Hi, well, thanks everybody. Welcome to, you know, happy Friday. And, uh, I don't know, I'm sitting in the Northeast. Do we have a beautiful day here? So hopefully everybody's enjoying a night. We had snow this week though. So we're, we're happy to see some sun now. Um, so I, I have the pleasure to introduce Dr. Ashley White here, who is from the university of Rochester. So she, uh, presently works with the university of Rochester orthopedics department, um, actively involved in foot and ankle, knee, and their running teams, as well as the orthopedic residency there. Um, her post-professional special interest in continuing education has really been focused on clinical examination of runners, clinical gait analysis, as well as strength and power development in endurance athletes. So, you know, it's really, it's, uh, I'm actually a U of R alumni. It's great to have a U of R person back with us. Um, and it's great to see this group. Um, so, so I will, uh, I will turn it over at this point. Thank you all. Thanks, Chris. And thanks for inviting me today. I'm excited to get to talk about our rehab protocol that we use here. I'm going to go ahead and share my screen. Actually, if I interrupt again, just do you mind? I mean, so questions along the way, I guess if you guys want to post them right into the chat, that works. Um, Ashley, I'm, I can, you know, defer to you too. Would you prefer, we just kind of post them and wait. Do you mind if I interrupt you? Yeah, no. If there's something that comes up, certainly you can stop and interrupt me. I know my, my presentation itself is going to run just about the full time. So if it's something that we can maybe answer at the end as a wrap up, that would be fine too. Great. All right. Thank you so much. All right. So everybody can hear me and see my screen. Okay. Then I'm assuming. All right. So, like I said, I'm going to be discussing some rehab considerations for the operative and non-operative management of Achilles tendon ruptures in the clinic. First, I will just mention that I don't have any disclosures to make related to this presentation. Just move you guys out of my screen. There we go. So the objective of my presentation are going to be to briefly look at the literature surrounding operative and non-operative Achilles management. And then we're going to dive into the URMC op and non-op Achilles protocols. I do have a patient outcome case comparison that I just want to go over briefly at the end. And then we'll finish up by summarizing PT goals for Achilles rupture management. So what does the evidence show us? As we know, Achilles tendon ruptures are really common. They're going to be most common in individuals that are in their third to fourth decade. Especially those weekend warriors who, you know, participate in those high demand sports. The incidence has actually been trending upwards due to a more active older population. And the incidence of operative versus non-op has actually been declining over the past decade. So for physical therapists, this is going to mean that we're going to need to know how to treat both patient groups, regardless of which direction that they decide to go in. And some of the early evidence was suggested of operative treatment, reducing the risk of tendon rupture compared to non-operative management. However, operative management is clearly going to have some complications related to the surgery. So then for us, this raises the question, how do we maximize functional outcomes for our patients and minimize the complications that we're exposing them to? I will mention too, that most of the traditional interventions related to non-operative management typically included a pretty long period of non-weight bearing and immobilization after the injury. So then looking at some of the more recent evidence, this randomized control trial was published in 2012. And it analyzed re-rupture rates as the primary outcome, but that they also looked at some secondary outcome measures, including some functional outcome scores. The Achilles tendon rupture score, which is a measure of strength, fatigue, stiffness, and activity of daily living participation. They also looked at the physical activity score, just the amount of accumulated activity that these groups were getting throughout the day. What they found is that whether or not patients went op or non-op, there really wasn't a huge difference in those functional outcomes. What they did notice though, is that through the functional testing, which concluded two jumping tests, two strength tests, and some muscle endurance tests, that there was actually significant heel rise work test difference between groups favoring an operative management. Another study actually took some of these subjects a year later and followed them to see if that heel rise work test improved at all. And what they found is that there was really not a huge difference even at that two month mark. This was suggestive that maybe the first few months of intervention are going to be imperative for us as physical therapists to make sure that we're not having our patients with any long-term impairments, but really despite the outcomes, patients are continuing to report that their physical function levels, they're happy with the way that they've recovered, regardless of whether they're op or non-op, which means that they may have adapted to a lower level of functionality. Another randomized controlled trial looking at some secondary outcome measures was conducted by Willits and this, they took two groups of people, an op and non-op, and then they looked at the isokinetic strength between groups, whether they chose to go operatively or non-op. And what they found is that plantar flexion strength between involved limbs between groups was not significant, but that there was actually a significant difference between the involved and the uninvolved limbs, basically over a course of two years. So what this means to us is that we really need to make sure that these individuals are getting as much strength back as they can right away. And both of these studies that we just looked at actually used an identical accelerated protocol. And, you know, the authors of these studies did condone that, you know, the studies were small, so it may have underpowered them to, to come up with any definitive conclusions. So more recently, there was a 2019 systematic review and meta-analysis that concluded that statistically significant, the re-rupture rates of conservatively managed Achilles tendon ruptures versus operative, it's low. And the difference between groups is small, but they also highlighted that it's small when an accelerated functional protocol is used. And then I just included a chart from that systematic review, kind of depicting how different the, you know, levels of complication are, of course, between operative and non-operative. And as physical therapists, there's going to be a lot more intervention related to wound care, wound management versus those that are going to be treated non-operatively. So then the question is who makes the call, right? At the end of the day, it's going to be the patient and their conversations with the doctor, a little bit of their past medical history. So those patients' specific factors and shared decision-making are going to be crucial to deciding which route they're going to take. So how do we provide optimal PT management? Well, implementation of that accelerated functional rehab approach has been shown to be key. But first we really need to define what that means. And if you do a literature search, there's a very wide variety of definitions and protocols for that. So here at U of R, we've worked hard to put together what we call our accelerated functional rehabilitation protocol, which is a combination of funnel of a gradual load progression, gradual range of motion restoration, and as well as a lot of patient education. So we actually use the same protocol for both of our operative and operative patients, and the next few slides are going to go through week by week, sort of what we do at what point in time. I'm going to go through some of the later phases a little faster, just because a lot of the patient education is done in the early stages of patient education and some of the strengthening information is just going to kind of carry over within weeks, but I will highlight some of the important aspects of that. So phase one, non-weight bearing patients are going to be cast and they're going to be transitioning into partial weight bearing status in a boot. So if we look at a microscope at this phase, we're in that inflammatory stage. We're having blood clots that are forming at the end of the torn tendon, and they're made up of primarily disorganized fiberglass. And it's not really until around two weeks when those tendon stumps are going to be fused by a fibrous bridge, and that fibroblast proliferation and collagen synthesis is going to continue here. So in this phase, it's going to be really important for us to educate our patients on the importance of adhering to protocol expectations. We know that the changes in Achilles tendon length are going to occur irrespective of whether or not op or non-op management is chosen, and the changes in the biomechanical properties of elongated tendons is going to increase the risk of re-injury. And we need to just educate them that they can't only use pain as a reliable guide to progress them between steps. Because we know that a lot of significant tendon degeneration can occur even without symptoms. So one of the most important things that we look at right away is looking at their hip strength, looking at their core strength, which we can do with them safely in a cast or a boot. And there was a cross-sectional study that was published in 2017 that found that middle-age recreational athletes with mid-portion Achilles tendinopathy demonstrated bilateral hip muscle strength deficits. And I think it's safe to assume that most individuals, maybe not all, but most are suffering from some form of Achilles tendon pathology before their rupture. So in order to capitalize on those first few weeks to months of recovery, as was suggested in some of those research studies we looked at, we need to make sure that we're starting this proximal strengthening early. And these are some of the exercises here that I like to include in my progression. Then I'll also use modified planks and bird dogs as well if it's appropriate. Phase two is going to be our transition to full weight bearing in a boot. So at this point, if we look at the tendon under a microscope, we're going to see early remodeling in that early three-week phase. Those collagen fibers are going to near the stump of the tendon, and they're starting to orient themselves along the tendon axis. But that distant scar tissue is going to remain disorganized. But that disorganized tissue is going to become more organized with progressive loading to that applied tendon. So how can we do that? We can increase that collagen production and accelerate tendon remodeling by adding stress and adding motion. Our objective has to be to increase the load to failure of that tendon by planning that mechanical loading. And we need to make sure that we're moving them safely, of course, early to avoid that excessive stiffness. So week three, this is how I've broken down the next few slides, what type of patient education, gait training, hip and core exercise prescription, as well as specific foot and ankles exercise prescription parameters that we provide our patients. So at this point, we're instructing them to wear their boot at all times. They're given a three-layer heel lift, which each layer is about a centimeter, one and a half centimeters. And we educate them, you need to wear this at all times. You want to be wearing it when you're sleeping. You're not allowed to drive. We also educate them on protocol expectations. We're lucky here at U of R, we have a BioSway machine. So we get patients on our BioSway right away. And that's helpful to educate them on what 50% of their body weight feels like. So we start gait training, usually the first day that they come into the clinic postoperatively, because we're usually getting them in right around that two to three week mark. We're starting those hip and core exercises right away. And then we're also starting some foot and ankle exercises. I do want to emphasize though, that they're obviously going to be in relative plantar flexion when they're doing these foot and ankle exercises. So we do start their band exercises early, but we make sure that they're sitting at the edge of the bed or sitting with their foot relatively flexed. So week four, we're going to continue with that same patient education. At this point, they're going to be 75% weight bearing. And then we're going to remove the first one and a half centimeter heel lift. So they still have two in there. We're educating them on appropriate device use. At this point, we're progressing them in the boot with their hip and core exercises, including things like stationary biking, weight shifting. And at this point, we're also incorporating a little bit of seated heel raising again in the boot with the two heel lifts. So they're not in a neutral foot position at this point. Week five, continue with that patient education. At this point, they're going to be 100% weight bearing in the boot and using an appropriate assistive device. Also, we're starting some 3D weight shifting. We want to make sure that when they are walking without an assistive device, that they're going to be safe in any direction that they may be moving. And at this point, we can start some four-way hip exercises standing on both feet. We are also going to start incorporating a little bit of weight to the seated heel raises. And you'll see here that as this protocol goes on, we're going to be increasing the weight to that seated heel raise by about five pounds each week. So week six is a big week. This is when we start to educate patients about weight bearing exercises being performed in the sneaker. But in their sneaker, they're going to have a low profile heel lift. So they're the three layer peel apart heel lifts that they have to wear whenever they're doing the exercises with us. Now, gait training, they're going to be in the boot, but we're removing their third heel lift and device as needed. But at this point, most individuals are doing pretty well without the device. We're continuing with the hip and core exercises. And now we're also incorporating a little bit of inversion and eversion with resistance, as well as some single leg stance in the boot. So why the foot? We know that increasing the tension on the Achilles tendon is going to be coupled with an increasing strain on the plantar fascia. So in these individuals, it's going to be important to initiate the foot core system to offload that passive structure by improving the recruitment in those dynamic stabilizers surrounding the foot and ankle while we're protecting that healing tendon. So a few of the exercises that I like to start with in this phase, and sometimes even earlier in that non-weight bearing position are foot doming and toe yoga. These pictures I have here on the slides for you. These muscles are going to provide the absorption and propulsion capabilities of all the dynamic activities that these patients are going to go through. And I really prefer the short foot exercise over toe curl type exercises, just because you're getting a little more activation of the abductor helices when we're doing this exercise here. And this one's kind of difficult to see because it's pretty small, but just keeping the great toe planted and lifting the lesser toes. Another aspect of exercise prescription that I'm looking at at this point is selective activation of the tibialis posterior. Tibialis posterior is the strongest foot supinator, and it's going to play a major role in stabilizing the medial arch of the foot, as well as assisting with that plantar flexion of the ankle. So in this study, they utilize an MRI to image how we can best selectively activate the tibialis posterior. They found that this closed chain foot adduction demonstrated optimal signal intensity. So I like to incorporate a little bit of this, again, in a sneaker with those heel lifts to make sure we're not quite in that neutral foot, or to even have them extending their knee out a little bit into a plantar flex position. So week seven, we encourage patients, if they are demonstrating appropriate control, they can start to drive with the sneaker, but they're still not going to be walking with that sneaker at this point. They're going to be walking with the boot for 12 weeks without any of those larger size heel lifts. We're doing some multidirectional hip and core exercises, and we're also going to be progressing the weights with the foot and ankle exercises. At this point, if they're demonstrating good safety awareness, I like to start with some eyes open, eyes closed, some stair tap exercises for some proprioception, and then also working on clock steps and balance, always being mindful of not putting them in too much of a dorsiflex position. The dorsiflex position. Now week eight, we're looking at that range of motion. We want to look at the dorsiflex range of motion, see if they're able to get to neutral. If they're struggling to get there, whether op or non-op, this is the earliest that we would start any light calf stretching. Personally, I've never had to use this light calf stretching with any non-op Achilles. I have had to use it in the past with operative Achilles, just because there's oftentimes an awful lot of sensitivity around the incision and they're kind of fearful of moving. So this would still be the earliest at which we would start to initiate some light calf stretching. And then again, we're continuing with all the exercises as prior. We're adding a two-inch step to the heel raises just to allow for that foot to come down in a little bit more dorsiflexion from neutral. Okay, week nine, we're going to start some two-inch step-ups, continuing with all of the other exercises, incorporating double leg heel raises and progressing to uneven surfaces with neuromuscular control in the sneaker with the heel lifts. So when considering, again, more exercise prescription at this point, I think it's valuable to consider the position of their lower extremity. So this study actually performed and found that there was a improvement in the recruitment of tibialis posterior if you have a 30 degree angle of foot adduction. And this also helped to increase the recruitment of the flexor digitorum longus. So it's a good way to manipulate which muscle group you're working on to ensure that they're going to have 3D control over their foot and ankle. Okay, week 10, we're increasing the step-up height. We're continuing with hip and core exercises. Week 11, same thing. Not too much is going to change here. Six-inch step-ups. And then phase three is our full weight bearing in the sneaker. So they're going to be weight bearing in the sneaker. They should be able to negotiate stairs reciprocally at this point. And we're starting to do some two-inch step downs. We're going to continue with the foot and ankle exercises, hip and core exercises. But at this point, we're reducing the exercise prescriptions just to allow for adaptations to the loads of the tendon and absence of the boot during gait. So week 12, continuing to wear those low-profile heel lifts in the sneaker. And we're avoiding any sort of running or agility until week 16. We're working on a little bit larger step-downs to add some challenge to that eccentric control of the Achilles. Phase four, we're looking at removing the first layer of that low-profile heel lift. This is where I'll change it up a little bit based on op or not. This is where I'll change it up a little bit based on op or non-op. I usually recommend patients who go non-operatively to just keep those heel lifts in their sneaker if it's not driving them crazy. I think the more we can help protect them and to avoid the lengthening of that tendon as we progress into more function, the better. If they're getting stiff, of course, which again, I see that more often in the operative category, this would be the time where you would educate them, wear these lifts, but keep taking one layer out each month. At this point, we're also starting a little bit of bounding, if it's appropriate. So for some return-to-run testing, so what we like to look at here is kind of a battery of tests to see where our patients are with limb symmetry index, which is LSI here. So we're looking at singling, pale arrays, or lateral step-downs, and what we're expecting of our patients is that they're getting at least an 85% or better limb symmetry between involved and uninvolved, and then we're also requiring them to pass two out of the three following tests, wide balance and reach, submaximal vertical hopping, which is just more so a qualitative test to look at their substitution patterns. Same thing with the jogging observation, just looking for any sort of compensatory strategies that are being used. And we also are fortunate enough here at U of R to have an altergy, so we've used that as well where we can get patients in the altergy to just start doing even some just light bounding in there at a percent decrease of body weight. All right, so weeks 20 through 24, this is the earliest that they would start to remove the second layer of that low-profile heel lift, if necessary. We're starting some 3D graduated agilities, and then we're also going to test them for sport-specific activities if needed at that point at 24 weeks. And that kind of brings me to my patient case discussion that I wanted to go through quickly. I wanted to highlight this gentleman here. He injured his Achilles tendon playing pickup basketball, and I evaluated him post-operatively with unfortunately the evaluation date was delayed a little bit due to scheduling conflicts, but I saw him in about five weeks post-op. He's a 38-year-old male, a BMI of 33, and he injured his Achilles playing pickup basketball, which seems to be the most common way that I've seen this happen. So looking at his PROMIS data, which is more so a functional outcome measure that we have our patients fill out when they come into doctor's appointments, come into PT appointments, it's going to look at a couple of different data points over the course of their care. So in this situation, his self-efficacy, overall health status, physical function, and pain status all pretty consistently improved between September and December of last year. So again, this was an operative patient that I saw about five weeks out, and I used an identical protocol with this gentleman as I did our patient number two. And this gentleman, he actually opted to go the conservative route. I evaluated him about four weeks after he had an injury. He's a 35-year-old male with a BMI of 37, so very close. It was kind of funny because somehow how it ended up, I would always have them on my schedule on the same day, around the same time, and they look very similar. And it was sometimes kind of like, wow, which one's which? Because it's amazing how similar they looked. But the one thing I will mention is that the gentleman that went post-operatively, he did have some sensory issues. He was really having some, we did a lot of desensitization, he was just having trouble with sneakers. And I think that pain and sensory disruption was actually inhibiting his strength progression a little bit. But either way, at the end of the day, he did really well. And as you can see here with this PROMIS data, looks very similar to the gentleman that had the surgery. They were both being treated by me for about the same amount of time. I will mention too, though, that both of these individuals were weekend warriors, I'll call them. They did get back into some lower-level activities. And some of the research has shown that there's a higher rate of return to sport in individuals that are looking to go back to lower-level activities than higher. So either way, they were both very pleased with their function. They got back into playing pickup basketball in some capacity that they were happy with. So it was kind of interesting to be able to follow these two patients at almost exactly the same time during the same phase of their rehab, both going one way versus the other. So in summary, I just wanted to go over our protocol's main goals. So what we're looking to do is safely restore the strength of the Achilles. We need to avoid excessive dorsiflexion movements. We need to achieve that proximal control to assist in normal tibial translation forward during walking, during squatting, during all activities of daily living. And then we need to promote optimal functional mobility to reduce the risk of re-injury through consistently, every day, educate that patient on the precautions. You know, it's important that despite good outcomes subjectively, their limited function that they're probably going to have could set them up for future injury directly at the Achilles or maybe even elsewhere due to compensatory strategies. So it's important to keep giving the individual as a whole, you know, a really good look at that before providing them with a home exercise program upon discharge and just setting them up with expectations for future exercise activities. And then, you know, always leaving the door open for them if they need to consult with you moving forward as they get back into the swing of things. And that is going to finish up my part of the presentation. Does anybody have any questions? I don't know, Chris, do we have time for questions? Yes, we do. Ashley, thanks so much. I think your presentation was outstanding. I will, you know, one question here about links. If you could provide a link to the protocol, Ashley, I don't know if you want to comment at all about what you have available in terms of the protocol, but I will also follow up. I think a question already came up in the main session about the slides and just access to slides. And I'll double check throughout this whole, the whole program. I know it is saved and will be available. I think if you guys have already sort of are already purchased the access, you may have access to all the slides later anyway, but I'll double check on that. Okay, great. And then otherwise the protocol itself, do you know of, I know U of R's kind of version of an accelerated protocol, do you know, is it in print in some fashion already? Yes. Yes. So we do have one and I can certainly speak with my manager about making that available in some capacity to you guys. Of course, it's a lot shorter. I like to put in a couple of different ideas of some three-dimensional activities that you can think about. I think, you know, oftentimes you look at a protocol and you kind of get stuck. You see, well, you start doing step-ups at week X, you start doing step-downs at week Y, but really it's the in-between and the creating a dynamic nature of all of the activities and really targeting each specific patient to their expectations is going to be huge. But I could certainly look at getting that kind of cut and dry protocol available to everybody who's interested in it. Great. And then, Tom, you had a question about the removal of the lifts. I think great question for clarity. Do you want to go ahead and ask that for some interaction or I'm happy to step in. I can do that, Chris, if you want. Can you hear me? Yeah. Yeah. Good. Yeah. So I'm just curious in there, you know, you have the three heel lifts when they start in the boot and I saw you, you remove one, I think around week four to six, I saw there was no discussion. Do you keep both heel lifts in for the remainder of the time they're in the boot or do you take one out or both out? How does that go? Yeah. So what we do is when we see our patients postoperatively, they come in with about a two inch heel lift that's separated into three separate sections. So while they're in the walking boot, we will take out one layer each week until those are completely gone. And then I also, I brought in a set of heel lifts because I kind of assumed I might have some questions on this. When I'm talking about the sneaker, I'm actually talking about this. So something very small, our postoperative lift that we're going to be wearing and transitioning out of in the boot is about this much bigger than that, than this lift. This is what I usually give my patients about a week before they're about to transition into their sneaker. And then you could see that this one much smaller in regards to removal than the one and a half centimeters. But yes, we do try to take those out one per week when we see them from that first week. And if for them, it would be at week three, I shouldn't say week one. Does that make sense, Tom? Yeah. So the heel lifts are completely out of the boot by about what you're saying, like week, what week would that be? So that is going to be, I just don't want to misspeak. All of the heel lifts are going to be out. So the first one's being removed at week four, second at week five, the third is going to be removed at week six. So that's going to give the individual patient some time to walk in the boot before we get them doing the weight bearing exercises in the sneaker with the little heel lift. Okay, thank you. That's what I want. Thank you. Yeah, no problem. That was one of those questions that I had too, when I first started working here, Tom, is I saw the protocol and it said, oh, lifts, lifts, lifts. And then when I finally saw the lifts, I'm like, oh, they're very two distinct kind of lifts. So I think it's important to bring that up. Thank you. Okay. Still time for another question. Everybody has one and wants to sort of pipe right in. I'll ask a quick question and maybe kind of silly, but in the early phases in the protocol, you mentioned calf raises and strengthening of the foot, they're supposed to be out of the boot yet, correct? Or those all okay to be doing out of the boot or how are you doing that? I, you know, that's where it gets a little, you don't want to push that so much, but how are you doing that in the boot if they're supposed to still be in it? Yes. So they're going to be in the boot all the time when they're not in PT. And some of our physicians will actually send patients over in a boot that has pins where you can unlock it or relock it. I'll be honest. We've actually gotten away from that a little bit, just from an operative standpoint, it seems like they are opera non-off for that matter. They come over in a boot that doesn't have that capability, but it's our opinion that the importance of that strengthening right away is going to be detrimental. So we actually allow them to come out of the boot, but we oftentimes have them just sitting edge of bed with the band around their foot. So they're relatively planner flex. So they're not going to be getting an awful lot of movement, but they're going to be getting some stimulus to start to initiate the activation of that muscle and start to get moving in the right direction. Hello. Hi, Chris. Could I ask a question, please? Yeah, please go ahead. My name is Magid. I'm from Qatar. Could I ask you please, if we have here a cam walker, we use a cam walker in the postoperative period. So could, Ashley, please, could you explain how to use a cam walker? And we can adjust it from a 30 degree of plantar flexion and 10, 10 degree. I don't know. Could you explain to me how you can do that, please? Yeah. So if you're asking what I think you're asking, we have the boots with the pins, which I guess would be considered the cam walkers. Typically what we'll do is we'll decrease the pin on that once a week if the heel lifts aren't available. So instead of taking lifts out, if we just need to adjust the boot, we would adjust it in the same manner that we're taking the heel lifts out. So if it's starting at 30, I would assume the next one would be 20, 10, and then eventually they're going to be in that neutral foot in the cam boot. All right. Thank you. Yes. Thank you for the question. Thank you. Great, Ashley. I was, I was intrigued and I guess it's great to hear that people don't lack dorsiflexion later on. Right. And you said you don't see that as much of an issue in the non-ops, however, I guess I'm still curious, like, do they really get dorsiflexion back or are they, is the goal really just neutral? And that's pretty functional at that point, I guess, really long-term, are these people staying in, you know, somewhat of a heel lifted sneaker to be, to, to, to sort of optimize their gait mechanics? Yeah. I would say that for the majority of my patients, at least that I can speak towards, non-operatively, I haven't really had any patients that have limited functional dorsiflexion in open or closed chain. I will say that operatively, I can think of maybe one or two patients off the top of my head that I've really struggled to get that dorsiflexion back in open chain that was functional. Closed chain, a little bit different story. And oftentimes that's accompanied by other things like the telephemoral pain, trying to get that dorsiflexion back just because they've been in a boot. And of course, that's going to throw off all the other body parts, which is always great to have to try to play catch up and get ahead at the same time with that. But I would say that for the most part, they, they do restore a pretty functional active range of motion and passive range of motion to allow them to function. All right. Any other questions? Go ahead with the questions if you do have any. I have a question. This is Jenny. It says Mary, but... Oh, hi, Jenny. Hello, hello. So a couple of questions on your summary slide, I think it was number three point, you were talking about doing proximal strengthening to decrease tibial advancement in gait. Did I hear that correctly? Okay. Yes, yes. So can you elaborate just a little bit on that? And then I think I have another question, but go ahead. Yeah, sure. So from, from just sort of a global standpoint, we always like to encourage patients to start to do that global strengthening right away, just because being immobilized, even if it is for a few weeks is going to obviously weaken the muscles. So that's kind of what I alluded to as far as generally lack of weight bearing, even if it is for a few weeks is going to decrease the ability for patients to control their midfoot to control all of their lower kinematics essentially. So that's why we're incorporating as much of the core strengthening as we can right away, just so we can really get a jumpstart on it. And then as far as the anterior tibial translation, of course, we're going to be getting most of that from the lower kinetic chain, but I think that there's some value to set up of the foot during gait. So when you're walking and sort of in that swing phase, you're going to have the glute medius, you're going to have the glute maximus sort of preactively engaging before foot flat. So if we can optimize, you know, restoration of that, we're going to put them in a better position when they initially strike the ground, which is going to only enhance their ability to control for that anterior tibial translation. And you're talking, are you talking about teaching them consciously to keep their foot in slight inversion at heel strike? And then, like, I mean, is this, are you saying, hey, let's strengthen them so that therefore when they're walking, it's going to naturally support them? Are you saying we're actually breaking this down for them clinically and saying, I want you to put your foot down this way. I want you to think about, is that? Yeah. No, no. I think that's a great question. And I think, yeah. So this kind of, it reminds me a lot of a question that I get a lot with running related injuries because oftentimes individuals will ask me, well, are you instructing them how to land, how to move their feet? And my kind of idea behind that is that you're not going to be able to make your body work in a way that's not taking the least amount of energy to get from A to B. So to try to mentally override your body's natural tendencies is I think kind of an inappropriate expenditure of energy. So rather than thinking about, well, let's walk with your foot slightly inverted or let's do this, let's just strengthen the correct muscles that we can as movement scientists clinically see are deficient and then the movement patterns are going to clean themselves up. Awesome. Yeah. Great question though. Thank you. Thank you. And, and one, one other thing. So when I'm, I rely a lot manually to assess tensile strength. I mean, it's just so, it's so obvious to me how slow it is for non-op or op Achilles ruptures to get that, that sensation of, of the tensile strength of the Achilles. There's two questions in here. One is how do you do it? How do you really go, okay, now I can feel that they're ready to progress this. And then secondly, when you're communicating with physicians, I don't know if this is how it works in your system, but this is kind of an inane question, but do they know what I mean when I say their tensile strength is compromised? I mean, like, you know what I'm, do you know what I'm getting at? Yeah. Yeah, I do. I do. And I think that brings up a really good question because I think I, I rely a lot on subjective reports of tolerance to exercises when considering that, because as we know, there's going to be that tendency elongation, whether we're going operatively or non-operatively. So I think that the tensile strength is always going to be a little bit limited on that side and being able to use limb symmetry testing to say, well, how, how many heel raises can you do? How many lateral step-downs can you do to demonstrate that control of that interior translation? You know, and that's a very good value point for patients because they may think they're good to go. Cause like I said, all these functional outcome measures that we're looking at at six months, 12 months, two years, people's, you know, scales are off the chart. They're so happy, but we look at them and we're like, oh no, like this, this might turn into a huge issue down the road. So I think using tests like that to test the strength functional activities can really be of huge value to the patient to kind of get them to buy into this is why you're not ready to run. This is why you're not ready to jump. And this is why, this is why you're going to end up back here in six months. And I'd love to see it again, but not in this environment. Right. So I think that that's valuable. And as far as communication with the doctors, I think that we have a great close knit. Like if I open this door and walk through the hallway and open another door, I can knock on the surgeons or, Hey, this patient's here. Can you come over? You know, something's weird. So we're, we're very fortunate in that situation. And I think that the doctors they were such a crucial part of putting together our protocol as well. We sat down and have, you know, round table discussions about it that they kind of know. And I don't, I don't tend to find that I have to that I have to really, I don't want to say convince them, but to sort of like, Hey, this is the situation. I just usually document where their strength is with those functional tests. And it's sort of an accepted, you know, clear when you want to clear them when you feel like they're appropriate. Cause really at the end of the day, not operatively they're, they're being judged, but you know, the surgeon's work is done or the non-op doc is done. That's going to be on us to make sure that they're progressing well and using our best clinical judgment. Okay. Thanks a lot. Yeah, of course. Thanks. Thanks. Maybe this is a great transition too. I think I'll bring us back to our main room, a little more discussion there. I think some of these questions that, that really get at the intersection of, you know, the surgery and the rehab and all that is, is perfect for that venue.

rehabilitation protocol

Achilles tendon ruptures

operative management

non-operative management

proximal strengthening

load progression

range of motion restoration