Open vs. Percutaneous Achilles Repair Part 2

Summary

Podcast Summary: AOFAS Orthopod-Cast

Episode: Open vs. Percutaneous Achilles Repair Part 2

Date: May 20, 2026
Participants: Dr. Bob Anderson, Dr. Martin O’Malley, Joe Park (co-host), Brett Smith (co-host)

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Episode Overview

In this episode, the AOFAS panel continues their deep dive into the nuanced debate between open and percutaneous (PARS) Achilles tendon repair techniques. The discussion features leading foot and ankle surgeons Dr. Bob Anderson and Dr. Martin O’Malley, who share practical pearls, technical considerations, post-op rehab strategies, and critical patient management advice. The tone is candid, educational, and highly reflective of real-world surgical and postoperative experiences.

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Key Discussion Points and Insights

1. Evolution and Technical Concerns with Percutaneous Repair

• Global Techniques and Nerve Safety

  • Dr. O’Malley addresses the origins of popular percutaneous techniques (Dresden, Mon Griffith) and their risks, especially nerve injury with multiple stab incisions ([00:39]-[01:01]).
    • “There were a fair number of thorough nerve issues in the original description of the Mon Griffith technique.” – Dr. Anderson ([00:51])
    • Both panelists agree: early iterations created concern about safety, particularly for less experienced surgeons.

• Ultrasound Guidance in the Modern Era

  • Younger surgeons, with their comfort using pocket ultrasound, are equipped to identify anatomy during a PARS repair ([01:01]-[01:46]).
    • “Some things I can see, some things I can't, some things I'm making up. But I get a pretty good idea.” – Dr. O'Malley ([01:07])
    • Dr. Anderson adds that new devices using ultrasound are “very clever” for visualizing the suture passing through tendon rather than muscle ([01:56]).

• Lessons from Experience

  • Dr. O’Malley humorously reflects on the learning curve: “I wasn't very good at cat's cradle either.” ([02:30])
  • Key insight: Device choice and surgeon familiarity play a significant role; technological advances are helpful, but they do not replace tactile surgical judgment.

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2. Postoperative Rehabilitation: Single Stance Heel Rise and Management of Atrophy

• Physical Therapy & Timing

  • Single stance heel rise is a major milestone, but both Drs. Anderson and O’Malley emphasize patience ([02:39]-[03:38]).
    • “A lot of these people can't even do it for four months, so why stress it?” – Dr. Anderson ([03:31])
    • They prefer mastery of double heel rise before attempting single stance.

• Calf Atrophy: Expectation vs. Reality

  • “Everyone has atrophy. Everyone has a smaller calf. In my experience, if you actually measure it. Everyone has a little bit of a smaller calf, but the constraint can be as good.” – Dr. O’Malley ([04:02])
  • Dr. Anderson reiterates, “You're gonna have a smaller calf... but it doesn't mean you're not gonna get your strength back.” ([05:11])
  • For elite athletes, muscle size isn’t always a predictor of ultimate function.

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3. Surgical Technique: Tensioning and Use of Contralateral Side

• Matching Tension: Old vs. New Philosophy

  • Historically, some tried matching resting tension to the contralateral (uninjured) side. Both experts now strongly recommend making the repair tighter ([05:11]-[07:20]).
    • “I just always got to the point where I just said, listen, I don't care what the other side’s doing. I'm going to go maximum tension, maximum plantar flexion.” – Dr. Anderson ([05:30])
    • “I am not leaving until that thing is tighter than the opposite side and as tight as I possibly can make it.” – Dr. O’Malley ([06:38])
  • Panel consensus: Use the uninjured leg for reference only, not as the end goal.

• Technical Pearls for PARS

  • Distal: Use PARS when ≥4 cm of distal stump present; otherwise, transition to tendon-to-bone fixation ([08:10]).
  • Proximal: True myotendinous junction ruptures are rare—PARS is almost always feasible, overdiagnosed proximally on MRI ([08:51]-[09:21]).

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4. Adjuncts to Healing: Collagen, BMAC, Modalities

• Augmentation Materials

  • Dr. O’Malley is liberal with collagen patch use on compromised tendon, seeing minimal adverse reaction ([09:54]).
    • “The collagen patches don't make a big reaction, which is very nice for me.” – Dr. O’Malley ([10:13])
  • Bone marrow aspirate concentrate (BMAC) and amniotic products are used when requested by patients ([11:01]). Clinical benefit is still being elucidated, especially in acute cases.
    • “In the acute rupture, you have a lot of stem cells there just because injury itself. And I'm not sure how much more we needed to place in there as far as biology is concerned...” – Dr. Anderson ([11:25])

• Rehabilitative Modalities

  • Blood Flow Restriction (BFR) training is now mainstream in sports settings, highly accessible, and considered beneficial despite variable evidence ([12:10], [15:44]).
    • “It does have merit when you look at the science behind it. I think there's definitely good science behind it... there's absolutely no downside.” – Dr. Anderson ([15:44])
  • Hyperbaric oxygen therapy is routinely offered to Dr. O’Malley’s patients, based on animal studies and wound benefits ([12:10]).

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5. The Role of MRI in Management

• Overuse of MRI

  • Both surgeons see MRI as often unnecessary except for differentiating insertional rupture or ambiguous cases with prior heel pain ([13:13]).
    • “I think it's way overdone. I don't think we need an MRI. 90 of them. But the only time I think we really need an MRI is if you have somebody with pre-existing posterior heel pain.” – Dr. Anderson ([13:40])

• Mechanism Over Age

  • Mechanism of injury is more important than patient age in predicting tendon quality ([13:58]).
    • “If you're 60... and you're walking down the street and you rupture your Achilles tendon, that's not a good sign. If you're six[ty]... and you're playing singles tennis... that's a good sign.” – Dr. O’Malley ([14:13])

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6. Patient Engagement and Long-term Recovery

• Objective Data and Motivation

  • Both highlight how rehab can be “boring,” and providing patients with tangible numbers (Biodex, force plates) maintains engagement and facilitates recovery ([18:13]).
    • “Give the patient a number, give them a goal. Because it's boring. The rehab is boring. And it's easy to skip.” – Dr. O’Malley ([18:18])

• No ‘Cookbook’ Approach

  • Recovery is individualized. Rehab, progression to dorsiflexion, and return-to-play timelines must be tailored to each patient ([17:25]-[17:53]).
    • “There is no set cookbook. We can say, okay, don't start dorsiflexion until this date. But after that, really everybody, I find, is different.” – Dr. Anderson ([17:25])

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Notable Quotes & Memorable Moments

• “I wasn't very good at cat's cradle either.” — Dr. O’Malley ([02:30])
• “Everyone has atrophy... but the constraint can be as good. I mean, these guys like Durant... one's a little skinnier right... but his strength is 99% of the other side.” – Dr. O’Malley ([04:14])
• “You want to be as tight as possible. And don't let it stretch out.” – Dr. Anderson ([23:45])
• “My gosh, whatever you're comfortable with doing, do that technique. Just make it tight, as tight as you can.” – Dr. O’Malley ([23:37])
• “Football is a horizontal sport. Basketball is a vertical sport. There's a big difference in return to play between those two.” – Dr. Anderson ([22:52])
• “If you tell them from Achilles that you should be able to be back by nine to 12 months. That gives you a good range... in your life, your stats should be about the same at 18 months as you were pre op. This is a long haul. Don't complain about how you are in four months because no one even cares.” – Dr. O’Malley ([22:29])
• On patient insurance:
  “I get great insurance. It doesn't really cover anything though. My co pays are just insane.” – Dr. O’Malley ([14:42]) “It will not cover Dr. Anderson's services. Trust me.” – Brett Smith ([14:48])

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Key Timestamps for Important Segments

• Technique Safety & Ultrasound: [00:39] – [02:08]
• Rehab Milestones & Calf Atrophy: [02:39] – [05:11]
• Surgical Tensioning Philosophy: [05:11] – [07:20]
• Distal & Proximal PARS Use: [08:04] – [09:21]
• Use of Augmentation Materials: [09:30] – [12:10]
• MRI & Mechanism vs. Age: [13:13] – [14:25]
• Rehab Modalities (BFR, Hyperbaric): [15:10] – [17:25]
• Patient Motivation & Rehab Data: [18:13] – [19:10]
• Advice for Young Surgeons: [19:47] – [22:52]
• Summary Pearls: [23:37] – [23:59]

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Summary Pearls & Final Takeaways

• Use technology like ultrasound for safety and precision, but don’t overlook tactile experience.
• Prioritize maximum repair tension—don’t simply match the contralateral side.
• Expect calf atrophy; focus on function rather than muscle size.
• Adjuncts (collagen, BMAC, BFR) have theoretical/early benefit; evidence is evolving.
• MRI is rarely necessary unless diagnosis or rupture location is unclear.
• Patient engagement and objective rehab metrics are vital for optimal recovery.
• There’s no substitute for individualized care—each patient and injury is unique.
• “Do what you're comfortable with... just make it as tight as possible.”

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Overall, this episode is an invaluable, conversational masterclass on Achilles tendon repair and recovery, blending pearls from decades of high-volume surgical experience with a focus on adaptability, patient education, and evidence-based care.

Transcript

[Podcast Host]

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.

[Dr. Bob Anderson]

Welcome back to the conclusion of our discussion on open versus percutaneous Achilles repair with co hosts Joe park and Brett Smith and guests Martin o' Malley and Bob Anderson. Let's return to the conversation.

[Dr. Martin O'Malley]

A lot of the percutaneous techniques around the world were kind of the Dresden or some Mon Griffith, which actually talks about going outside the peritoneon. But that's wrong.

[Dr. Bob Anderson]

Well, it's scary.

[Dr. Martin O'Malley]

It's scary, right?

[Joe Park]

Yeah.

[Dr. Bob Anderson]

There were a fair number of thorough nerve issues in the original description of the Mon Griffith technique. And I just. I'd be very concerned about those kind of techniques with the multiple stab incisions.

[Dr. Martin O'Malley]

So now the young guys. So a lot of you younger guys are well trained in ultrasound. Like, I have this thing with me all day long in my pocket, this little pocket ultrasound. I'm like, all day long I'm looking at things. Some things I can see, some things I can't, some things I'm making up. But I get a pretty good idea. I've been doing it for like 20 years, doing ultrasound in my office. But I saw a guy came into my office with the ultrasound parts, Right. So he showed me, put the ultrasound on, went through there. That may be a way for people who are. Who are trained in ultrasound. Most of the younger fellows get trained somewhere to take an ultrasound course to do that, to make it easier to do a PARS technique. Because you can actually see the tendon versus the muscle.

[Dr. Bob Anderson]

Yes.

[Dr. Martin O'Malley]

That's what I said to him. I said, and I called up one of the guys in the hospital, said, this is for you. You're like a PARS guy. Yeah, I'm not going to use it.

[Dr. Bob Anderson]

You're right. Some of the new devices coming out that rely on ultrasound are very clever. And I think you're absolutely right. You can probably see the needle actually go through the tendon rather than the muscle when you utilize that technique.

[Dr. Martin O'Malley]

Yeah, I think that made me a better PAR surgeon. I think I was low the whole time. I'm sure I was trying to stay away from the skin. I can know which I was going to stand away from the skin. And I was arguing that I don't want to be too close to the skin because I kept thinking I wanted that suture right under this through the 10 in the skin. I would make it too deep and then I invariably, I'd get all the lockers, I'd be done and I thought I'd be done and I, and then I'd have like an airball and then I'm like, oh, God, I'm just bad at this. Yeah, I wasn't very good at cat's cradle either. So, you know.

[Joe Park]

Right. So another question related to single stance, heel rise. I know a lot of physical therapists, that's like their biggest thing they stress on, like even when we do a flat foot. That's all they really care about for you guys. Like when you advise your patients, when do you say they can do a single stance, heel rise, and when are they equivalent to the other side? If ever?

[Brett Smith]

Yeah.

[Dr. Bob Anderson]

You know, this is why it's so important to have communication with whoever is doing the rehab, the recovery, the post op care, the. Whether it's an athletic trainer, physical therapist, you have to tell them exactly what you want, what you don't want. And I have found people get a little too aggressive with their, you know, pool jumping and, you know, some of the other single limb maneuvers. I just, again, I'm not in a hurry, you know, I want to get that calf muscle back. I want to make sure that they're doing the right thing. I want to do a double before I do a single. A lot of these people can't even do it for four months, so why stress it? Why put them through all that? So for me, it's usually about four months when they really can start to do that.

[Dr. Martin O'Malley]

I, I tell them four months if they do it before. Good for you. I don't care. But I really work on double heel rise. So I, Everyone gets a reverse slant board like the in. So they're doing all their exercises with their foot pointed down at the beginning and they're working like crazy on this reverse slant board just so they don't overstretch. But I spend a lot of time with doing a double heel raise and maintaining the heel height as high as you can on the injured side. And then gradually just like, like taking a little bit of your good foot away just to try and maintain that, that high E center contraction. That's I, that's my focus at the beginning. I'm doing that because. And then there are people. I can't do a single horizon 10 weeks. I'm like, yeah, that's in the comments. Everybody will have some atrophy. Like everyone has atrophy. Everyone has a smaller calf. In my experience, if you actually Measure it. Everyone has a little bit of a smaller calf, but the constraint can be as good. I mean, these guys like Durant, if you look at his legs, he's got skinny legs and one's a little skinnier. Right. And. But his strength is 99% of the other side. Right. And so we've shown that it can be a little smaller, but it can be stronger. And this is people who have the best nutrition, anything you could want, the best care, the 24, 7pt, everything. So if you expect a guy who's going to work after two weeks and go into therapy three times a week not to have some calf atrophy like you're. It's just not going to happen.

[Dr. Bob Anderson]

Yeah, I tell everybody, just like we've already seen, expect calf atrophy. You're gonna have a smaller calf, but it doesn't mean you're not gonna get your strength back, but you're gonna have a smaller calf. But it's just the way it. Just the way it goes, you know, Joe, I want to go back to something I think Marty might have mentioned and sort of a warning for everybody. And Marty, I don't know if this, if you said this or if I picked up on or not, but I have seen people come out of the operating room too loose because they've tried to match to the contralateral side. It used to be back in the old days, people would advocate prepping out the other leg and trying to set the resting tension similar to the other. And I found people got in trouble doing that. I just always got to the point where I just said, listen, I don't care what the other sides do. I'm going to go maximum tension, maximum plantar flexion. And I have seen people have tried to match the other side, and it's turned out where they weren't tight enough, they were actually probably too loose coming out of the operating room. So, Marty, are you still prepping out the other leg?

[Dr. Martin O'Malley]

I'm prepping out, but I'm still. I'm not looking till after. It's like that. Zero micro goes in and I've made it as maximally tight as possible. I'm just doubling down to make sure that actually is tight enough because I want it to be tight on the opposite side. And most of the time at that point, I'm feeling pretty good. But I've been like, you know what? And it's often with a lot of stuff, like sometimes the rupture is hard to tell, like where you end your sutures, and it just Gets to be too much tissue in between. You're going like, you know what? I can resect a little tendon and make it a little tighter, but I am not leaving until that thing is tighter than the opposite side and as tight as I possibly can make it. So I just use it as a guide to make sure I'm tighter and just. And it's also a guide for me post op. I know what it looked like in the operating room, and that's got to look like that when they lay on their stomach when they come in the office.

[Dr. Bob Anderson]

Yeah, but you'd agree, don't try to match the other side.

[Dr. Martin O'Malley]

I mean, that's the baseline. That's the least you can do that. Like, you don't want to be close to that. You want to be tighter. You want to be visibly tighter.

[Brett Smith]

Yeah, Dr. Anderson, that's a fantastic point. I'm the same way. I don't prep out the other side anymore. I used to. I think that, you know, Dr. O' Malley's point is good that you can say, hey, that's my baseline. I got to get better than that. And that's a really good point. But at the end of the day, it's got to be tighter.

[Dr. Martin O'Malley]

Yeah, it's got. I mean, you're trying to make it as tight as possible. One of the problems with making it crazy tight is your wound closure. Like, that's. That's an advantage of the pars. Actually, the wound especially get down low. When you get down low, right above the heel, that skin gets all kind of bunchy, and you're trying to match the skin, and then they have to dorsy flex to get those skin edges. Untighten it to try and get your skin marked up. But, like, when you're making it so tight it's low, you're like you're trying to operate around some bad stuff. Fortunately, it heals pretty well as long as you keep your incision medial.

[Dr. Bob Anderson]

Yeah, the patients do love the cosmetic, you know, advantage of the pars. They love the fact you're brilliant. See their incision.

[Dr. Martin O'Malley]

Bob, what's your indication for pars? How distal will you do the pars?

[Dr. Bob Anderson]

Well, I mean, you can do the pars even 10 to 10. And as long as you have about 4cm of distal stump left, again, you can very you. I could do all kinds of fun things with the jig. I can take the jig in and out. So all my sutures are very distal. They're right just right off the calcaneus. You know, the only Thing you really can't do if it's really distal is you might not be able to lock it. Definitely not lock it twice. But it makes a little more of a challenge to lock it if you're way distal. Once I get to less than 4 centimeters, then I'm going to be going to the heel. Then I am going to be utilizing the, you know, the, you know, variation where you go then tendon to bone and just have to go down and get good fixation into that bone. Just because you don't have enough distal stump to do tendon and tendon.

[Dr. Martin O'Malley]

And then how about proximal?

[Dr. Bob Anderson]

Well, I don't think there's a. I'm, you know, I know people go oh well you can't repair Achilles tendon that occurs near the muscular tendonous junction. I just don't see that. I think most of what we think is musculotellous junction I think is just a very proximately retracted mid substance. I think sometimes we over read or even radiologists over read the mri, they give us reports saying it's a proximal rupture. I just really, in my experience I haven't seen that. I just, I really have not had a proximal mid substance rupture. I was not able to get the pars to work.

[Dr. Martin O'Malley]

I agree with that. I think a lot of it's over read. Like you get in there and it's like not, it's like never right up the gastroc. I mean it's like doesn't occur.

[Brett Smith]

It's not. No, no, I agree. I have a quick question for you guys. So augmentation, not from a structural standpoint, but anything you gravitate toward in terms of trying to help the Achilles heal, in terms of, you know, wound, the tendon itself, collagens, amnio, all the different things out there.

[Dr. Martin O'Malley]

I'm pretty liberal with the bad looking tendon using the collagen patch and as after I do my primary repair and my epitendinous suture, I'll put it on the more anterior portion of the tendon, wrap it 2/3 of the round if it really looks bad. And the nice thing about that, I used it early on with a couple things around the ankles. A guy who had a posterior tip dislocation. I was a little bit. The tissue didn't look very good so I did it. It doesn't make, the collagen patches don't make a big reaction, which is very nice for me. And I have a couple MRIs post op that Looks like it's. I can't see that I did it. So I'm using the collagen patch. A lot of times people like, I work in New York, so people want. They want to use bmac. Does the BMAC add anything to it? And when do you put the B vac in? I usually put the B vacuum. I'm done. I lay it in under the peritonea, close everything, and then I just inject the bmac. I try to get in the tender. When I'm done. People want bmac, they want stem cells. I think that's the two things that I use mostly is bone marrow aspirate and a collagen patch. Safely and collagen patch.

[Dr. Bob Anderson]

Yeah, I agree. I mean, some people will come in, they'll ask for it. If they ask for it, then I provide it. So same thing. I'll do bmac and I'll, you know, put it into sort of a clotted form, so to say. And I'll put over my repair, just like Marty said, underneath the peritina, you know, with the transverse incision pars, you really don't have a whole lot of room to put a whole lot of things in there. And so you can use some of the, you know, amniotic umbilical cord products that are, you know, small, thin, and put that up there as well. But, you know, I just figure in the acute rupture, you have a lot of stem cells there just because injury itself. And I'm not sure how much more we needed to place in there as far as biology is concerned at the time of acute injury like that. But if they ask for it, I'm happy to do it. I think the modalities post op, Brett, I think that's where I think really we've had a huge change over the years. Things like, you know, blood flow restriction has been a trap, I believe, with the whole healing process. Now we're utilizing, you know, radio shock wave and all these other kind of modalities that are available in the training rooms. Not only professional, but college level. So there's so many more modalities now we can use post op.

[Dr. Martin O'Malley]

That seemed all my patients, like, there are three things. They get the reverse slant board, they get the BFR little pamphlet, and they order a BFR machine. And. And everyone gets a couple hyperbaric sessions pre and post op. And they just do it and often do it just to just for the wounds. And like, you know what, there's data about early, like just rat study about, like cutting the Achilles Tendon, repairing it and doing hyperbaric, not to hyperbaric. And it's clearly shows to be beneficial. Now does he really need that? One of the problems is if you look at a lot of MRIs of Achilles tendons, they look really bad. Like the MRI doesn't really predict like what it's going to look like. We have some that look terrible to get in there and look too bad, some that look pretty good. So the MRI is not, you know, is the MRI necessary? There's a good study that out of Baltimore showed like it over read like it underrate a couple partial ruptures that were complete ruptures. Because a lot of people have an MRI by the time they get there, but it's really. Bob, do you take much credence in what the MRI looks like, whether you're going to get augmented?

[Dr. Bob Anderson]

No, I don't. I just, you know, again, I think you're absolutely right. I think as soon as you get in there and the MRI look pretty good, you see it's just a very tendinotic, you know, looking Achilles. And then other times it looks great. So no, I don't, I don't. I look at the mri, you know, again, unfortunately, so many of our clients, Marty, they come to us with an MRI already in hand. I think it's way overdone. I don't think we need an MRI. 90 of them. But the only time I think we really need an MRI is if you have somebody with, you know, some pre existing posterior heel pain. You can't feel a defect. You aren't sure exactly whether that's going to be an insertional rupture mid substance. And it helps to have the MRI in that situation. So I always get an MRI if somebody's got a history of posterior heel pain. But otherwise I think we've been getting too many of them. And I really think the only value in most people is just to know where the level of rupture is.

[Dr. Martin O'Malley]

How about age? Like if I rupture mine, you're going to get me an MRI and see if I've got. I mostly go with not age. I go with mechanism. Like, right, if you're 60 years old and you're walking down the street and you rupture your Achilles tendon, that's not a good sign. If you're six years old and you're playing singles tennis. Unrupture, okay, you know that that's a good sign. But I go a lot with mechanism, how I did it. If you're walking and rupture your Achilles tendon. That cannot be a good tendon.

[Dr. Bob Anderson]

That's a very good point.

[Dr. Martin O'Malley]

Yeah, I just got up and it ruptured. I'm like, you know, that's not good.

[Brett Smith]

Dr. O', Malley, if Bob won't get you an MRI, I will. Okay. I will take care of.

[Dr. Martin O'Malley]

You ordered me one.

[Dr. Bob Anderson]

I want to see his insurance first. Brett, I want to see.

[Dr. Martin O'Malley]

I get great insurance. It doesn't really cover anything though. My co pays are just insane.

[Brett Smith]

It will not cover Dr. Anderson's services. Trust me.

[Dr. Martin O'Malley]

Really good. It's really good. Insurance doesn't cover my own. I don't take my own insurance

[Joe Park]

so quickly. Bob, you mentioned blood flow restriction and I, you know, I, again, I didn't know that our guys were getting blood flow restriction at UVA for, you know, the, the trainers didn't really tell me that this was happening, but they've been doing it for a long time.

[Dr. Bob Anderson]

Probably for years.

[Joe Park]

Yes, exactly. But I've had a few patients that I've done an Achilles repair and their calf, the, the amount of atrophy was quite minimal. And in fact, one of my patients, his operative calf circumference at the end of, I think three months was actually bigger than his non injured side, which I thought was kind of interesting. But I, but again, I don't know that atrophy, like you said, I don't know that it automatically correlates to stronger tendon function or better outcome. But you know, these, some of these athletes, they really think about that, you know, how does their calf muscle look? Right?

[Dr. Bob Anderson]

You know, and like so many things, Joe, we don't have a. There's not a good prospective study out there, you know, comparing BFR to no BFR and really having good, you know, parameters as far as outcome analysis. And so, so I think those kind of studies need to be done. But you know, bfr, again, it's very available. It's virtually no cost, you know, at all. You put a blood pressure cuff around the thigh and then you have to do some, you know, isometric maneuvers so they're not going to stretch out their repair. And you know, it's supposed to create like an anoxic environment for your, you know, lower muscle groups, which increases lactic acid, which supposed to challenge the whole healing process. And so I think it, it does have merit when you look at the science behind it. I think there's definitely good science behind it. And again, I look at it, there's absolutely no downside. I haven't, I just haven't seen it. Down.

[Dr. Martin O'Malley]

He did a pretty good study in the ACL and looked at the quad and felt like it was better. That was random, controlled. That was the best study so far in bfr. We don't have a good one. Mark Dracos did one on for Achilles. Was not randomized, you know, double blind kind of thing. But the she study on the ACL is pretty good and it showed less quad atrophy. It also, it engages the patient. Like, this is. I tell, like it's the same thing. Like, you know, why these guys come back. This is like 50 minutes of my work, right? And the rest of the time is like, slow down, don't stretch out. And then you got to work with your therapist. It's not like there's a magic trick that I have, right? I'm just making it tighter than the opposite side. And then I'm just getting into a good therapist with some good instructions. And don't stretch out. And then you work hard, you'll do well. You don't, you know, you don't work hard. You just like, you know, then maybe you won't do so well.

[Dr. Bob Anderson]

That's not, it's not usual. Okay, guys, you know, as I think we go back and talk about this a few minutes ago, but you got to really take care of everybody individually. You know, there is no set cookbook. We can say, okay, don't start dorsiflexion until this date. But after that, really everybody, I find is different. Some guys come back very quick, some guys take a little bit longer. I have had people that they thought they're rehabbing really well, and they get to 10 months, 11 months, they're disappointed they can't do X, Y and Z.

[Dr. Martin O'Malley]

And.

[Dr. Bob Anderson]

And I've actually done biodex studies comparing their, you know, operative side to their non operative. And basically, you see, okay, you got a 40% deficit, you know, well, I've been working really high, doc. Why would I have a 40% deficit? So we haven't been working hard enough. You know, you'll get these kind of situations where you'll have people that just, they think they're working hard at rehab, but then they really aren't.

[Dr. Martin O'Malley]

I agree. I try to get everyone some sort of number. Like here you are at four months. This is your strength, right? And I make sure I get the therapist they get. Give me a number. What? It's a force plate or biodex or something. Give the patient a number, give them a goal. Because it's boring. The rehab is boring. And it's Easy to skip. So now you're four months and you don't see much progress. But if you go back at five months and now you're going from 40% deficit to 20% deficit, you're like, okay, I'm going the right way, I'm going the right way. But if you're going just doing your stuff and you can't still can't do a single heel rise, then you're like, this isn't working, you know, So I think the numbers, that the numbers are really important to a patient. And the BFR is the same way. You have to engage in. This is on you. I just, I'm like, I'm done after Bob's done 25 minutes. I'm done in 50 minutes. Right now you're working, giving some instructions. But to get back all the way, it requires a lot of work. Yeah.

[Dr. Bob Anderson]

And even though it's not perfect, it's nice to have that objective number.

[Dr. Martin O'Malley]

Yeah.

[Brett Smith]

Yeah.

[Joe Park]

All right, well, to be respectful of your time, you know, one, thank you so much for being on our show. But number two is you guys have both been such great mentors to Brett and I and to everyone else in the AOFAs. And, you know, I feel very privileged to have had to call on you guys for help. And you've always been very gracious. But just to conclude, do you guys have any advice that you would give, let's say the younger foot and ankle surgeon who's trying to take care of these type of injuries, Athletes, let's say, for example, do you guys have, each of you have one pearl or piece of advice you could share with those of us out there?

[Dr. Martin O'Malley]

You go first, Bob.

[Dr. Bob Anderson]

Piece of advice for taking care of what, like an elite athlete? Yeah.

[Joe Park]

Or, yeah, high school. Just someone trying to get back to school.

[Dr. Martin O'Malley]

Everyone's an elite athlete with the NL money.

[Joe Park]

That's right, exactly.

[Dr. Martin O'Malley]

Three million bucks. Three million bucks. Like a big school to play basketball. He's 17 years old and I just did like a brushstrom and I'm like, oh, my God. So, you know, what do you tell, like three just got three million.

[Dr. Bob Anderson]

Yeah. No, it's changed. I think you do, I mean, take away the whole professional aspect of, I mean, just think of the elite athlete, high school or college level. I mean, what I've learned is you got to really, you got to really set expectations before you do the surgery. It's amazing to me. I try to tell people, listen, we aren't going to fully know exactly what your post op care is going to be like. Or you know, what kind of prognosis you're gonna have until we get into surgery. But I'm oftentimes very careful not to try to set too strict of estimates before I go into surgery. I try to calm down and say, okay, sit down with the patient, the family, and say, you know, here's what the problem is, here's what the treatment options are. And you know, this is what I think is best for you.

[Dr. Martin O'Malley]

You.

[Dr. Bob Anderson]

But we'll know a lot more about this injury and how to recover from this injury after the surgery itself. I think the worst thing to do is to try to play your hand or give them estimates before you even know what's going on. You got to backpedal that way. So I would just say, you know, be a little, you know, give them all the information they need because they can take a good educated decision then. But as far as return to play, I would be very vague pre op.

[Dr. Martin O'Malley]

I don't give any numbers. All I say is, number one, we have to like for Achilles specifically, I'll say we have to make it tight on the opposite side. Now number two, now we have to worry about your wound. That's all I care about is wound in your calf muscle. In the first two weeks, moving your calf muscle and if your wound looks good, we slow down your calf muscle. But the wound is number one. Like wound calf muscle. We get through that now we're, we have a healed wound. Now we can move on working your calf muscle and not stretching out. Right? So now we can progress you from non vaping to wait. But this is not, it's not. Everyone's the same. You're going to be like, things can change. You could get a blood clot, you could have a hematoma, you could get a wound separation. We have to slow everything down so it is individualized. If you, and if you tell them from Achilles that you'll should be able to be back by nine to 12 months. That gives you a good range, right, Kevin Durant, and come back 16 months and that you tell them, I tell them that. And I tell them your stats, whatever your stats are, you know, in your life, your stats should be about the same at 18 months as you were pre op. This is a long haul. Don't complain about how you are in four months because no one even cares.

[Dr. Bob Anderson]

There is no cookbook, Joe. There's no cookbook.

[Joe Park]

Yeah, I think that's great advice. I use the 9 to 12 months even. It's pretty vague. It's sort of at that point where they're starting to feel better. So.

[Dr. Bob Anderson]

Well, I think the other thing, too, that Marty would agree with that again, you know, he's done a lot of basketball players. I've done a lot of football players. There's a difference. You know, as I tell people, football is a horizontal sport. Basketball is a vertical sport. There's a big difference in return to play between those two sports.

[Dr. Martin O'Malley]

Yeah, I agree. I agree with that completely.

[Brett Smith]

Well, if I would have one takeaway to the listeners, this is one of the reasons that these are two of the greatest mentors I've ever learned from, is you just listen to them talk about these two different techniques. But at the end of the day, when they summarized it was all about the patient, their care and the return and the recovery and how you dealt with that. That's the takeaway point. Doesn't matter, really. At the end of the day, what we do as a carpenter, it's what we do to treat our patients. Right? So that was wonderful, guys.

[Dr. Martin O'Malley]

My gosh, whatever you're comfortable with doing, do that technique. Just make it tight, as tight as you can. Right.

[Dr. Bob Anderson]

I was going to summarize it, that you want to be as tight as possible. And don't let it stretch out.

[Dr. Martin O'Malley]

Yeah, perfect.

[Brett Smith]

That's what I'm saying. This is greatness right here. I mean, this is why these guys

[Dr. Martin O'Malley]

are the great idea.

[Dr. Bob Anderson]

Achilles 101.

[Dr. Martin O'Malley]

Yeah.

[Joe Park]

All right, well, thank you guys so much for joining us.

[Dr. Bob Anderson]

Thank. Thanks for having us.

[Dr. Martin O'Malley]

Thank you, Joe. Thanks.

[Joe Park]

It's always a privilege. Thank you.

[Dr. Martin O'Malley]

Good to see you guys.

[Podcast Host]

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