Weeks 1-3: Treatment Decision

You've survived the first chaotic days after your Achilles rupture. Now comes one of the most important decisions in your recovery: surgery or non-surgical treatment? This guide will help you understand your options, what happens at your specialist appointment, and how to set yourself up for success in these crucial early weeks.

The Specialist Consultation

What Happens at Your Orthopaedic Appointment

Your specialist appointment (typically at a fracture clinic or orthopaedic outpatients) is a pivotal moment in your recovery. Here's what to expect:

During the appointment:

1. History review: The specialist will ask about how the injury happened, your symptoms, and your general health
2. Physical examination: They'll examine your ankle, feel for the gap in the tendon, and perform specific tests
3. Discussion of findings: You'll learn about the severity of your rupture and treatment options
4. Treatment decision: Together, you'll decide on the best approach for you
5. Boot fitting: If you're not already in a boot, you'll likely be fitted for one
6. Follow-up plan: You'll receive a schedule of appointments and rehabilitation milestones

Physical Examination: The Thompson/Simmonds Test

The Thompson test (also called the Simmonds test) is the key clinical test for Achilles rupture:

• You lie face-down on the examination couch with your feet hanging off the end
• The doctor squeezes your calf muscle firmly
• In a healthy tendon, this makes your foot point downward (plantarflex)
• In a ruptured tendon, the foot barely moves or doesn't move at all

Other examination findings:

• A palpable gap in the tendon (you can often feel this yourself)
• Increased passive dorsiflexion (your foot can be pushed up more than normal)
• Weakness when trying to point your toes
• Swelling and bruising around the heel and ankle

Imaging - Ultrasound vs MRI (When and Why)

Not everyone needs imaging, but it's increasingly common and can be very helpful:

Key information from imaging: The size of any gap between tendon ends, whether the tendon ends will come together in a pointed foot position, and the overall quality of the tendon tissue.

If ultrasound shows the tendon ends come together well when your foot is pointed down, non-surgical treatment is usually an excellent option.

What Does "a 4cm Gap" Actually Mean?

Patients often hear a number like "4cm gap" and understandably panic. Here's the plain-English version:

• The Achilles tendon has torn and the two ends can sit apart — like the ends of a snapped rope
• On ultrasound, the clinician may measure the distance between the ends and describe it as a "gap"
• That number can change depending on foot position. If your foot is scanned more neutral vs more pointed down, the ends can look further apart or closer together

Surgery vs Non-Surgical Treatment - The Facts

This is the big question. Let's break down what the evidence actually says.

What Does Surgery Involve?

Surgical repair of the Achilles tendon involves:

Types of surgery:

• Open repair: Traditional approach with a longer incision (~80% of UK surgeries)
• Minimally invasive/percutaneous: Smaller incisions with special instruments (~20% and growing)

Recovery after surgery: 1-2 weeks in a cast, then a walking boot. Same rehabilitation protocol as non-surgical treatment. Total recovery time: 6-12 months (same as non-surgical).

What Does Non-Surgical Treatment Involve?

How it works: The tendon ends heal naturally when held in the right position. The body forms scar tissue that bridges the gap. This healed tendon is just as strong as a surgically repaired one.

Re-rupture Rates: The Real Numbers (2-4% Overall)

This is where the numbers get interesting:

When re-rupture typically occurs:

1. Early rehab period (weeks 0-8): Non-adherence to advice (taking boot off, walking without boot), getting into dorsiflexion too early (especially with speed and eccentric contraction)
2. When first coming out of boot (weeks 10-12): After 8-12 weeks in boot, patients think "we're done", try to walk normally too quickly, tendon hasn't developed enough strength yet

The key message: Re-rupture rates are very low regardless of treatment choice. The bigger focus should be on preventing elongation (tendon stretching), which is the real problem affecting long-term recovery.

Key factors that reduce re-rupture risk:

• Early functional weight-bearing in a boot (not prolonged casting)
• Proper boot positioning (maintaining equinus/pointed position)
• Compliance with wearing the boot 24/7
• Following the rehabilitation protocol carefully
• Not rushing boot removal (wait until tendon is strong enough)
• Not rushing back to high-impact activities

The UKSTAR Trial - What It Proved

The UKSTAR trial (UK Study of Treatment for Acute Achilles Tendon Rupture) was a landmark study that changed how we treat Achilles ruptures.

What the trial found (comparing plaster casting vs functional bracing with early weight-bearing):

• No significant difference in long-term outcomes between surgical and non-surgical treatment
• Functional bracing allowed faster return to normal activities
• Lower complication rates with non-surgical treatment
• Significant cost savings with non-surgical approach

Early weight-bearing in a functional brace is a safe and cost-effective alternative to plaster casting

What this means for you: Non-surgical treatment with a walking boot is the first-line treatment for most people. Surgery is reserved for specific circumstances. Early weight-bearing and functional rehabilitation are key to success.

Your Walking Boot - The Foundation of Recovery

Aircast vs VACOped - Which Boot is Best?

The two most common boots are the Aircast and VACOped. Both can provide excellent outcomes, but they work differently.

Understanding Wedges and Angle Progression

Your foot needs to be held in a pointed position (plantarflexion/equinus) to allow the tendon to heal at the correct length.

Why this matters:

• Too much angle = foot pointed too far down, uncomfortable but safe
• Too little angle = tendon ends not close together, risk of elongation
• It's better to be too pointed than not enough

Fitting Your Boot Correctly

A properly fitted boot is essential. Here's what to check:

Sizing:

• The boot should fit snugly without being tight
• Your toes should not press against the front
• The heel should sit securely in the heel cup
• Most boots come in S/M/L sizes

Strap tension:

• Straps should be firm but not cutting off circulation
• You should be able to slide one finger under each strap
• Re-tighten straps throughout the day as needed

Wedge placement:

• Wedges go under the heel, not the whole foot
• Stack them according to your protocol
• Make sure they're secure and not shifting

Common problems:

• Foot sliding forward = straps too loose or wedges incorrectly placed
• Toe pain = foot sliding or boot too small
• Pressure sores = straps too tight or poor fit

Living with Your Boot - Weeks 1-3

Learning to Walk with Crutches and Boot

In weeks 1-3, you'll be getting used to walking in your boot, likely still with crutches for support.

Walking technique:

• Most protocols allow partial weight-bearing from early on
• Use crutches for balance and support, not to keep all weight off
• Aim for a heel-to-toe rolling motion
• Keep the boot on for all walking - no exceptions

Progression:

• Week 1-2: Crutches with light weight-bearing
• Week 2-3: Gradually increasing weight through the boot
• By week 3-4: Many people can walk without crutches (but keep them handy)

Tips:

• Start with short distances and build up
• Rest when you need to
• Swelling after walking is normal - elevate afterwards
• Use a shoe leveler on your other foot to prevent back pain

Weight-Bearing Guidelines

Weight-bearing protocols vary between hospitals, but the trend is towards early weight-bearing because research shows it improves outcomes.

Common approaches:

• Immediate weight-bearing as tolerated: Put as much weight through the boot as feels comfortable
• Progressive weight-bearing: Start at 25%, increase to 50%, then full weight over 2-4 weeks
• Non-weight-bearing then progression: Some older protocols still use this

What "weight-bearing as tolerated" means:

• Listen to your body
• Some discomfort is normal; sharp pain is not
• Use crutches for balance and confidence
• Gradually put more weight through as you feel ready

Signs you're progressing well:

• Decreasing reliance on crutches
• Increasing walking distance
• Swelling manageable with elevation
• No sharp pain

The Importance of 24/7 Protection

Why 24/7 protection matters:

• One moment of unprotected dorsiflexion (foot bending up) can pull the healing tendon ends apart
• This could cause the tendon to heal elongated (stretched out), reducing your final power
• Elongation is the biggest problem affecting long-term recovery - more important than re-rupture risk
• In the worst case, it could cause a re-rupture

The only exceptions:

• Showering (with specialist approval and extreme caution)
• Early strengthening exercises (when prescribed, typically from week 2-3 onwards) - done OUT of the boot briefly, in a safe position (foot pointed down), boot goes back on immediately after
• Using a night splint (when approved by your specialist)

Recovery is like Snakes and Ladders: Each week sees you closer to the finish. But one small mistake is like landing on the big snake - taking you right back to the beginning.

Sleep Solutions During the Boot Phase

Why Sleeping in a Boot is Miserable

Let's be honest: sleeping in a walking boot is one of the most challenging aspects of recovery. Common complaints include:

• The boot is heavy and awkward
• Your foot gets hot and sweaty
• You can't move or change position easily
• The boot makes the sheets dirty
• It's just plain uncomfortable

Unfortunately, protecting your tendon overnight is absolutely essential. One accidental stretch during sleep could undo weeks of healing.

The Night Splint Alternative

A night splint designed specifically for Achilles rupture can be a game-changer for sleep comfort.

When can you use it?

• Typically from week 2-4 onwards (check with your specialist)
• Must wait for any surgical wounds to heal first
• Only for sleeping/resting - not for walking

It is fantastic that Thetis Medical have produced this night-splint. It is certain to improve the recovery experience for patients.

Tips for Actually Getting Rest

Whether you're in a boot or night splint, here are strategies for better sleep:

Position:

• Sleep on your back with your leg elevated on pillows
• Or on your side with a pillow between your legs
• Avoid sleeping on your stomach

Environment:

• Keep the room cool (your foot will be warm)
• Use breathable sheets
• Consider a fan directed at your feet

Practical tips:

• Wear a thin cotton sock under the boot for comfort
• Keep crutches next to the bed
• Use a nightlight for bathroom trips
• Empty your bladder before bed (fewer night-time trips)
• Limit fluids in the evening

Mental approach:

• Accept that sleep will be disrupted for a while
• Rest even if you can't sleep deeply
• Nap during the day if needed
• This phase is temporary

Essential Purchases for Weeks 1-3

Must-Haves

Nice-to-Haves

Common Concerns and Red Flags

DVT Symptoms to Watch

Continue to be vigilant for blood clots throughout your recovery:

Signs of Infection (Post-Surgery)

If you've had surgery, watch for:

• Increasing redness around the wound
• Wound becoming hot to touch
• Pus or unusual discharge
• Fever
• Wound opening up
• Increasing pain after initial improvement

Contact your surgical team if you notice any of these signs.

When to Call Your Doctor

Contact your medical team if you experience:

• Suspected blood clot symptoms
• Signs of infection
• Sudden increase in pain
• Your boot or cast becomes loose or damaged
• You have a fall or accident
• Your foot slips out of position
• Numbness or tingling that doesn't resolve
• Concerns about your medication

FAQs for Weeks 1-3

Summary: Your Weeks 1-3 Checklist