bad shape as any he’d seen. It’s possible (though unlikely) that I was really an exceptional “outlier” in both cases, but it’s more likely that both of these illustrious and senior surgeons were Sweet Talkers, good at saying things that make their patients feel better whether recovery goes perfectly or not.

It’s also worth mentioning that ATR care is generously smeared with assumptions that are so logical they MUST be true, which are proven wrong when they’re finally subjected to scientific tests. That’s why we cringe at “Best Practice” from just a few decades ago, and why the future will probably cringe at ours.

By normofthenorth on Oct 10, 2013 | Reply

Steve, we’ve had a bunch of posters here who have been disappointed with results from non-op immobilization for tendinosis, whether or not they later had an ATR. This I know from nothing, and I’ve never seen any scientific studies, and I make no recommendations. The science I’ve seen is all about the excellence of non-op treatment for COMPLETE ATRs. Some of those ATRs were preceded by tendinosis or other symptoms, but most came out of the blue like my two.

One thing’s true for sure: even for a non-op booster like me, avoiding surgery is NOT the goal! The goal is optimum recovery with minimum pain, disruption, delay, complication risk, and (sorry!) cost. Of course. I hope you achieve all of that by following your carefully considered plan.

By normofthenorth on Oct 10, 2013 | Reply

Bribur, I hope i’m responding soon enough, but I think you’re already up to speed — probably better informed than most or all of your experts!

Yes, the UWO Study (unlike Twaddle’s) found a small but consistent “raw” strength deficit on the non-op side — not statistically significant despite a pretty large cohort (

150 total), but visible nonetheless. And this website is sprinkled with post-op patients with serious complications. No guarantees either way.

My own tiny sample should not be over-generalized, but the main take-home shocking messages for me are these: (1) Even my large lingering strength deficit on my left (non-op) side — witness a wimpy 1-leg heel raise — hasn’t hurt my performance in competitive volleyball, beach or court, AFAICS! And (2) with a post-op right leg that’s healed a but short and a post-non-op left leg that’s healed a bit long, it’s the RIGHT leg that’s threatening to end my volleyball career, by pulling my right knee out of alignment!! Who’d a thunk it. More details on my page about healing short. And I’m still actively pursuing PT and exercises and stretches, and haven’t played v-ball yet this season, so that verdict isn’t in yet.

Good luck whatever you decide. You’ve been very smart about the decision so far, IMHO.

By bribur on Oct 10, 2013 | Reply

Thank you all for the thoughts - I have contacted my surgeon’s office and asked to speak to him. No word back yet and the clock is ticking.

I wasn’t sure what the amount of heel raise was. It looks like it is about 2cm (1 cm each) in the inside of my boot (yes I took it out to measure - maybe bad). I had a higher degree equinous splint initially from the ER.

The interesting thing is that when I put the angle of the two inserts on a protractor it looks like it is about 10 degrees (not sure what that results in terms of degrees of plantar flexion). I have Twaddle’s regimen in front of me and it says 30 degrees equinous cast for two weeks. I wonder if that is an important difference from the UO study and the Twaddle study - 30 degrees of equinous versus 20 degrees of plantar flexion. It might make sense why the 30 degrees would heal shorter and therfore have a slightly higher plantar flexion (and probably increased risk of re-rupture).

Anyhow, I am probably going to do the surgery just for the piece of mind but I really feel like it it is voodoo not science.

By steve01 on Oct 10, 2013 | Reply

Thanks for the feedback, Norm. I can tell you this — I did not want surgery, and that was before I had any idea how trying the recovery would be.

While attempting to rehab my tendonosis I tried following a regimen of eccentric calf exercises that have been widely published. They hurt like hell and I wonder if they contributed to, or caused, my rupture.

At this point I don’t know how it happened or if it matters. The healing is what counts!

By hyperhidrosis on Oct 18, 2013 | Reply

Earlier today, I just posted a bunch of questions on on the main site under the “just ruptured…section”:

but seems like posting on this page gets faster responses, especially regarding nonsurgical route.

I am a bit worried about my cast as it seems like I often flex my foot/toes upwards rather than downwards, especially when working at my computer. Does the cast ensure that the foot is always pointed downwards like they initially made me do before the casting? I think my foot has moved up slightly inside the cast from the initial downward position.

By hyperhidrosis on Oct 18, 2013 | Reply

Also, to add to the above, is their any site on the internet where one can post their MRI images to try to get feedback from the lay person? There was only so much I could ask the surgeon. I want to know more details about the exact height of my tear (she said it was small), the width of my existing achille’s and how it compares to an average man (since I assume wider vertical dark strip area on MRI means stronger tendon than thinner dark strip), whether any other tendon weakness can show in all the white streaky marks on the images, etc…

By normofthenorth on Oct 18, 2013 | Reply

HH, a cast or a boot should be snug enough to keep your foot immobilized, especially the angle of the ankle. As the weeks go on, more movement is OK — and then we come out of the boot completely. Actively pulling up on your toes inside a boot or cast should be pretty harmless as long as you don’t get anywhere — i.e., you’re using a different set of muscle-and-tendon, not the calf and AT. But actually flexing in that direction (dorsi-flexion) is dangerous in the early weeks.

I don’t know of a website where people examine MRIs, though you could try posting one here after you set up a blog of your own. If you search my blogs, you’ll find the experiences that have soured me on BOTH ultrasound and MRI as accurate high-res definitive images of reality. Maybe better than “shapes in clouds”, but maybe not much better.

By hyperhidrosis on Oct 18, 2013 | Reply

So how active are people in the initial phase when they are in a cast? For the most part, I sleep or sit at my desk working on my computer. I walk (using crutches of course) to the kitchen maybe 7-8 times each day. Plan to try to have a friend pick me up and take me to the grocery store or elsewhere in his car once every 2-3 days. Would I be ok walking on crutches for an hour a day outside my apartment to get air?

Is it better to find a way to put my foot up on a stool while working on my computer (I read you want to try to put it above your heart for better blood flow)? Right now, I just rest it on pillows under the computer.

Finally, suppose I heal, but after a year, I still feel some weakness and slight limping. Could I still get surgery to improve on the non surgical healing process at that point?

I think that is all the questions I have, at least for this week. Thanks for answering here and on the main site.

By normofthenorth on Oct 18, 2013 | Reply

HH, you ask about “people in the initial phase when they are in a cast”, but increasingly, most people skip casts entirely. Post-op patients often spend a week or two NWB in a soft plaster (absorbent) splint, because their wound would be messy in a boot. (Some people buy an extra liner with their boot, so they can wash and dry one while using the other — but most don’t.)

After surgery, most ATR patients don’t feel like doing much, for days or a week. I spent most of week 1 in bed after surgery for my first ATR. Eight yrs later, after my second ATR was slapped in a boot (Aircast brand), I kept working (at home on the laptop) without skipping a beat. In fact, I’d been padding around in shoes for a few days before I went to see my fancy sports-med surgeon, and I expected him to book me for an operation. Instead he talked me out of it and sold me the boot. That evening, I had a meeting of my sailing club followed by a get-together at a pub. I attended both, in the boot, with my crutches still at home in the basement. Basically, I postponed the beginning of my ATR treatment ’til bed-time, and spent the next 2 weeks NWB, following bit.ly/UWOProtocol .

When I sat at my computer, I had my booted leg propped up on a chair. I went out to dinner soon after, and got the restaurant to provide an extra chair for my boot.

Post-op patients usually find standing or even sitting painful for a few days, because the blood rushing down to the traumatically wounded leg (on top of the normal inflammation) hurts a lot. I think most non-op patients aren’t bothered much by that pressure change. But YMMV, and you’ll soon discover what bothers you and what doesn’t.

I’ve never been a big proponent of elevating the ankle above the heart. I loved elevating, but I found that a more moderate elevation gave me enough relief, from swelling and discomfort. Again, YMMV.

I wouldn’t spend much mental energy now wondering about your options if you’re unhappy in a year. Focus on recovery. With a good non-op protocol, your odds of being unhappy are about the same as those of a surgical patient — not zero, but pretty slim. Some people “heal long” (either way), and some of those opt for surgery to shorten their AT. I think I’ve met two people here who’ve done that, maybe three, so it’s pretty rare.

There’s also a non-zero risk of re-rupture (either way, maybe 2-5% average with a good protocol), and most of those (but not all) are treated surgically. Based on no good evidence, just logical-sounding arguments. At least 2 people here went non-op after reruptures, and I think they both came out OK, though the vast majority went under the knife.

With any injury or illness or treatment, there are no guarantees, and there’s lots of opportunities to drive yourself nuts thinking about the rare complications and the worst cases. Heck, more and more of us are joining “the worried well” even when we DON’T have any injury or illness or treatment underway.

By hyperhidrosis on Oct 19, 2013 | Reply

Could not keep away for even a few days.

Norm, when people complain about calf muscle atrophy, is it because of being in casts for many weeks, or can you also have the same problem in boots? Are people who have surgery more likely to complain about calf muscle atrophy than people who go the non-surgical route, or is it vice versa?

Also, does the person who operates this website post here regularly?

By normofthenorth on Oct 19, 2013 | Reply

HH, if any of those atrophy correlations are true I haven’t seen any evidence, either scientifically or anecdotally. Most all of us get hit with atrophy, decreased strength, size/shape/definition, and propriocentric control (like balance). It sounds logical that thise who get active (WB, exercise, PT) soonest would suffer least, but I’m not even 100% confident of that!

People with boots get to wiggle their feet much more often and sooner than people in casts, and none of the most successful studies have used casts. That all makes sense to me as cause and effect, but even there, it’s hard to prove scientifically that it’s not mostly a change of fashion.

In my typically blunt and judgmental opinion, health centers that use successive casts for ATR treatment are just Out To Lunch, because (1) the evidence suggests that boots produce better outcomes, (2) the vast majority of patients find boots more comfortable and adjustable and are happier with them, and (3) the all-in cost of a boot are surely cheaper than the all-in costs of a series of custom-made casts, even when they’re made by junior technicians. Multiple casting is just indefensible, IMHO, and is a handy “marker” labelling professionals and institutions who are very likely to give inferior ATR care. The ill effects are especially severe for non-op ATR patients, according to the evidence, but are also present (as are the convenience and comfort factors) for the post-op.

By normofthenorth on Oct 19, 2013 | Reply

At a funeral today, I crossed paths with the young MD daughter of close friends, and I should soon have the e-mail address of her young MD friend who’s still in touch with a classmate from UWO Med School who’s still there, working with Dr. Willets, the UWO Study’s chief author. I’m going to take another shot at getting that sub-study done (on their existing data) to determine whether or not ATR patients who begin non-op treatment SOONER (during the first 14 days) end up doing BETTER. Inquiring minds want to know — mine, for sure!

And Dennis does post some, but not as much as he monitors and maintains the site. I think he gets notified whenever one of us “takes his name in vain”, as I just did. I think this is still more a hobby than a part-time (&-producing) job, though I haven’t actually asked. What a site though, eh?

By hyperhidrosis on Oct 20, 2013 | Reply

I am now so into this that I started searching on “achilles tendon” in city-data. The below is a great thread, but the person who started it has had some bad luck. See post #268 (I am linking to that page):

I feel so much better at only waiting 8 days.

By hyperhidrosis on Oct 24, 2013 | Reply

Has anyone ever successfully gone from 4 wks or more cast directly to two shoes without the boot via the non-surgical route? Not planning on doing that, but curious.

By normofthenorth on Oct 25, 2013 | Reply

I don’t think any of the top protocols went to 2 shoes as quickly as 4 weeks. Sounds close to the speed of the UNsuccessful protocol that RyanB and I discussed, either above here or on in the comments on my “studies” page. Of course, even the worst documented rehabs have SOME successful patients — in fact, almost all have >50% non-reruptures. . .

So your Q “Has anyone ever successfully. . .” is way too easy a test, if you want to maximize your chances for an optimum result. Imagine you’d asked “Has anyone ever successfully smoked 2 packs of cigarettes a day and lived to 100?” I’m sure somebody has. What then?

By hyperhidrosis on Dec 13, 2013 | Reply

Hi Norm, thanks for your replies. Is there one page on the main site that gets the fastest replies from everyone?

By normofthenorth on Dec 13, 2013 | Reply

Don’t think so. Site lists Site-wide Recent Comments and newest blogs. Your own blog would probably be best, more info and continuity, helpful widgets…

By normofthenorth on Jan 6, 2014 | Reply

I just tripped over a supposedly authoritative book that is OUTRAGEOUS on a number of topics that concern us here, including op vs. non-op and how non-op treatment should be done. It’s _Mann’s Surgery of the Foot and Ankle_, the latest edition (2013). It’s at least partially available at http://books.google.ca/books?id=DYErAQAAQBAJ&pg=PA1627&lpg=PA1627&dq=ankle+gravity+equinus&source=bl&ots=-MngspxIt8&sig=ZSCrvAoG8TZiv9n9xIyWmn5bi3U&hl=en&sa=X&ei=ezPKUsK2Cabi2wXY04C4CQ&redir_esc=y#v=onepage&q&f=false .

I think it may be a good example of how authoritative “bibles” (and experts) gradually go from doing good to doing harm: They start out summarizing the info that’s known and believed at the time, then they get revised over and over again, becoming more of a confusing and confused hodge-podge each time, because the author doesn’t learn ALL the lessons from the latest evidence, or doesn’t revise all the passages that still refer to discredited beliefs. I HOPE there aren’t many OSs and other “experts” who rely on this book as their “bible”, but we hear of so many confused experts here that I fear this (or others like it) may be a best-seller.

Here are some examples of the whoppers I’ve found (without trying):
[AAARGH! Turns out Google Books doesn't let me Cut-and-Copy, so I'll have to re-type a few sentences.]
“As treatment evolves toward managing more sedentary patients nonsurgically[?], surgeons must not forget the lessons learned from and the treatment protocols of those who treated [ATRs] successfully without surgery.” [So far, so good, eh? I think that's what I try to do! -Notn]
“Inadequately immobilizing an [ATR] for an insufficient duration places a patient at risk for rerupture and increases the possibility of delayed reconstruction or a period of further immobilization [Table 30-9]. [I can't see that table on Google Books. -Notn]
WHAT.
The only support for this incredibly backwards statement — in a book that includes citations to the 2010 UWO Study, with its wonderful results with blazingly fast non-op (and post-op) rehab — comes a few paragraphs above on the same page (p. 1626):
He’s discussing the excessive rerupture rates that are documented in some non-op studies — precisely in the SLOWEST non-op studies with the LONGEST immobilization, NWB, and delay until exercise and PT, it’s very clear — and writes the following amazing passage:
“Another study reported most reruptures occurred within the first month after 8 weeks of cast immobilization and reasoned that ‘the time of immobilization is inadequate’. Longer periods of casting or brace protection after cast removal have been recommended. [Both statements have end-note numbers, but I can't see the notes in Google Books. -Notn]”

I think the key phrase is “reasoned that”. Medieval philosophers used to “reason” about how many angels could dance on the head of a pin. They weren’t slow-witted or evil, they just had no interest in learning from evidence, the way scientists (supposedly) do. And if a slow “conservative” rehab has too many reruptures, one could logically “reason” that it just wasn’t slow and “conservative” enough. In fact, most smart experts believed that until the evidence started coming in and proving that they had it exactly backwards! But that time is now long gone, and this “brand-new” book includes references to a number of the newest studies that prove that these passages are encouraging medical mal-practice — but still the old “reason” persists into the latest edition.

The other source of “logical” or “reasoned” error is this: Relatively few ATR patients, surgical or non-op, actually rerupture while they’re in a cast (or boot), even if they’re stuck in it for months. The period of highest risk is soon after, while the AT is still weak, and the protection of the cast (or boot) is gone. Soooo. . . it’s “logical” for non-scientists to conclude that the problem is caused by the treatment DURING that high-risk period. But the evidence, when you compare results from different groups with different treatment protocols, clearly shows that the problem is caused by an excessively slow and un-agressive period of immobilization, PRECEDING the period with the actual reruptures.

All in all, I’d say AAAAARGH. [/rant]

By hatcher on Mar 6, 2014 | Reply

Norm some great articles! Thanks for putting so much time and effort into your posts. I ruptured my right achilles late January 2014 and opted for non surgical with one PRP injection. I have created a blog handle but am at a loss trying to start one so that I can elaborate on my story. I wonder if it’s related to use of an iPad vs a basic laptop.

By normofthenorth on Mar 6, 2014 | Reply

Thanks, Hatcher. The iPad should work OK. I’ve posted a lot with an iPod, no problem except the typos! But you’ve got to start with the email, as outlined on the Main Page. Then you should see your blog on the list a few days later.

Don’t go slower than UWO non-op!

By normofthenorth on Apr 2, 2014 | Reply

At achillesblog.com/mikejp88/2014/03/08/one-year-after-what-id-do-different/ , Mikejp88 just brought the Mother of all non-op studies to my attention, by Wallace et all in Belfast, Ireland. It’s summarized and discussed at achillesblog.com/cecilia/protocols/, and the full text is at http://boneandjoint.org.uk/highwire/filestream/17691/field_highwire_article_pdf/0/1362.full-text.pdf .

Here’s what I just wrote about it on Cecilia’s page:

I think UWO is the only one of the three that randomized the patients for -op vs. non-op. Exeter may have divided theirs primarily based on “informed consent”, and Belfast treated everybody non-op — including reruptures and “stale” ATRs! — UNLESS their torn AT ends could not be approximated by immobilization in equinus, as diagnosed by the senior author.
In a way, the Belfast study is (IMO) the most impressive of the three, because it seems to nail the key question in ATR care: “Is there actually a benefit from surgical repair, or not?” By customizing the equinus angle of the initial cast (based on observation and palpation) in a very large number of patients, the authors achieved a near-zero rerupture rate and claim a 99.4% return to pre-rupture sporting activity, with the other 0.6% “healing long” and receiving surgery.
Of 96 patients with “stale” ATRs, 70 could be approximated and were treated non-op with clinical results identical to (or a smidge better than!) the prompt ATRs(!).
The small # of reruptures were all(!) treated non-op, with 100% success.
These results seem pretty brilliant to me, and with a total of 975 patients, nobody can claim that the results lack statistical power, or represent a fluke. OTOH, there is no quantification of post-rehab strength to compare to the numbers for post-op patients in UWO and a few other studies. I.e., it’s still possible that all these happy non-op patients returning to their pre-ATR activities had a slight strength deficit, slightly larger than other, post-op patients.
This study is also interesting because (unlike UWO, which divided patients randomly then treated them all identically) it honors the “We’re all different” principle by (a) adjusting the initial ankle angle so it approximates the torn AT ends and (b) sending all patients whose torn ends canNOT be approximated to surgery.
As fond as I am of the demonstrated “road map” of UWO, this slightly more customized approach seems very smart — though dependent on a health professional who is as good at this as Dr. Wallace, the chief author.
But isn’t it an embarrassment to all the fancy specialist OSs out there, that Wallace seems to be the only Dr. in the world who can do this simple and obviously needed diagnosis. ”

By mikevball on Apr 27, 2014 | Reply

I’ve just found your Blog and I love it. I ruptured my AT about a month ago at the gym, I was doing sprints with resistance, it popped and I looked around for the weight that hit me, then I knew it what had happened. I’m a surgery nurse and I’ve played competitive volleyball for 40 years (yes, 40, college, USVA, Nationals, and beach) I’ve seen it happened to at least 5 friends on the court and now it was my turn.

I was able to see an ortho within 4 days and “insisted” that I have surgery. It was scheduled for day 10 post injury. I was in pre-op and he came to me and told me that the surgery had been bumped due to an emergency and he could schedule me in two weeks but he said that he didn’t want to go in and breakup all the healing that had been occurring in the previous 24 days.

He showed me several studies about non-op results that made sense vs complications of surgery.

I opted for non-surgery at that point. I’m in a very loose splint with plantar flexion at 45 degree. I have 3 weeks to go in this splint. It seems that for every surgeon there is a different rehab protocol.

For people that have problems with crutches I found a devise that has made my life so much easier “IWalkFree” it’s a hands free crutch. going up and down the stairs is so much easier. I even mowed my lawn using it last week, though I won’t do that again.

I’ll continue to comment on my rehab and when I get my boot, but for now thanks for the site, I’ll give it to my surgeon for references. I was a hard sell.

By normofthenorth on Apr 27, 2014 | Reply

Thanks, Mike. Looks like I just wrote a note to you at achillesblog.com/about/#comment-5361 without seeing this note first.

Here’s my note (again):
Mikevball: (1) If you drive a stick-shift “properly”, using your left foot ONLY on the clutch, and your right on gas and brake, I don’t see a problem doing it in a left boot. BUT I’ve heard that some governments and some insurers disagree, so you may want to check first.
(2) The evidence is super clear that non-op treatment can produce reliably wonderful results, but ONLY if a fast modern protocol is followed, and your schedule is much slower than all of them. Before about 2007, non-op care was consistently slow, aka “conservative casting”, and it always had a scary high rerupture rate, often in the 12-25% range. With the new fast protocols — bit.ly/UWOProtocol is the good one I’ve got on a hotkey! — the rerupture rate is in the <3%-5% range. More details in Cecilia’s blog.
The most recent and biggest non-op study — from Wallace in Ireland — reported maybe 2.7% rerupture rate among almost 1000 non-op patients. As Wallace says, most surgical studies can’t approach those numbers.
But virtually all of these studies use a boot early, and get to FWB at the 4 week mark, and most start exercise and PT sooner than that. There seems to be a relatively narrow range of “recipes” that works well non-op. There are LOTS of studies that went slower and produced inferior results, and I’ve seen one study that went much faster and also produced inferior results. In both of those outlier directions, surgical patients come out ahead of non-op patients, but in that “sweet spot”, the non-op patients seem to get equivalent results without the pain, scar, time off (desk) work, and surgical complications.
Lots more info on my blog and elsewhere here, or just follow the links in the table on Cecilia’s blog.

By normofthenorth on Apr 27, 2014 | Reply

And Mike, as I’ve written elsewhere, the only problems with all the various nifty crutch substitutes are (1) If you’re spending more than 4 weeks on crutches, you’re doing something wrong, and 4 weeks minus the time to get a substitute isn’t a long time to come out ahead on your time and effort and money, and (2) The second half of those 4 weeks, from 2 weeks in to 4 weeks in, you should be PWB, retraining your injured and booted leg to walk normally, while a decreasing % of your weight is carried by CRUTCHES! None of this PWB stage can be done on any kneeling substitute, and I think it’s important. So now we’re down to TWO weeks minus the time to get a substitute! I wouldn’t want anybody to linger NWB any longer than necessary (least of all a non-op patient), because they love their crutch substitute!

By goldman on May 9, 2014 | Reply

I finally took the time to download and read in its entirety the Wallace, Heyes, Michael 2011 paper.

I am trying to better understand and wrap my head around a couple issues that this paper brought up, and hoping you can shed a little more light on due to your extensive study on this subject. Besides my non-expertise in this general area, the British English may be confounding me a bit.

One area I am trying to understand is the issue of separation distance in a full rupture, and at what point, if any, does it make sense to forgo non-operative treatment in favor of operative. Part of my motivation is driven of course by my own injury experience. Right before my injury I had two pretty swollen Achilles on left and right legs. I know this because the first surgeon who examined me made that comment after she confirmed rupture on right, and felt my left side for comparison. Thankfully they both didn’t go at the same time, and I really babied my left for the first four weeks after the injury, but I do think that if I continue with any sort of high impact exercise or sport once my right heals, there is a higher-than-average probability that my left side will rupture. This thinking due to (future) favoring my right, and perhaps a tad less strong due to not being consciously repaired. And therefore I want to be as prepared as possible for when (if) this happens. Of course I am going to try to do things physically and mentally to avoid a rupture of the left or re-rupture of the right, because as you know luck favors the prepared.

Anyway, so from Wallace et. al paper I read this:

“The decision on non-operative treatment was based on whether the tendon ends were found to approximate well on palpation with the foot in plantar flexion.”

“The tendon ends always approximate well on palpation when there has been no delay in presentation.”

So begs these questions:
– What exactly does “approximate well” mean?
- Does it mean that when the foot is plantar flexed that the tendon ends get close together?
- If yes, what defines “close”, is it 1mm, 1cm, 3cm, 7cm <– at what point is the distance considered too far?
– palpation: I had to look this term up also and understand it’s the physician using his hands to examine the area. I guess a really experienced doctor can actually feel the tendon ends, eh? Seems odd to me as in wouldn’t one have had to have done a few dozen surgeries already and actually have felt human tendon ends inside a person’s leg, to be an expert at determining where the tendon end is and whether it’s close enough for non-surgical approach?

- This sentence: “…approximate well on palpation when there has been no delay in presentation.” — what does “no delay in presentation” mean — no delay in the patient showing up for diagnosis/treatment? or something else?
He also mentions the phrase “acute presentation” - is that similar meaning or something else?

Well enough questions, and I thank you in advance for any gaps in my knowledge you can fill in.

By normofthenorth on May 10, 2014 | Reply

Jon, wjhen an AT ruptures, it usually leaves a gap inside and a visible “divot” or “notch” on the outside, where there’s no tendon to help support the outer tissue and skin. By looking and feeling, Wallace can tell roughly where the gap is, and whether or not it closes up when the ankle is plantarflexed (and how far).
Haven’t you ever seen a double-braid rope or bungie where the inner core has torn, leaving a skinny section of empty outer braid? Similar deal.
(And yes, the ends get closer together when the ankle is plantarflexed. The top — calf-muscle — end stays put, but the bottom — heel-bone — part gets pushed up with PF. That’s why we’re immobilized “in equinus” = PF.)
I think Wallace’s working theory — buoyed up by his great results — is that “approximated” (just butting against each other) is the best position for the ends when immobilized, to let the body rebuild an AT of roughly the original length. No gap, and no overlap.
As he writes, he used this approach on primary ruptures treated within a week or two — “acute presentation” — as well as on reruptures and on misdiagnosed and other “stale” ATRs (which he calls something else). As he says, in his whole huge sample, he never failed to get the former type to “approximate”. But some of the stale ones wouldn’t, and got sent to surgery instead. But precious few, even when they’d been ignored for a long time(!).
As I’ve written elsewhere, his non-op success with ordinary ATRs is remarkable, but his non-op success with the other two kinds is really really revolutionary!
As fond as I’ve been of modern fast non-op treatment for ordinary primary ATRs, I’ve discouraged many rerupture and stale-ATR patients from going non-op. I suspected that reruptures would work OK non-op, but I never thought that stale ATRs would. It just didn’t seem plausible that good healing would occur after the initial flush of inflammation and healing had passed, and the two torn ends had healed separately. But theories and guesses are just that, and evidence is evidence. As the phyysicists like to say, “If it exists, it must be possible!”
Does that answer all your questions?

By normofthenorth on May 10, 2014 | Reply

Two more things you may or may not know: (1) This site’s Studies and Protocols page has a link to an interesting study analyzing the excess risk of an ATR patient rupturing the other (contra-lateral) AT within the first few years. Bad news and good: For all of us, the risk is HUGELY higher than for “normal people”, like 200x higher. And it obviously doesn’t drop down to the backround risk after the first few years, either.
(2) Before Wallace, the UWO-study folks published two studies testing the theory that small ATR gaps would heal up better non-op than bigger gaps. One just looked for a correlation, and found NONE! The other was related, and asked whether ultrasound could help “stream” ATRs into op and non-op treatment, and concluded that it wasn’t useful. (It’s possible that the two are the same study, which I saw twice!)

By goldman on May 10, 2014 | Reply

Yes that answers the questions, thanks, though I was a bit depressed to learn that I now need to find that study link you refer to and read more about the “HUGELY higher…like 200x higher” risk. I was guessing more like 2x when I first commented here - being off by two orders of magnitude is a bit sobering

By normofthenorth on May 10, 2014 | Reply

But even 200x the background risk is only a coupla % during those few years, so you’re more likely to escape with your asymmetry intact. Or you could do the other one 8 years later and get the chance to skip the surgery - like me!

By ejbvmi on Jun 14, 2015 | Reply

Thanks for posting, Norm. I ruptured my right AT last Saturday, and was told that night at the ER that it was a complete rupture and I would probably need surgery. Given my ignorance at that moment, it seemed to be a logical conclusion. I spent Sunday researching, and posts like yours helped me go into my Monday meeting with the Ortho surgeon MUCH better prepared to make an informed decision. In this instance, the surgeon was inclined toward the non-surgical path with early weight bearing protocol very similar to UWO. Had I not had the benefit of all my Sunday reading, I would not have fully appreciated the value of her advice and may have been in surgery before the end of the day. I know every case is unique, but I am hopeful and will diligently pursue my rehab and PT. Thanks again.

By normofthenorth on Jun 14, 2015 | Reply

ejbvmi, thanks for the great and gracious thanks! I’m really glad that my posts on this great site can still inform and reassure people who need it, even after I’ve kicked my addiction. Best of luck on your recovery, and keep the gang here informed.

By crawllimpwalkrunjump on Jun 15, 2015 | Reply

Well to add from personal experience, I just wanted to be of help regarding non surgical healing. I mean no disrespect to anyone who chooses surgery and obviously for those that must. It’s a very very tough decision and one i have had to make…twice in my life as I tore both Achilles. The reasoning I chose non surgical was because I truly truly believed in the same principle…that for partial tears only, it is a viable option. I have heeled 200% from my first one in 2009, and after just two weeks of being completely bedridden from my other tear recently, I have been walking the last 3 days. Obviously still a ways to go with no heel raises yet, no stairs, and still limping and slow pace…But I know I will be OK because as I said, I am a living example of some partial ATRs being able to heel on their own if the gap is not huge and its not at the calf or cutaneous heel. Both of mine were I’d say 1-2 inches above. Extremely lucky as most ATRs are simply devastating. It takes time and journey still the same but obviously it’s unorthodox with me and requires lot more patience and a healthy dose of very slow weight bearing at the right time. But I just wanted to give confidence that it truly is very possible to recover and I was playing basketball at a high level about 9 months later in 2009. But you must never push yourself before your body has healed and the first stages of weight bearing are very very light. I would still say…my Achilles honestly was strongest after 1-2 years. And if anyone can believe it..if u train right, really focus on walking, excersizing, being cautious through your first year rather than full on sports, you really can make the Achilles stronger than it was weeks before it tore. After doing this twice, I understand…the signs were there both times but I ignored them like a fool. Never again. I won’t be playing any ball til maybe October or November and definitely no more hardcore. Time to take it easy and appreciate..walking. That’s just me…I’ve been blessed twice by the man upstairs and I think it’s sunk in finally. But I can confidently say, non surgical is a viable option and under the right circumstances, recovery is very much possible with minimal risk to the future. Hope this helps a bit and it just my own opinion for my own experience. I know we are all different..and trying to get to the same place

By normofthenorth on Jun 15, 2015 | Reply

Thanks, CLWRJ! But the preference for treating PARTIAL ruptures non-op is NOT based on the evidence. All the evidence I’ve seen, including Wallace’s amazing study with almost 1000 ATRs, deal only with COMPLETE ATRs. And non-op works very very well. It may well work just as well (or not, or even better) with PARTIAL ATRs, but I’ve never seen a study to document or substantiate that “old Doctor’s tale”.
I’ve seen ONE small study testing the tale that non-op works better with small gaps than large, and the results said that tale was false! Plausible, but false, like so many ATR tales. That’s why we need science. I’ve posted links to those studies, and more, at least their free abstracts.
We’re all different, so it’s scary (though natural for humans) to assume that our buddy’s experience will become our own. Even a large study with stat-sig results doesn’t guarantee specific results for any individual. Good luck still helps! But patients who follow a protocol with great results need less luck than others.

By crawllimpwalkrunjump on Jun 15, 2015 | Reply

I’m not really sure if the intention of sharng my stories was to discount any science, data sets, or weblinks. I was just speaking from my own experiences…My intention was to share some positive stories, maybe not part of any data set, but part of my real life experience. If there is anyone who may feel even the slightest bit positive or it helps someone get thru the journey in some way, then that is all I truly care for. Nothing in life is guaranteed, and by no means would I expect all our experiences to be the same…but to see another person go through it, however way, whatever protocol, whatever advice or data set they may fall into…that is the beautiful thing on this site. I think it’s OK…to hope and pray that each little tidbit of another’s story, or a moment in someone else’s journey, may indeed become in some way part of our own. Of course it’s likely it won’t..but I’m not sure its so scary to feel or have hope that someone else’s journey..someone else’s progress..may indeed be shared. I’m not sure if that is human or alien…but I think I simply call that feeling encouragement. I hope my story like many others may bring that to someone else possibly. I apologize for the misunderstanding on science. I guess I’m still an old doctor’s tale…with a lot of good luck i admit. I came here years ago for encouragement..and I just hoped to give it back to someone else. I meant well

By normofthenorth on Jun 16, 2015 | Reply

Me too, CLWRJ! I was partly afraid that your statements about non-op being specifically good for PARTIAL ATRs like yours - statements like “I chose non surgical was because I truly truly believed in the same principle…that for partial tears only, it is a viable option” - would be needlessly nervous-making for somebody like ejbvmi (the poster right before you), who is following the evidence to treat a COMPLETE ATR non-op.

There’s a huge benefit to new ATR patients just to realize they’re not alone, and to hear reassuring stories from people who’ve made it through to the other side, like us. And all our stories are valid, and may do somebody some good. But I also put a high value on separating the scientific signal from the anecdotal noise, so people who care about that sort of distinction can find it.

By edhdez on Jun 19, 2015 | Reply

Hi Norm, hope you can read this. I was 18 weeks post surgery and I just tore my repair, I’m definitely not considering surgery this time around, it was way too painful, got infected, clot scare, etc., seems like I had it all in the process. I looked at your conservative protocol and I will go with it, still haven’t talked to OS, I have an MRI later on today and my appointment on Tuesday. For now I’m back in the boot NWB and starting the protocol you follow. Is there a way to get in touch with you for a more in depth of excercises and all you did during your protocol. My insurance may expire soon and most likely I will be on my own. At least I have now experience from my surgical repair as to what to expect and the care I need + excercises. Thanks for coming back and your addiction to achillesblog, I’m sure many folks are just as greatful. Cheers.

By normofthenorth on Jun 19, 2015 | Reply

Sorry about your rerupture, edhdez! And thanks for the kind words. My fave way to discuss ATR care is this way, on the open forum, so it can help everybody who can find it.
As you can read on my pages and others, we all used to think reruptures called for surgery, until Wallace proved they don’t need it, in his 2010 study! The link is searchable on this site, including on Cecilia’s page comparing 3 non-op studies. What I’d do if I were you, is (a) find it, read it, and learn Wallace’s “trick”, then (b) find some smart trusted health professional (maybe an OS, but not necessarily - it’s not surgery!) to apply that trick to your reruptured ankle! I.e., this person should gently manipulate your ankle to find the PF or “equinus” angle that just brings your (twice) torn ATR ends together (the angle that “approximates” the ATR ends). Then they should measure that angle, and adjust a boot to that same angle - either a fixed boot with just enough heel wedges, or a hinged boot, set at THAT fixed PF angle.
I think it’s probably impossible to do that on your own leg, just like giving yourself a Thompson test.
But using that “just right” immobilization for the first

2 weeks, instead of an arbitrary 𔄙 size fits all” angle for everybody, is probably the key to Wallace’s wonderful non-op results - and on reruptures and (most) stale ruptures as well as fresh ones, too! So I wouldn’t skip that step/trick. Unfortunately, most practitioners of non-op ATR treatment DO still skip it. And most also still don’t know that Wallace got non-op results with his reruptures that were just as wonderful (in its near-zero rerupture rate and 100% return to sport) as his results with his 900-plus fresh ATRs - better than most published surgical studies!
Almost anybody could probably learn that trick, but it’s got to be learned, and done. An OS, a GP MD, a PT, a family member who knows geometry and trig…

By edhdez on Jun 19, 2015 | Reply

Thank you Norm. I’m having an MRI later today to try and determine the damage. I ordered a VACOCast last night and should be here tomorrow. I’m on the generic aircast boot, which from the beginning was a bit too large for me. I will definitely mention the Wallace trick to my OS, but so far after the re-rupture they sent me home to my luck, and I had to get my old boot on myself, fitted with the 3 wedges that I used in the original rupture. I’m on the boot now, and before I put it on there was a lot of swelling still, and had some ice on it. Now I’m scared to hell to take the boot off and apply some more ice, since I’m worried about moving the tendon. Do you think it should be ok to get my foot out to put some ice? I haven’t been able to sleep all night due to pain, they didn’t give me anything either for pain and worried and racing thoughts have kept me up. This has been harder than the first time around, lot more life complications, I just want to get it right this second time around without surgery. I appreciate responding to my plea for help.

By edhdez on Jun 20, 2015 | Reply

Hi Norm. I had my MRI last night. I don’t get the results until Tuesday’s appointment with PA. I’ve been wearing the boot since Thursday after the re-rupture, with no Wallace trick since I did it myself. I’m elevating it and applying ice outside the boot. I’ve had totally forgotten how uncomfortable this thing is, but it beats the elephant cast I’ve got after surgery the first time around. I have a couple questions about UWO protocol, hope you can help me with. I also posted them on my own blog http://achillesblog.com/edhdez/

0-2 Weeks
Since this is the second time around on this journey, I wanted to ask about non-weight bearing. The first time I was so freaked out to rest my foot even on the on the floor, I was mainly in bed for 2 weeks, but I had help which I don’t have now. So what really is non-weight bearing? I know to not put any weight while standing or walking on crutches, but is it ok, to sit down on a chair and rest your foot on the floor? What about when using the toillet? As I said, back in my first journey on this I had a stall with a pillow for me to rest my foot everywhere I sit, but as I had help to help me carry it around. Also, now I have to get rides in a car where I can only fit on the front and have to rest my foot on the floor, this while sitting, is that ok?

Another question about the UWO protocol http://bit.ly/UWOProtocol, it says boot 24/7, does that mean no shower with foot out? No icing with foot out of the boot either? Change of sock? It’s hot in Florida and I can feel the sweat in it. Also, I’m afraid of clotting, so is it a good idea to wiggle my toes on the boot? Or what kind of exercises would it be recommended to get some blood flowing that way? It is crazy but I know I’ve been thru this 4 months ago with the original ATR, and I kinda blocked everything that happened. I appreciate all help and advice Norm, I’ve been reading your blog and the insight you give other fellow ATR’s, what you are doing for others is a great thing. I’m truly thankful.

By normofthenorth on Jun 20, 2015 | Reply

Resting your foot on the floor is fine! You just can’t use it to bear any of the rest of your body’s weight!

Your 24/7 Q is a bit trickier. The UWO protocol - you’ve got my link - is mute on that, and I don’t know what they did. Showering can be hazardous early on, but sponge-bathing your bare leg, while it’s on the floor - taking care not to move your knee forward over your ankle = neutral - or legs crossed, should be safe (as long as you’re nervous!).
Ditto icing, often done while elevating.
I found changing socks scary while NWB (and later!), so I did it as seldom as possible. I often manhandle my ankle joint while changing socks, and that’s a serious no-no. But if you can do it gently, while keeping your foot in equinus, do it.
Sleeping bootless is another big milestone. With or w/o surgery, advice seems to average 4-6 weeks, though with a wide variation.

The logic is simple: your healing AT doesn’t really know or care whether you’re booted or not, just whether your ankle is at “that” angle or not (and whether or not the angle is changing).

Re: “Also, I’m afraid of clotting, so is it a good idea to wiggle my toes on the boot?” Absolutely! And after 2 weeks (IIRC), UWO recommends gentle foot-wiggling exercises, boot off. Either on a footstool or with crossed knees. But not past neutral for a few more weeks.

Finally, UWO recommends a sudden cold-turkey jump from equinus with a 2cm heel wedge to neutral, at 6 weeks. My own ankle disliked that, so I spread it out over a few days, and that makes more sense to me. Post-op protocols (& some non-op) start sooner and spread it out over a week or 2 which may be better, worse, or no diff.

OK, one PAST finally(!):
Making ski boots fit properly is a PROFESSION, and a respected one, but making orthopedic boots fit properly is an afterthought, usually left to patients and their family and friends. Sad. But small changes in sizing, adjustments, and tweaking (adding or shaving padding, etc., adding bandages or sleeves to the leg) can make a HUGE difference in comfort. The angle shouldn’t change, and it’s still got to immobilize and protect. But it doesn’t have to hurt!

By edhdez on Jun 20, 2015 | Reply

Hi Norm, thanks a lot for responding and helping me out with my concerns. I’m trying to stay on top of it this time and don’t leave it in the hands of others, so far it hasn’t take me that far on my recovery. I’ve been also reading alton2012uk blog, and I will use his information to have my own protocol and show it to the OS and PT, but that may change next Tuesday after I have my appointment to see the MRI results. Oh, and before I forget, you said ditto ice, is that ok out of the boot during the first 2 weeks boot 24/7? And what about other exercises during these first 2 weeks? I appreciate it and have a good weekend!

By normofthenorth on Jun 21, 2015 | Reply

Yes, icing out of the boot should be OK even during NWB times. But be gentle and don’t manipulate (or move) your ankle yet. First 2 weeks are for immobilization in equinus. UWO doesn’t start any exercise (except tow wiggling in the boot) until 2 weeks in, IIRC. (But you’ve got their protocol already.)

By edhdez on Jun 21, 2015 | Reply

By brad on Jul 7, 2015 | Reply

Stuart suggested I seek your input. I have read thru some of your blog. Wow! A wealth of information. No doubt you have had a positive impact on many!

I ruptured my left Achilles 1 Dec 2014 (badminton) and turned 50 the next month. I am hoping you can comment on if my Achilles healed long and or if my progress to date is reasonable. I weigh 185 lbs and exercise regularly, but no jogging or high impact training since injury. I too live in Canada (east coast).

Non-operative treatment started night of injury. The orthos here follow the UWO protocol. The boot I used was a Gregg with

Seven months post injury and I can barely get my heal off the floor using injured leg only (keeping leg straight). Using momentum and bending my knee, I can raise the heel an inch or more. The increase in heel lift from week to week is minute and difficult to noticeable…that is the concerning part for me.

The dorsiflexion is about the same in both, maybe a tiny bit more on injured left. There is Achilles scar tissue about 1.5 inches long at ankle height and a lump is noticeable during dorsiflexion. While standing up and pushing against sideways against both Achilles, the injured side has more movement. When not relaxed, both Achilles feel tight.
The ortho called the ATR a full rupture and about a 5 mm divot was noticeable in the Achilles. Both dorsi and plantarflexion were possible right after ATR.

I can walk a few miles without limping, but I feel the reduced push-off power on injured left. When I try jogging, a small limp is noticeable. The calf of injured leg is about 3/4 inch smaller than right…I am right handed in all activities. When road biking, the left is less stable. When standing on the left pedal clip, the left is weak compared to the right, but has improved when I first returned to biking 8 weeks ago.

For strengthening, my PT has me going up on two and slowly down on injured side, …3 sets x 15 reps, no more than twice a day. Have been doing this for 3 wks now. PT also has me doing 2 x 15 reps of squats, using body weight only. Prior to this, I was doing 2-foot heel lifts. After half hour on the elliptical or road biking or eccentric exercises, the calf feels fatigued and I usually have a small limp afterward. With every push-off on the injured side, I can feel discomfort on the achilles at the injury point and tightness in the calf.
First appointment with new PT 2 wks ago. At my urging, he pushed against both feet and thought the DF was about the same in both.

Any feedback/comments appreciated.
Brad

By normofthenorth on Jul 7, 2015 | Reply

Thanks for the kind words, Brad, and sorry you’re disappointed with your recovery. My first reaction is that 7 months is still early times to expect running and jumping and 1-leg heel raises. Yes, progress seems glacial on “the frustrating plateau”, but that experience is common, w/ or w/o surgery.
And if you did heal long - either the link to the Gastroc or to the Soleus or to both - you may still end up functionally 100%, or at least so close that you don’t notice any deficit. But you won’t know that til close to next December, IMO.
If you search my more autobiographical pages, you’ll find that my own UWO/non-op ATR ended up with a significant strength deficit (not one full height 1LHR ever!), which seemed to have NO effect on my performance in court volleyball, running, jumping, cycling, or anything else. I can’t explain that paradox, but I’ll take it!
The fact that your max DF is not enhanced suggests that you’re not healed very long, though ankles are complicated, and remote diagnosis by an amateur is no more reliable than it sounds!
If I were you I’d hang in, stay with the program, count your blessings, and hope for the best. And give us an update every couple of months.
If you stay frustrated enough, I don’t think there’s a solution other than surgery, which may or may not help.
My own experience with my first, surgical, ATR is cautionary: My surgeon fixed it short, so I had - and have - great 1LHRs, but my knee started blowing out 10 or 12 years later. I’m keeping it all OK with constant stretching, per PT.
Now, my Good News and Bad is that my right shoulder is my only body part that’s limiting my (beach) volleyball.

By xplora on Jul 7, 2015 | Reply

Morning Norm - it is here anyway. Thanks for looking after Brad. Much the same as I said so I hope it reassures him. Hope all else is well with you. Worst snow season in 50 years here but expecting some in a couple of days and even as low as our house. Days are numbered for the resorts but many are now gearing up for summer activities and hoping the hoards will come.
Regards, Stuart

By normofthenorth on Jul 7, 2015 | Reply

G’day Stuart, good to hear from you! And glad we still agree a lot of the time. I’m doing pretty well, surviving my withdrawal symptoms from breaking my AB.com addiction!
Weather pattern here in North America have been interesting for a couple of years. East of center we’ve had very cold winters and summers, while the West has been warm and dry. Tough on the big Western ski resorts, but a boon for the older Eastern resorts.
I’m in Toronto, on Lake Ontario, and the Great Lakes have experienced (near-)record levels of freezing over the past 2 winters, which keeps the following summers cold. Western Canada is now plagued with smoke from >100 forest fires, and the winds may blow some of it our way soon.
Best,
Norm

By edhdez on Jul 7, 2015 | Reply

Hi Norm, hope things are good, just wanted to give you an update as to how things developed with my OS and how are we proceeding.

Basically after a physical revision of my tendon, my OS concluded that it seems to be continuity on the tendon, it seems to be together and concluded that surgery is not needed. No explantion as to what could have gone wrong, he couldn’t explain it himself as he had not have any re-rupture in 10 years.

He recommended to stay on the boot Non Weight Bearing for another 10 days, for a total of 28 days (4 weeks) after re-rupture, then I can start Partial Weight Bearing.

I can start from now some limited Range of Motion exercises and increase flexion as in the boot degree increments.

4 Weeks - In 10 days start PWB - ROM exercises continue.
5 Weeks - In 17 days from today I can reduce the angle of my boot dorsi flexion to 20º (PWB in boot) ROM exercises continue.
6 Weeks - In 24 days to 10º (PWB in boot) - ROM exercises continue.
7 Weeks - In 31 days to 0º and Full Weight Bearing (in boot) - ROM exercises continue.

Next OS Appointment 8/3/2015

I’m happy with this, but I’m not sure about the new protocol, it seems a little aggressive as far as the degree increments and stepping towards FWB. Also I am not sure as to how gradually I can increase my ROM exercises, and/or if I can introduce other ones.

He said no therapy until next visit a month from now, then we would look into strengthening exercises. He also mention that since it is a re-rupture we need to take it slowly to avoid any more setbacks.

I also contacted another surgeon and he suggested to have surgery or otherwise I wouldn’t be able to play soccer or any other sport that requires explosive moves, basketball, tennis, etc., I’m not planning on going to the soccer field any time soon, but he even said I wouldn’t be able to run fast. Obviously he also said surgery is the only alternative to come back to competitive sports, which tells me he is an old school surgeon.

Nay feedback I will truly appreciate it Norm. As always, thank you for all what you do here in the blog to help the community.

By normofthenorth on Jul 8, 2015 | Reply

Ed, the only significant evidence for non-op treatment of reruptures is from the Irish study I’ve already shared above, and he (Wallace) got great results, so I’d follow his lead.
Your protocol is different, mostly slower but also just different. I like to bet on a winner, not break new ground. Wallace disproved the old common myth that reruptures need slower rehab than fresh ATRs, so why revive it?
Did you try to get your OS to measure the ankle angle that just approximates your ATR ends? I’d use that angle, and keep it into FWB, which I’d get to as quickly as Wallace did. If the separation is fine, just stay at a a reasonable angle, maybe UWO’s 2cm (maybe =

20°).
There are lots of areas of life where creativity is terrific, but not when somebody is fixing my busted leg - or yours.

By edhdez on Jul 8, 2015 | Reply

Hi Norm, unfortunately my doc didn’t measure any angles, just put me back on my boot at 30°. He did mention that there was continuity in the tendon and the way my foot rests shows there is a union on the ends of the tendon. I will start UWO protocol tomorrow as another blogger did start at 3 weeks (altonUk22 I think) with same angles increments, and go from there. I really appreciate your help and advice. Thank you.

By brad on Jul 8, 2015 | Reply

Hi Norm - Thanks to Stuart and yourself for the advise and encouraging words as I move beyond month 7….very helpful!
Visited with my PT last night just before he goes off to the Pan-Am Games. He encourages me to be patient and worked on breaking up the scar tissue with a fancy electronic thumping tool so as to promote new healing. Then 10 minutes of ultrasound. On his suggestion, I am wearing a say .25-inch off-the-shelf foam heel wedge when I am vertical. His thinking is that this MIGHT help the Achilles heel/shorten over the next few months. Do you know of any research or results that would support this theory?
I continue with the 2 up 1 down eccentrics and other exercises to build strength.
Thanks very much for your earlier info!
Brad

By normofthenorth on Jul 9, 2015 | Reply

Good luck, Ed.
Brad, I’ve never seen a study proving that a long AT can be shortened that way, but since consistent long-term stretching does have an effect, maybe avoiding stretching your AT (with the wedge) will also have an effect. As the punchlines to several jokes go, “It can’t hurt!”

By xplora on Jul 10, 2015 | Reply

Brad - the electronic thumping tool sounds a lot like radial shock wave therapy which can be useful for breaking up scar tissue and tendonosis. It is relatively new and not accepted in some circles. I think it works though from personal experience. If that is what was done you will need a few treatments to be effective. I do doubt it will shorten the tendon though. Stick around and send us a comment when you can. Best to use Norms page.

By edhdez on Jul 12, 2015 | Reply

Hi Norm now entering week 4, I guess I’m a week behind on UWO protocol, hope this doesn’t throw me off, but now on it I’m trying to do as much as I can without over doing it. It’s been really difficult for me to accept the re-rupture and to be doing the same exercises I was doing 4 months ago, and to be honest really depressing. I have to find the mental strength some how to keep going. Needless to say this also brings a lot of fears and insecurities. At least going non-op this time has open a new set of questions and seems like a new process, different care, etc., in my opinion if I had known how less painful and traumatic conservative treatment was, I wouldn’t have hesitated to go this way my first time around, but along come fears with that. At least with surgery you know the tendon is attached surgically and non-op you are letting your body heal and work its magic naturally. So, with that in mind, my main concerns with PWB and ROM this week are:

1) How much walking is recommended once at PWB (protected on VACO and crutches) or is it full time now and walk at any opportunity? Is it safe to sit most of the day?
2) How many degrees increments on Inversion and eversion per day? Or is it as tolerated? How many repetitions a day?
3) When should I start dorsiflexion? My major fear of tearing what is healed.
4) How much exercise (in boot) leg raises, knee extensions, core.

Needless to say I haven’t had significant pain since the day of my re-repture. I’m also feeling rush of blood/fluid coming down my leg when I sit my foot down, I’ve had edema before the re-rupture and now it seems like a balloon filled with water when it swells. I’m following the accelerated protocol UWO on my own and with the help of youtube videos and social media. Unfortunately my OS instructions were very vague “Start ROM exercises and FWB by next appointment” really? No PT until next visit at week 8.

Thank you in advance, not looking for a concrete answer but for any experiences you may have had during this period on your recovery and how would your PT go about at this stage. It’s hard to judge by yourself with out any supervision or help from your doctor. Have a great day and keep up the healing!

By johnjk on Jul 12, 2015 | Reply

Sorry to hear that stay strong and be encouraged. I had surgery last week and am home resting and icing.

By normofthenorth on Jul 12, 2015 | Reply

Ed, I’ll try to hit your main Qs:

1) How much walking is recommended once at PWB (protected on VACO and crutches) or is it full time now and walk at any opportunity? Is it safe to sit most of the day?

Walking is fine, but it should be punctuated with relief from elevating, resting, maybe icing, and possibly compression, to control swelling/inflammation, and just to avoid overdoing. Long stretches of either - stop or go - probably aren’t ideal.

2) How many degrees increments on Inversion and eversion per day? Or is it as tolerated? How many repetitions a day?

I think the UWO protocol gives some guidance. I never viewed eversion and inversion as scary, but you’re not trying to stretch anything to its limits, just avoid the worst atrophy of soft tissue tone and proprioceptive feedback loops - i.e., get your leg to remember that it’s still a leg!

3) When should I start dorsiflexion? My major fear of tearing what is healed.

Sensible fear. I thought UWO was pretty clear on the progression from gentle wiggling, 0 resistance, NOT past neutral, to more. I’d stay close to them. If you’re a week behind, I’d try to catch up, but gradually.

4) How much exercise (in boot) leg raises, knee extensions, core.

I don’t think there’s much reason to hold back, as long as your ankle is secure and you feel OK. Bad enough you have to lose a bunch of calf muscle…

BTW, I think your comments on op vs non-op are spot on. Non-op is a breeze compared to surgery, but it’s much easier to worry that “nothing is happening” or “I’m just leaving it to heal by itself.” The mental game is tough either way, but non-op has a few extra mental challenges.

The good news is that many ATR patients look back at long-lasting improvements in both physical and mental strength.

By edhdez on Jul 12, 2015 | Reply

Thank you so much for your help and insight as usual Norm!

By edhdez on Jul 12, 2015 | Reply

By edhdez on Jul 13, 2015 | Reply

Hi Norm. I was just wondering the difference between UWO and Belfast. My OS recommended 4 weeks NWB as in Belfast (Wallace), but I started as in UWO at 3 weeks. I’m just worried since Wallace recommends 4 weeks NWB as my OS, would it make a difference if I started protected PWB 10/15% at 3 weeks. Sorry, kinda freaking out when I noticed Wallace’s 4 weeks NWB. Thanks Norm.

By normofthenorth on Jul 13, 2015 | Reply

You can see Cecilia’s handy comparison of 3 successful protocols at bit.ly/3protocols. (NOT 𔄛Protocols”, sorry!) I read Wallace’s diagram as 2-3 weeks NWB, following 1-2 weeks pretreatment. Most of us start counting when treatment starts, and most patients hobble around until then, so it shouldn’t count. UWO did 2 weeks NWB for sure.
My guess is that Wallace’s actual protocol may not be quite as good as the other two, but his “approximation trick” is so good that he can get best results with an slightly sub-optimal protocol.
For sure, going slow non-op produces inferior results with higher rerupture rates. Whether 4 weeks NWB does that or not I can’t be certain, but I wouldn’t spend that long before going to either PWB (UWO) or FWBAT (Wallace).
Keep breathing! Paying attention and worrying is good, freaking out Not So Much!

By normofthenorth on Jul 13, 2015 | Reply

Stuart, you recently wrote ” Wallace who is a surgeon in Ireland doing non-op AT studies will recommend surgery for some if it is not healing right.”
Where did you get that? My reading of his study is that he referred some “stale” ATRs for surgery IMMEDIATELY, if he couldn’t get their torn ATR ends to approximate. Everybody else got non-op treatment, including all his reruptures(!).
If you found different info, I’d like to know.

By edhdez on Jul 13, 2015 | Reply

Thanks Norm! I appreciate it the advise as usual, not freaking out now

By normofthenorth on Jul 13, 2015 | Reply

By edhdez on Jul 13, 2015 | Reply

Hey Norm, guess what? I talked to a Physio hoping to start PT, and he told me that re-ruptures should be treated at a slower pace because of the risk of re-rupturing again. He said that if NWB was for 2 weeks the first time then 4 weeks should be the way to go. This is the 30yr experienced PT I got recommended and planning to go see to get treated, but now I’m not sure if this is a good sign. He suggested to stop PWB until Friday when I complete the 4 weeks NWB, and he assured me that probably no damage had been done to the tendon during the 3-4 days I partially bear weight 10/15%. What do think?

By normofthenorth on Jul 13, 2015 | Reply

Lots of pros are educable, even after 30 years’ experience. And hardly any bother to keep up with the literature. If it was me, I’d give him copies of the 3 studies and talk to him, unless he seems uneducable. If that, you could maybe keep shopping around.
I think there are 2 durable myths here:
1) Before Wallace, we all “knew” that reruptures needed special treatment (usually surgery).
2) Before the new studies started in 2007, everybody “knew” that going faster was scary, and adding an extra week or 2 or more would always be safer. “Give it some time to heal first.” “You don’t want to go through this twice.” Yadda yadda, all perfectly logical sounding, all now proved

By edhdez on Jul 13, 2015 | Reply

By edhdez on Jul 13, 2015 | Reply

Will do Norm, thanks! by the way this is my check up at 2 weeks https://www.youtube.com/watch?v=K1gxZFDPoqI

By pharmdrx on Jul 14, 2015 | Reply

First and foremost thank you for sharing your experience and research.

I completely ruptured my achilles on 7/11/15 playing basketball. I had a positive Thompson’s test, and an MRI done to confirm the rupture. My rupture is 6.6cm high, with a 1.3 cm retraction. I am not sure how severe that is because I don’t seem to find a lot of numbers on this blog. However, I did see a orthopedic surgeon, he recommended the non-op route which I am happy with. I am looking to follow the protocol that you suggested, however, my doc told me that there isn’t a need for a 2 cm insole at the heel. I have seen the 𔄚 cm” wedge mentioned almost everywhere, so I am having 2nd thoughts about my doctor. Also, I am using the AirCast XP walker. My doc said that the elevation in the back of this walker is enough. Do you have any thoughts about this? if I choose to get the wedges, which and where do you suggest i purchase them. Thank you in advance.

By normofthenorth on Jul 22, 2015 | Reply

pharmdrx, your ATR height seems average and your retraction — I assume that means the gap between your torn AT ends — seems on the small side. I’ve only seen one small study testing whether either ATR location/height or gap size has any affect on non-op outcomes, and the conclusion was that neither did.

Everything I see about the AirCast XP walker online indicates that (like the older AirCast model I own) it’s a standard “fixed” boot, which will hold your ankle at a “neutral” 90 degree angle (some say 0 degrees) unless your heel is elevated with wedges. I am unaware of any study documenting good non-op results starting with immobilization at a neutral angle, and it sounds scary-nuts to me, so I am also having 2nd thoughts about your doctor.

I don’t know where you are or how many choices of OS’s you have, but (a) you may be able to do better, and (b) especially after a Thompson’s test, a doctor’s exam, and an MRI, you may be able to proceed under the care of a non-OS, maybe a GP or a PT or even “less”. (There are a few successful stories online, including YouTube, of ATR patients who have treated themselves non-op. I cannot counsel you to do so, of course…)

Heel wedges for boots are a pretty standard item, whether for orthopedic boots or ski boots or other footgear. They are generally made of very firm foam rubber, and taper near the front from 1cm (each) for the section under the heel, down to zero under the calf. I don’t think they taper straight from the back to the front, but have a flat full-thickness section for the back few inches. The idea is that the rubber is firm enough that your weight (once you’re FWB) does not significantly compress it.

A “surgical supply” store, a sports-medicine clinic, a sporting-goods store (esp. one that sells ski or snowboard boots), maybe even a good shoe store, should all stock standard 1cm heel wedges, and they shouldn’t cost much. Ideally, you’d start with the number of wedges that corresponds to the angle that just brings your torn AT ends together (the way Wallace did with his patients). Failing that, I’d probably start with 2cm (2 one-cm wedges), the way the UWO study did with theirs.

I’ve just looked online for the kind of heel wedges I’m used to, and it’s not easy. “Heel LIFTS” works better than “Heel WEDGES”, because the latter refers to fashionable women’s shoes, and to orthopedic wedges that correct pronation and supination!

Maybe the closest I’ve found are the “Clearly Adjustable” heel lifts — though they’re clear vinyl (not foam), and they’re straight wedges (not “stepped” with an un-tapered section under the heel). But I think they’d do the trick, if you can find them locally. The Adjust-A-Lift Heel Lifts may do the job, too. But all these are a bit too thin (and too $$), partly because they’re designed to be worn in shoes and not in orthopedic boots. clearlyadjustable.com/selecting.html seems helpful, as does their clearlyadjustable.com/achilles-tendonitis.html .

Most universities have decent sports-medicine clinics, if you can get in without enrolling! My local one takes non-students (including me), with their GP’s referral.

By edhdez on Jul 22, 2015 | Reply

Hi Norm,
Almost 5 weeks tomorrow and I started PWB last thursday. I’ve been doing good, I was building some momentum and almost walking with just one crutch at about 80lbs until I talk to a former ATR and told me to slow down and take it easy since I’m re-ruptured. I’ve been trying to listen to my body as many of us do, but how safe is to put more weight. I honestly think I could walk FWB now, but I was suggested 25% increments every week and my OS didn’t give me a set schedule/protocol to accomplish FWB. So there is my dilema “To bear or not to bear weight”

By normofthenorth on Jul 22, 2015 | Reply

I think I’d trust UWO’s FWBAT @4 weeks - though I’d cross check against Wallace, since he’s actually the only published expert who got great results with reruptures. (UWO sent all their reruptures to surgery.) In general, slower studies did NOT get better results, they got worse, especially non-op.

It’s tough to wrap a brain around that fact, but it seems to be a fact. I’ve only seen one study that went fast enough to get bad results (post-op and especially non-op), and it went VERY fast. (Linked and discussed above, IIRC.)

AT means that you should feel NO discomfort near the actual ATR, or near the AT insertion point, behind your heel. If either of those, back right off. But discomfort UNDRR the foot (especially the heel) is common and usually transient, during early FWB and again at early out-of-boot.

By edhdez on Jul 22, 2015 | Reply

Thanks Norm, let me see if I understood correctly. By “got worse” do you mean that by going slowly on bearing weight studies showed more re-ruptures after a re-rupture? And by “fast enough” bad results after re-rupture, did they end up in a new re-rupture? I’m experiencing some pain under the foot for sure, and some faint throbbing on the AT area but no real pain. It keeps swelling a lot tho even after couple of hours. Needless to say I’ve been really stressing about my decision of going non-op after a re-rupture since I haven’t really found much information about it. My foot feels and I feel like I’m healing better than the first time after surgery, but it does stress me the fact that most re-ruptures get treated surgically. Thanks Norm for everything.

By normofthenorth on Jul 23, 2015 | Reply

Ed, by “got worse” I did mean that by going slowly on bearing weight studies showed more re-ruptures — but NOT specifically after a re-rupture. It’s almost impossible for any medical center to treat enough ATR reruptures to run a Randomized Control Trial comparing the efficacy of two different treatments, so nobody does and nobody has.

So what we mostly have for reruptures is logical assumptions that last a long time until some evidence supports or undermines them. The assumption for a long time was that surgery seemed to work for reruptures, and non-op might not, so reruptures should get surgery. Then along came Wallace (pub. 2010) and he had sent all his reruptures (post-op or non-op) into NON-op treatment, and they did GREAT!! So that assumption was seriously undermined — I’d say pretty well trashed.

We have lots of studies reporting non-op results with faster or slower protocols (though mostly comparing their non-op protocol with surgery, rather than comparing two non-op protocols with each other). From those, we can see that the faster non-op protocols consistently have lower rerupture rates than the slower ones (except for one crazy fast one).

Those studies all deal with complete primary ruptures (not reruptures), typically “fresh” ones (less than 14 days old).

But Wallace submitted 2 other kinds of ATRs — “stale” or neglected ATRs and reruptures — to exactly the same treatment as his “fresh” ones, and he got results that were at least as good! So far, I think his study is the only one that sent a good number of reruptures through non-op treatment and reported the results, and they were excellent results. So one approach would be for you to follow his exact protocol, because it’s the only one that’s been proven to work on reruptures. But a second logical approach is to believe that Wallace has shown that the other two kinds of ATRs are NOT significantly different, or harder to treat non-op, than “fresh” ATRs, despite the apparently logical arguments to the contrary. And if that’s true, then all of the modern (fast, aggressive) non-op protocols that have produced excellent results in complete ATRs, will very likely produce excellent results in reruptures, too. Personally, I have gravitated to that second approach, but it’s your leg.

Yes, the one study that went crazy fast did report unacceptably high rerupture rates, especially non-op. But many studies that have gone slower than UWO and Wallace and the UK study ALSO produced unacceptably high rerupture rates. So if you go much faster or slower than those three, you’re following a path that has demonstrated worse results — mostly higher rerupture rates. And if you think Wallace’s study does NOT prove that reruptured ATs can be treated non-op just like fresh ATRs, and it only proved that they can be treated exactly the way Wallace treated them, then you had better follow Wallace’s protocol — but starting with his trick to determine the correct angle for your immobilization.

You are in a stressful mental exercise now, and all I can do is wish you well and urge you to stay the course, follow the program, and stay sane. I used to have a book about how to grow an indoor avocado plant from a pit, and at one point in the process — I think it was just after you’ve chopped off the apical bud at the top of the plant, and you’re waiting a couple of weeks for signs that it’s forgiven you and recovered and will NOT drop dead — the author writes something like “This is an especially difficult time for the gardener.”

And there’s also an old joke about the farmer who kept uprooting his carrots to make sure they were growing OK.

Hang in, stay sane, and Watch Your Step. Don’t forget that most FRESH ruptures ALSO get treated surgically, but that’s not based on evidence that it works better than non-op, much less that it’s worth the added risks, costs, and pain.

By edhdez on Jul 23, 2015 | Reply

Thanks Norm. I will stay the course and trust my gut, and try and not to stress about it anymore. It’s just been a hard year dealing with this and the thought of a third rupture just makes it even more difficult. I appreciate the advise.

By ajstander on Jul 23, 2015 | Reply

I hope life is good on that side!

I am also starting to doubt everything I am doing at the moment. I am non operative and Full NWB for the next week. I am worried that the tendon is not healed at all (because when I look at it it looks like it is not healed). Now I am scared that I have been to active on the crutches by moving around the house etc. My leg is almost never sore and I do not keep it elevated simply for the sake of elevation. I just make sure that I never put weight on it and that I never do anything without my boot on…and I mean everything (Sleep, Shower, Bath) My leg has now been in the boot for just over a week at an angle and I am progressing to PT next Wednesday. I can also fully move my toes, and I do that mostly without me knowing about it (I stop as soon as I realize what I am doing), again not knowing if it is a bad thing.

What I am trying to say is that I have so many doubts and worries about what I am doing and might have done wrong, but I am focussed on the protocol and hoping I understand what everything correctly.
For instance…my understanding of non weight baring is that I never put weight on my foot, but I can stil move around. I am hoping it does not mean being in bed for 2 weeks because then I missed it completely.

My mental madness is mainly focussed ont he fact that I do not know what my foot is doing, but I am hoping it is healing. I am scared I am doing something that might cause me to start from scratch bla bla bla…

I just want to get training again, and with that I mean upper body only and core… and hopefully that is not to far in the future…

Anyway…I am glad I am not the only guy on earth dealing with this, and the fact that some one like a Norm exists makes life a hell of a lot better..

By ajstander on Jul 23, 2015 | Reply

Now that I read my comment above I seem a bit whiny…shees ! I have doubts, but I have chosen a path / protocol and I have to stick with that and believe that it will work out!

Thanks for listening to a little girls moaning

By normofthenorth on Jul 23, 2015 | Reply

This non-op ATR cure is only one of many aspects of life that would be SO much easier if things came with guarantees. Instead, we do what we think is best and wish each other (and ourselves!) Good Luck.

AJ, your understanding of NWB sounds right. And there’s no reason you couldnt start pumping arm weights or hang from a chinup bar now. I think a few people here have posted some core and arm and even leg exercises that shouldn’t arouse (or scare) your calf muscles. Bad enough that one lower leg has to atrophy.

By pharmdrx on Jul 24, 2015 | Reply

Hey norm, I’m approaching the 2 week mark and want to start PWB, however, is it ok to start the week 2-4 PWB and flexion to neutral if I still have a positive thompsons test?

By normofthenorth on Jul 24, 2015 | Reply

Pharmdrx, the most successful studies did not adjust their schedules with Thompson’s Tests, so I don’t suggest doing that either. And if you search through this site you’ll find lots of conflicting evidence from T Tests used (long after diagnosis) to check “how the carrots are growing”.

Further, I’ve slowly started wondering how much damage a T Test (or repeated tests) might do to a newly reattached torn AT. After all, we suffer the major inconvenience of weeks of NWB and PWB just to avoid tugging on that fragile bond… then we have somebody squeeze our calf muscle to make it contract to tug on it, just to watch our foot jump. Hmmm.

I think it’s probably still worth doing one to help diagnose an ATR, but I’ve turned sour on subsequent repeats, both because they don’t seem to lead to differential treatment and because they just may Do Harm.

So if your fave of the 3 most successful non-op protocols says it’s time to go to PWB, or WBAT, I’d do it.

By pharmdrx on Jul 24, 2015 | Reply

Tomorrow marks the 2 week mark since my injury, I want to try PWB. What is the correct way to do it? Do I continue walking on my crutches and just put my food down lightly with every step? How do I make sure I am not doing any damage to the healing? I also watched a YouTube video of Brady Browne and he was without crutches by week 2, he just managed to walk on the boot.

By normofthenorth on Jul 24, 2015 | Reply

Yes, pharmdrx, you do just as you say to start PWB. You start loading that foot with near zero weight as you crutch along, gradually and incrementally adding weight, as it continues to feel good, and following the approximate schedule that starts at 0 weight (at say 2 week in) and finishes at FWB(AT) at say 4 weeks in. If your leg complains you back off, if everything feels like you could have done it a few days sooner, you keep progressing incrementally.

There are no guarantees involved, but waiting longer to add weight definitely does harm (or adds risk), so we’re trying to follow the path that yielded the best results. Those results weren’t perfect either, but they were better than the alternatives.

Brady B may have gone faster still, I don’t recall. But he’s a data set of 1 data point, and UWO and Wallace and others have much larger data sets, and statistically significant results that compete favorably with surgery.

The closest to a guarantee we can get, IMO, is to follow a path that produced excellent results in a large number of patients.

By pharmdrx on Jul 26, 2015 | Reply

After laying down with my foot elevated, sitting, and after sleep, when I get up and start to walk I extend my leg (now I do pwb) I’m 2 weeks into recovery, my calf muscle hurts especially higher up closer to area behind the knee. Is this normal?

By normofthenorth on Jul 26, 2015 | Reply

I recall having lots of funny feelings and discomforts during each of my ATR rehabs. Not sure if the one you describe is one of them. And it’s probably always possible that the same strain that R’d your AT also caused some pain to your calf muscle. Even if so, I’m not sure that would change the therapy.

When people start sleeping without the boot, they often find that getting back in the boot in the morning is “a stretch”, because their calf muscle has tightened/shortened a bit overnight, pointing their toe down into equinus, PF, more than the boot. But you’re still sleeping in the boot, right?

By pharmdrx on Jul 27, 2015 | Reply

Yea I sleep in the boot. I also understand at this point I am allowed to start some dorsiflexion movements ?

By normofthenorth on Jul 28, 2015 | Reply

As long as that’s what the successful protocols say. I haven’t been checking them, but you should.

By ajstander on Jul 29, 2015 | Reply

2 Week mark reached. My first PT session today. The area around the AT where I suspect it snapped is still swollen and fairly hard. I have been NWB now for 2 weeks in the boot + 3 days after injury. I had one or 2 slight mis steps along the way, but had no pain when I accidentally added slight weight on the leg when semi falling over etc Slowly easing in to PWB and FWB during the next 2 weeks and extremely nervous about it, but putting the head down and trusting the results.

Imagining sleeping without the boot sounds like science fiction to me at the moment. I have had some serious dreams recently and my AT woke me up and reminded me that real life is still a dream so to speak !
Recommendations for sleeping without the boot and when?

I have been back in the gym doing some core work so at least I feel semi human.

By normofthenorth on Jul 29, 2015 | Reply

Re sleeping without the boot, I think 4-6 weeks in may be average hereabouts, post-op or non-op. I don’t think any of the protocols says much about it.

Main fear is getting up during the night and standing on it before you wake enough to know what you’re doing. Another concern is that you go into plantarflexion/equinus/ballerina during the night, so getting back in the boot is “a stretch”.

In either case, you could wait a bit more. I don’t think the timing is usually vital for the cure - not like progressing to PWB and FWB, etc.

By oscillot on Jul 29, 2015 | Reply

Speaking to my own experience, AJ, I wasn’t psychologically ready to sleep bootless until week 9.5. I liked keeping it stretched out at night, and didn’t want my two year old grabbing my foot and yanking it back while I slept (a rational fear, I think). I was just more comfortable in my Vaco cast turtle shell.

There are definite benefits of sleeping bootless, but my Achilles is extra tight now in the mornings, requiring extra care when stumbling to the bathroom and until it warms up.

By ajstander on Jul 31, 2015 | Reply

Thank you for the response Oscillot, I am also very comfortable in the boot at the moment. Had my first PT session on Wednesday and was petrified when she came closer to even touch the AT…after my initial horror of someone touching it, I could almost move it to neutral before having some discomfort. She advised that I do the wiggly exercises more often but not as long…rather 10 times a day for a few minutes instead of 3 times for 30 minutes. I have a question…the protected weight bearing with crutches in week 2-4, how do I interpret that? At the moment I am on crutches and only rolling my thick sole of the boot as I walk…but with very little to no weight on the foot…

By ajstander on Jul 31, 2015 | Reply

This might sound like a really stupid question…but how do you know if the tendon has attached or is being attached being non operative…?

By oscillot on Aug 1, 2015 | Reply

Options to tell if its attaching include the Thompson test or MRI.

For my PWB, my doc had me use a scale to judge 40 lbs, then had me add 10 lbs of pressure every day until I was FWB. By the time I got to my full body weight, it wasn’t scary or painful to ditch the crutches.

By ajstander on Aug 1, 2015 | Reply

I heard the Thompson test was not very accurate…will probably then do a MRI at some point…when would be a good time?

By normofthenorth on Aug 1, 2015 | Reply

AJ, I don’t think it’s worth scratching the itch to check your internal progress. I liken it to the (joke) farmer who pulled up his carrots every day to make sure they were growing OK. You’re following a path with around 97% or better success rate, and most of the failures were from slips and trips. If we had MRIs or Ultrasound machines at home, we’d probably do like the farmer, but it wouldn’t help. And not JUST the non-op patients either, though we’d use them more. But even post-op, all of the REAL cure is done by the body itself, POST-op, so there’s lots of room for doubt and anxiety that the magic is happening.
I figure that by the time you’re running and jumping again, you’ll lose the itch for diagnosis. Until then, stay insane and follow the path.
BTW, I’m especially nervous about multiple early Thompson tests, because I know fear they can do harm. The other tests produce shapes in clouds that often mislead. I’ve posted my own personal embarrassing stories about both technologies elsewhere. And there have been a number of studies showing how MRIs of the back can Do Harm, so I don’t see why ATs should be that different.
In one study, a bunch of chronic back pain sufferers all got spinal MRIs. A randomized half had an expert MD show them the images and discussed them. The other half got no follow-up, as if they’d been forgotten. After 1 year and two, the forgotten backs were significantly better than the backs of patients who SAW their MRIs!
I have no idea what my healed ATs look like, or did while they were healing. And I’m so busy sailing and bicycling and playing volleyball etc. that I have no time for it. Hang in!

By ajstander on Aug 1, 2015 | Reply

Ha Ha Ha…I had the same idea. We are way to concerned about what the “experts” say. Thanks Norm!! Much appreciated. Cant wait to be to busy with life than worrying about my AT.

Have a ridiculous weekend!
AJ

By ajstander on Aug 3, 2015 | Reply

What does protected weight bearing with crutches mean…? My assumption is that I roll my foot as I walk on the crutches with very little or no weight? But as well all know, assumptions are interesting at best. Should I add a little bit of weight as I roll the boot?

By normofthenorth on Aug 3, 2015 | Reply

AJ, I think your understanding is about the same as mine. “Protected” WB is probably just UWO’s version of “Partial” WB. Most people start at 0 body weight, just rolling their boot on the ground while crutch-walking, then gradually add weight as long as everything feels OK. As long as you stay incremental and Watch Your Step, it should be fine.
The transition from PWB to WBAT is sometimes seamless, more a label change than a change in what you actually do. You just keep gradually adding weight until you start forgetting where you left the crutches — usually soon after 4 weeks in.

By ajstander on Aug 4, 2015 | Reply

So what you are saying is that I can in week 2-4 already start adding weight incrementally and slowly to hopefully be FWBAT in the boot at +- 5 weeks. Obviously slowly as is tolerated, but adding weight as we go along while doing ROM exercises to neutral etc…

By normofthenorth on Aug 4, 2015 | Reply

AJ, if I’ve misrepresented bit.ly/UWOProtocol, then go with it, not me. I recall PWB starting at 2 weeks in, and WBAT at 4, which usually means FWB by

By ajstander on Aug 4, 2015 | Reply

Perfect…what I thought. Thanks Norm, your input is much appreciated!

By damonboost on Aug 9, 2015 | Reply

Norm, Question for you. I am trying to cross reference the capabilities of the Vacocast to what is recommended as far as starting point and progress with the degrees of the boot thoughout recovery (vs the 2cm heel lift of the non-op protocol that you have provided) and also the available soles of the vacocast… Could you provide some insight. Thank you.

By ajstander on Aug 11, 2015 | Reply

I hope life is keeping you to busy for achilles blogs:)

I also have one or 2 questions relating to the degrees of the boot etc…

I am in a vaco boot at 30 degrees(done before this blog became relevant for me, I will wean of a bit slower I suspect if needed), and tomorrow marks 4 weeks into the protocol. I can move my foot to neutral fairly painlessly. I am confident that I will also be able to add more weight during the course of the next week to be FWB by 5-6 weeks.

My question is…should the boot hinge now already from 30 in my case to neutral and if not now when can the boot have unlimted plantarflexion to neutral?
Also, at what point do we allow dorsiflexion in the boot and to what extend?

By normofthenorth on Aug 12, 2015 | Reply

damonboost, I think I was too busy to get to your Q 2 days ago, sorry! It’s often said that each 1cm of heel lift is roughly equivalent to 10° of plantarflexion, so 2cm = 20°, etc. I’ve tried to confirm that with simple trigonometry, and it doesn’t seem that close to me! In addition, the length of a foot varies greatly among us, and the same heel wedge will produce a bigger angle under a short foot than under a long one, so any equivalence would only be accurate for feet of a specific (average?) length.

In short, It’s Complicated, so I usually just pretend the simple equivalence is true - as do many others. The implicit errors may or may not be important.

AJ, I don’t really know the answer. I don’t recall the details of the evidence from studies done by Vaco or using the Vaco boots with early use of actual hingeing or ROM. I’ve mostly focused on the 3 studies that Cecilia summarized, and I think they all used simple fixed boots with wedges, or hinged boots set at a fixed (PF) angle.
In my own 2 ATR rehabs, I did use the hingeing feature of my (non-Vaco) boot, but only fairly late in my rehab, as a transition from the boot to the totally free-hinged 2 shoes. 2nd time around, I switched to the hinged boot around 7 weeks in, slightly against my OS’s directions. (He wanted pure UWO.) I set it up so it would not dorsiflex at all (”stop” at neutral), but would PF without limit. I loved it, it felt great, and I walked very fast. (I once tried walking BACKWARDS, which was a big mistake! Don’t Go There!)
Toward the end, I tried letting it DF past neutral maybe 10°. I hated it and quickly put the stop back at neutral. But others - Hillie comes to mind - have enjoyed using a ROM setting that includes DF, and I think Vaco got good results using that. But I’m not sure the results were any better than those from the other 3 studies, and my leg was anxious when I tried it.

By damonboost on Aug 13, 2015 | Reply

Norm, Do you have any links to your Physical Therapy Protocol and/or exercises throughout your recovery? I am going to be at much of this solo as I cant find many here who support the Protocol you supplied along with my crappy insurance being well crappy.. Thanks so much in advance.

By ajstander on Aug 13, 2015 | Reply

Had a few steps today without the crutches and I had no real pain. I could feel my calf muscle a little bit afterwords, considering it has not really been used for a while I suppose its ok. Will anyway keep it slow for the next week with crutches assisting and hopefully be a pirate without crutches by week 5. Did you experience any discomfort when starting the transfer to FWB?

By Hillie on Aug 16, 2015 | Reply

Hi Norm, you back here now?

Damonboost, the reason for my comment to Norm is that he and I and many others are pretty active between 1 and 3 years ago, swapping experiences, asking for advice, all sorts of stuff. I know I drifted away, dipping in occasionally for a read, fully(?) healed, and Norm, where did you go?

Anyway, Norm has included my experience of the Vaco boot above, and it is quite true, I did enjoy its hinged and progressively increasing range of movement, right from 30º PF to a RoM of 30º PF to 10º DF. I followed the Exeter protocol, one of the 3 mentioned by Norm. I stopped wearing the boot in bed after 4 weeks, fwb between weeks 3 and 4, and thereafter no crutches unless on difficult or uncertain terrain. The RoM may take a few hours to feel good after increase, but this was minimised by the leg not being booted at night. I was non-op and on the same rehab protocol as Exeter’s surgical cases.

2 years ago, Suddsy put together some great blog pages here. Take a look at suddsy/2013/06/24/end-of-wk-2-wow-progress/ (I hope that works but if not you’ll find it ok). Suddsy was a surgical case, in London I seem to recall.

Good luck with the recovery.

By damonboost on Aug 16, 2015 | Reply

Hillie, thank you for the reply.

I haven’t been able to find as much information on the Exeter protocol as I did the UWO. Is there anyway to view a broken down version much the same as the version comparible to what Norm did here: http://achillesblog.com/normofthenorth/the-non-surgical-protocol-ive-been-following/ . I would love to take a look at it especially with how you progressed.

Additionally, I am looking for a rehab protocol as far as exercise and a timeline. I am pretty much going at this thing rouge as I went to to Dr’s that I did not feel comfortable with and my insurance is relatively crappy so I choose to pretty much go at it on my own.

By ajstander on Aug 17, 2015 | Reply

I like the look of your protocol. It does look like all of the more modern protocols are the same in the sense that movement and weight is re introduced quite quickly. Damonboost the link is below…
http://achillesblog.com/pgat2013/files/2013/09/vacoped-rehab_suddsy.pdf

Up to now the protocols look very much the same and I have been following with the exception of the full weight bearing at 2 weeks, but being non op that might be a bit soon. I am full weight bearing now and life is indeed better (4,5 weeks).

Quite interested in the dynamic hinges in the Vacoped Accelerated Protocol.

By brad on Aug 27, 2015 | Reply

Glad to hear you are being cured of your addiction to the site.

Would appreciate if you could comment on my most recent blog post. I am at the 9-month mark and chatted with a foot ankle specialist about options.
Thanks.
Brad

By ajstander on Sep 18, 2015 | Reply

Long time and no chat! I am now 10 weeks and it is going well. I used a bit from Suddsy’s protocol. From week 8-10 i set the boot to hinge between -10 and +10 and I must admit initially it felt very stretchy but now it feels really good. My question is what your opinion is regarding the use of heel lifts when transitioning to shoes and walking barefoot or do we just transition to shoes period and take it easy. Have a good one!

By normofthenorth on Sep 18, 2015 | Reply

1) Brad, I hope I’ve already responded. If not, soon!
2)ajstander, practice is totally mixed (random?) on heel wedges in shoes, and nobody’s tested it with a RCT, AFAIK. UWO didn’t use ‘em, so I didn’t either. If you do, you need one more transition schedule than those who don’t…

By normofthenorth on Sep 18, 2015 | Reply

Brad, I finally responded, at http://achillesblog.com/brad/2015/08/27/nine-monthsshould-i-try-surgery/comment-page-1/#comment-20.
Dennis, I hope you don’t mind me making an exception to your rule that I only post on my own blog - in response to Brad’s request (here and there). If it’s a problem, I can cut and paste and move it here instead.

By xplora on Sep 18, 2015 | Reply

I hate logging in to comment Norm. AJ, Stuart here, Norm and I differ on wedges. I used them in the transition to shoes and liked them. It is better if you even up the other side. I found they enabled me to walk faster and helped with push off strength. I started with 2 and removed one each week or so. Each time I removed a wedge I had to slow and shorten my stride until adjusted which took a couple of days. I don’t know any other way personally but my strength increased quickly this way and it did not hurt. It may have been the same not using the wedges but I could feel their effect in a positive way so that is all that matters to me. I was also in 2 shoes before the UWO recommendations.

By normofthenorth on Sep 18, 2015 | Reply

I hope I was clear that I’m not pushing against wedges. For most of us, the transition to 2 shoes is the most double edged sword - an important step forward that feels like a step backwards! After finally getting good at boot walking (I think I was going faster than I’d ever walked before!), you feel naked and vulnerable while you take your first slow, nervous, asymmetrical steps in shoes. Some people get more comfortable walking barefoot than in shoes, some get wedges and generally support them, others go straight to flat shoes and generally support that. Most of us progress further OK (despite “the frustrating plateau) and end up near, or at, 100%.
I’d love to see a good study that demonstrated whether heel wedges help or hurt or neither, but I don’t think one’s been done yet. So we follow our doctors, or PTs, or our fave protocol.

By ajstander on Oct 2, 2015 | Reply

Hi Norm…I hope lie is good on that side of the world.

Today marks the 12 week mark since the rupture and I am walking 80% and I can heel raise 1/3 of my body weight. I have started with plyometric exercises in the swimming pool, and in the water I feel normal. So generally not bad at all. My range of motion is not nearly the same as with the “normal” leg yet…probably 50%. Did you just stretch more aggressively to get the ROM back (Especially Dorsi). Another thing that seems to help quite a bit id the scar tissue massage.

Many thanks again for all your help to date, it has been invaluable to my recovery !!

By normofthenorth on Dec 29, 2015 | Reply

I just tripped over an interesting new article - secondary research, kind of like my own - by a repeat author. It’s at http://www.braceworks.ca/2015/12/22/treatment/battle-of-achilles-ii-how-the-debate-is-informing-clinical-practice/. Actually published in lermagazine.com, 5 years after the same guy wrote another long and interesting article there, which I posted here (maybe on this page) and commented on.

Even more interesting, he cites a couple of new studies - primary scientific publications - that apparently help advance our understanding of ATRs and how best to treat them.

I haven’t read those studies, much less wrapped my head around them. And it may take a while, since I’ve busted my addiction to things ATR (sorry!).

By mcdz on Apr 21, 2016 | Reply

Not sure if you still check this, however, I recently just ruptured my achilles tendon 4 days ago. I went to the doctor 2 days ago and he was adamant on going the operative route, but having read your post and many youtube videos of people who went non operative, I was hesitant on going under the knife if not absolutely necessary. Your post has been extremely helpful and made me more comfortable pursuing the non operative method of treating this injury. I went to another doctor yesterday, he was a strong advocate for non operative. In fact, he was one of the researchers in this study (http://fai.sagepub.com/content/24/10/775.abstract).

In any case, my question is, he mentioned that the way he treats non operatively is by putting the foot in a cast/boot for 4 weeks, then changing and putting the foot in another cast/boot for 4 weeks in a more “neutral” position, and then out of the cast to rehab. All the while, the foot can be bearing weight.

Do you think that’s okay? I’ve currently got the vacocast, and have just been walking around in it (albeit tenderly). But still walking around–it doesn’t hurt at all, but I’m still placing some form of weight on it. Is that not a good idea? Should I be in crutches for the first 2 weeks? Will walking around in a boot from weeks 1-4 hurt my recovery?

Appreciate any feedback! Thanks!

By normofthenorth on Nov 23, 2016 | Reply

Sorry I missed your note when it arrived, mcdz. (No, I don’t “check”, but I often/usually get emails notifying me when somebody’s added a comment to one of my pages. If it arrived this time, I missed it.)

I hope everything went fine. That new study uses an unusual, new-to-me approach. The abstract doesn’t give much detail, though it does present his basic results, which seem mixed. The rerupture rate isn’t as good as those of the 3 studies summarized on Cecelia’s page, but his “Calf circumference and ankle range of motion were not statistically different between the two legs.” does sound good. And the “The injured leg tended to be slightly weaker than the uninjured leg, but the difference was not significant for most of the quantitative strength measurements.” sounds quite similar to the results of the UWO study, where the strength results were generally “not statistically different”, yet there was a general bias of slightly greater strength in the post-op group.

BTW, the UWO — the University of Western Ontario — has recently “rebranded” itself, and likes to be called “Western” (its long-time common name) or “Western University” (which was NEVER its common name). And they say they’ve NEVER liked to be called “UWO”. Sorry, “Western”!

By halfpipeatr on Mar 16, 2017 | Reply

Hi Norm, I’m a new ’subject’ for the ATR club and have read most of your posts over the past few days. One question I have is related to the wearing of the boot. I have the Aircast and am following the non-Op, aggressive rehab (Feb22, 2017 -injury date) and I have the luxury of working from my couch, which allows me to take the boot off most of the day, while on the couch. I continue to work gently on ROM and have just recently started light PWB (in the boot). Are there any studies about letting your foot breathe, outside of the boot for extended periods?
halfpipeatr

One thing to be careful of if you’re not in the boot is the angle of your foot. The boot will keep your foot at neutral (or whatever setting is appropriate for you). The tendency if you just let your foot hang naturally is to tilt forward, which can lead to the achilles healing shorter if that is done for an extended period of time.

By halfpipeatr on Mar 16, 2017 | Reply

cserpent, thanks for the prompt reply and advice. I’ll try to wear it a bit longer during the day to prevent the shortening potential. I have another question related to the PWB and trying to determine how much weight to bear. I tried a scale, but of course that’s pretty static, versus crutching along and tenderly applying pressure. Do you have any tips, or does one just apply the pressure that doesn’t hurt?

By normofthenorth on Mar 16, 2017 | Reply

1) halfpipeatr, I don’t think I share cserpent’s concern. As long as you’re doing gentle ROM while you’re “hanging”, I wouldn’t expect any healing short. Also, since it’s much more likely that you’ll heal on the long side…

My concern would only be that you’ll do something forgetful, dumb, and dangerous, like getting up and rushing to pick up a phone or answer the door. If you’re safe from that, I’d expect you to be safe.

2) I think the short answer is that no two people agree on what PWB means, but most people agree on some principles. It’s more than NWB and less than FWB, and it usually progresses incrementally from N to F. Since we never get any reliable “root cause analysis” to explain imperfect or bad outcomes, it’s pretty impossible to say “avoid doing THIS, or you’ll (likely, surely…) experience THAT” in a scientific way.

So we’re left with logical-sounding maxims that may be right (or may be like 4 elements): If it hurts, it’s probably too much too soon. And if it’s much more than you’ve done before, you may find out in a few hours or a day that it was too much too soon, even if it doesn’t hurt immediately. We’re looking for “cautiously, thoughtfully, and incrementally aggressive”.

By halfpipeatr on Mar 16, 2017 | Reply

Thanks Norm for the comments and well wishes. I’m going partially against Doctor’s ‘orders’, as he recommended NWB for 6 weeks, from injury/first cast, but encouraged the ROM daily, or more often. Curiously, the protocol sheet that they left me with shows PWB (up to 50lbs max) from weeks 2-6, but his instructions were NWB. I also have 3 heal lifts, which i’m supposed to remove 1/week. At week 6, FWB is allowed, as well as driving and sleeping without the boot. Aircast walking until week 12. PT at 10 weeks, no heel raises, single or double at 10 weeks. So, some pretty conservative values, mixed with aggressive. So I’m planning on more of the UOW (now W) protocol), but your comments are appreciated.
Fellow Canadian, in Calgary.

By xplora on Mar 17, 2017 | Reply

halfpipeatr - I have to echo Norms words. There is no real danger of healing long if your foot is out of the boot unless a force is applied that causes it to dorsi(upward)flex.There will be a temptation to just walk that little bit without the boot and that should be avoided. Since you are already past the initial healing phase then no harm is done with Active ROM exercises as you are doing and I too would start weight bearing as tolerated and let pain be your guide. Many start weight bearing day one but mostly it starts around 4 weeks. The protocol seems a bit odd to me, allowing you to drive in shoes at 6 weeks but still walk in the boot until 12. No doubt you will end up with a transition from boot to shoe over the time. It is about being sensible and careful. Good to know Norm is still around.

By halfpipeatr on Mar 17, 2017 | Reply

Thanks xplora. It really seems to be quite variable about the rehab protocol, which is obviously confusing. I was also reviewing the recovery rate table, to get a ‘feel’ for the various PWB, FWB, 2 Shoes and the variability there is pretty extreme as well. Of course everyone heals at different rates, but the discrepancy is pretty startling. I also have a somewhat reluctant PT, recommending NWB for 6 weeks and not seeing him until then. You would think he would want my money) So now I need to find another PT, which likely won’t be as convenient, but I don’t really want to wait 3 weeks.

By normofthenorth on Mar 17, 2017 | Reply

BTW, I think one of the co-authors of the UWO report is now (teaching?) in Calgary. (I’d remember his name if I looked at the list.) Maybe he has a recommendation for a good ATR-rehab PT.

By halfpipeatr on Apr 7, 2017 | Reply

Norm, as you seem to be an analytical type, I’m curious if there was ever a comparison on this site comparing surgery vs non-op, at the various stages, right out to the 2 year mark?
Rgds,
halfpipeatr

By normofthenorth on Apr 7, 2017 | Reply

No, not among users of this site. Of course, most studies do their own comparisons, which is the most meaningful, because different protocols (especially non-op) produce different outcomes.

By bacchus on Nov 19, 2018 | Reply

Hi Norm,
Not sure if youre still managing this blog - but I came across it today. I suffered a ATR on Oct 25th and am not doing surgery. My doctor (as well as a 2nd opinion) recommended it, and put me on the UWO Willets protocol for recovery. I’m from Toronto and the hospital is rather busy so it took me a while to get my first couple appointments. My concern has been however, that so far (im at 3.5 weeks but have been in my boot for 1.5 weeks out of 3.5) I havent been doing enough PT excercises as per the protocol. My doctor hasnt been too helpful. Basically she just told me that until my 4.5 week ill be in the boot with the 2-CM raise, from 4.5-6weeks she may drop me down to only a 1 CM raise. And through all this time i should (at home) just try to lift my foot as much as i can (so only a little) and return it to a pointed down position. Do that a few times a day and thats it. Ive read your blog as well as a ton of other sites and a blog you commented on (Andrew Tucker in 2010) that mention more “vigorous” PT starting at the 2 week mark and by 4th week i should be on Partial WB, which i dont know if i should be doing that myself given my progress. Through your blog i found this protocol (http://achillesblog.com/cecilia/protocols/) which is similar to what i received but overall my doctor hasnt given me much direction. I’d love to connect with you to hear your thoughts. Could i send you my email address?

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