Abstract
80 year old female attended the orthotic clinic with chronic complete achilles rupture. She was seeking conservative treatment due to the high level of risk factors linked to surgical repair. Main aim was to return to active lifestyle. Presented in clinic with inability to fully extend hip and knee due to reduced eccentric control of excessive DF by Achilles, or push off of the 4th rocker. Balance and moblity was poor. Supplied with Allard Blue Rocker AFO with instant response. On 2 week review balance and quality of life improving using AFO.
in conclusion the biomechanical impact of Achilles malfunction must be considered in chronic Achilles rupture.
Introduce
Achilles ruptures are recommended to be surgically treated in younger patients, soon after injury, to prevent change in tendon length which may prevent correct binding of the ends of the Achilles. Current conservative treatment is moon boot with ankle PF to allow the tendon to heal with early mobilisation (Landvater & Renstrom, 1992, Wong et al 2002). Main complaints of conservative treatment are bulk of orthoses, reduced mobility, and reduced quality of life. This case study is being presented to demonstrate conservative treatment in chronic rupture in a patient not suitable for surgical repair. It aims to highlight potential orthoses to use that recreates the 4th rocker control and biomechanics of the achilles (Owen, 2009).
Case Presentation
An 80 year old female presented to a Northumberland clinic with a complete Achilles rupture. Patient has a relatively high activty level, she is a keen walker, walking serval miles a week with her husband, as well as attending regular dance groups. During the winter the patient had a chest infection and she was unable to leave the house for 2 months. On her first walk in the January the patient though she had developed a blister on her left heel. She was seen at NSECH with suspected DVT, this was proven to not be the case of the lower leg discomfort. After 6 weeks she was diagnosed with full Achilles rupture. She was seem in Orthotic clinic 4 months after injury occurrence. Patient was seeking conservative treatment as had been advised due to severity of rupture, and time passed since injury occurred, there was a high risk of failure.
Discussed with the patient what she was hoping to achieve from her orthoses.The patients' main aim was to be able to start having longer walks again. Currently she walks short distances, no more than required to do a grocery shop. She uses a walking stick and reported her main problem was her balance as she would often drift to the right. She didn't complain of pain, only some discomfort if walked further than normal amount. Her confidence of being outside was low due to poor balance, and general mood was low due to drastic change in a reasonably active lifestyle.
In clinic she presented with left sided dorsiflexion power 5/5, 0/5 plantarflexion. It was clean to observe the Achilles tendon was not complete. she was unable to fully extend her left knee and hip at late stance due to lack of eccentric control of DF. She is also unable to produce PF force to transfer weight to right left correctly. Walking in corridor, using a walking stick, patient was having to correct her direction of walking as drifted to the right with short stride length.
Patient was supplied with a left Blue Rocker AFO from Allard. This allowed the patient to achieve a knee extension and hip extension moment. Patient walked in corridor without her stick and didn't drift, demonstrating immediate benefit from the device. Additional padding was added to the anterior strut of the device as she found this uncomfortable pressure against her ankle.
At a 2 week phone RV patient reports wearing AFO all day, only removing for driving. She still uses walking stick when outdoors, however this is a confidence issue, and she does not use the stick when in shops or other people's houses. She has already returned to dance classes, starting slowly. She is waiting a couple more weeks before trying a longer walk. She reports no paint or discomfort, and she is leaving the house more since receiving the AFO with an improvement in her quality of life. She had tried several types of footwear with the device and mainly uses a fully enclosing Hotter shoe as this gives her the greatest amount of stability. Patient is due for initial review in clinic in 4 weeks' time.
Conclusion
Current conservative treatment of an Achilles rupture is focussed on maintaining Achilles length and reduction in further damage occuring. In long term treatment further consideration needs to be made of the biomechnaical changes involved with the loss of full Achilles use.
Key Points
Chronic full Achilles rupture. Allard Blue Rocker. Biomechanics. 4th Rocker.
Further information
Patient was seen for a 6 week follow up. Reports walking 1 mile everyday and able to participate in more dances. Suffered a back injury in RTA 3 weeks ago which has hampered progress of increasing time on feet.
Videos were taken in limited clinic space to demonstrate gait with and without AFO. Without AFO it can be seen how patient has difficulty to walk in straight line, she moves the right left in front of the left leg. On the sagital view withput the AFO she is unable to fully extend her left knee, with a drop in her knee at late stance, due to lack of plantarflexion power.