← The AOFAS Orthopod-Cast
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- [00:01]
A
Welcome to AOFAS Ortho Podcast, where leaders in foot and ankle orthopedic surgery discuss the issues that affect you and your practice. Please note that the views expressed on this podcast do not necessarily represent the views of the AOFAS or its members. Welcome to the AOFAS Ortho Podcast. We're talking about Achilles tendon ruptures today, and we have a very special recurring guest on the AofAS Ortho podcast, Dr. Martin O', Malley, who's a clinical professor of orthopedic surgery at HSS, team physician for the Brooklyn Nets, consulting physician for the Giants and Devils, and obviously well known among the AOFs community as one of our influencers, you know, one of the OG influencers of foot and ankle surgery. And I'm Matt Conti. I'm at the Hospital for Special Surgery, and we're also here with Joe park, who's a professor of orthopedic surgery at the University of Virginia. So thanks. Welcome to both of you.
- [01:06]
B
Honored to be here.
- [01:07]
A
I'm sitting right next to you, even though you can't see us on the screen. All right, so I think we wanted to jump in and just, you know, this year in the NBA, eight Achilles tendon ruptures, you know, Tatum and Halliburton most recently. And so why do you think the incidence of Achilles tendon ruptures continues to increase?
- [01:27]
B
That is the question of the month or the year. The MBA is very interesting as well. If you look back at the history of this, there's an article in 2013 from American Journal Sports Medicine that said the instance was 0.78 per year. And up until this year, I would give the lecture and I'd say, well, there's like two or three per year since we started taking care of everyone and having a better database. In 2019, the year Durant did his Achilles, there were six. Right. Last year, there are none. In 2020, 21, there's one. So, you know, if you look at the overall instance, this year was definitely a huge outlier. And it was an outlier for a couple reasons. It was some very famous people. Durant was the most famous. He was the only starter in the year. He did it this for 1, 2, 3, 4. There's. There's six of the eight were starting players, and also they did it in front of national tv. So we had, you know, how many million people watched? Durant was 13 million, but about 11 million watched Lillard, 14 million watched Tatum, and then like 16 million watched Haliburn. So it's in everyone's mind. Now we've had a couple calls with all the NBA and team docs about why. The question is why? There's a lot of theories. So I'll just go through the different theories. Well, there's the high top and the low top. There's no data on that. Right. So that's been thrown out there with the shoe wear because players definitely use mid shoes and lower top shoes compared to before they all used to high tops. That doesn't seem to really hold much because most of the guys are wearing mid shoes. They were the same last year in their killings. Player size, speed of the game, all that stuff has been the same size and speed of the game. The same number of minutes this year than last year. They they were worried about the seasons condensed because of the in season tournament. There's a break in the middle they have in season tournaments. So there's more frequent games on either side of it. The way it went this year we had three on the Indiana Pacers. We had two guys did it in November early in the season, 22 and 23 years old, both healthy guys, you know, in the second quarter, no history of anything before. And then we had a sprinkling of guys through the year until finally we had the big three at the end. No one really knows. You know, they always talk about the step back move where the player takes a step back. But if you look at every and I reviewed all the NBA Achilles operations I did, so I have a tape of every guy. They're all making pretty much the same move. Their foot goes backwards. But you can't get around someone unless your foot goes backwards and they've made that backward foot back or that foot drop step thousands of times during the year. Now if the player has some injury before on the ipsilateral low extremity, you could think that it's a risk. And you know Halliburton has a well documented time off. You know, came out of a couple games during the playoffs before he rushed for his right. But he passed all the tests and his imaging looked fine. So did it have anything to do with it? We don't know. Durant had a gastroc documented gastroc tear beforehand. He was imaged the night before he ruptures Achilles tendon We used to think that getting a gastroc would make you less likely to rupture your Achilles tendon. Maybe it makes your leg a little stiffer up higher as the gastroc heals and more pressure on your Achilles. The bottom line is no one knows. We're trying to look at it. The only way you could really tell is by doing some sort of dynamic ultrasound for preseason for all the guys. And if you went and did the entire team and had some data before the season and then you had data at the all star break and the day at the end of the season to be able to tell the player you're at risk to rupture your Achilles tender. But to right now it may just be bad luck. That's what Halliburton says. Most of the guys think it's bad luck.
- [05:14]
C
I'm really lucky to be speaking to you and you know, you've helped me so many times in my, you know, youngish career, I guess 15 years in. But I have seen the same thing. I've seen it in our college athletes, 18, 19 year old kids, running backs, wide receivers, you know, at the University of Virginia and other schools in our area. One thing I suggested and someone interviewed me about why they're going up too, one of the things I've found is that our younger athletes are doing heavier and heavier weightlifting like earlier on in their, let's say early teens it seems, you know, these kids are coming in like more like full grown men than they are, you know, 17, 18 year old kids. And is that something you're seeing in the NBA as well? Just more muscular people or.
- [06:00]
B
I think the same size. But I agree with you 100. I never, when I first started we would never see college guys rupture their kills or even high school kids. And we have Division 3 football players all the time rupture their Achilles tendons. And young girls as well, which is, you know, was unheard of. The average in our study we wrote on women in Achilles ruptures the average age was 35 and it was mostly playing tennis. We've had some young college athletes rupture. The Hercules tend to the question is it the trend towards single sport trait? Is it just obvious if you're a basketball player and you are going to play in the, you know, in the NBA, they pretty much know you're going to play in the NBA by about age 14. So you have gone to some special high school to play basketball, then you've played at some PG or they've gone one year of college and you have just played basketball your whole life is because you haven't developed those other muscles. And that's probably the strongest argument the sports specific training. That's what's probably changed in the last 30 years. There are very few three sport athletes anymore. And so that. That may be it. And also, we don't know. But, you know, all these kids are taking creatine. They're all taking some sort of supplements. We don't know what the effect of that is. Yeah, yeah. Factors. But I. For my gut, I think it's. The single sport player is the one that's mostly at risk because they just never get a break and they're doing repetitive movements the whole time. The same move they're doing all the time, and they never get a break. So that's.
- [07:30]
C
I mean, I even notice in my, like. So my son is 14 and in the past year he grew 6 inches. And, you know, I can just thinking about that, like, your tendons aren't really growing. Right. They're just sort of being stretched along with your long bones. And, you know, if you add that dramatic growth with weightlifting and like you said, maybe creatine or perhaps even other supplements that we don't know that they're taking. I mean, I just, I always wonder, is it that they're developing muscles so quickly that the tendons aren't able to stretch accordingly? And like you said, they don't have an off season anymore from these sports.
- [08:06]
B
Yeah. So, I mean, I think that's probably the only thing we can implicate so far. Be hard to change that. We're going to try and get some objective data because all the teams want to know what's going on before this year. What are we doing in terms of preseason? The NBA therapists are very much involved. When somebody has a sore Achilles, we shut them down. What are our criteria besides just get an mri? Most players by the end of the year will have some signal in their mri. So what we need to determine is there a critical, massive white signal on a T2 image that says you should be shut down or you're at risk to rupture your Achilles tendon? We don't have that data yet, but there were none last year, which is a pretty powerful statement. You know, it's a long season, a lot of guys playing, and nobody rushed through their killings the entire season.
- [08:52]
A
What about in, like, the normal person? Have you seen an increase in pickleball injuries in, like, the everyday athlete? I mean, I think we were talking about before the podcast started, like, pickleball, you know? Well, yeah, you know, so what others. Have you just seen it in general? Is it pickleball the main culprit? Like, what have you?
- [09:07]
B
Well, I mean, I live in New York, so I have the, like, I've done nine Achilles in the last two weeks.
- [09:13]
A
Yes.
- [09:15]
B
So, and that's mo. And it's the usual. Is the weekend tennis athlete, you know, the Hamptons or some, you know, people trying to flee New York and go play tennis in the weekend. But I did have a. It's my second NHL player who was just doing preseason workout, 22 year old guy. And when this year I went last year doing the same 10 yard sprint. I had a professional soccer player. But he said, look, at 88 minute, we had paid three games in a week and my legs were done. He knows exactly why. And then I had a, you know, European basketball player, you know, a little older, 35. So, you know, a lot of wear and tear there. But if you look at it, the pickleball athlete is a little bit older. Pickleball is a start stop sport. I mean, you look at these people playing pickleball, they're at all sorts of outfits. They're all sorts of. No one's warmed up. It is ripe for Achilles tendons. I mean that's like an annuity. Pickleball for Achilles tennis surgeon.
- [10:06]
C
I think it's. They all wear knee braces and they. Right. They all have some contralateral injury.
- [10:12]
B
They're playing pickleball because they have something else that prevents them from playing tennis. Exactly. So they stiff hip. Something in the system is not giving as well as it should.
- [10:22]
C
And in my practice too, they refuse to even consider non operative treatment. The thing they always tell me, they say, you know, Dr. Park, I want to get back to pickleball as soon as possible. And I say, but non operative might work great. And then they'll say, well, you fixed my friend's ankle and she's 10 years older than I am. And so at that point it's hard to argue that non operative is the right path. And they do well. These are older patients, they listen to what you ask them. Probably much more so than our athletes, I bet. And they actually get how important it is to stay active. So it seems like they're more compliant.
- [10:59]
A
I mean, they probably do well either way. I think about this all the time. I'm like, I think I. I have the same like patient population, Joe. And like they come in and they want surgery and they've convinced themselves they want surgery. And then I like do the surgery and they do well. So that's great, you know, and then. But in the back, and they're very thankful. And then in the back of my mind I'm like, you probably would have done well without surgery too. But that's okay, that's just between, that's just between us.
- [11:20]
B
Right, but, but then again, if you look at do a deep dive in the data, the re rupture rate is significantly higher with non operative treatment. Right.
- [11:29]
C
What do you, what number do you quote, Marty, when you talk to these?
- [11:32]
B
I quote it's a Mirvold study which had 2 re ruptures in the 300 operative treatment, 64 re ruptures in the like 500 non operative treatments. I mean it was like, it was like almost a tenfold increase in re ruptures. So the rupture rates higher. You know, the, you know, I tell people if you're going non operative because every so often I'll treat someone non operative, which is pretty rare. But I'll say as long as I get them quickly. If I get within 48 hours, I put them in a plantar flexion cast, I said you'll be okay, you know, you're not going to be running around. I'm not so sure you'll ever do a single heel rise, but your tendon will heal. The only reason to fix the tendon is set the tension. And if you don't need that much tension, you know, for daily life to walk around, as long as you're sort of okay, you'll have a good result from a non operative treatment. Get them early enough.
- [12:28]
A
I will say I've had some older patients that like, you know, 60, like 90, 60s, like nine middle, so like 70, 75 who are treated non operatively with the protocol. They're very unhappy because they stretched out and they feel like they're falling over their foot and like, you know, and some sometimes I think about that too, like they're fine, right? They never ended up with surgery. They're walking around, you know, they're able to do their activities, do a living, but they're not. Like the last time I saw them, a year into this, they're like still not that happy, honestly. And so sometimes I'm like maybe that's the one that, that's those two or three patients that I've done that are very unhappy. But like getting through life, like I kind of think maybe like then I makes me think I should fix even the older patients, you know, because they probably stretch out more, you know.
- [13:08]
B
So I like patient comes to me, I tell them, I quote a lot of articles, I give them a PowerPoint, I say non operative and mini. Right? That's the big study. Complication rate is the same. They even had infections in the non Operative people, if you put them in a cast, I mean, the complication rate was the same. Infection rate was the same. Re rupture rate was way higher than non operative Sural Nerve injury is way higher than mini. Yeah, mini one. I'm like, just fix your Achilles. If state medial affects your Achilles, you know, the rate of infection is very low. And I tell them I'm going to fix it. I want to fix it tighter because you're going to stretch out. Everyone stretches out. So if you start out equal, you're going to be stretched out. If you start out equal, the other side. So I want you tighter and I want you tighter until you're like six weeks. And then we can stretch out and they'll come in, they'll go like, oh, I'm too tight. But you are never ever if they wouldn't get too tight. So that's my rationale. Fix it tight and rehab them faster. Because if I fix it, then I can let them rehab and I can work on plantar flexion really early so the calf hatchery doesn't go away. I mean, it doesn't always work. I have a kid who's now D1 athlete. He's 26. I mean, his calf has never come back and he did everything right. He's worked so hard. He can do a little bit of single hero rise, but it's nowhere near the other side. And then you start wondering whether we just sewed these things together. And you look at the anatomy of the Achilles with the twist. If you look at all the twists in the Achilles tendon, is it maybe the ones that are really twisted are the ones that are more likely to rupture. And as we fix them, should we try to twist it again? Because we'll have the patients who come in, their lateral gastroc looks great. The medial gastroc is medial gastroc. And so whatever we did to restore it, we haven't reloaded the medial gastroc as well as the lateral gastroc. So I think we still have a little bit of a ways to go besides just throw it together. There may be some, you know, future way to look at this thing and should we be twisting it back the way it goes? I don't know.
- [15:12]
C
So, Marty, just because Matt and I obviously know your practice very well and obviously you're so respected and taking care of these high level athletes, can you just. I know that you prefer the open technique and I know I've shown you some complications I've seen and I've encountered myself in my own practice, do you mind just going through your basic concept of why you prefer open? And then also if you could talk about the worst, let's say mini open or docking technique, patients outcomes you've seen.
- [15:43]
B
I give the patient, so I give them four. When I tell the give the Achilles PowerPoint, I say, here's your choices. Number one, operate or treat data. We're going to go through that. And if you treat down and I show a picture of me doing a lamp, I have like a 12 inch vertical leap and I show that, I show my son doing a header who has like, you know, has some hops. I say, you know, if I treat myself non operatively, even though I would treat myself properly, it probably wouldn't matter because my shots still get locked, man, I lose 15, I got a 10 inch vertical leap. I'm still not surgery, right? But I think I'm going to be better, right? So for me, non operative is a, you know, is dealer choice. As long as you get early. It's hard to get just the, you know, the data. In Canada, the air docs put them in the split right away. The mechanics of the United States, these are done on the weekend. They see the er, the air sends them to the doc season a few days. It's always four or five days. I mean in the reality of things, right? And so for regular people it's four to five days no matter what. So most time I'll go operation. So now I think you should have an operation because I think I need to set the tension, I want to set the tension tighter than the opposite side. And you have three options. And I show open procedure or the traditional open procedure, the mini incision and the docking technique, the speed bridge. For six months I bought, I did the PARS procedure. I said I'm just going to do it. And Dr. Anderson convinced me, you should do the pars. So every time someone came with Achilles, I had the pars technique. I put it open and half the time when I was done, I like pushed down the tendon and I checked the tension. I was like, this is not good. So I opened it up. I'd always do a longitudinal incision of the pars so I could bail out. And so it was about 50% of the time I was doing the pars and I was doing an open technique. And it was never that pretty after I did the pars, my open technique, as if I started. But I tried it. And then one day I had a guy who I did the pars on, who I Would see these people after pars, it would be swollen at this incision. It would never look as good as an open one. But. And I couldn't figure out was infected or not infected, but they would have this soft tissue reaction which I believe is a reaction to the fiber wire just sitting under the skin. And I had a 28 year old dentist had an open re rupture through the skin because the skin gets macerated, gets all brown back there and it just opened through his skin. It's like someone took an axe to the back of his leg and he was just doing a light jog at nine months on a beach. So I said, okay, I'm never doing the parts again. So I call up the other guy, said, have you seen that? Oh, we've had a few cases of that open re rupture. I'm like, well that I think is the worst complication I could get from Achilles. So I'm done with the parch. So subsequent to that, I've seen now five professional athletes who re ruptured after pars technique. You know, three football players, all the same story, all about 10 weeks, all not doing much. But the thing pops, you know, if you look at Clanton study on the pars versus open, he'll tell you that the pars have to be protected longer, which is sort of against what you're doing in a sort of rehab program. And their biomechanic waste inferior to the open technique. So I pushed everyone to the open technique. So the worst one I had that was the guy who reopened, then had another girl who had it done in Montana and she had the speed bridge technique and she ended up with re rupture, osteo over calcaneus and open re rupture and osteo cancer. It's all got masturbated, then got infected, then spread her cocaine. So she got six weeks of a PICC line. She got, you know, an FHL transfer with this, you know, skin graft and everything. So she was 25 years old and healthy, like so. So for me to put anchors in someone's heel, it has to be right off the bone. And I tell them people have pain in their heel when I put anchors in their heel for a haglin type procedure. And I used to do it all the time, used to do this, you know, what's it the double row or the speed to put those anchors in. And Achilles didn't hurt, but their heel hurt. So I'm very weary of putting anchors in people's heel. And I don't know whether because we make it too tight when we put the Achilles back and distressed at the anchor or just the anchor itself in that cancellous bone is not very good. So I don't really do any sort of anchor in the heel unless it's evulsion and most of the time it's an avulsion. It's a chronic condition. I'm usually using a hamstring, weaving that through and I'm anchoring the hamstring with the tendon back of the bone.
- [20:04]
C
Here's a question for both you and Matt. Let's say you have an older patient. Let's say I'll give you an example of a patient I just took care of in his, let's say late 60s, healthy, very active guy, has a rupture that is felt to be in the watershed area, but there's slight calcification. What's your next step? If you're going to say operative versus non operative, what imaging study do you use if you're not quite sure what you're looking at? What's your go to imaging modality?
- [20:33]
A
I mean I would go to an MRI because I don't have a handheld ultrasound next to my phone.
- [20:38]
B
I have two.
- [20:39]
A
I knew you're. I just, I knew you wanted to bring it up.
- [20:40]
B
So I have no, no thing on this. But I have two ultrasound machines so I. Everyone gets an ultrasound in the office for an Achilles. If you're over 50, any prodrome, you're getting an MRI because you're that one. I would do an MRI because in that case you're probably looking at extensive degeneration. If you look at the data on MRIs of Achilles tendons, it's scary what they look like. Two guys, 27. I showed the picture. Two guys, 27 years old, both professional basketball players. One looked perfect black the gap, another left that looked like a bomb went off. So the MRI I'm not so sure does anything except scary. But in the older patient there's a lot of degeneration. Then you clearly, especially with calcification. Then you think about some augmentation FHL hamstring doing something to augment that repair.
- [21:29]
C
Yeah, this case I had, he actually chose non operative. My PA had seen him and said, oh, we're going to do nonop and seemingly appropriate. And then he for some reason had a second thought and we got an ultrasound and it had Vol 6 cm from the calcaneus. And I had to do a strayer above it. This was now three weeks post op. And then I was able to get him stretched down. I mean, we'll still see how he's a few weeks out now, but that kind of like you said, that made me think perhaps in patients who are a little older that a ultrasound or MRI should be standard. You know, luckily it just thought that clinically it seemed a little different, you know?
- [22:07]
B
Yeah. You know, if you look at the ALS recommendations, positive Thompson tests, you know, palpable gap, increased doors function. That's the recommendation for you don't need any extra imaging in office. Ultrasound is pretty easy. And it's one of the few things like an orthopedic surgeon, you can do it like five times, then you'll know what Achilles looks like. I mean I don't do an ultrasound. I do it also on very few things. But the Achilles they do it all the time on. And I just mostly I ultrasound to inject things. So I'll ultrasound the Achilles if I'm worried I'll get an mri. But most patients won't get an mri. They'll just. Here's your gap. Okay, let's go.
- [22:41]
A
I mean I don't treat as many Achilles as you, but the I also saw just going back to worst complications. But I also saw a young kid recently who had a calcostio from someone. Did he want it like I guess they went, you know, when Aaron Rodgers tore his Achilles and everyone was doing like that. So he went to someone, someone did that and they ended up with Calcosteo.
- [22:57]
B
Oh yeah. My worst one is a 20 year old football player for Division 1 school who had a rupture kind of Haglin's kind of rupture off the bone. Had transverse incision his heel like they put it back down and then that got infected. Dressing changes, this whole disaster. They had a big swollen area there. Went back and played the next year. Scored a touchdown, was on the sports center. Crazy. He's in practice the day after he scores a touchdown, he ruptures off the bone again right now. Now ruptures off the bone, but with an open wound right now it turns out he's had a chronic osteomis superior calcaneus for like a year. Shave his calcaneus and so you end up with the osteo propeller Flap is you take the skin and the muscle and you rotate it 90 degrees down to cover flap at an FHL. God, you went back and played amazing. But infection osteo calcaneus is not something you want to get. So to instrument someone's calcaneus, you're just adding Another layer of possible complication.
- [24:12]
C
I mean, I agree too. And the thing that I have noticed a lot of these patients who have the docking technique, and again, I have no sort of skin in the game either way. But the thing that I've learned is that if they stretch out early, they often don't hurt and they don't really have symp. They're not going to tell you I stretched out early. It's just on exam. You know, they hyper dorsiflex, they can't generate enough force. And I think that's what has made me go back to the open technique. Especially, you know, talking to you and seeing some just insane, like the amount of proximal involvement you can get. It's pretty incredible in these athletes.
- [24:49]
B
Well, there's also with the docking technique, you're not really fixing the tendon, you're not fixing the two ends. You know, if it works out in long term, it shows that's a really viable technique. Great. But there's no data so far and you may just be stress shielding that tendon to repair it. May never have. You know, the tendon likes to be loaded, but if your sutures are holding it at a certain level, your two ends of the tendon aren't feeling anything. It may.
- [25:12]
A
Yeah, yeah, talk to us a little bit. You know, we talked about a conference here, so I'm lucky that I get to learn from you. But for everyone else, like talk about your rehab protocol because I mean, it's one thing to just tie the two tended edges together, which I know is like has its own nuances. But also I think the rehab that these athletes get, I tell them all.
- [25:31]
B
The time it's all about the rehab. And honestly, you know, it's so time intensive to take care of these athletes. Most people shouldn't be doing it, you know, unless you can generate a bill to take care of those athletes. Right. So if you're getting workman's comp from the state for $400 and you're Zooming these people every two days, you will lose your mind. Right, but so there's two categories of patients. Like there's the athletes who have someone living with them, they will have surgery by two days, they'll be out of their split, they'll start doing bfr. I use a reverse slant board a lot just to protect people. So they get their foot other slam board this way and they just start doing heel rises. They'll do bfr, they'll do east of their calf. And this will all start in the first couple days, the regular person, since I saw them back there, the regular people, I usually see it a week, right? I see them in a week. I put them in their wool looks, okay. I put them in a boot and I start with therabands at a week with their foot pointed down. And at two weeks, I use a vacoped boot, which I have no interest in, but the back of head boot with the large lift on it at level three. And then you can do some touchdown weight bearing, but it's almost impossible to put full weight with that thing. Your foot is so pointed down, but the tendon likes a little loading. Your lower extremity is a little loaded. You won't get osteopenia. So they do that and they'll do that. And they'll work hard on the slant board. They'll work hard on the therabands at four weeks. Most regular people, I'll send a PT at that point because at that point they'll get so many sessions. I want to ruin it before they get there. At that point, there'll be probably 50 to 60% weight bearing with their foot pointed down. And I'll change the level to like level two with a smaller bottom. At six weeks, they're still walking in the boot and crutches. They're still a little bit of plantar flexion and they're still working. They can get on the bike, but they're on their bike again with their foot planner flexion. When they get to eight weeks, I'm okay with them getting to neutral, right? That's. I just don't. I don't want to see neutral before eight weeks. And so at eight weeks ago, I'm too tight. I'm like, you're fine. Now. That's only for a primary kiss fhl. You probably want to go a little faster because it doesn't stretch out as much. But at eight weeks, I'll stretch. I'll let them walk around their boot and then they come out of their boot at home. At 10 weeks, they're most between eight and 10 weeks. They're mostly out of everything, right. At three months, they're working out, but they're not like doing any sort of ballistic motions. They're not doing any jumping and running. Something that they're on the bike. They're just working with, you know, working with their therapist. Four months now we start to introduce some sporting. Because if they're good and the attention's good, will them start to hop a little bit?
- [28:10]
C
5 months, single stance hop.
- [28:12]
B
Both Do a little single stance hop. We'll start, if they can, by five months. We'll really introduce some real. Like, if it's a basketball player, they'll definitely have the court going up the toes, trying to do some jumpers, things like that. And at six months, I'll return them to their team. That. That. So I'm not worried about it. At six months. At six months, they just have to make them be a professional athlete, which takes a long time because these guys have never taken that much time off in the life. Yeah. The regular person, like, add three months to it. Yeah, yeah. So, like the regular person who has a job, who can't spend all day rehab with their Achilles, I tell them you'll hopefully be running by nine months. That's your goal. Unless you're like a crazy, you know, motivated person who's doing two or three hours on your own each day. It takes that long. But it really. Working in plantar flexion early on really decreases amount of calf atrophy.
- [29:05]
A
When are you taking your sutures out?
- [29:06]
B
You see him two weeks.
- [29:07]
A
Two weeks. So you see him one week. Two weeks.
- [29:08]
B
One week. You check the wound Like I knock on wood. You know, if the wound looks bad, you want to know about it early. Yeah. You know, so I look at it a week, and then I work my plantar flexion, and almost everyone gets back to do a single. They may not be able to get the heel height the same height as the other side. But there's an old study that the predictors of heel height after Achilles are the two independent factors are age and tightness to repair. Can't do anything about the age, but make the repair tighter. So that. That's why I choose the old one. I can't make it that tight with the parts. I can make it equal to the other side, but it's hard for me to make it tighter because it just bunches up. I even. I'll even take down my own repair and redo it. And so when I do the repair, I do the big main stitch, and then I'll do the epiton stitch. That eponon stitch will tighten things up even more. You can get a little bit more plat flexion just with, like a 3.0Viper. Doing an MBT Knox injury just to.
- [30:04]
C
Be cognizant of time. Obviously, Matt and I can sit here and ask you questions for all night. My final question I want to ask is, at what point do you let people try to do single stance heel rise after an acute repair?
- [30:17]
B
So they Start on the slant board. Right. So they're on the slant board doing double heel rises. I mean, the guys now, we've are all doing W rises on the slant board now. And they'll start to do the single hill rise supported on the slant board, you know, 10 weeks. But that's not a real single heel rise.
- [30:37]
C
Right.
- [30:37]
B
By three months, if you have good support. What I really like to do is at the beginning, try and get them up on two and just be able to hold it. That's my first goal, is just to have them hold concentric. Just like a real concentric contraction of their calf and hold it. And even if they have to tap their other foot and to keep them up there or support themselves with a couple bars, that's the first step of it. But most people really don't try and get up to four months. Some of the athletes get up earlier because they've had this person living with them and working on them, you know, eight hours a day.
- [31:11]
C
And just to clarify. So you mean that you're going to be on a slant board with the foot in plantar flexion, and then you have them go up on their double stance. He'll rise from that position.
- [31:24]
B
So they never go to neutral. They just go from 20 to going up that way. So when they're coming down, they're never stretching it out.
- [31:32]
C
Gotcha.
- [31:32]
B
Okay. That changed a lot of my rehab. I don't really start that a year ago or something that really. One of the therapists brought that in, said, that's a really good idea.
- [31:41]
C
That's interesting.
- [31:43]
A
Well, I learned today that if I tear my Achilles, I'm going to have you fix it. I'm going to come live with you every day.
- [31:51]
B
Every day. We're going to do. If I rub your mind, we'll probably just throw me in a boot.
- [31:56]
C
Yeah.
- [31:57]
A
I mean, I'll be like, you'll be in the Jerry.
- [31:58]
B
I'll go back to work. What'd you do? I ruptured my Achilles. Yeah, Patty's treating me. Forget about it.
- [32:05]
A
All right, well, I think that was perfect. And so thank you so much for your time. We really appreciate it, Joe and I, and. And then we look forward to seeing you on our next podcast.
- [32:13]
B
Thanks for having me, guys.
- [32:14]
C
Thanks, Marty. That was great.
- [32:16]
A
Thank you for listening to the AOFAS Ortho podcast, a Convey Med production. To learn more about joining our dynamic community of highly skilled orthopedic specialists, visit aofas.org.