*WK 12-13: Doc Checkup, PT, Calf Raises, and Fighting the Limp! (Sept 1st-15th, 2016)
September 15, 2016 by agnesatr
2016-09-26 Update: Vlog from week 12 and 13:
The last 2 weeks were mostly about trying to walk as normally as possible and about lots and lots of physical therapy (PT).
DOCTOR’S 14 WEEK FOLLOW UP
I had a follow up with my doctor today. Doc examined my tendon and was really happy with its healing progress. He assessed the tendon as firm and strong. The thickening of it is there, but I was told it is normal at this stage. Doc mentioned that it is not as thick as seen with post-op patients at this point in recovery. Doc performed Thompson test and he saw plantar flexion movement of the foot. Then I got ultrasound, which showed thickened intact appearing tendon with disorganized collagen architecture. Doc did ultrasound of my healthy tendon as well to show me the difference. I was told that the injured tendon collagen might never get back to the same state as before the injury, but that this would not have impact on tendon’s strength and capability. I was told that the next ultrasound will be in 3 months to check the difference. I asked for a referral to massage therapy, since my insurance covers few of these and my calf could really use some massaging after all the work it is put through daily.
I was also cleared to start some dorsi flexion stretching. My PT measured me yesterday and I am now equal in both feet in plantar flexion (thank you toega!) and am at 18 degrees dorsi flexing my healthy leg and 5 degrees dorsi flexing my injured leg. I was told that this is good indication of healing normally and not long. I was also cleared to do stationary biking with natural leg movement (until now I have been biking with toes pointing down to avoid dorsi flexion of the foot). I also was told no running, jumping, or cutting/pivoting exercises for 3 more months. That means I am not going back to my insanity or p90x workouts for a while.
Below is the thickness difference in my tendons at this point.
And here is the thickness difference in my calves. My calf is growing! It does not look like much, because my right injured calf was 1 inch thicker than my left calf, so I might just end up symmetrical after I am done with this injury.
I also asked about skiing. Given the fact that my summer was pretty much gone as far as sports and hiking, I am now looking into winter season. I was told that given my recovery status and if all goes well from now on, I should be able to ski at the beginning of 2017. I was so thrilled with the news! I cannot even drive myself at this point, so thinking of skiing in Jan/Feb really is something that I am looking forward to!!! 
Now I just need to be careful until then to not re-rupture and stay on track…
HELLO CALF/ACHILLES STIFFNESS
I read a lot of people writing about leg stiffness and the last 2 weeks I found out why. I was fortunate enough to not have a lot of it until week 10 or 11. Now, however, every morning immediately when I get up I walk pretty much like a broken robot. I figured out that if I do my PT right after getting up, the stiffness disappears and I am good to go. Warm shower helps with it as well. Nothing is better for me than seated heel raises and calf raises for calf and achilles stiffness; balancing for ankle stiffness; and squats for sheen muscles stiffness. Sitting at the computer for extended periods of time also brings stiffness back and I need to do few exercises to get rid of it in order to walk more normally.
WALKING
It’s been almost a month of walking with no boot. My walking in shoes has been work in progress. I am slowly getting hang of it. I still have to think about almost every step, but only to try to avoid limping. When I am not tired or stiff and think about it, I can walk with almost no limp. I can see, however, that at the end of the day, or when I need to walk faster, or when I am immobile for a while, my walk is choppy. Also, I do not know if it is only mental, or not, but it is easier to walk when I wear my compression sock. Somehow, I am able to walk smoother and more easily when wearing it. I was told that some of the limp is due to lack of dorsi flexion at this point, so this should get improved with stretching from this point onwards. I still do not walk bare foot. I wear gel inserts in my shoes for little elevation and comfort. My shoes came with memory foam inserts, so double softness definitely helps and I feel heel pain only at the end of day if on my feet a lot.
BOOT
I almost booted the boot completely. I wore it only couple of times in the last 2 weeks to mow the lawn and when we went to a crowded place. I will continue doing so when I need to be on uneven surfaces or in uncertain situations. Otherwise, I am doing everything in 2 shoes now. Yay!
PHYSICAL THERAPY
That has been the biggest part of the last 2 weeks (along side of working on proper walking). It takes up a LOT of time, but I feel it is worth it as my leg is feeling stronger. No more floppy, loose meat on my injured leg! I am told by my physical therapists that there is not that much scar tissue around my rupture site. I got some Graston tool massage done on it in week 12 and 13 and it hurt quite a bit, but it was good pain. Also, now that my calf is working so much more I do get little bit of muscle soreness. It is so welcomed, because that means my muscles are coming back! Again, yay! The PT massages are feeling so good now as they massage the knots out!
As far as PT exercises, I moved from shorter 3 x day sessions to 2 x day, longer sessions. In the middle of the day I do some seated heel raises and calf raises to warm up the leg when needed. The exercises are as I showed in last post with the following changes.
1) Calf raises pumps were substituted with eccentric calf raises. This is in preparation for single calf raises. I go up on both legs and come down 90% on injured leg. These were hard in the first week, but I am now doing 3 sets of 20 at a time. I do these at least 2 times a day. After my research of tendon and eccentric exercises, this is definitely the way to go. I still put towel under my heels to not put too much pressure on achilles and do not stretch it too much.
My PT wanted to check my ability to do a single calf raise, since the above are going so well and that was a flop, haha. I stood there on one leg, was willing it with my brain to go up, but nothing was moving. Such a weird feeling. No pain, no strain, just nothing. Just imaging looking at your finger and telling it to bend and nothing happens. We tried horizontal leg press machine and I was able to do single calf raises on it with 20 lbs (It was really hard!) and single leg bent knee calf raises with 40 lbs. I will be working on these in coming weeks to get to single calf raise.
2) Seated heel raises: I do them now with 45lbs weigh on my knee. I tried 50lbs and my calf was fine, but my knee was not appreciating the weigh on it, so I told my PT that this is my knee’s limit and I would stick to 45lbs. We replaced seated heel raises in PT with horizontal leg presses. With that I can do more weight while in PT room, but at home, I still do seated heel raises with 45lbs few times a day. Seated heel raises seem to fix my sore from walking calfs. After days where I am on my feet the whole day, there is nothing better than couple of sets of seated heel raises. Somehow all my muscles in my ankle and calf relax after it. Tendon also feels better.
3) Heel raises in wall sitting position: This one is new. I basically do a wall sit and do heel raises. I started with each foot separately and now do both at the same time.
4) Toes raises in wall sitting position: This one is new as well. Again, I do a wall sit and do toes raises one foot at the time.
5) Balancing with bands: balancing on one leg was not challenging anymore, so now I use bands on my ankles and do the below. I also am trying to get to 2 minutes of balancing on injured leg with closed eyes.
6) Horizontal leg presses: As mentioned above my physical therapist was experimenting with me with leg presses in preparation for single calf raises. It is nice, cause we can isolate each calf and compare its ability. I am now up to 20 lbs in single calf raise and 40 lbs with bend knee heel raise while using the machine.
7) Lunges: I asked for it, we tried it and I was cleared to do lunges. Finally! For now when injured leg is behind, I put it on a bench behind me and lunge with my good leg. When injured leg is in front I can do regular or bench lunges, I just need to be conscious of not too much dorsi flexion on the front leg.
Rest of the exercises remain the same as in the previous week. Still doing a lot of stationary biking and increasing resistance. That has been really good for hips.
The fun part this week was that my hubby tried one session of exercises together with me. I keep nagging him to take care of his calfs to reduce the chances of rupture happening to him. I was glad to hear he was sore the next day. That should convince him to do the exercises with me more often and strengthen these calfs and hips!
So, that’s my week 12 and 13 in non-op (conservative) route. Regardless of your status in recovery, wishing you happy healing and lots of mental strength to get through it. Hard work definitely pays off in this stage, but it also needs to be balanced based on how the tendon feels. So, definitely listen to your body. Also, another point is that no two bodies are the same and we all heal differently. Some stages are faster for some, some are slower. As long as one follows good protocol and works hard when needed, it will get better!
You have nailed it. Excellent post for those behind you to read. I agree the limp is mostly due to the lack of dorsi flexion and that will improve. Also a good sign that you have not healed long as you said. Good also to have the ultrasound. The disorganised collagen (type III) will be replaced in time with the better stuff and your tendon should thin up a lot but you will still have the type III around to some degree. Well done.
Thank you Stuart. It’s good to see you pop up so often and share your advice to so many people on this site.
As far as collagen and tendon, yes, my doc mention it might take even 2 years for the tendon to thin down. I’m good with all that. I only want it to get as strong as possible. I can live with 2 slightly different sizes of tendons.
Did your injured tendon ever come back to the same size as pre-injury?
Anges - my injured tendon did thin down a bit over the years but is still thicker than the other. I have no issues with strength and in fact I probably trust it more than the other. I also find no difference in stamina and my raises are every bit as good on the non injured side. I do notice that my injured side calf muscle will shrink a bit if I do not keep up eccentric exercises (bent and straight leg). I can do all I did before although I have stopped running those ridiculous distances. You are a great encouragement to others as are many others here. I visit regularly but comment less as I feel it is better for those closer to the action to reach out. Looking forward to your next update.
Thanks so much for your well written blog! I ruptured my left achilles on 9 August, so it’s great reading about what I can expect in the next few months! I’ve just started FWB and it sure feels good! It’s great to read about your dedicated approach to rehab. I’m a premier netballer so quite interested in how dedicated rehab can improve recovery rate (I’ll need to progress very well to play netball next season). Keep up the good work!
Nicola - Congrats on “graduating” to FWB. Now things will start getting more exciting for you! I definitely feel that doing very regular rehab helps with the calf/ankle progress. Also, if you are needing to get back to sports, do not neglect the rest of your body and work out while in the boot. There are a lot of workouts you can do in a boot (if you are not doing so already). Keeping rest of the body definitely helps me now in rehab. I have no hips issues and can concentrate on my calf and ankle during PT. Rest of the body is in the same shape as before the injury.
Wishing you great recovery and good luck with walking now that you are FWB!!!
Thank you
Yes I am rowing and biking and doing lots of strength work. It is scary how much muscle I have lost on my injured leg, but I know with muscle memory it will come back fairly quickly.
One question for achillesblog members - I’ve noticed that most protocols gradually reduce the angle of the foot while in the boot. My specialist recommends maintaining a full heel raise up to 8 weeks post-rupture, and then a smaller heel raise for another 4 weeks. Note, I’m non-operative as surgery is very rarely used in New Zealand. I know my specialist is trying to address the risk of healing long, but it seems to be an uncommon approach. It also makes it difficult to FWB without a limp in the boot. Any thoughts from anyone on this?
Nicola, it does seem a bit conservative to not gradually reduce the angle while in the foot.
Have you consider getting something like Even-up to raise your healthy foot? I am still at -20 degrees, but with my shoes + even-up, I can have a fairly normal gait.
Thanks, I contacted my doctor and he has given me the ok to remove some of the heel raise to improve my gait. Whew - even just taking out one wedge felt very odd!
I have been wearing boots with a heel on my other foot - this helps a lot. I only just learnt about Even-up, so it wouldn’t have arrived in time unfortunately!
Thank you Elyliu, a very good blog and video. Inspiring for someone who is only beginning the journey (4 weeks)
Fantastic blog and thanks for sharing. I’m week 9.5 and a 27 year old male on the non op route. I’ve been doing gentle dorsiflexion following my protocol. There is not much information on healing long that I can find so I have found reading your thoughts interesting. Congratulations on the recovery. I hope I can be just as successful.
Joe - Crossing fingers for your recovery! Ya, my doctor and PT were very cautious about healing long as non-ops have higher chance of healing long (our tendons are attached by scar tissue only as opposed to sutures in op cases). My PT started stretching me in week 19 only. Before that he made me work pretty intensively on calf/glutes/hips strength. He was always stating that he knows many ways to stretch my calf, but he will not be able to shorten it if I heal long. This seemed logical to me and so far it’s worked out just fine. So, just be careful with too much stretching too early! Btw, may I ask you what made you choose non-op? The reason I am asking you is that in USA active young ppl are are put under knife almost by default. I had to see few docs before I found one comfortable with non-op for me and I am quite older than you. Happy healing!
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