splint have been moderately compliant because the thing is it turns out that what you're saying actually does happen and it's only the people that you can talk to about surgery and non-surgery. You know who comes in not in a plantar flex sprint? The smoking diabetic person with the Achilles rupture. So to get back to your question, I think I have like a, I actually just present them with Dr. Ayer's slides and then we go over all the studies and then I have like a slide at the end that says like check yes or no and then they just get to pick. But I typically do have a reasonable or what I think is reasonable conversation with them about you know you're in a splint, I can transition you to a cast for the next couple of weeks and then transition you a boot and avoid surgery versus my operative protocol which is actually fairly similar to my non-op protocol. So even for patients that I operate on, they go into a splint for two weeks and then sometimes I still put them in a cast if I don't trust them for another few weeks. And so there certainly is a risk if I fix you that you may be in a cast longer than if I, if you choose to do functional rehab. And so recently like I had a gentleman who was, I don't know, he was whatever somewhere around there but he had a bunch of kids at home and had a lot going on and he was like I don't want surgery, I don't want this. And we did discuss, so I generally will discuss the management, my management protocols for both op and non-op like how I manage you post-operatively. I do talk about the re-rupture rate and I do talk about early motion and kind of this functional rehab protocol. I typically give everyone the Glazebook protocol for surgery and non-op patients. And if I can, if they are a reasonable person and I think they actually generally will do well, non-op. There are some patients who do like the idea, right, it's very reassuring to you as a surgeon to know that if you tie their Achilles ends together that they're together, right, that you know how tight you made it, that you checked their resting plantar flexion. And there is like something reassuring about that to a surgeon as opposed to like I'm hoping that you don't lose too much plantar flexion strength when we do this. And granted the studies have shown that you don't lose significantly more but if it ends up in a stretched out position that is a lot harder to fix. And so I do talk to them a little bit about the risk that if you end up feeling particularly weak on that side compared to the other side or you end up healing in a very lengthened position that can be problematic. And it doesn't, it's not like it happens that frequently because all the studies indicate that they should be fine. But I think that I probably, I don't know, I try and make it as non-biased as possible but I think it's hard frequently to you know not feel like in somebody who's young and otherwise healthy that like I can just fix it in 20 minutes and know exactly like how tight your Achilles will be. So but I try and present as unbiased of a presentation as I can about their options and their recovery and rehab. And the patients I've managed non-operatively have done great and every time I manage somebody non-operatively I think why do I ever operate on this. I agree sometimes it's nerve-wracking and it's amazing to me you go through that whole conversation and you tell them you know difference is a risk of infection yet the majority of people already have in their mind that they're getting it fixed. I don't know if you guys come across that same thing. Yeah I would I would share that. I would echo a lot of the similar statements. I really try to get a feel and you know if there's a significant other like on the FaceTime or whatever sort of or in the room for whatever reason I try to get a feel for how compliant will the patient be with the functional rehab because the the worst thing is that hey they decide to go down this route and then of course it just you know they end up like just not walking on it when they shouldn't be or like not staying immobilized with wedges or whatever it is when you are banking with some degree of compliance with that in order to maximize the to maximize the tension when just as Dr. Fanchery said you're not you don't have the luxury of knowing how tight you made it. I also I also think that the you have to sort of be very proactively I don't want to say scare the patient but just really get them to understand what are the risk benefits of each and I think that's absolutely critical because other otherwise you know they're coming back to you later on and while I have started doing more chronic rupture repairs the reality is that the biology is not the same it's not the same as when they first come in and there's a giant hematoma with you know growth factors that you could take advantage of in the vicinity of the tendon so I think that those are all sort of so I try to you know again as Dr. Fanchery said really lay it out for them as much as possible and I probably I push who I think should get surgery I don't necessarily push who I think shouldn't get surgery but again some patients I want surgery anyway and then I'm that much more vigilant with them I'm also that much more vigilant with the patients who are in terms of it who are you know who are coming to me maybe subacutely so like four weeks or six weeks or whatever and or even like more chronically and I might then I stare at them that much more I immobilize them that much more just in order to ensure that the creep through that tissue is not going to sort of outdo what the therapists want them to do as well and I think that's the third thing I'll say sometimes the therapists are extremely aggressive and I don't know Dr. Ganey and Dr. Fanchery what your thought on this is but sometimes they'll take a wedge out every single week and in certain patients that's fine no problem but then some patients they take it out every single week and then the tendon is now stretching completely because the quality of the repair or whatever or even the functional rehab is not as great so I would just kind of put a question back to both of you what do you think of like how frequently do you remove the wedges whether you're doing surgery whether you did surgery or not? So I do I think my wedges must be taller than yours because I don't they're not quarter inch mine are a little bit bigger than that but I think mine are half inch and so generally everybody gets two wedges to start if I non-op you I'll you're in a splinter cast for two weeks generally cast for two weeks and then when I put the wedges in you stay with two wedges in until six weeks and at six weeks you can take one out sorry you stay in two wedges till six weeks yeah at six weeks you can take one out at eight weeks you can take another one out and then at about 10 weeks when you're flat in the boot you can start going into a shoe once you're able to tolerate that for my operative patients it's pretty much the same I if I cast you until week six then you go into a boot and same thing we cast a wedge out of six weeks wedge out of eight weeks if I put you in a boot right away and I like make you a little bit more advanced which I think I've been very reluctant to do early in my career because I get very anxious about it then I will have you take out them starting at four weeks so I'll do four and six so they're flat by eight instead of ten. Yeah I think my protocol is similar I have the two wedges in and then so at six weeks full weight bearing with the two wedges then I'm sorry so it's zero to two weeks is non-weight bearing in a splint two to four weeks partial weight bearing with two heel lifts four to six weeks full weight bearing with two heel lifts and then six to eight bringing you down to neutral and then at eight weeks can transition out but I mean so for everyone listening Dr. Fancher is referring to the Glazebrook protocol which he's talking about is if you go to that Glazebrook article that we pretty much the landmark article that everyone quotes as far as surgical versus non-surgical it's a 2010 article out of JBJS that in their appendix they have a really nice protocol similar to what we're all talking about so that's a really good resource I always pass that on to my residents who are leaving and going to be doing some of these in their practice that's a nice reference for everybody. So question for for both of you so obviously you know not necessarily common where you have a patient come in plantar flexed and compliant so what is your and and Dr. Iyer you kind of referred a bit to this but what's your cutoff at which point you no longer feel comfortable offering non-operative management? Dr. Fancher why don't you go for it or should I go for that first? You can answer it I don't know no go for it go for it so for me if you're so most of the functional rehab studies that are done essentially right they're largely done in socialized medicine countries where they have a large database of patients they can capture right so there's a lot of Norway and Sweden and Canada and in at least one or two of those studies if you show up to an office more than three days out they've already kicked you out of the protocol and so they they are capturing these patients who are managing the functional rehab but they're patients who showed up to their office in the very first three days right I think one of them is like a week but it's very early so for me if generally you're probably two weeks or so out I can't get your tendon to oppose with plantar flexion like if I maximally plantar flex to you I can still feel a gap like I think that there is no way that those collagen fibers are going to jump that gap or that you're not going to heal in a very lean position then that to me is like an indication that you get converted to surgery so it's somewhere probably between one and two weeks out generally at one week I'll still give them the option but somewhere floating in that range between one and two weeks and anyone with a gap that I feel like I can't close I know that there are people who are doing ultrasound in their office like Dr. I talked about like if you can plantar flex them maximally and it looks like the tendon edges are abutting they'll manage those non-operatively I don't I mean for the same reasons you talked about I don't do that but essentially if I if I think that the tendon is touching I will try and cast you in maximum plantar flexion if it's two weeks out I mean maybe not maximum but a fair amount of plantar flexion and then but if not and and I can you've been walking flat for 10 or 14 days I essentially and you're like a normal person who's not diabetic vasculopathic not a super high risk for infection then I really sway you into having surgery I follow I probably do something very similar but the kind of to kind of make it more algorithmic as mine and Dr. Gainey's former fellowship mentor used to say I would so if someone comes in within a week and irrespective of whether they've been immobilized or not I will offer them the the surgical like surgery versus non-surgery and have that discussion with them and this is again talking about mid-substance ruptures specifically if someone comes in two weeks or more and they have been adequately immobilized and I can still sort of the tension is there I can kind of feel the the edges and they're reasonably opposed then I will give them the option again surgery versus non-surgery if someone comes in two weeks or more and has not been immobilized in any way and they're just walking in like one of my patients a couple weeks ago then I will push them towards the surgical issue towards surgery to be honest. So what do you mean between one and two weeks? Oh as long as if it's between one and two weeks and they come in well granted I have I work at Jackson which is a very interesting place so patients come in I didn't even know I had a rupture it's been six weeks but I will I will still so if it's one in two weeks still like you know if they had been immobilized great if it's if they haven't been immobilized I get those edges together that's fine too and I can still offer them op or non-op but I kind of use two weeks as a you know kind of cut off knowing that a significant amount of healing is probably already taking place in light of the hematoma being there. The one thing I will always highlight when it's getting kind of closer to two three four weeks I always talk about the scarring issue and needing to wade through scars sometimes and whatever healing has taken place because even if you're using the little minimally invasive technique I and especially with the chronic ones I've done I find that if I have to do a lot more dissection and we know that the peritoneum scarred in and is the source of nutrition for the tendon that that in and of itself may increase the risk for wound healing complication at least in my humble opinion so I always kind of talk to them about that in particular especially if they're a little bit further out than just the truly acute rupture happening within one or two weeks of retaking the network. Great and everyone if you have any questions too you want me to pose because I'm taking over then feel free. Another question for you guys do you have any absolute contraindications to surgery? Minor essentially diabetic risks so I these are not acute ruptures but the post-operative infections I've had in Achilles are both um diabetics um and uh who I mean they actually had acute whatever it's a long story but they were both diabetics with high A1Cs and so um that were like huge that end up you know requiring a very prolonged course cutting out their Achilles like this whole thing right trying to salvage this and so um for me even if you have an acute rupture if you have an A1C like my general cutoff for effusions and things is like 7.5 but if you're A1C is I'd say for Achilles but I don't know it's probably somewhere around there eight but depending on how but somewhere between eight or 7.5 but I like I can't find the risk worth it anymore. Yeah if I would have a group coming in and so just to let everyone know we're just we're talking about um we're talking about anyone with contraindications to surgery. Yeah I would I would say that um if biggest contraindication is when the patient doesn't show up um that's probably a good contraindication for surgery like today um so for people listening my case literally this morning um decided to flee the city and I as a result with the with an Achilles rupture so not exactly sure how that's happening mechanistically uh I would say that the the ones for whom um when I talk to them I don't get a great feel for they have a poor support system at home um they are have comorbidities like diabetes as Dr. Fancher alluded to or other immunosuppressive sort of conditions um then I will and if they're significant you know depending on how far out they are right and you know to what extent they you know like if it's like six weeks eight weeks whatever like I often see uh and so for the but in the acute setting specifically I would really say that those who have major medical issues um are the ones for whom that are not that's not well controlled um and or history of infection as well um those are the ones for whom I might I'd probably talk to or steer towards a non-operative route um but again I have the same conversation with everyone and obviously individualizing uh the risk profile depending on the patient so I think that that's a particularly important thing to discuss and then of course you have to weigh that against their ability to stay compliant you know work with the work with a good therapist as our therapy colleagues have just joined us uh and I think that that's a that's important kind of part of that discussion too. All right so uh we're just going through some some questions and scenarios so anyone that has questions go ahead and throw it in the chat um if we get through all the questions and I do have you know a couple cases we can go through a little more unusual to to get people's opinions on um we have it we do have a question Dr. Grosanz any thoughts on repairing anchoring to the calc versus the pars Dr. Iyer you mentioned a little bit if you wanted to kind of review those two different techniques and if you you have any thoughts on that? Yeah uh um Dr. Grosanz good to good to hear from you and uh I think it's a great question and you know I think the you know so a a lot of people have transitioned to um using the sort of newer system that's out there where you can still pass a suture sort of uh minimally invasively uh but then really being especially if you don't have a lot of distal stump or the you have truly an avulsion injury or evulsive injury off the calc and then restoring your tension at the suture uh calcaneus interface with uh with anchors um or swivel locks from from Arthrex as a system designed to use um I actually uh I actually was like a huge fan of doing that for some time because I especially for especially for these you know kind of subacute chronic ones I say you know that distal stump is just not you know not the greatest um or many times if it's a short stump I'm like I'll just bypass that and then you know you know drop it in there it doesn't take very long at all but what I was realizing what I've seen um and actually the sural nerve patient I was referring to earlier she um she actually has had issues with one of those screws and so I actually have to go in and try to fish that out for her is one of the things we're going to attempt to do and I find that many many patients not all but many patients end up having pain uh from the drill site and or from the actual swivel lock itself backing out or just being so even mildly prominent because the skin is so you know it's kind of thin there um and the tissues are always on tension in that area it creates some semblance of irritation so I I have used it multiple times um I think it's a very reasonable option um but kind of I kind of pick and choose with whom I use it for the other thing I'll tell you is it's not always easy to get the maximal to maximally tension with it um I think it's a little bit harder in that way so I really if I'm using that specific technique I really try to you know get you know keep the leg bent up with the knee bent the foot plantar flex with a mayo stand maximally um before uh you know dropping those you know anchors in um I in contrast to the end-to-end technique where you're passing the Wolverine jig around the tendon on both sides and tying the sutures off, I've had more success with that. But again, I've also seen wound healing issues as a result of it. And just because of the suture tapes irritating the skin from deep. So I think it's really dealer's choice, but I think the tensioning piece is probably most ideal with the end-to-end repair in contrast with the suture anchor repair. All right. Well, if we don't have any more questions, I'm going to share my screen and do a couple cases in the last, it looks like we have 15 minutes here. Lauren, maybe while you pull those up, can I jump in with just, we had some nice discussion in the other room too. And I wondered if it might cross over a little bit on plantar flexor power later on. So whether post-op or non-op, the few months out and now returning to really functional activities, whether that's various levels, whether that's running or even just lower level. But if the concern is real return to strength or power in plantar flexors, from a rehab standpoint, and then also on the medical management side, when is that an issue? When does it go back? When do we need to really have that communication between the groups? So the question being, at what point are we concerned about not rehabbing at the same, where we want to be essentially? At what point are we concerned about their progress? Yeah. I'm curious just for both groups to engage in, when does that discussion occur? Yeah. And Dr. Fancher, you want to take it first? Are you there? Maybe not. Dr. Iyer, are you there? Yeah, sure. So I have this conversation even before, when they first come to see me, as far as how this notion of weakness and how long it can take to really regain their maximal strength. But I am always very clear, the vast majority of the time, that the leg may never feel the same. And so that's something that I make it clear to them from the jump. And that's regardless of whether they are going on up or off and their relative activity or expectation levels of what their activity is going to be like afterwards. Usually most patients, by the time they're kind of out of any contraption. So it's maybe, if you kind of heard any conversation between Dr. Gady and Dr. Fancher and myself, it sounds like it's maybe about eight to 10 weeks by the time that they're out and getting back to a regular shoe. I probably expect them by that time to maybe be about between 4.5 out of 5, most patients. Now, again, these are also patients who are complying with the therapy. And certainly some patients, if there's been increased creep, then that certainly can influence their relative strength. But then when I see them back close to the six month mark, I usually see them back again, closer to that 4.5, maybe nearly five on average, closer to that six month mark. But again, it's very patient dependent. That's also sort of my, I'm looking at the calf symmetry and the relative bulk and how aggressive they've gotten with calf raises in particular and isometrics to really get that gastroc to kind of bulk back up. And it is the patients who are the most aggressive with those types of activities in particular, the strengthening piece that they come back to me by six months or so. And they're able to now, they've got the single heel rise going on. They can really get into the float phase for running, et cetera. And when patients say, oh, when can I get back to whatever? I said, I've seen, so my Tokyo Olympic athlete patient, I don't know if she's actually going to the Olympics or not, but that's what her aspiration was. I told her that by four months, by four months out, she was able to single heel rise, partially anyway. And I said, she could get back to her activity level. So if people can do a single heel rise, that to me is the marker that there's enough strength that they can start really ramping up their activity, but you have to sort of couple it to, that discussion has to be coupled to on an individualized basis. So I really runs a gamut based on the patient, but I would say, you know, a lot of it comes back by like between three and six months in my mind. And then again, the vast majority or where it will plateau is probably as far as two years as some studies have shown. You have better outcomes than I do. So my discussion with patients is, you know, and everyone wants to be an athlete. So I like to compare it to athletes. So I tell them, listen, the easiest part of this is the surgery. The surgery takes 30 minutes. It's the rehab that's going to take the longest. And if you're an NBA athlete, you're out for a season, you know, and your only job is to rehab, right? The rest of us have other things to do. And so for me, as long as they're making progress, I'm happy. You know, as long as this month is better than last month, I expect that they'll get there. And I tell some of them, you may never single leg heel raise, right? If you're that, you know, patient that goes for walks and walks their dog and, you know, you're 50 years old, that's probably fine. And if you ever asked them to single leg heel raise on the other side, they probably didn't realize how hard it is. And a lot of people don't realize they can't do it until I asked them to do it. So I think, you know, to Dr. Ira's point, it depends on their goals. I think people that really have high goals are going to get there sooner, but if they don't ever get to a single leg heel raise for a lot of my patients, that's fine. And they're going to be able to do the things they want to do. So I tell them you're going to fatigue quicker. You know, initially it's going to take you a year to get there. It's going to be nine months to a year before you single leg heel raise, if you can. And as long as they're making progress, then I keep them in PT at some point they get stagnant and hopefully they're at a functional level that is okay for them. I just, I just want to say one more thing before Dr. Fanchuri responds as well. It's very interesting because I just, I have a, I have a patient who just, who emails me all the time. It's like a high school gym teacher or elementary or middle school gym teacher. And he was hands down one of the most vocal patients I've had. And I actually, to Dr. Groshin's point earlier about using this anchoring technique as opposed to end-to-end, I actually did this suture and dunking the sutures into the heel technique on him. Ironically, one of the anchors backed out about halfway through his rehab. He just messaged me the other day saying, Hey, I wanted to share some photos with you. I placed fourth in my age group, 30 to 35 in his first half marathon that he ever did. And he is a year and some change out. So I share that because I think it's very patient dependent on how, what their goals are as Dr. Agheni just mentioned, and how aggressive they're willing to get with the therapy, both in and out of the actual PT office. So it sounds like lots of variability somewhere between four months and a year, single leg heel rise. Ashley, can you kind of, is that operative or non-op? Do you think it's the same? Yeah. So I think depending on the patient and how much, like I said, how much work they're willing to put into it, we're pretty aggressive right away with both of our patients. So to kind of pick everybody back up to speed, if you weren't into my breakout, we use the same exact protocol, whether we're going non-op or op with the assumption that we're going to take the operative. I don't want to say faster, but I'm oftentimes a little more conservative when it comes to removal of heel lifts and restoration of dorsiflexion when we're looking at non-op, because we understand that there's going to be some tendon elongation, regardless of which route they go. So we tend to maybe slow it down a little bit there and pay a little bit more attention to things like scar management, desensitization. But I think that, you know, either way we have pretty good outcomes and we use limb symmetry index here at our clinic to quantum strength. So just to kind of jump and piggyback off of what Dr. Gainey said, you know, if a patient can barely do a heel raise on one side, well, we can't expect them to be able to do a 25 single leg heel raise to show five out of five strength before we're going to allow them to run. But if they can only do five on one side and four on the other, really how functional are they going to be or were they before the injury? So I think it's, you know, to allow patients to get back to what they can do safely and comfortably. And, you know, also there's been some retrospective observational studies that have shown that individuals who are looking to go back to a lower activity level, lower speed, high impact activities, they're going back a lot more often than those that are in those higher level activities. So I think that that, you know, their expectations of themselves is also going to drive that. So I'm interested to hear from everyone, you know, I found that there's some people who after this experience and going through it, they're very hesitant to return back to whatever sport was, you know, people never want to play basketball again. So, you know, interested in everybody and if you see that a lot and how you manage that. Can you guys hear me now? Okay. I think the workers outside are like running over my internet connection and just keeps kicking me out. But so I think the older the athlete gets, the more keen they are or more likely they are to tell me that they're retiring from their sport, right? And so, you know, I fixed an Achilles rupture in like a local, like Hartford city detective, who he does like narcotic detective. And I think maybe he chases some people. I don't know. But when he talked about it, he was just like, yeah, I did this playing basketball. I'm not playing basketball anymore. Like I'm just getting back to my job. Right. I'm 37. I tore my ACL three times and I've had five knee surgeries. Like I've retired from basketball as of 2020. You're welcome. So I, you know, like things like this. And so I think people kind of like fall into line with this, where they just like choose other priorities or choose to go back to sports that are more in line with what they want to do. Right. So people would share their Achilles and we're fairly active before largely for me, at least they stay active, but they are doing different things, right? They went from playing soccer to cycling or just finding like lower impact activities. My rehab protocol is exactly the same as, you know, my whatever post-op, like when I let them do back, I accepted instead of one single limb heel rise, you have to be able to do 10 in my office before I tell you that you can go back to sports. So if you could do 10 single limb heel rises, I say that you're fine. And that takes a long time, right? It takes months and months. And I'm definitely with Dr. Gainey. That takes me most of my patients somewhere around nine to 12 months. I've had one physical therapist as a patient. He was one of my first Achilles ruptures ever. He by far did the best out of any of my patients. So I don't know how much rehab he was doing in the office, but he killed it. Like single limb heel rise at four months, like was dunking by six months. Like he did great. So whatever. So I sent all my Achilles ruptures to him now in hopes that he could replicate that. But I think in reality, people modify their activities as they get older and realize that they, they probably aren't going to put in enough work over the longterm in order to get back. I mean, again, like we can say whatever we want about Kevin Durant, but 30% of NFL athletes don't go back to playing professional football after rupturing their Achilles. And Kevin Durant didn't play for 18 months. And so as we sit here and talk about people going back to playing beach volleyball, I mean, they will probably never get the exact strength back to go back and like hit a ball you know, at a rec league volleyball league. And part of it is because they have a life and they have a job as Dr. Gainey talked about. And I think it's too hard for people to really be able to generate that much strength again out of their calf. Right. I mean, if it takes two years to develop that, it's a lot of work to put in. And so I think generally if people stop going to therapy somewhere around six months for most of my patients, I think like they generally go from six weeks to about six months patients who really want to get back, you know, after that, they're like, okay, like I can't afford it anymore. I've made it as far as I can. And I'll just kind of wait it out, but they don't go home and after six months and keep doing those strength exercises nearly as much. And so I think I don't know, it's hit or miss for me, but patients that are older, like in their thirties, I think most of them don't go back to what they were doing. My younger patients, like really in their twenties, who still want to like get after it at their next bachelor party soccer game. Like they still do it. Yeah, I would I, there's probably a lot of modification. I mean, even, you know, we're, we keep talking about Kevin Durant because it's obviously the most notable thing in the media of recent years, but you know, you take even Clay Thompson who had his ACL and tore his Achilles most recently, but they even Kevin Durant has modified, even just watching him, he's modified some of what he's doing. And I think that that's also just kind of testament to the fact that people modify their activities. And I would say, you know, out of some of the ones I can probably describe including the guy who just ran a half marathon training for an Ironman, you know, he's an exception, right? He's not, he's not the norm. I wish they were all like that, but that's obviously not the case. I mean, I can think in my head, the handful of patients, including the case I showed earlier where, you know, he developed a wound infection and that's set him back. Right. And then of course they have, and then if there's more creep in the tendon that their body can tolerate that can set them back. Right. And so it's just always hard to know how well they're going to end up doing, like in terms of their, they can all get back to activity. We know the vast majority get back to activity, whether they truly get back to exactly what they're doing. That may, even though studies may have shown, yes, they do. That's going to vary on an individual to individual basis. And again, as Dr. Genshi said, what their priorities are as well. All right. Final question for everyone. Yes or no. Would you get your Achilles repaired, Dr. Iyer? Probably. And I say this because, and I say this because. I'm going to say no. I'm going to say no. I had a patient ask me, would you get it fixed? And I said, no. And she was like, as soon as I said it, she's like, she really wanted to get it fixed. I said, that's because I can't operate on myself. I had an ophthalmologist asked me this question this past week, acute rupture within like just a couple of days. And I was having this conversation. He came in feeling convinced he had to have it done. I was sharing with him all the data and he asked me, what would I do? I said, well, and I never answered, what would I do? I always answer in the context of you were my brother or if you were my family member and my brother, specifically for what he does, his schedule is so busy. He could not naturally be compliant with physical therapy. And so if I could be compliant with physical therapy, I hands down believe that I could do the therapy and be totally fine. However, because I just don't think that I can be that compliant is the reason why I would say yes for myself, but I don't tell patients. All right. We have one quick question here. It looks like we just have a couple minutes. So if you develop infection, how do you treat it? Dr. Fantry. So unfortunately these infections are fairly complex because you are typically putting in non-absorbable sutures into the Achilles. And once there's non-absorbable sutures in there, right, you need to be able to go in and take out all of the sutures. So I typically do a mini open repair. My surgery incision is not, I don't know, maybe it's a stitch or two bigger than what Dr. Ayer showed for his, you know, jig setup, but I just make a tiny incision and do a direct repair. And so generally you then have to make a bigger incision than you had before. You have to go get out all of your crack out sutures, obviously debride any kind of infected tendons, send cultures and multiple cultures in there. And if you can catch it acutely when they're just draining and you could take out the sutures, splint them and plantar flexion, and the wound can heal with PICC line, IV antibiotics, culture sensitivities, then you kind of win, right? Because yes, like they, their Achilles function may not be as good, but it may kind of scar in and be okay. But once you, if you are unable to do that or the wound, you know, if it shows like it's not draining, you have actual wound dehiscence, like the picture that we saw in Dr. Ayer's slides before, where you have to either choose to cut out some of the Achilles and try and close over the gap or it's, you know, necrotic enough that it's been there long enough that you have to cut out some Achilles that, you know, starts getting into this much bigger problem down the road, because now you've literally removed some segment of their Achilles and they're never going to be real candidate for a graft. And so I think that gets a lot harder. Obviously, if you end up with a big skin defect, they need plastics involved. So for me provisionally, it's IND, remove every non-absorbable suture, send cultures, PICC line, big gun IV antibiotics, and telepromptivities with six weeks of antibiotics. And, but... Uh-oh. Internet down. Yeah. All right. We're gonna, she went down. So let's, you came back. Oh, hi. You went down. I can hear you guys the whole time. You guys never leave. I think I just leave. But I think that was, I don't know. Did you get most of it? That was... No, we got it. We got it. Thank you. All right. So let's do a five minute break for everyone. Stretch your legs. My iWatch is yelling at me to get up. So let's take a five minute break and then we'll come back for our next session on running, which I'm excited about.

Achilles tendon injuries

management

rehabilitation

surgical cases

individualized treatment plans

timeline for rehabilitation

return to sports