Physio Network

[Case Studies] Achilles repair recovery: the rehab roadmap with Scott Greenberg

Share episode

In this episode with Scott Greenberg, we explore an interesting case study on a real patient of his - a gymnast who had an Achilles rupture and went down the surgical path. We discuss: 

  • How to determine surgical vs conservative management
  • The key indicators of success for surgical management
  • Return to sport after surgical management

This episode is closely tied to Scott’s case study he did with us. With case studies, you can see how top clinicians manage real-world cases and apply their strategies to get better results with your patients.

👉🏻 Watch Scott’s case study here with our 7-day free trial: https://physio.network/casestudy-greenberg

Scott Greenberg is a physical therapist at UF Health with a doctorate in physical therapy, an MBA, and certifications in strength and conditioning. He is also the co founder of The Gait Geeks educational resource and a Certified Performance & Sports Scientist. He works with Division 1, professional, and Olympic athletes, focusing on injury prevention, rehabilitation, and performance, while also serving as director of UF Health’s physical therapy residency programs and emphasising strong personal connections with his patients.

If you like the podcast, it would mean the world if you're happy to leave us a rating or a review. It really helps! 

Our host is @Noah_Mandel from Physio Network

👏 Become a better physiotherapist with online education from world-leading experts:

https://www.physio-network.com/

UNKNOWN:

you

SPEAKER_01:

On today's episode with Scott Greenberg, we discuss a case of an elite gymnast who suffered an Achilles rupture. We discuss how to navigate the decision between surgery and conservative management, the three major goals to focus on after an Achilles repair, and lastly, some important outcome measures to pursue that go beyond a simple calf raise. Scott is a sports medicine physical therapist, strength and conditioning specialist, and performance and sports scientist with over 25 years of experience. working with elite NCAA Division I athletes, professional athletes, and Olympians. He is the Manager of Operations for the University of Florida Health Department of Rehabilitation, Director of the University of Florida Health, Sports, and Orthopedic Physical Therapy Residency Programs, and Membership Chair for the American Academy of Sports Physical Therapy. He is also a co-founder of GateGeeks, whose mission is to empower healthcare professionals and enthusiasts with specialized knowledge in walking and running gait analysis and the fabrication and implementation of foot orthoses. Scott has done a case study with PhysioNetwork on this exact case where you can dive a lot deeper into this area than we were able to in today's episode. You can click the link in the show notes to watch Scott's case study with a 7 day free trial. You're going to love this episode as you can gather insight into how some of the best athletes in the world recover from an Achilles rupture. I'm Noah Mandel, and this is Case Studies.

SPEAKER_02:

Sure. So I thought this was an interesting case to present. It's an extremely, extremely high level gymnast. And we have a lot of video of when the actual injury took place, which I thought was added benefit. And then, you know, being that it's one of our athletes, you know, we have the ability to do certain things such as get ultrasounds periodically. We have force plates. We test periodically as well. Somebody I saw on a regular basis, I knew they were going to be there consistently. So I thought it was a really, really interesting case. And, you know, she had some pretty lofty goals and we kind of just documented the progress and those goals are starting to be met. But we've got obviously long term goals, which is Olympics 2028, but some shorter ones that are occurring now about six months post-op. So there's just a lot of information, a lot of cool videos and a lot of data that we can share.

SPEAKER_01:

Yeah. And all of that is within that case study, all those videos and the data. And you mentioned she's six months post-op. So you're sort of beating me to the punch here. And I was going to ask you about the that decision after the Achilles rupture happened, what went into that surgical decision? How did you decide to go down or how did the patient decide to go down that route versus the conservative route?

SPEAKER_02:

So I think whenever you're dealing with an athlete that's 20, 21, 22 years old specifically, which is basically, I deal with them like 18 to 22, let's say generally in the college setting, division one college setting, the majority of cases, if not all the cases are treated operatively. You know, it's funny, I got to add at a recent conference to defend the non-operative approach to Achilles tendon repairs, which is something that I don't necessarily see that much in my population. Because again, the long-term outcomes are fairly good with a non-operative approach if you catch it early enough and you put them into a plantar flex position early enough and you're a little bit more cautious early on. At a year out, a little bit more than a year out, the strength deficits are pretty much similar. The re-rupture rates are not necessarily significant although they are a little bit higher in the non-operative group but the infection rates are obviously a lot less and the complication rates are a lot less in the non-operative group but when you have an athlete that's looking to get back to really high level things having that surgical repair plus the immobilization early on is really almost like a double whammy to really kind of allow you to be a little bit more aggressive early on and with this particular case having her goals be as lofty as they were to come back as quick as they were, that really wasn't an option.

SPEAKER_01:

Got it. So you mentioned there that it's important to reduce that infection chance. That's one of the main goals after surgery, right? What are other goals that you need to consider after you have a patient who has an Achilles repair?

SPEAKER_02:

So I usually think about three big factors when you're dealing with Achilles tendon repairs. I think about number one, making sure that the wound is clean, making sure the wound closes. The skin on the back of that the heel area is very very thin and if you in any way shape or form get challenged by your ability to allow that wound to close via due to infection or rubbing or what have you it's a disaster not only is it going to require in a lot of cases other surgeries grafts etc it really slows down the whole progress of everything else and really can limit their ability to get back to the level that they want to because you've got other you know a lot of healing a lot of scarring and it's it just can create a whole disaster so So I do everything in my power early on to make sure that the wound is clean and it closes. And anything I do that would potentially jeopardize that is something I try to avoid at all costs. So that's number one. Number two, the thing I really am concerned about is really preventing any type of early tissue elongation or creep. I really want to make sure that we maintain some rigidity in that tendon. So in an athlete such as this that needs to be exposed, explosive, if you prematurely stretch out that tendon by being too aggressive, trying to get ankle dorsiflexion back too early, you're going to lose that athlete or that athlete's going to lose the ability to load and explode as effectively as they need to be powerful. And, you know, a good analogy people often say is, you know, once the toothpaste is out of the tube, there's no putting it back in, right? So, there's no way to kind of remake that tendon rigid once you've kind of creeped it and stretched it out into that into a lengthened state. So I do everything I can to really prevent that. I'm really conservative in that regard. I don't put my hands on my patients in the effect of manually stretching into dorsiflexion till at least like five or six months out. I will do some soft tissue work on the tendon to make sure it's gliding and sliding appropriately. I may even do some talocrule mobilizations in a nice relaxed position, but I'm not going to manually crank on them into dorsiflexion, nor will I have them do any prolonged stretching themselves into dorsiflexion because I really want to maintain the integrity of that tissue for as long as I possibly can. I allow that dorsiflexion range of motion to come back with a lot of the functional exercises that I do at the appropriate time. You know, there are phases of healing that we really got to take into account, and the last phase is the maturation phase, and it's broken down into basically two components. And really, that maturation phase really plateaus, we'll say it starts to plateau around five, six, seven months, but it really can go out to about a year, if not longer. I'm really comfortable at that stage to be a little bit more aggressive if I find that there lacking that dorsiflexion to do the activity that they need to do. So that's two. So it's tissue closure, decrease infection, one, avoiding tissue stretching, elongation, creep, three, get them strong. And the thing that I find is the biggest limiting factor as to when the athlete can return to their sport is their strength. And Rob Panarella kind of built on the Al Vermeule, who's a strength coach, built on his model of this pyramid of athletic performance. And basically, it just talks about how there's a hierarchy, just like when you're building a house, The bottom floor and the structure needs to be strong if you want to have a nice house on top of it. If you don't have a good foundation and strength, you can't be explosive, you can't be reactive, and you can't have speed, right? So a good foundation of strength allows those other important things that an athlete needs to come back at the right time. It's just like you can't run before you can walk, you can't walk before you can crawl type of thing. So tissue healing, no infection, don't stretch it, get them stronger. You do those three things well, you're going to have a successful return to sport.

SPEAKER_00:

Beautiful. That was a great summary.

SPEAKER_01:

Yeah, that's a great summary. Some pretty basic stuff there. What do you look for outside of that and specifically within this particular case from an objective measure standpoint?

SPEAKER_02:

So that's a great question. So again, like I said, I won't stretch dorsiflexion, but just like even if you're dealing with a shoulder, right? You have protocol guidelines and you notice that you're not going to make those goals, you know, because they're stiff, right? So you can be a little bit more aggressive early on because they're so stiff. Same thing with this. Like if somebody's coming back and they're really, really stiff, you're not going to make those goals. Okay, you might be a little bit more aggressive, maybe with some of your functional activity choices and whatnot. But again, if some of these motions coming back good, I ain't going to press that that target, let's say, to be symmetrical to the other side. But what do I like to look for? I like to look at peak force. I like to look at whether you're doing it with a dynamometer or a force plate. You know, there are different ways in which you can measure strength, you can do it with a seated, I have a seated dynamometer through the peak force system, just to name one, you can do it through like the force frame through through volts force frame, you can do it on a force plate. deck in the standing position. And the peak to body weight ratio is going to change depending on the position that you're in. Even seated, it's going to vary depending on the amount of ankle dorsiflexion that you allow. So again, side to side comparison is super important. Being consistent in how you do it is going to be important. And then comparing it to other norms that you have in that given range is super important as well. So, you know, I like to look at peak strength early on. Also, you can just do simple things like calf raises, right? You know, you can do an endurance calf raise. Rob Panarella recently, he's another He's somebody I really follow. I really love his work. Write some really cool articles on LinkedIn. But he mentioned that within the last month or two months, he mentioned this Achilles load test where you basically get on your toes and you walk 10 yards on your toes without allowing your heels to drop down. Then you walk back regularly, normal heel toe, and you repeat that five times. And if they can do that without having any drop in their heel throughout the entire duration of the test, so the 50 yards worth of walking, it shows that they've got adequate strength to return to sport But I think that's too general, right? And it leads me to another kind of whole caveat I have, which is the demands of the sport need to be taken into account when you're talking about return to sport, right? So in this particular case, for example, we're lucky it's that it's a gymnast. So gymnastics is great because it's broken down into four very unique, different activities, especially female gymnastics. What you do on the floor is very different than what you do on the beam, which is very different than what you do on the bars. I'd say the vault and the floor are the most similar. In this case, this athlete's goals were to not redshirt this year. She wanted to get back and compete and she wanted to compete on bars and potentially beam. Those are the goals, right? So six months out, is she able to land from height safely, right? Does she have enough protective strength and does she have good enough form to land safely on two feet from height? And if we look at that Baxter article that It shows, you know, the amount of load that goes through a tendon. You know, landing on two feet is very, very mild compared to a lot of the other explosive activities that we're talking about, some of which she's already been doing, you know, hopping on one foot and those type of things. So I was very, very confident and comfortable with her resuming those type of things. And with all of this, there's always a progression, right? So, you know, you don't just say, okay, you're good to go, go on the bars and land, right? So all throughout this progression, even starting as soon as like eight weeks out, she was on the bars. She was doing her skills on the bars, just not landing. You know, she would land, just drop down on her good side, or she would land in the pit, or she would just, you know what I mean? So she was doing skills so that she could, when able to return to that actual dismount, be ready with the other stuff to just add the dismount. When we add the dismount, we added it into a foam pit, we added it onto different mats, and then we kind of make that progression into the regular circumstance. So that's kind of how that all goes. But, you know, we're going to get her back to sport, competing, on that event, but she's nowhere near ready to compete on vault or floor. And we're starting to incorporate some beam skills now. And again, a lot will depend on that given athlete. Like what does their dismount look like? Are they taking off on their injured foot? Are they taking off of their non-injured foot? What does their series look like? Are they landing on one foot or two foot? Are they jumping off of that injured foot? Are they jumping off of the uninjured foot? So all of that plays into it. And if you've got a good coach and a really talented athlete, oftentimes you can get them back quicker than normal if in fact you can make a routine that kind of stresses their better side when I say stress puts more of the load on the better side in the sense of jumping off of that side instead of jumping off of the injured side so things like that can help but I think we're in a good place with her with regards to her beam and her skills and what she's doing but I can happily say in the first meet she competed and actually landed her bar routine at literally it was almost exactly like six months I think it was a hundred and ninety nine days after her repair or it was either 199 days after her repair or 199 days after the initial injury. I don't remember exactly, but it was really close between those two.

SPEAKER_01:

Either way, that's impressive. And the fact that when I was watching your case study, I was seeing that she was returning to gymnastics-like activities at around eight weeks. I thought that was remarkable. And it's very interesting how you grade those activities and all of those progressions are in the case study. And believe it or not, we just scratched the surface here you go into everything you just discussed in a lot more detail in that presentation and you can watch Scott's full one hour presentation on this exact case with our seven day free trial and you can find the link to that trial in the show notes to get access to it Scott thank you so much that was excellent you fit in so much information in the last 15 to 20 minutes so it's been a pleasure to chat and thanks for coming on thanks for having me I had a great time doing it

UNKNOWN:

Thank you.