Click here to download a PDF version of the transcript 

David: Hey Peter, how are you?

Peter: I'm really good. David, how's it going?

David: Yeah, great, thanks. Thanks for coming back on the podcast. It's been a while since we've had you on the podcast and really enjoyed our last chat. And then , when I met you and, and heard that you've got a focus now or you've been exploring some achilles tendon rupture research and I wanted to get you back on and have a chat about some of that.

Tell us a little bit about that journey, how you went from diving into tendinopathy to exploring more research around Achilles tendon ruptures.

Peter: Sure. So I've always seen lots of achilles tendinopathy and tendinopathy in general in the clinic. And then it just was a natural progression. People started referring more ruptures over the last 10, 12 years. And I've just started seeing more ruptures. And initially I didn't really enjoy them that much. But then over time I started enjoying them more. And started thinking, these are actually quite interesting. It's a bit like the ACL rehab because it's all about progressions and criteria. So I really enjoy that. There's lots of measurements that we do as well which is really interesting.

Keeps it, keeps it interesting and, and lots of really good objective criteria. So, yeah, so I started enjoying it and then more recently started doing some research in the area as well. David: Yeah. Awesome. And so what are the problems that achilles tendon rupture patients experience or that, therapists seem to experience when they're treating patients that have had Achilles tendon ruptures?

Peter: It is a catastrophic injury. People are very fearful. Patients are very fearful of it re rupturing, doing the wrong thing. The clinicians are very fearful of doing the wrong thing as well, and there's a lot of uncertainty. I think in just generally, and even from the top down.

If you speak to surgeons, they're also uncertain about how we should be loading and how we should be progressing. And then if you speak to the physios, they're also uncertain. So it's no surprise that the patients are uncertain about what they should be doing because no one really seems to know how to progress, how fast to progress, what to do. so a lot of it is based on historical, just, , we should be careful to allow tissue healing. A lot of it is very dated in terms of what we do. So I think that's what I see a lot. So I was in the clinic yesterday. I saw out of my list of 15 or so people. I would see a handful of Achilles ruptures within that. Yeah, the, they just present with , am I doing the right thing? I saw a guy who was six weeks down the track yesterday, and he's gone to a big local private hospital, which is The Alfred here. And they've done a good job. They've, , reassured him. But he still, , didn't quite get enough in terms of answers to some of the questions that he needed. So, for example, he asked the guy how much walking can I do and how much can I weight bear? And the way he relayed the story to me. the guy sort of wasn't sure and said to him, oh, just, you know, see how you go type thing. , make sure it's not too painful. so, , there's that type of thing that happens I think quite often because people are just not sure. Providing some reassurance and some certainty in terms of the program that people have, is really beneficial. So that's the sort of problems you see. But I mean, in terms of problems in healing, there's lots of those. The two main ones are re-rupture and then elongation. So people end up with a long tendon or they end up with a re-rupture. So they're the main things that we see in terms of people not having a good outcome.

People underestimate how big a problem it is to patients. And it's a massive psychological and mental problem for them when they're going through an Achilles rupture. It's similar to an ACL and the type of pathway and, , mental struggle that people go through with an ACL.

David: Yeah, definitely. Especially when it's impacted their ability to walk, to be able to do pretty much all their activities of daily living for a while. And like you say that maybe the patient's not sure about how much they can walk, even their therapists are not sure how much they can actually do and how much to load them up and how much to let them rest, that sort of thing. So, I'm really looking forward to diving into some of those questions because they're the questions that patients are going to ask us all the time. So if we, we'll get some clarity. So physios out there will know how to answer patients and how to guide them on the best way to progress through their rehab and progress their function and their walking, that sort of stuff. If we talk about the common presentations. So if someone comes into a physio what are they likely to report, first off, when they've had an Achilles tendon rupture?

Peter: The classic is they will report that they're running along, so it's usually non-contact. They're running along and someone's kicked them in the back of the leg. Someone's kicked them in the back of the leg or they've felt a snap, they've heard something. And usually they have a limitation in pushing off and weightbearing walking straight after. So they'll, they'll feel all those things. They'll report those things. The guy yesterday, I'll just give you an example. because he was, he was an initial that I saw yesterday. He was playing paddle and he lunged and he basically felt that someone kicked him and he looked at his partner and then he looked back and his partner was way too far away and he realised it wasn't his partner. Something else had happened. So that's like your typical history.

In terms of mechanisms, it's basically dorsiflexion. So people usually are doing some eccentric or some concentric fast activity in dorsiflexion. It's usually that changeover from eccentric to concentric where people get a rupture. Ruptures don't occur in plantarflexion, and that's a really important point because that plantarflexion loading is safe. That's what I define as safe loading when we're loading in plantarflexion. And that then transfers to our rehab and stuff we'll talk about later. But when you load them in plantarflexion, generally they're, they're okay. They're not going to get any problems there if you do it in a safe way. So they will generally report that typical mechanism , loss of ability to plantarflex. It's interesting how commonly though these types of injuries are missed. There's reports out there if you look at emergency departments, up to 20, 30% of people with Achilles rupture are missed which sounds shocking and surprising because you just think to yourself, these people generally can't push off. But a lot of people can still plantarflex and that's one of the issues they will be able to plantarflex because they've still got their long flexors their long deep flexors.

So they will retain, especially young people, some ability to plantarflex and that puts some people off. And also the Thompsons test or the Simon's test that people do is quite equivocal for some people. It can be negative even when someone has a rupture. So you do need to look, and I guess we'll get onto diagnosis.

I'm not going to talk about it now. But we do need to look at a thorough diagnostic workup to make sure you're not missing them.

David: Is it more common in specific age groups? Like if you've got a patient come in and they're in their early twenties, are they likely to have one or is it, what's the common age groups that can have that?

Peter: Yeah, a really good question. We are currently doing a review looking at the incidence in different groups and different age groups and that data we're looking through at the moment it's not led by our group. It's one that I'm collaborating on from overseas people, but partly at Aspetar, partly in Greece. What we're finding there is that it's, it's surprising actually, some people can get a rupture as young as 12, 13 years old. And then you get it right up to, people in their nineties. So effectively the key age groups are your late athletic, so late twenties, early thirties, that are still quite active. And then the other key age group is the 45 to 60-year-old people when they start to get a little bit more degeneration and issues with their tendon. David: Yeah. Interesting. It's probably a lot younger with some of those age groups than what you'd think or especially you mentioned some of the, around the 12 to 13-year-old. I mean that's probably not, most of us are probably thinking those 30 to 40 year olds that are playing basketball or whatever, rather than the 12 to early adolescent phase athletes. Peter: That was really surprising actually. And I think if you look at some of the data, you do get a lot of gymnasts that actually get ruptures and they get it quite young. Track athletes get it quite young as well, so you can have track athletes in their late teens who get ruptures. , so it is quite common.

It, it doesn't happen that much in distance runners. So distance runners, because they're not doing maximal activities. Generally it will happen when you are young, when you're doing maximal activities. Now, maximal activities are maximal jumping, maximal sprinting, maximal cutting. So if you're doing those activities that involve lots of dorsiflexion and powerful calf contractions in dorsiflexion, you're at risk of those injuries. But the older demographic, they can get it doing all sorts of activities, not necessarily these maximal activities. So it might be just walking along. It could be just running, going for a run. I'll tell you a bit of an anecdote that happened to me. I had a patient recently in the clinic he was probably in his early fifties. He's a hairdresser, so he spends a lot of time standing. And I was treating him for an insertional achilles pain. And we were treating his right Achilles. And the second time I saw him he was progressing well, I asked him to hop on his right side, which is his painful side. And it was absolutely fine. He hopped on his right side. It was a bit labored, a bit painful as you would expect with an Achilles, but it wasn't too bad. and then I got him to repeat that on the left side, and his left Achilles snapped.Right there in e in the rooms.

I had a student with me who went white. I went white. The only one that was semi okay and not freaking out was the patient himself. And he he was completely fine. He was so, so nice about it. And we got him a boots and we spent another hour with him. And, then he ended up going off and having surgery coming back, and now he's done all the rehab.

He's completely fine. But I guess the point of that story is that you really can rupture it with just a very, very , something that doesn't seem very much at all, just a hop test that everyone does in clinical practice. But , you can, if someone's tendon is, is weak, it will rupture with that.

And this is that over 45, 45 to 65-year-old group where they don't need to be doing maximum activities. If they put a bit of stretch, shortened cycle through the tendon that they're not used to, the tendon can rupture. So that, that was a, that was definitely a bit of a shock for me.

I always tell that story when I'm teaching and everyone asks me, do you still do hop tests?

And I still do hop tests because, they are safe and I've been hopping patients for, 20 years now, and that's the first time that's happened.

So they are very, very safe tests to do. but, if a tendon is ready to go, it will go regardless of what we're doing. Could be walking, could be doing anything. So that, that is something to keep in mind. The interesting thing about his case as well was that I, I scan everybody that I see with an Achilles and when you look at his scan on the Insertional right side, he had some typical insertional pathology. When I looked at his left side, it was pretty normal. It was pretty healthy, so there wasn't much going on. and that was interesting because the mantra at the moment is that and we might get on and talk about this as well, but the mantra is, a healthy tendon does not rupture. That's what people say and that's what the evidence shows. So if you look at the classic Canis 1991 paper. That paper, they looked at almost 900 tendons from all around the body that presented to emergency that had ruptured. And they took a sample, a biopsy part of that tissue, and they looked at it. And in all cases of rupture, I think it was like 90, , something percent, 98% or most of the cases of rupture had pathology when you looked at it under a microscope. So that, that's where that mantra, that healthy tendon doesn't rupture comes from. But if you look at it with ultrasound, which I did for this guy, he had a tendon that looked healthy. So I think there's a difference between what we're seeing with scanning and what, what's happening in the tendon itself. Now, the other possibility is that it's just weak. he's got this tendon that's structurally, mechanically weak, even though it's healthy.

And that can be from deconditioning that could be from not enough loading from various factors. So, so that, that was interesting to me as well. because I guess before that, one thing that's changed in my practice from that experience is I, I would generally say to people, , if your tendon looks good, really good on ultrasound, it is probably less likely that that tendon's going to rupture. But I'm not so confident in saying that now. So now I think what we need is that mechanical evidence of stiffness in the tendon and we might talk about stiffness because that's really the best measure of how strong a tendon is.

David: Yeah. And do we know much about the predisposing factors you mentioned there that if we've got an unhealthy tendon in that, , can of study that , a, the large proportion of those people had achilles tendon ruptures, had some yeah. Tendon issues or tendinopathy going on within the tendon. So when patients ask, why is it my Achilles ruptured? How do you tend to answer them?

Peter: Yeah, it's a good, that's a good question as well. I think we do know something about, , why people rupture and it's definitely mechanical loading and it's the stuff that we talked about earlier that real high stress, sprinting max efforts that will that will definitely be a factor.

The other factor is age. is a factor. Prior pathology in the tendon, that is a factor. Any disease process, metabolic disease, all those things are related as well. So if you've got, cholesterol, you'll start to get tendons that are less healthy and we know that they, mechanically they're not as strong. So all those things are factors as well. Medication use, steroid use, , long-term steroid use. All those things relate to achilles tendon rupture. We don't have great evidence that mechanical biomechanical factors relate to rupture. Aside from that really heavy, high loading in dorsiflexed positions.

David: And you mentioned before that in ED's, 20 to 30% of these are missed. What are they often misdiagnosed as? Peter: Yeah, look they often can be misdiagnosed. I had one recently misdiagnosed, an ankle sprain. So especially if the person is a bit vague about the history, so they say, oh look, I tripped, I tripped off a curb or something like that. And they got swelling around the ankle. That can be a bit misleading for an ankle sprain. I've had them diagnosed as Achilles tendinopathy or Achilles, Achilles problem, Achilles partial tear. So various things.

I remember one guy I had, this is when I was working in London about 15 years ago. I I. Worked in a tendon clinic there. And there was one guy, older guy, it was probably in his seventies. He had been misdiagnosed for six months and that was the worst case that I've ever seen. He also had two lots of imaging right. And was still misdiagnosed. And the reason he was misdiagnosed, even though he had imaging, was that with ultrasound, the tendon tears in different places so the tendon can tear in the middle. The mid portion, which is the most common the tendon can tear at the muscle tendon junction, to the soleus. And then the tendon can also tear at the insertion. So it can pull off the bone. So there's those three places . So this guy here had had ultrasound and they just looked at the mid portion they hadn't looked further up where he had his muscle tendon junctions tear. So you can miss them. Even when they do get imaging, they can be missed. So you've gotta be careful. I had a really interesting one recently. This guy's in his seventies as well, and he is got some comorbidities that we were just talking about. He's got diabetes. He's even had some surgery to amputate some toes because of his diabetes. So he, was in that group of people that was deconditioned after one of his surgeries. Got up and about after that, ruptured his Achilles. So then I saw him a few weeks after. And he came in with his imaging report from the radiologist and the imaging report said mid portion Achilles rupture. so I looked at it with with the scanner in the clinic, and he had a clear insertional achilles rupture. So the mid portion was completely fine, but the insertion was ruptured. I then took my images and I took a dynamic video just looking at what I was seeing there. And I, I checked it with a radiologist that I worked with David Connell really closely. and he confirmed this is an insertional. Rupture. So then I went back to the imaging place because the guy was really confused I was saying to him, look, you've got this, , insertional rupture. And then the imaging place was saying you've got a mid portion rupture. So we ended up clearing it up, but it took quite a few phone calls to sort that out.

It can be difficult to get a really good diagnosis and handle on what's going on with, with ultrasound if you're not careful and you're not looking carefully. so that was an interesting one. And it does matter where the injury happens because it influences management. So with the insertional ones, they are generally repaired. So generally people will repair those. now this guy here that I'm talking about, he didn't have surgery because he had so many comorbidities and he's got diabetes and et cetera. But he's now doing conservative treatment. But the the insertional ones are usually repaired. The mid-portion ones can be either repaired or they can be non-surgically treated. And we know now the trend is more for non-surgical because there's no real difference in outcome. Whereas the muscle tendon junction injuries are not repaired.

So they are not repaired. They cannot repair those, generally they don't do surgery for those, they are non-surgically treated. Okay. So there's, so it does make a difference for this guy. As an example where exactly that injury is.

David: Interesting. And you mentioned there about the different locations of tear and how that might impact whether they go down a surgical pathway or a non-surgical pathway. Are there any other findings or any other aspects of the tear that might make someone more or less likely to go down one of those pathways.

Peter: I think the, the main things that people look at are age and how active someone is. So if you are younger and more active, you are more likely to have surgery. They're the sort of main things, there's other things that rule you out of surgery. So say you've got , comorbidities, like we're talking about diabetes and things like that. , you, you've got poor healing, smoking, surgeons will look at all those factors. But generally the trend seems to be that a lot of people are going non-operative because we know that the outcomes are just as good with non-operative. But if they're younger and they're more active, then they're more likely to be repaired. So, for example, if you look at elite sport, most people in the elite sport context will have a repair rather than non-surgical. My, my advice to people is even with elite, younger, non-surgical seems to be as good in terms of outcome than surgery. I think people just have that feeling that surgery is going to lead to a better outcome. it's that real, , ingrained thought process of people that , if they have surgery it's going to be better. But I think the outcomes are probably quite similar.

Surgery versus non-surgery outcomes are quite similar. It's going to come down to how the rehab goes.

David: What about the size of the tear? Is there any, , cutoff If they're over, if they're around, you know,, 10 millimeters or less or more, does that impact whether they go down a surgical or nonsurgical pathway?

Peter: That is a good point. That's another factor. So the other factor that people consider is has there been a delay in presentation? So a delay in presentation will mean that people are walking around on this rupture.

And it might be that the, it's irreducible if you just put them in plantar flexion. generally the treatment is if you catch it early, you go into Plantarflexion straight away in a boot or back slab, front slab or a cast for two weeks and then you go into a boot whether it's a Vacoped or whether it's a moon boot, you're probably going to have a good outcome.

Getting it early is very important. because what happens is you start to get swelling in between the ends of the tendon and that swelling then forms a scar and you also get fatty tissue that goes in between the ends. So the sooner you can get it into a boot the better. So one advantage of the guy whose tendon I ruptured in my clinic was that he, he got it diagnosed immediately and we got him straight into the right position and he healed really well.

He healed in good position. I think there's a lot of reasons why people get elongation, but one of the major ones is delayed presentation. That's one of the key things that surgeons also look at, and I think that's important, and that's where imaging comes in. So generally, I don't advocate imaging because there's been a couple of studies in from the UK, and actually one recent one from Copenhagen, the Carter study, if people want to look it up, that there's a couple now that show that even if you do image and you base the decision on the imaging gap, it still doesn't reduce the risk of elongation. So imaging does not reduce the, the risk of elongation. we know that now from a couple of studies and trials. So I don't generally advocate imaging, but I do think that if someone has been walking around for weeks, they need to get imaging and they probably will do better with surgery.

David: Okay, so the size of the tear on imaging doesn't tend to impact like the treatment pathway.

Peter: Doesn't seem to, it doesn't seem to. So if you look at the study recently from. Copenhagen, they looked at, so basically their pathway was ultrasound examination, showing that the tendon ends could overlap if you went into plantarflexion. They also looked at elongation of greater than 7% in the tendon, and they measured that with ultrasound.

And if they had either non-overlapping tendon ends or elongation of greater than 7%, they went to surgery. And then if they didn't, they went to non-surgery and they found no difference in the outcome at the end of elongation. So I think that surgery is part of it and elongation at the start is part of it, but I also think that you can mitigate, the effects of elongation initially by good rehab. So I've seen in clinical practice people that sometimes people come to me at 10 weeks or 12 weeks and it's not too late, but they have some elongation already because I'll measure it with ultrasound. So I'll measure how long the tendon is with ultrasound and they have elongation that's substantial. But then at 26 weeks, six months, that elongation has gone down. you can reverse some of the elongation if you do the right type of rehab, I believe as well. So, so there are mitigating factors and elongation is complex. It happens at multiple parts of the pathway. It happens initially when they're walking around.

It can happen at surgery. if the surgery is not good, that can lead to elongation and and then that's also hard to reverse. It can happen in the boot if they're doing the wrong thing in the boot. It can also happen when they come outta the boot. It tends to happen right up until at least six months.

Some studies have shown that it might happen even up to a year. So elongation, we don't fully understand it. But it doesn't seem to be as simple as, okay, if they're long at day one, we're going to put them in the surgery pathway and it's going to be a better outcome. That doesn't seem to be the case.

David: You've brought up some really good points about elongation and you've mentioned particularly that that can be an issue. And sometimes when, , people have a physio hat on, they're thinking that some of the issues are often around restricted range of movement or restricted strength, and they're thinking, oh, maybe we need to, , stretch it to maintain their dorsiflexion .

So it sounds like, in actual fact that elongation or lengthening tend is more of an issue than , restricted dorsiflexion. Is, is that how it is? And tell us a little bit about elongation.

Peter: Yeah, yeah, for sure. Elongation is in my opinion, the biggest problem that happens with the achilles tendon repair. Risk of re-rupture is actually quite small. In the order of 2% to 5% in most good studies, sometimes it can be bigger, but generally if you are doing something sensible, the risk of re-rupture is actually quite small. What is more of a risk is elongation. Now everyone gets elongation. Everyone gets some elongation, but it should be small. So we're looking at depending on how you measure it. You can either measure it directly with ultrasound and then you get a, a millimeters of elongation measure, and you want to be within one centimeter of elongation or that's what I look for.

Or you measure it with something called the Mattels test, which measures if you put them just relaxed over the end of the bed. It's how their foot dangles, it's how one foot is dangling in more dorsiflexion. because they've got a bit more slack in their achilles and calf complex.

So they're the two ways to measure it, one's direct, one's indirect. So I track both of them over time and generally with elongation in terms of preventing it, which is what we want to do, I think the key things are you've gotta be in the right position in the boot. So they've gotta be in a good plantarflexed position in the boot. Now my go-to is to be a bit more conservative. So it's funny, I'm seeing at the moment one of the secretaries of a surgeon that I work with and that's been an interesting experience because he's a great surgeon. And she's a typical patient, not sure what to do, in the boot.

And she's now at six weeks. I saw her yesterday as well. And she was relaying to me that the surgeon thinks I'm very conservative. I. And that , he's , , wanting her to take wedges out and be a a bit more aggressive. My go-to is to try and keep them in the boot until some criteria is reached and, and my go-to is to have the wedges in for longer rather than shorter. If you look at something like the Willits protocol, which is a really common one that people would be aware of, that was one of the first what they call accelerated rehab programs. So in the Willits program, they try and get them out of the boot at eight to 10 weeks.

They get them mobilising full weightbearing pretty soon. , after that initial, , 2, 3, 4 week period, it's all based on how they feel. They get them outta the boot quickly. And they also take out the wedges quite quickly. So I think at week four, maybe you take out one and then week six and then week eight it might even be sooner than that.

I can't remember the exact days, but my go to at the moment is do anything for six weeks. Keep them in the three or four wedges. So five centimeter wedge for, for at least six weeks. Take one out at eight, and then take one out at 10. And then keep the last one in for the duration till 12. the other thing I try and do is have a criteria for, for getting out of the boot. when they're getting out of the boot, they should be able to push through plantarflexion in a seated position around about 70 to 80% of their body weight. So that's my criteria for getting out of the boot. So some people will stay in the boot for 13 weeks. Some people will stay in the boot for 11 weeks, but obviously you don't want to keep them in the boot for say, 14, 15 weeks, because then they'll get a lot of atrophy. So if they're getting close to that criteria, I'm happy to take them out of the boot. But I think it is important to have some criterion to say, okay, you're getting stronger. so, so one of the things that I've done over the last, five or so years progressively has got a little bit more and a little bit more, a little bit more aggressive with them in the boot. it's just been an experience thing, just trial and error, seeing how they go. And they generally respond quite well, but we get them into planner flex positions, what I call safe plantarflexed positions where there's something under their heel. They're sitting down with their. with their thigh parallel to the ground, their tibia is vertical. they've got something under their heel, like a weight plate or a couple of books. So their heel is raised by about an inch or an inch and a half. And then they start to raise into a calf raise and they just hold that position. So initially they're just holding without any weight at all. and then you start to load them. you start putting weight on their knee and it might be five kilos initially, then 10 kilos et cetera, until they get to around about 70 to 80% of their body weight. Now, at some point what we do is we transfer them into a Smith machine where they can do the loaded because at home you're limited to about, say 30 kilos safely of putting weight on your knee. So we transfer them into a Smith machine. So that's been our program over the last little while, and that's, that's a key, key difference to all the programs that are out there at the moment. It's a lot more progressive, so I often have to, and this is, this is where, coming back to the conversation that we had with a surgeon who's the surgeon is sort of saying that I am too conservative.

But I think in a way, when you look at the loading in the boot I'm probably more aggressive than what a lot of people are at the moment. because in the boot, what you tend to get is people doing theraBand plantarflexor type contractions or even active movements generally in the boot. So I try and go a bit harder with the plantarflexion in safe positions initially. But I'm a bit more conservative when it comes to walking because I think the walking is the thing that's going to be more likely to get elongation. So that's a summary of what I try and do when they're in the boot.

David: That's fantastic clarity and, , nice progressions for people to give ideas about, , why you might be interested in preserving the wedges in there so they're not getting that elongation. And then how you actually load them up.

You mentioned there that you're doing the holds, how long do you get them to hold for and what are your guidelines to the person about what's a safe load and how do you identify that safe load and uh, when to progress?

Peter: Yeah, yeah, it's a good question. So people can be quite anxious about it. and the first couple of times I did it, I was quite anxious about it as well. because , you think how much load can this actual Achilles sustain? but then you start to get the confidence, because you start to think in this plantarflexed position, it's actually quite robust and it's actually quite strong because you're, , the tendon's not elongating. And the trade off there is that you're not putting as much strain through the tendon. So there's not as much stimulus for the tendon to adapt and to heal, but you're still getting enough stimulus and enough load through it to have some signaling and mechano transduction to get a bit stronger. So I guess there's a lot of reassurance initially just to make sure they're comfortable and safe getting something under their heel making sure they're comfortable with something over their legs.

So they've got the weights on there and they feel comfortable. So it's, it does take a bit of time. I'll spend a whole session just going through the right position and teaching them what to do so they can go home and replicate it. And then I also get them to take a video of exactly what they're setting up like at home. because the last thing you want is for them to go into dorsiflexion. that's what I try and really drum into them. You don't want to put your foot into dorsiflexion, so you don't want to put the heel back. So you've gotta set yourself up in the right order and make sure that they are in plantarflexion, that safe position.

So I think anything in plantarflexion is fairly safe. They're not going to do any major issues in plantarflexion. The reason we have something under the heel, just in case they get fatigued and their heel drops, make sure there's not a sudden dorsiflexion. We try and build that up really gradually, really slowly. The receptionist of the surgeon that I'm seeing at the moment, she's onto now 30 kilos. I saw her yesterday. So she's doing really well. So I transferred her yesterday onto the Smith machine, and she works in with us. So she's going to be able to go down and use a Smith machine. And all they need to do is generally they'll do three times a week with the Smith machine. Once they get to 30 kilos she's doing 20 second holds. You can do 30 second holds. Generally 20 to 30 seconds by five is what I go for. And trying to get them to 70 to 80% of their body weight. So 20 to 30 seconds by five. They'll do that three times a week. Now they'll also do some loading at home. She'll continue to do some lighter loading at home with as much weight as she can because it's lighter at home. She'll probably do that loading with the, , increased duration. So she might go to a minute, and do that a few times. Generally it's once a day, but because some of the sub maximal loading that they're doing at home, it's not that, , high, it's not that taxing in terms of fatigue. We can do that a couple times a day as well at home. David: And when to progress the weight? So you're thinking, okay, we, she start off with, , body weight and you've gone to five kilos. When do you think, okay, we can progress here to 10 or to, how do you tend to progress that?

Peter: Yeah. So look, it's all based on initially how they feel. And one of the things I try and relay to them with the reassurance is that it's, it's quite normal to feel some sensation around the healing Achilles. So that's quite normal. It's okay because a lot of them will be super sensitive and super , on alert about any sensation from that Achilles tendon. So it's quite normal to feel something. what's not normal is sharp pain. So if they're getting sharp pain, that is localised, that's a problem. We give them that reassurance. Generally they'll start to feel the calf working. It sometimes takes a little bit of time because the calf hasn't been working very well, just to activate the calf and get a little bit of sensation and feel so they'll start feeling the calf working. And they can then start to do that at home and make sure that they're safe and they're not overloading, but generally that , , reassurance about, it's fine to be a bit painful. It's okay if you're feeling something in that area is, is very, very important. I've gone off track, I think, what was your, what was your question, David?

David: I think you've stayed on track. Think that's it. But I was mostly interested in, in your progression criteria and , when it's okay. So you've definitely covered when it's okay to load and what they should feel. But tell us a little bit about when it's okay to progress them.

Peter: so, basically the pain is part of it. So as long as they're comfortable and it's, it's still that minimal small amounts of awareness they're getting, that's absolutely fine. They can still progress. And then it all comes down to how much load they can actually sustain. that rep range and that amount of time. So my advice to them is, and this is what I said to the lady yesterday you are doing 20 to 30 second contractions now. If you can get through your five sets of 20 to 30 second contractions and you feel like you can do more after the next time, the next session, you're going to add some weight to that. Okay. And even if it's two and a half kilos onto the Smith machine or five kilo onto the Smith machine, add some weight and see how you go. And sometimes they'll add weight for just the first or the second set of those 20 seconds and just based on how they feel. So it's a very incremental increase of weight based on really how they're coping with the exercise. David: How soon after the initial injury do you actually start to get them exercising into plantar flexion?

Peter: good question. I tend to go quite early. And that's again, something that has got a little bit more aggressive over the years that I've been doing it. So initially it was probably, , five, six weeks. Now it's more like three, four weeks depending on how they're going, how they're coping, how they're feeling, how the scar is feeling if they've had surgery. So there's a few factors to consider. I usually start them off with just a isometric push. So I'll get them out of the boot get them not any weight and not weight bearing, so not seated. just pushing their toes down. And they're holding that for 10 seconds and then relaxing, doing it 10 times. Once they're used to isometric, pushing without any weight, then we start to progress and we get them to seated. So that could take a isometric push could start at week two. Okay, so, so pretty soon I'll start with that. The other things that I'll do is just some range of motion. So inversion, e-version as well, in that early phase, I don't really do a lot of TheraBand, so most of the protocols talk about TheraBand to do plantarflexion. I don't do a lot of Theraband, I do the seated work, so the, the seated in at home or in the Smith machine. What else do I do in that early phase? I try, I generally avoid doing things into dorsiflexion. That's a really important part of that, overall management, but especially that initial management. So I think you alluded to it before, a lot of people are quite concerned about flexibility. And not, and making sure that, , people are not getting stiff when they're, when they're in the boot. Most people don't have a huge issue with flexibility though, so most people, once they get out of the boot they start to walk a bit.

They might be a bit stiff initially with knee to wall and dorsiflexion. But it's not really something that lingers for a lot of people. So it's, it's quite rare for people to get , a joint contracture where they have , a real stiff ankle that's quite, that's quite rare for an Achilles rupture.

So I, my advice is, don't worry about dorsiflexion, it will probably just come over time. It improves over time as you start to do over the step calf raises, which I start to do generally a few weeks after. They've come out of the boot. So coming out of the boot is a key time . You want to protect their gait. They don't want to be walking too much. So volume of walking is important, but also protecting the way they walk. So small steps, still using the boot if they're walking a long distance or , using some support if they're walking a long distance, making sure they're wearing the right shoes, heel wedges. so I do that for a good few weeks after whilst they're developing single leg strength ability to single leg calf raise. once they can do a single leg calf raise and they can do a few of those, then we start going into negative territory with dorsiflexion. At that point they've already been doing a little bit of walking and the dorsiflexion looks after itself.

You don't need to worry about dorsiflexion very much. David: So when you're looking at the, the dorsiflexion range and you worry about elongation, what are some of the risks of actually having an elongated tendon, and why is that a problem? Peter: So with an elongated tendon, it basically, there's a couple things that happen. So if you think about, think about the tendon and muscle in series so you've got this achilles tendon, you've got the fascicles of the gastroc and the soleus. So if you, if you have the tendon being longer, that means the fascicles are operating at a shorter range. So therefore they're less efficient. And what happens with a lot of people when they first come out of the boot is they get a lot of fatigue with calf raises. Even just a two or three calf raises is enough to fatigue them. And that's because of the efficiency of the muscle tendon unit. So it's not working at its optimal length in terms of the fascicles. So there's some evidence that that adapts over time. So what that means is you've got sarcomeres in series, so the muscle sarcomeres are in series and the muscle reduces the number of sarcomeres in series over time. And that then reduces this effect of less efficiency of the, of the fascicles. So, so that happens, but that's a slow process and that probably takes a year or two. in the meantime, you have this really weak, inefficient calf muscle. So you can't really walk long distances without getting tired. Your tendon is overstretched and therefore not efficient at storing and releasing energy. So it's just not a very good and efficient situation to be. And we know there's really strong relationship between the elongation that people gets and also their strength. So people who are elongated are much weaker and find it a lot harder to then develop some of the calf strength again. David: So sometimes in physio we think about increased range being a great thing, but in this case, elongation, they've got more resting dorsiflexion. It just sits in a more dorsi flexed position, and they've got a less efficient calf and muscle tendon unit. And so functionally what's you mentioned, they're often weaker.

Any other functional issues they have with that , elongated tendon?

Peter: Yeah. So they do, they do have a lot. If you look at them hopping they will hop in much more dorsiflexion. So then the heel will touch the ground sooner. They just can't develop power as well. If you look at them calf racing, they're not going to get very high. they've got very low heights with calf raising. Some people, I've seen some extreme elongation, like really? And, and this is what we're talking about before, elongation happens to everyone. So everyone's elongated to some extent. You don't escape elongation after an Achilles rupture, but you can minimise it. I've had a couple of people who almost have no elongation, but that's quite rare. So my advice to surgeons is always, if you can make it as tight as possible, if they're going to have surgery uh, that's going to help in terms of the long term elongation. Elongation, affects everything they do in terms of strength, in terms of how much they can calf raise in terms of power. The extreme ones are unable to do a calf raise. If you have extreme elongation, so you've heard about the surgery that people do, where they they elongate the calf muscle when you've got real tight calf, like equinus of the calf. Now some people that in historically that was used as a treatment for things like, , plantar fascia and things like that, if you've got a really tight calf, lengthening the calf muscle, basically. I had, this is just an example of an extreme elongation. I had one one girl who was just in her thirties and she had she had undergone this procedure where they'd lengthened her calf muscle and it just became too long. She ended up not being able to do a calf raise at all. So she was unable to lift her body weight. and that was a real difficult thing to overcome for her. So we did a year of rehab and she did get to doing a calf raise and she even got back to running, but she was always going to have a limitation of calf strength. Because if you think about the muscle tendon unit, the only place these people have strength is in extreme, extreme dorsiflexion. And this is what I do to test them put them into a position where they're leaning on the wall and their foot is about a meter, meter and a half away from the wall. So they're in full dorsiflexion and get them to do a calf raise and they can do a calf raise in that position. But if you get them to stand up straight as we usually. Test people for a calf raise, they're unable to do a calf raise. So they, they have this muscle tendon unit that is only able to function in that extreme long position. So it's not functional at all. So it's a real, it's a real problem if you get someone, I've only seen a handful of people who were young and at a point where they're probably going to have a permanent, problem with their calf because of elongation.

I've got one guy at the moment who came to me probably about 12 weeks after getting outta the boot, and he's got quite severe elongation as well. And it's just hard. It's hard because it takes a long time to get back the function they need in dorsiflex, in plantarflexion. So I do a lot of stuff where I do isometrics in very inner range positions where they're right up on their toes. I do isometrics in flat positions. I do isometrics in dorsiflex positions, just to try and recover. Strength. But initially, and this is what I was talking about before, I, I believe you can reverse some of the elongation for some people, especially in the early phases when the tendon is still really pliable and still healing. You can reverse the elongation if you do a stack of loading in an inner range position. So you do stacks of stuff inner range and it starts to stiffen up the tendon. And I think you can reduce some of that elongation that we see. Whether that is a long-term short-term thing, we still haven't a handle on that. But I've got a couple of PhD students now who are doing Achilles rupture type projects the first thing we're going to do is test the way that we do it in the clinic, our rehab protocol for Achilles rupture in a pilot. And then hopefully go to a full scale trial after that.

So that's going to be the first thing. But we're also testing a bunch of other things like elongation and how elongation goes over time. And, what factors relate to elongation? So it's at Ortho Sport Victoria, where I work now, we've set up a, it's almost like a specialist rupture clinic with myself, some PhD students and some other staff that are there. Ortho Sport Victoria is a, clinic owned by surgeons in Melbourne and some physios and other people. They've historically done a bunch of ACL testing. So it was perfect for us because I started work there a year and a half ago, and they were doing all this ACL testing.

They had all the equipment, like all the valve force plates, 3D motion. So now we just do similar stuff, or we're starting to develop processes for Achilles rupture as well. So people come through and get tested ultrasound of, , the length of the tendon and healing over time. But also they get all their rehab and performance measures like hopping strength measures, et cetera.

David: Yeah. Perfect. Your aim or clinical reasoning is that by targeting that inner range plan flexion strength, that potentially you can improve the efficiency or maybe help to , decrease the elongation of the tendon by getting the strength up in that range, and particularly targeting with a bent knee, like you're looking more around that, that soleus rather than gastrocs or rather than with the knee extended.

Peter: I do mostly bent knee when they're in the boot because it's just easier for them. because you can add weight based on how much they can do when they're at, as soon as they're out of the boot, I start standing and it's usually double leg to start with and then they progress quickly. So one of my key progressions is standing isometric in different positions with double leg using scales to make sure that they're weight bearing as much as possible, as much as they can tolerate on their affected side and getting to full weightbearing.

So a good progression target is you are able to get them on their toes, putting their full body weight through their Achilles. so that's, that usually happens if everything's going well, within two weeks of post boot removal. That's a really good outcome. So then they can start to do a lot more in standing.

So then I've got the standing stuff going, the, the seated at the same time. Back to your initial point with that, I do think that the tendon we know is so moldable and there's a lot of still mechano transduction and adaptability that's going on the tendon for about a year or two. So if you follow it, if you track it with ultrasound you see that the tendon just looks like mush. I used to work with a radiologist in. London, Otto Chan, and he would say that the tendon looks like a dog chewed it. And that's like that for the first six months, and then it starts to look like a normal tendon with, parallel alignment of fibers. To get to that point, it requires a lot of signaling to tell the tendon that it needs to, the cells need to align the collagen in parallel to the force. So you need to put the force in consistently for that signaling to occur. So I think it's a very adaptable tissue if you give it the right signals. And most of the time what we see is when you see these people a year down the track, they've got a really strong tendon, and their tendon on the affected side is actually stronger than their unaffected side and really stiff. And it's, it's not going to be a problem for them. because they really worry about it happening again. I had one guy, it was probably one of of the worst ones that I've seen. He came to me I think about two years into his rehab and he had suffered three re ruptures. Already. So he had had surgery, re ruptured. He had a skin infection, which didn't help as well. So he had ended up having a skin graft. he then had another surgery. Re ruptured. He then tried conservative and it re ruptured again. And then he came to me and he was, in his thirties wanting to get back to basketball and has young kids and had been told by the surgeon the last one that he would never be able to walk again without a limp, let alone go back to basketball. so we basically just went through the program that we do from scratch again, ended up getting a good outcome. He ended up going back to basketball, took ages, but he, he got there. Then two months after I. He went back to basketball, he ruptured the other side. And this goes to, can you prevent Achilles ruptures because we were doing all the heavy loading, all the stuff you need to do to that we think would mitigate the risk of rupture on the other side. But he's still got a rupture and his tendon looked good on that side as well. So, , if you asked me can you predict a rupture, I'd probably have to say no. because I mean, someone with a fairly healthy looking tendon who's done stacks of loading still got a rupture and there's probably a deconditioning element because he hadn't got used to that maximal, maximal, maximal, even though we did maximal plyometric progressions. He probably just wasn't right at the point where he needed to be. For some of the things he was doing on the court, but I guess the point that I'm trying to make there is if you rehab an Achilles, because it gets so thick, it's not going to rupture again once it's rehabbed, the other side that might rupture and that's the problem. It's a bit like ACL in that way. There's a strong genetic component to it.

David: What a nightmare for that poor bloke.

Peter: Mm-hmm.

David: Yeah. And why do you think it, uh, rehab was successful on that third, do you think it was that the surgery hadn't had, comprehensive rehab through the first couple of surgeries? Or was it that he managed that in the third one? Or what do you think was the, the factor that made the difference there? Peter: I think based on what he was saying about his prior rehabs and what we had been doing, I think it was just a case that we, we were using criteria and were progressing him really a, a lot more intensely than he was before. So a lot of people will, , as I say, do the TheraBand in the boot, do lots of standing work, maybe with a bit of load when they come out of the boot. Whereas we were getting him to do calf raise in leg press machine in seated calf raise, standing calf raise, Smith machine. He was doing all those progressions. He progressed to adding faster concentric movements. He progressed to plyometric work, he was doing just a really good, solid rehab and he was focusing on inner range initially.

So some of the things that yeah, we've talked about before, I think were different to what he had done before.

David: So when patients ask you, am I likely to be able to get back to be able to play explosive sports or get back to those sort of things, what's your normal response to them?

Peter: Well, it probably depends on how on what stage they're at and what they're like. so for example, say the guy I saw yesterday who's come from the Alfred. He's one of those guys who's super conscious about his health and wanted to do the right thing. And he's followed the instructions. And I said to him yesterday, he's got almost no elongation. So he's, he's really healed in a really good position, and he's six weeks. So for him, he asked me that question. I said to him, you'll have no problem whatsoever. He wants to get back to racket sports. So paddle, Tennis and squash he'll have no problem. He's young as well. He is 39. But the other guy that I was talking about who I saw six weeks after removal of boot, and he's got stacks of elongation that is more of a borderline one. So you just gotta see how the rehab goes with someone like that. So he really has a lot of work to do. to get as much function outta the calf as you possibly can. And it's a mental battle and strain for them because you see them coming back and they're doing all this calf work over so long and the benefits are just so incremental and so small. It's a motivation thing as well for them. some people just can't really keep up with it or just lose track after a while and they won't get a good outcome. And that's probably why if you look at elite sport, if you look at the percentage of people that return to elite sport after rupture, it's quite small. Most of them do, it's more than 50% that return, but in some studies, up to 30, 40% will not return after a rupture. And that's partly because they're older. So it happens when they're in their early thirties and they're towards the end of their elite sport career. But also it happens because some will get suboptimal healing and elongation, and they're just not the same athlete as what they were before. So it's really important to make sure that we, are doing as much as we can to reduce elongation. David: When they ask you if I'm able to get back to sport playing basketball or soccer or whatever it might be, and they say, how long is it likely to take me, if everything goes well? what's your normal responses there?

Peter: Generally around about six months they can start to do a little bit of plyometric running. Generally around nine months they can start to get back to training. Generally, generally around 12 months they can start to be really, really able to return to sport. But you know, a lot of people in elite sport will try and, , reduce the timelines and they can.

There's obviously reports in elite sport where people have got back sooner as well, I think that's fine. The risk there is that they will go back and they will have less strength. They're not going to be as, as powerful. Their performance might be a bit lower. So, yeah, the, the famous one was Aaron Rogers.

He was quite old. He was 38 or 39 when he ruptured his Achilles. He was doing all this stuff to try and, get himself back. And he just committed so much time to, it was doing all this, , additional stuff and all this rehab. but it still ended up taking him 12 months to get back in the end. And maybe that was partly because his team didn't actually make the playoffs, so there wasn't as much pressure. but it did take a while. There's no shortcuts to achilles tendon healing. It's going to take time to get a strong tendon.

David: And how do those timeframes compare when you're looking at, , conservative or non-surgical versus your surgical management? Does it, is there a difference there or are they both gotta work through the similar process and, and with similar timeframes?

Peter: Pretty much identical in, in my view. Yeah, pretty much identical. Some people say that with surgery initially you can push them a bit harder because you've got the surgical sutures there and the sutures can take up to 30 or 40 kilos in themselves. Some people say you can push them harder, but I do identical rehab for both. So my rehab doesn't change and I think because it's in a safe position, I'm happy to load even the ones that are treated nonsurgically , from an early time point. I Don't think it makes a huge difference. And therefore then the outcomes, because the rehab is the same, the outcomes are also similar in terms of time.

David: Beautiful. And I just want to step back a few steps because we've explored some awesome parts of the, the rehab process and the recovery and return to play. But I want to just come back a little bit more to some of the factors that we slightly touched on earlier, which was around the assessment and some of the diagnosis and misdiagnosis.

Anything else you want to add before we move back to the assessment stuff about that rehab?

Peter: No, I think we've covered a lot of bases there. Yep. Happy to talk about assessment.

David: You mentioned sometimes patients still have some active plantarflexion. So a patient comes in and they report that common mechanisms of injury that you discussed earlier, then you are working through your objective, you're suspecting an achilles tendon rupture, what are some of the tests that you're going to do to help to identify it and to rule out some of the other potential differentials?

Peter: Yeah. So there's three things that are really important to do. One is Matles test or the, the way that the Achilles rests when you have them lying over the edge of the bed. if you look at the angle, it should be in a bit of plantar flexion because there's a bit of tension in their calf. If you see that one foot is in dorsiflexion, that's pretty much a giveaway and most people will have that. the other one is palpation. So you palpate for a defect. Okay, that's quite useful. The, the last one is the Thompsons or Simmond's test. And that really is the classic one that most people do. But that can be misleading in some people. And you gotta be careful. because if you, if you've got someone with not much calf bulk, you're probably pushing on their deep, long. flexors as well. And that might give you a negative on the Thompsons test. So you've gotta, yeah, you gotta think about all those things together. The other thing is gait and push off. So just look at them, , try and look at them walking. You don't, if you suspect it I'm not going to get them up and do a calf raise, because you want to try and reduce the amount of load going through and put them in plantarflexion as as quickly as possible. But if you are, if you're not sure, you might look at that or just observe them when they're coming in off in the waiting room. If they haven't got a push off, that's, that's also a giveaway. There's also the mechanism, which is quite important. So all the stuff we talked about earlier with that dorsiflexion mechanism that's also very, very important. That's usually quite, present and quite characteristic. The other thing you can go to is then imaging.

So ultrasound, if you've got access to it in your clinic or , MRI looking at soft tissue imaging for the tendon. But, , generally you don't need imaging to diagnose an achilles rupture. You can diagnose it just on clinical based on the history and based on some of those tests as well.

David: With Matles test that's performed, your got them prone . Peter: Yeah, so Matles test, the classic one is you get them into knee flexion. So you get the knee flexion and their shin is vertical, so the shin's vertical. And then you just make sure that the foot is nice and relaxed. And then you measure, I put an inclinometer on the top of the foot and it measures the angle. So say on the good side, it might be 17 degrees, so 17 degrees of plant deflection on their affected side it might be 10 degrees. So they've got seven degrees of deficit of that plant deflection. So that, that would be an indication that there's something going on there. The resting angle varies a lot as well.

Some people have, almost no resting plantarflexion. In those cases, there's not much of a difference between resting and the affected side. So that can also be a little bit hard with some people, but generally it's a more sensitive or more reliable test than the Simmond's or calf squeeze.

David: And that's without any pressure. You're just basically resting that inclinometer on the foot and just assessing that with the angle rather than any pressure

Peter: Exactly. And you can also do the same just lying over prone with a feet dangling over the edge of the bed. the only difference is you're picking up a bit more you're picking up a bit more gastro there the gastro is on a bit more tension. So you can do both. I generally would do the knee flex one primarily. David: Yeah. Okay. And then so say your, your patient comes in. They've had that history that's pretty common with the achilles tendon rupture. You've done those tests and you suspect now that you're pretty confident that they've got an achilles tendon rupture. You've done Matles test and it's got increased dorsi flexion.

You've done your, you've palpated and you can feel it, maybe a defect and maybe your Thompson's test is, is positive. So you've got, you've got a bunch of strong positives. You're thinking, yep. Okay. We're, we're likely to have this here. What's your first stages of management there in the clinic?

Peter: The first stage of management is lots of education. So it's like okay, this is the, this is the pathway, this is what's going to happen. Then it's a patient-centered decision around treatment. So surgery versus non-surgical. Then it's education around most people say, look, I want to see a surgeon anyway, for an opinion.

And I, and I encourage that. I think it's very important to involve a surgeon just to say, look, get an opinion. , They're experts in Achilles ruptures, so see foot and ankle surgeon. So then the next step would be into a boot. Make sure the boot is fitted properly and it could be a Vacoped, which is the hinge boot, or it could be just a moon boot.

As long as they're in the right amount of plantarflexion. Some people, if you're in hospital, they go with like a cast. So initially for the first two weeks and non-weightbearing, but I don't think it matters too much if they're in a boot as long as you're in the right position. The other huge bit of education is around what they should be doing. So making sure they're not weightbearing in the boot initially. Making sure they're keeping the boot on all the time, including when they sleep. Some people will say, take the boot off at night. I tend to tell them to keep the boot on at night. because I think things can happen when you're sleeping and moving around. Then there's education about walking with crutches, like, , gait how to walk with crutches. There's education around activity, keeping active with whatever aerobic and other stuff they can do. , keep making sure they're doing anything they can for the other side. so there's all that stuff that I try and cover in the first session. There might be something for swelling so some ice coming out of the boot. There might be something for maybe some compression, depending on how much swelling they have around the ankle. That can vary as well. And it can be, swelling can be an issue , that stays with them for. , a few weeks after the rupture as well, sometimes even after they've got out of the boot. so that, , often related to being on their feet a lot. So ed education about that as well. so there's all those things that I'll try and cover pretty much day one them.

David: You get them into the boot and you give them all that education. You talk to them about the surgical versus non-surgical pathways. And what's your, your advice to patients that are thinking, oh, I don't know if I need to see a surgeon. Would you manage them yourself or do you say you, you really should be under somebody? Particularly what's your, your general advice there?

Peter: My, is always give them the option to see a surgeon, and I encourage that because I think it's important to involve multidisciplinary team. There might be something you've missed. There might be something about that particular case that might be more amenable to surgery or, so I, I would always get the surgeon's opinion, or at least offer them if they, if they say, look, I really don't want to see the surgeon, that's fine. But that's the way that I would approach it. it's also good because then they've got the surgeon's protocol and the surgeon will then come back and they'll say, look, this is the protocol. And you can, , work together and try and individualise that protocol with them. Often I'll have a conversation with the surgeons to say, look, this is the protocol, but we're going to try and accelerate a bit by doing this type of loading. So some of the seated calf raise loading that we've talked about and maybe accelerate some parts and try and slow down some of the other parts.

I think it's good to have a conversation, with them about that. My go-to is to always get someone else involved as well. David: Imaging wise, do you find that you will tend to request imaging or you they go see the surgeon, the surgeon requests imaging, or how commonly is imaging used and what are the best types of imaging that you've found for that?

Peter: Yeah. So look the most common one because it's so accessible is ultrasound. People will tend to look with ultrasound and, and it's, , it's fine. It will pick up a rupture if, if done by someone who knows what they're looking for. So ultrasound, if you need to confirm the rupture, but it's really in cases where you're not sure if there has been a rupture or if you're thinking this person's been walking around, he's been missed for a long time. Let's see what's going on. To see how much how much retraction of the muscle there has been. So it's in those, it's in those cases that you generally would go for imaging.

David: Lovely. And do you notice with the ultrasound that there's any, , misdiagnosis very commonly or, that there's errors within it?

Peter: It's a bit of, look, it is a bit of an art more than a science ultrasound. So for example, , people talk about the gap, but it's not clear. Everyone's got different ways of measuring the gap and where does it start and where does it finish. some people do dynamic ultrasounds where they go and plantarflexion and see the opposition. and again, how much plantarflexion do you go into? What position is the foot in? So there's all these variables that are not clear from the literature. But I think if you do a good ultrasound dynamic assessment, you can pick it up. Sometimes you see there's a few fibers hanging on, like a partial tear. and that, and that would be a case where you won't have a positive Matles test and you won't have a positive Thompsons tests either. So, so you can see some of those cases and that's where ultrasound can be quite useful. because you're thinking this guy can't really do a calf raise, but he hasn't got any of these positives for any of these other tests. So then that makes it a little bit clearer when you look with ultrasound.

David: Lovely. And there's just two, two final things that I want to chat through with you before we we wrap this up. because we've covered a lot of great stuff. So timeframe. So if someone comes in and they've, acutely ruptured, they've got, , lots of options on the table. When they come in and they're a little bit down the track.

Maybe it's been a while, it's been missed, how does that impact their treatment and their treatment options?

Peter: Hmm. So generally if they're down the track a bit, it will be more important to go and see a surgeon and have imaging. So definitely get them to see a surgeon. the other good thing about imaging, actually, which we haven't touched on, it does localise where the tendon rupture is. if you've got clear, clear palpation of a defect in the ropey part of the tendon, you don't need imaging. But if you can't feel that, but they've got all the signs of a rupture, most likely it's an insertional or muscle tendon junction rupture. And they will then need imaging to confirm that. So that's where imaging can also be important. Make sure you do imaging if you're not getting that palpable gap. Yeah.

David: If they've been a delayed presentation, then you're going to send them off to the surgeon to just make sure we find out what their best options really are. So I think that that answers that really nicely. And, finally, just when you know. We're looking after patients, whether they've had surgery or a non-surgical pathway. What are some of the things that people need to keep an eye out for when they're going through their rehab process? That potential red flags or things that could pop up that we need to be aware of?

Peter: Yeah. There are a few complications to consider. So the, the most common one is DVT. People will get a DVT because they're just stuck in the boot for a while. So making sure they're not getting any symptoms and signs of DVT is important. Surgery does have more complications than non-surgical, so you've got things like obviously infections and you've also got nerve damage that can can occur after surgery. So just, , being conscious of those complications look, checking the wound and checking healing of the wound is important after.

The complications that happen more commonly with non-surgical are re-rupture. So with non-surgical, and this is a contentious debate topic people do have reported in the literature pretty consistently that there's a bit more re rupture with non-surgical, but it's very, very small. So this is what I explained to patients, and there's a really good patient decision aid actually by Josh Zaro from Sydney Uni, which is about the decision of whether people should have surgery or non-surgery for Achilles tendon rupture. it goes through all the risks, but the key one to consider if you're going non-surgical is that you have a higher chance of re-rupture. But the chance is, I think it goes from two out of a hundred to five out of a hundred. So it's still quite small. and when you put it in those terms, most patients are happy to take that risk on. they're then reducing the risk of some of the other things that can happen from a complications point of view.

So, so they're the main ones. And obviously elongation is also a risk, but that is the same, regardless of whether you have surgery or you don't have surgery. So there's no difference in elongation with any, anything in the literature. Pretty much, , people have been looking to try and do things to reduce elongation for years if not decades.

But there's really nothing that we know of at the moment that can really reduce elongation. so we don't have a good handle on it. And that's where all the accelerated rehab stuff came into it years ago. The Willet's paper we've talked about, that was the first one in the early 2000's, the whole rationale behind it was to reduce elongation and improve outcomes and, reduce re rupture. But it didn't do any of those things. Unfortunately. It's all the rates were exactly the same. So accelerated rehab basically means accelerated walking, coming outta the boot, which does not help elongation.

David: You brought up a good point there, because that was actually one of the things from, , early on in the interview where you, you brought up one of the questions that, patients ask therapists, it's how much walking can I do? And they're often not sure how to answer that. I said we're going to wrap it up, but I think we've actually got two more questions that are, and one of those is about that walking and how you can guide patients on that.

Peter: Yeah, yeah, no problem at all. As soon as they get outta the boot, my priority and the patient's priority is mini minimal walking. And what I call protected walking. So protected walking is small step length wearing really good high shoes wearing the heel wedge, all that stuff. And I just progress based on their comfort.

Usually they'll get a lot of calf cramping, fatigue, soreness, and just progress gradually. So they might progress a few hundred meters or, , a little bit longer. I tend to track either how far they're going in terms of meters or steps. So it's quite fine for them to progress up to, , two, three, 4,000 steps in the first six weeks.

But I try and put a cap on it. And the reason is if they're walking too much, that's when elongation occurs. So if you think about what usually happens when you go to the surgeon at 12 weeks, the surgeon will say, or even at eight weeks, if you're doing the Willits program, the surgeon will say, right, you're outta the boot.

Off you go. You don't need to worry about anything. And that's usually the advice they get from the surgeon and that's why surgeons, if you really talk to them, they love working with physios, who have got some more advice around that because they usually say, go to the physio. The physio will tell you what to do. And they, they want us to fill the gaps in terms of what to do after. So, so then the patient comes to me and says, the surgeon said to me, just go off, do whatever you want. And I say to them, right, just, let's just let's just slow that down a little bit. We'll start with a little bit of walking and we'll progress gradually. I think it's the elongation happens when people are gung ho. They come out of the boot and they think they can do everything. So that's a key, key risk time for elongation. So that's also a very important education point to tell patients that we've got to slow them down around that point.

David: Finally, when you've got patients that've come outta the boot and you are, you're progressing through their rehab and you talk through some nice, , ways that you guide patients while they're in the boot and, and into that inner range plantarflexion and in increasing their plantarflexor strength, after they come out and you're starting to get them working into more isotonic exercises, what sort of sets and reps do you help to guide them with?

Do you tend to have a go to that you tend to use with patients? Peter: Then it becomes a bit like Achilles tendon rehab, it's a bit like a strength and conditioning type approach. I'd try and build some endurance. I'd try and build some higher heavy load strength with six repetitions type dosages. I'd try and do that two or three times a week. We'll get to one leg really good strength, and then we'll put in some power after that. So it's just your structured rehab after that. It's and yeah, that's, that's the, the process. It becomes very similar to just looking at an Achilles tendon in terms of recovering strength.

David: Are you worried about, , targeting hypertrophy specifically, or are you just, if that comes, if it comes, or what's your thoughts there?

Peter: Yeah, I think hypertrophy I would. That is a real, that's important, so I'll include some dosages where initially I start eight to 12 repetitions, then work down. But we also know that hypertrophy will still be there most likely, pretty much forever.

Just like the tendon's going to be thicker for pretty much forever. Although if you look at them two or three years down the track, the tendon's almost, almost looking healthy for some people. It's much thinner and and really healthy, so it's amazing how it can recover. But we know that achilles tendon is so complex. You've got the sub tendons, you've got the tendon from gastroc medius, gastroc laterals.

You've got the Soleus tendon, they all intertwine and you're never going to reproduce that in a ruptured Achilles, so you're never going to get intricate tendon arrangement and hierarchical organization of tendon back again. But you can get a functional tendon that is working well. just like you can get a functional tendon that looks not very good on ultrasound. so it's, it's amazing how adaptable the tissue is, I think the problem we have at the moment is we just don't give ourselves long enough to rehab things like this.

David: And I think that's a great place to wrap it up. Are there any sort of key messages that you want to reinforce for people that are seeing these.

Peter: My message would be uh, have that dialogue with a surgeon. Involve people and think about the tissue healing, think about tendon stress. Think about what's going to get those tendon cells to start to signal that this needs to be a tendon that we're going to get stronger again, and putting some load through the tendon a little bit earlier.

So I guess take home messages, load more in safe positions, but delay the walking until they've got a stronger tendon. David: Perfect. And that's that's lovely. It's been a fascinating chat. We've really explored a, a lot around achilles tendon ruptures and it's, obviously some exciting stuff going on within the space, and it's great to see people applying that clinically and seeing where to push and what, what makes sense clinically and how to target those deficiencies and the elongation that that often happens.

So it's been really interesting chat. Really enjoyed it. Tell us, Peter, where can people find out more about what you've got going on and , that sort of thing.

Peter: Fantastic. Thank you so much for having me on. David, it was a pleasure and that one and a half hours passed very quickly, so that's good. I, I guess the main thing is if you've got an Achilles rupture, I. If you want to get in touch, we do our Achilles rupture service at Ortho Sport Victoria in Melbourne. If you want to learn about Achilles ruptures or Achilles or just tendinopathy in general I've got online courses that are at tendinopathyrehab. One word.com and I do stuff there. We've got a new course coming out on Achilles rupture, actually, very soon. And we've also got a new tendon course coming out. So yeah, that, that's probably the, the best place. But if you're a clinician you've just got questions, just email me. That's absolutely fine.

David: Excellent. Well, I highly encourage people to check those all out. You've got some great resources there and lots of great thoughts. And what about on social media? Where, what's the best place for people to follow you?

Peter: Social media, the main one I'm getting into these days is LinkedIn, but I'm also on X . And I'm starting to get into Instagram, but I think I'm, I don't know, not something that comes naturally to me. Instagram, think I'm a bit old for Instagram.

David: Right. Well, there's some, some great places to follow along. So uh, jump on over and, and give Peter a follow and check out his resources and online courses coming out. Once again. Much appreciated Peter. It was awesome to share so much great information with people and I hope people have got lots of awesome ideas.

Thanks again.

Peter: Thanks very much. David.