アキレス腱断裂を手術せず固定直後から歩行開始する治療法（アキレス腱断裂保存歩行療法）の世界中への普及にご協力ください

アキレス腱断裂保存歩行治療とは

この治療法は吉沢勝喜先生が創始され40年に亘って磨かれてきた治療法です。世界で初の固定直後から杖なしで歩行をして、固定期間は最短4週間の短期間という画期的で独創的な治療法です。

既存の歩行療法（観血・保存問わず）では足関節強底屈位にしないとアキレス腱の断端が近づかないと考えられているため、固定肢位は尖足位（以前ほど強い尖足位ではなくなってはきましたが）です。そのために患肢を着いての歩行ができず松葉杖を使っての生活です。そして、ある期間経過後にウェッジを入れたハイヒール肢位の装具で荷重を開始する方法などが行われています。本法は足関節自然下垂位（軽度底屈位）で固定し、足先を外向き（股関節外旋位）にして、左右の足を少し開き気味に（休めの肢位）して、固定直後から足踵部に全荷重して杖無しで歩行する治療法です。

私はこれまで300例以上の症例を持っております。また、いわゆる再断裂例（断裂から3か月未満の完全癒合前の断裂がほとんどですので「癒合前断裂」が正しい呼称だと私は思っています）の症例もあります。再断裂の治療は現在では多くが観血療法が選択されていますが、本法で遜色なく治っています。再断裂例の中には当院のものも含まれていますが、他院の手術治療後・保存療法後のものもあります。当院の症例には再々断裂も１例あります。これらはすべて問題なく治癒しております。

また、過敏性大腸症候群でステロイドを服用されていて軽度な負荷でアキレス腱断裂し手術を断られた例も含まれています。さらに、受傷から長期間放置された症例も数例あり、受傷後に5週間放置してあった症例もあります。1週間程度の放置例は全く問題なく固定期間が5週程度で良好に治癒しております。長期間放置例は癒合状態を見て固定期間を延長しています。

This treatment method was created by Dr. Katsuki Yoshizawa and has been refined over the past 40 years. It is a revolutionary and original treatment method that allows patients to walk without a cane immediately after immobilization for the first time in the world, and the immobilization period is as short as 4 weeks.

In the existing gait therapy (both open and conservative), it is believed that the Achilles tendon is not approached unless the ankle joint is in a strong plantar flexion position, so the fixation limb position is the pointed foot position (although it is no longer as strongly pointed as it used to be). Because of this, the patient is unable to walk on the affected limb and is on crutches. After a certain period of time, a high heel orthosis with a wedge is used to start loading the foot.

In this method, the patient is immobilized in the spontaneously drooping ankle joint (mild plantar flexion position), with the toes facing outward (hip external rotation position) and the left and right feet slightly open (resting position), and immediately after immobilization, the patient walks without a cane with full load on the heel.

I have treated more than 300 cases so far. I have also had cases of so-called re-tears (I believe the correct term is “pre-union tears” because most tears occur less than 3 months after the tear and before complete fusion). Although most of the re-tears are now treated by hemoperfusion, they heal comparably well with this method. Some of the re-tear cases are from our clinic, but some are after surgical treatment or conservative treatment at other clinics. There is also one case of re-tear in our clinic. All of these have healed without problems.

There are also cases of patients with irritable bowel syndrome who were taking steroids and ruptured their Achilles tendon under mild stress and were denied surgery. In addition, there are several cases in which the injury was left untreated for a long period of time, including one case in which the tendon was left untreated for 5 weeks after the injury. In cases left unattended for a long period of time, the period of fixation is extended according to the state of fusion.

観血療法と保存療法と保存歩行療法（本法）との比較

以前から保存療法が観血療法に比べても遜色ないという論文が多く出ていています。US-NEWSで、アメリカでNo.１の病院に選ばれたメイヨ―クリニックのホープページにも保存と観血の治療の差はないとの記載おあります。今後アキレス腱断裂の治療法は保存療法が主流になってくるでしょう。しかし、既存のギプスを巻いておくだけの治療法は多くの問題がありますので、それらの問題を解決する本法を普及させたいのです。

アキレス腱断裂の治療は可能な限り断端を近づけなければならないと考えられていて（手術療法においては断端をしっかりと寄せて強固に縫合をしている例があるようですが、それが治癒後にアキレス腱が硬くなる原因になっている可能性があります）、足関節強底屈位での尖足位固定が標準とされています。以前はMPから大腿部に及ぶ固定が行われておりましたが、近年では膝関節を固定しなくても、腱の癒合に問題がないとされ、現在は大腿部に及ぶ固定は行われず膝下までになっています（まれに行われているのを見ますが）。最大底屈位の固定は関節拘縮や機能の低下起こしやすいですし、下肢への荷重が行えないという大きな問題があります。患者さんにとって松葉杖の歩行は難行です。特に腕の力が弱い女性の多くが松葉杖歩行は不可能なので、室内ではキャスター付きの椅子を使っておられました。これらの人達は歩行療法に変更すると、松葉杖歩行の苦行からの解放で歓喜されるのが度々でした。　

断端の間隙は、従来の保存療法で最大底屈位での固定でも完全に近づくわけではないと考えます。下腿三頭筋側の断端は断裂直後の筋緊張が緩解すれば下方に下がってくるかもしれませんが、踵骨側の断端は近づかないわけで断端の間隙は残っているわけです。また、最大底屈位で固定しても、軽度底屈位で固定しても断端の間隙の差はそれほど無いのではと考えていますが、今までの症例で、たとえ間隙が大きくても、断端が離れていても問題なく癒合（逆に速やかに癒合）し、機能不全は起こりません。腱の癒合再生時に元の長さになるように治癒機転が働いていると推察しています。

　アキレス腱の癒合の悪さやリハビリに長期間かかる原因は、これまで行われてきた固定中の無荷重が原因の、循環障害や筋・関節・神経（最近では脳の萎縮も指摘されています）などの機能低下なのです。本来アキレス腱断裂は癒合しやすく、運動機能の回復も早いケガなのです。従来の治療法こそが、アキレス腱断裂の回復を遅らせる原因だと考えています。

本法の固定をしていていると、整形外科の先生から「そんなことしていると癒合しないし、癒合しても延長してしまう」と患者さんが言われることがありますが、コペルニクスが「地動説」で異端審問にかけられても「それでも地球は回っている」と言ったように「それでも吉沢式の方が早く良く治る」と私は言っています。この治療法はアキレス腱断裂治療のパラダイムシフトなのです。この革命的治療法の普及にご協力ください。

Conservative therapy vs. conservative therapy vs. conservative ambulatory therapy (this method)

There have been many articles published in the past that show that conservative therapy is not inferior to blood therapy, and the US-NEWS Hope page for the Mayo Clinic, voted the #1 hospital in the U.S., also states that there is no difference between conservative and blood therapy. Conservative treatment will become the mainstream treatment for Achilles tendon ruptures in the future. However, there are many problems with the existing treatment method of just keeping the tendon in a cast, and we want to promote this method that solves these problems.

It is believed that Achilles tendon rupture treatment should be as close to the rupture as possible (in some surgical treatments, the ruptured tendon is tightly brought together and tightly sutured, which may cause the Achilles tendon to stiffen after healing), and apex foot immobilization in a strong plantar flexion position of the ankle joint is This is considered the standard. In the past, immobilization extending from the MP to the thigh was used, but in recent years, it has been deemed that there are no tendon fusion problems without immobilization of the knee joint, and now immobilization is not performed extending to the thigh, but only below the knee (although we rarely see it done). Maximal plantar flexion immobilization is prone to joint contractures and loss of function, and also has the major problem of not being able to apply load to the lower extremity. Walking with crutches is difficult for patients. Many women, especially those with weak arms, use chairs with wheels indoors because walking with crutches is impossible. These people were often elated at the relief from the hardship of walking on crutches when they switched to gait therapy.　

We believe that the gap between the transected ends is not completely approached even with conventional conservative therapy with immobilization in the maximum plantar flexion position. The triceps side of the triceps muscle may move downward as the muscle tone relaxes immediately after the tear, but the calcaneus side of the triceps does not approach the triceps, so the gap between the transection edges remains. In addition, we believe that there may not be much difference in the gap between the transected ends when immobilized in maximum plantar flexion and in mild plantar flexion, but in our past cases, even if the gap is large or the transected ends are far apart, they fuse without problems (or conversely, fuse quickly) and do not cause dysfunction. We speculate that the healing machinery is working to restore the tendon to its original length during fusion and regeneration.

　The cause of poor Achilles tendon fusion and long rehabilitation time is the circulatory disturbance and functional deterioration of muscles, joints, and nerves (recently, brain atrophy has also been pointed out) caused by the non-weight bearing during immobilization that has been performed until now. By nature, Achilles tendon ruptures are easily fused and motor function recovers quickly. We believe that conventional treatment methods are the cause of slow recovery of Achilles tendon ruptures.

When patients are fixed with this method, orthopedic surgeons sometimes tell them, “If you do that, it will not fuse, and even if it does, it will prolong the fusion,” but just as Copernicus was subjected to the Inquisition for his “geocentric theory” but said, “Still the earth is turning,” “Still the Yoshizawa method is the best way to I say, “You will heal faster and better. This treatment method is a paradigm shift in Achilles tendon rupture treatment. Please help spread the word about this revolutionary treatment method.

保存歩行療法（吉沢式）の利点

観血療法のリスク（術中のリスクおよび癒合後の瘢痕、アキレス腱の拘縮、皮膚の癒着など）はもちろんありません。　

本法の固定は、単に足関節の動きを止めるだけの固定ではなく、むくみを予防する配慮した固定であり、歩行し易くなるように考えられた固定です。プライトンをたった2枚使って薄く、前後をサンドウィッチ状に固定をして、包帯を巻いた上に伸縮包帯を巻き適度の圧迫を行い固定のゆるみを防止します。そのために適度な弾力があり歩行がしやすく、軽度の圧迫がむくみ、循環障害の予防をして（適度の圧迫がけが血流の速度を上げるという文献があります）、アキレス腱断裂を速やかに癒合させ、固定後の障害の予防を図る治療法なのです（これは既存のギプスを巻くだけの保存療法や既存の歩行療法にもない点です）。

吉沢先生はヒールを用いた歩行と本法の股関節外旋位での踵荷重歩行を筋電図で比較する研究をされていて、歩行時の下腿三頭筋は既存のヒール装用の方法では筋収縮が認められ、本法では認められないことを示されましたし、本法での腱の癒合状態の3DCT画像を発表されています。

固定直後から患肢に全荷重でき、松葉杖をつく必要もありませんので、日常生活が妨げられることも少ないこと、患肢に荷重するため既存の治療法での無負荷で起こる機能低下が少なく、循環障害が起きにくいため最短4週で固定除去ができるなどなどのメリットがたくさんあるのです。

本法では固定中たくさん歩いて頂くよう指導します。外回りの営業職の方などや、もともとウォーキングをされていて固定中もよく歩いていただいた方は回復が早いのです。主婦専業、事務職で歩行が少ない方の中には経過が悪い方がいます。これはむくみの悪化が大きく関係していると考えています。

本法のもう一つの特徴は、アキレス腱部を元通りに近い状態に再生癒合するために、綿花綿子で断裂部の内外側から挟んで整えます。既存の保存療法のように足関節の固定だけの治療ではなく、アキレス腱を元通りに近い形になるよう整えるのです。これにより従来の治療法より良い状態で腱が癒合します（腱への適度の圧迫は腱の再生時に腱の繊維が整うとの報告もあるようです）。

本法を世界のアキレス腱断裂治療のスタンダードとして普及していきたいと考えています。興味のある方、ぜひご連絡ください。

Advantages of the Yoshizawa Method

There are, of course, none of the risks associated with open treatment (intraoperative risks and scarring after fusion, contracture of the Achilles tendon, skin adhesions, etc.).　

This method of immobilization does not merely stop the ankle joint from moving; it is a thoughtful immobilization that prevents swelling and makes it easier to walk. Only two pieces of Plyton are used to make a thin, sandwich-like fixation in the front and back, and an elastic bandage is wrapped over the bandage to provide adequate pressure and prevent loosening of the fixation. This makes it easy to walk with moderate elasticity, and the mild compression prevents swelling and circulatory disturbance (there is literature showing that moderate compression increases the speed of blood flow), and it is a treatment method that quickly heals the Achilles tendon rupture and prevents disability after immobilization (this is something that existing cast-only conservative therapies and existing walking therapies do not have). (This is a point not found in existing conservative therapies that only cast the tendon or in existing gait therapies).

Dr. Yoshizawa has conducted a study comparing walking with heels and this method with heel-loaded walking in the hip externally rotated position using electromyography, and showed that the triceps femoris muscle during walking shows muscle contraction with the existing heel-applied method but not with this method, and he has published 3DCT images of the tendon fusion state with this method.

The method has many advantages: the patient can fully load the affected limb immediately after immobilization, there is no need to use crutches, daily life is less disturbed, there is less functional decline caused by no-loading in existing treatment methods because the limb is loaded, and immobilization can be removed in as little as 4 weeks because circulatory disturbance is less likely to occur.

In this method, patients are encouraged to walk a lot during immobilization. People who work as salespeople or walk a lot during immobilization tend to recover more quickly. Some housewives, office workers, and those who do not walk much may have poor progress. We believe this is largely related to worsening swelling.

Another feature of this method is to prepare the Achilles tendon area by pinching it from the inside and outside of the rupture with cotton wool in order to regenerate and fuse the Achilles tendon area to a state close to its original state. This is not just a fixation of the ankle joint as in the existing conservative treatment, but is an arrangement of the Achilles tendon so that it is in a near-return-to-normal shape. This allows the tendon to fuse in a better condition than with conventional treatment methods (some reports suggest that moderate pressure on the tendon helps to align the tendon fibers during tendon regeneration).

We hope to promote this method as the standard for Achilles tendon rupture treatment worldwide. If you are interested, please contact us!