bobfv’s AchillesBlog

My Physical Therapist gave me a copy of my Post-Op protocol, which I am following now 4 1/2 weeks after surgery, and I thought I would post it for you.  I am glad I chose my surgeon, with an aggressive protocol.

• 2 WEEKS Post-Op

Begin PT

Partial WB in boot with heel lift

No dorsiflexion past neutral

Edema control

Ankle AROM all directions

Ankle mobility/joint mobilizations

Foot intrinsic strengthening

Scar tissue mobilization, STM along gastroc/soleus complex

Quadricep/Hamstring/Hip strengthening and stretching

• 2-4 Weeks Post-Op

Progress WB

Stationary bike in boot

Seated BAPS

Begin resisted plantarflexion (seated heel raises, theraband plantarflexion)

• 4-6 Weeks Post-Op

Wean off crutches (2 crutches to 1 crutch to FWB)

Begin closed chain lower extremity strengthening in three planes of motion when FWB (Mini-squats, wall squats, leg press)

• 6 Weeks Post-Op

Wean out of boot at home (with heel lift in shoe)

Progress to no boot over next two weeks

Ankle brace if prescribed by doctor

Single leg proprioceptive exercises

Normal Post-Op on June 19 visit four weeks to the day after my surgery.  Dr. Kartelian performed the Thompson test, everything looked good.  Wound site looked fine, the surgi-strips hadn’t fallen off yet, no problem with that.  I showed off my range of motion, rotating my ankle and lifting my toes up to neutral.  He performed a strength test with me pushing against his hands.  Everything was great!  He told me to continue to wear the boot, keep the heel lifts in the boot, continue physical therapy, continue with the vaso pumps, and over the next two weeks go to full weight bearing (FWB) as long as there was no pain.

Great!  I was so happy I put my boot back on, picked up my crutches, and walked right out of his office on my own two feet.  To be honest, I had been "cheating" a little throughout the week, putting full weight on my right foot while still on the crutches - no pain at all, everything felt fine.  At home I used one crutch a little but mostly no crutches and that night I walked up the full flight of stairs to my bedroom without crutches!  What a relief to be able to use my hands to carry things while I walked, and to be able to bear my full weight for personal hygiene activities in the bathroom!  Taking showers is still a little tricky, taking my boot off while sitting in a shower chair.  I actually started kneeling with one knee on the shower chair which makes showering much easier.

Looking forward to the next two weeks of physical therapy in which I will begin "mini-squats" and other exercises to begin lengthening the Achilles and increasing my range of motion.  By protocol weeks 4-6 will see me wean down form 2 crutches to FWB, but I am already there!  No pain whatsoever, and no pain meds since the surgery.  I still elevate, ice, and use compression pumps in the evening for a few hours, and I strongly recommend that regimen to eliminate pain.  Still sleeping in the boot, I hardly notice it now.  Yesterday my wife told me I "look good" in the boot, and with the full beard that I started growing on the day of my surgery.  Walking with this boot I guess I sort of look like a pirate - the beard stays until a client meeting or other exigency dictates that I shave it off!

I have mentioned the vaso pumps a few times - here is a photo of one on my right leg - I love these things.

This post describes the period between my 2 week post-op visit on June 3 and my 4 week visit on June 17.  My visits are on Wednesdays, as was my surgery, so they correspond exactly with my week "anniversary" dates from the surgery.

I was told to begin partial weight bearing (PWB) but I still used the knee scooter almost all the time after coming home from my 2 week post-op on June 3, 2015.  That all changed when I went in for my first physical therapy (PT) session on June 9.  My orthopedic surgeon is part of a medical group in Reston, Virginia called Town Center Orthopaedic Associates.  It is an eight doctor group conveniently located in the same medical complex as our local hospital and ER, and in the same building as the outpatient surgery center where my surgery was done. Sharing the office suite with my orthopedic surgeon is the physical therapy facility, which is really nice because the therapists are part of the same practice, they have access to all the surgeon’s notes, and use protocols developed specifically by my surgeon.  Also, I was getting PT done here for my Achilles tear before I had the ATR, so I already knew and really liked my therapist, Chris Marino, DPT.

On June 9 I showed up for my PT evaluation by Chris. As I mentioned, we know each other.  He took a look at my wound, massaged it a bit with the boot off, and did some basic strength tests.  He looked at the scooter and told me that he never wanted to see it again, that I was done with it, and the we were going to start PWB immediately.  To that end, I put the boot back on, held on to the handlebars of the scooter, and walked across the room holding on to the scooter like a walker.  It felt funky in my right foot and hurt a little bit, but I was walking.  Chris explained that my protocol called for PWB and some basic flexibility during weeks 2-4.

So I started my PT - twice a week.  During this week 2 to week 4 I mainly did flexibility but also some strengthening of the unaffected part of my leg.  I used a BAPS board, picked up marbles with my toes, did seated knee lifts, had my surgery site pretty vigorously massaged. This is a pretty aggressive protocol but I really enjoyed the sessions.  One thing I was seriously warned about by my doctor was not to lift my right foot past 90 degrees of "neutral".  I was still in the boot with two heel lifts so my basic position was slightly toes down.  Man, did it hurt the first time Chris gently flexed forefoot up just a little bit to make my foot neutral at 90 degrees, but after a week I was doing it on my own.

Physical therapy is great.  I also started riding the exercise bike in the boot.  This was great because I had not been getting any exercise.  Chris cleared me to ride the bike as much as I wanted, so on Saturday I went to the gym and rode the bike trainer for half an hour.  I was still getting pain when I didn’t elevate my foot occasionally, so I found the recumbent bike trainer was much better since my feet are naturally elevated on that machine.

My PWB increased dramatically over these two weeks, and by week 3 post-op I was PWB to the extent that I was only using one crutch at home, and when walking with two crutches I was basically walking in the boot and just balancing and taking a little weight off with the crutche. This was progress over those first two weeks.  And yes, I stopped using the knee scooter completely.  I did not consciously increase the proportion of weight on my affected foot, but I found that I unintentionally used it more and more as the pain went away.

Also - I had been using some light aluminum underarm crutches that they gave me at the hospital, but they were very uncomfortable and I found them difficult to use. I went online to a place called "DME Direct" and I spent about USD 80.00 on a nice pair of forearm crutches - fully adjustable with spring tips.  What a difference these made!  No more pain in the armpits, and the spring tips do a great job of absorbing shock. I strongly recommend them - just like I strongly recommend the knee scooter for the period when you are non weight-bearing (NWB).

Between my initial Post-Op wound check visit on May 26 and the second one on June 3 I stayed home, non weight-bearing, with my legs elevated as much as possible.  I stayed in my boot except for my daily sessions with the vaso pump on my lower legs. I scooted around the house on my knee scooter and occasionally on crutches. Nothing too exciting happened during the week, but being non-weight bearing was becoming a major inconvenience.  I really didn’t have any pain during this week - obviously the area with the stitches was still quite tender and I had to be careful to keep pressure off of it when my legs were up.

One thing I want to mention is how significant it is to pick the correct sock to wear with you boot.  I have a tall Aircast boot with two air bladders and a built in pump. It has a foam liner which gets pretty gamey. I tried using boot liners made of synthetic wicking fiber (Coolmax) but they were uncomfortable and difficult to put on and take off.  On Amazon I found socks made by the same company as my boot, Aircast, called "Aircast sock liners for Aircast Walkers".  This is the greatest purchase ever.  The socks are oversized so they don’t squeeze the surgery site when putting them on and taking them off - they are also soft and fluffy. My foot is so comfortable that I don’t even want to take the boot off!

On June 3 I returned to my Orthopedist, Dr. Kartelian. His Physician Extender, Tori, removed my bandage and wound dressing and told me that it looked great - no sign of infection and good healing - my stitches were coming out today!  She put on gloves and took a little scalpel and hemostat and I just heard a little snipping, very tiny pinching sensation but no real pain, and the stitches were out in a flash.

Dr. Kartelian did the Thompson test and I am told it showed that my Achilles was functioning completely normally. Tori put about 5 "Steri-Strips" over the wound site where the stitches had been. These are like butterfly closures. She said that they might stay on for a day or they might stay on for weeks, just leave them on and let them come off on their own.

Ah - I was cleared to go home and shower!  So happy about that, as I had been taking "bird baths" for a couple of weeks and I was starting to smell more like a goat than usual. Dr. K told me to make physical therapy appointments and said that I could go partial weight bearing as long as it didn’t hurt. I was told to remain on two crutches but that I could put partial weight on foot in the boot as long as there was no significant pain.

So that’s it - I was a new man - partial weight bearing!  PWB!  As I left the office I very gingerly used my booted foot not to really bear weight, but to just catch my balance as I walked on the crutches - what a difference in mobility!  I was ready to start physical therapy and the road to recovery. My next appointment with the doctor was scheduled in two weeks.

I didn’t know what to expect at my first post-op visit, six days after my ATR repair surgery.  I was doing well, non-weight bearing. I just stayed home and moved as little as possible, keeping my leg well elevated all week.

At the orthopedic surgeon’s office, we were greeted by Tori, who has the title "physician extender" - she is a certified athletic trainer who works with the surgeon helping with exams, arranging the surgery schedule, and assisting with durable medical equipment.  Tori put me face down on the table and removed the plaster and the splint and bandages and exposed my ankle for the first time since my surgery day. Dr. Kartelian came in and said hello, he said that the stitches looked fine - clean and dry and not swollen, and he announced that he was putting me back in the boot, with heel lifts. He did the Thompson test and everything was working fine (a “negative” result from the test)  He also had Tori order me a set of vaso pumps to prevent blood clots.  These are like blood pressure cuffs that go on your lower legs and inflate and deflate to move blood and prevent blood clots.

So my instructions for the following week were no weight bearing, stay in the boot except 3 times a day use the pumps for about a half hour, elevate as much as possible, use ice, keep the wound dry.  They left the stitches in and covered the stitches with a bandage and some flexible adhesive tape which wrapped around my ankle a couple of times.  I was thrilled to be going back into the boot after just 6 days!  I would have to wear the boot all the time, including in bed, but again, I could take it off to ice and to use the vaso pumps.  My next appointment would be in another week, and hopefully my stitches would come out then.  I have posted a photo of my stitches 6 days after surgery,

I awoke the morning after my surgery on Thursday May 21. I still had the cast/bandage on my right foot with the toes pointed down. My toes were still numb and the nerve block was still clearly in effect from the afternoon before.  I had prepared a bedroom on the main floor of my house in what is normally an office, since my wife and I have our bedroom up a full flight of stairs.  There is also a bathroom on the same floor as my makeshift "bedroom". I had positioned the knee scooter and the crutches next to my bed and sure enough, I had to wake up to pee the previous night, and it was fairly simple to just swing my knee from the bed to the scooter, scoot a couple of short steps to the bathroom, and I could even manage the act of urination while still on the scooter!

The morning of May 21 (the day after surgery) I got out of bed and scooted right over to my power recliner and just settled in.  My toes were quite swollen, so much so that I considered calling the doctor, but as soon as I got my foot up and put a little ice above the bandage I was fine.

About 1500 that afternoon, pretty much exactly 24 hours after my nerve block was administered, it wore off.  The tingling in my toes which had been so annoying disappeared, and I could now feel sensitivity around my stitches and had to make sure to keep my pressure off of that area.  I accomplished this by having the recliner footrest up with a pillow on top, then I just rolled my leg from side to side to keep pressure off the stitches.  The pain was quite manageable - the Vicodin which I had been eating like candy before the surgery was totally unnecessary now and even as I write this, a month after my surgery, I have not felt the need to take a single narcotic pain reliever since the surgery.  A couple of times I have taken two extra strength Tylenol but that is it - no severe pain at all.

So I did not go back to work for that first week and I remained non-weight bearing.  After a couple of days of having my wife bring me my meals, I decided to venture into the kitchen, which required going up two stairs.  Unfortunately, while I had practiced on the crutches before surgery, I did not practice going up and down stairs.  It is harder than it looks.  So the day after my surgery with my wife helping I got off the knee scooter and up on to the crutches - they are basic aluminum underarm crutches that I had gotten from the hospital.  With my wife at the top of the two small stairs I hopped up with one foot to the first step and lost my balance backwards.  I fell back but I knew I could not put any weight on my right leg so I just let myself crash onto my right elbow.  It was a spectacular crash and I severely bruised the elbow but thank God I did not put my foot down and rerupture the Achilles.  Lesson learned. I got back up and with my weight positioned forward managed to hop up the stairs and join my wife in the kitchen for dinner.

The rest of the week was just ice, rest, elevation. I went in for my first follow-up with the orthopedic surgeon on Tuesday May 26, six days after surgery.

My surgery was scheduled for the Reston Surgery Center on May 20, 2015, 10 days after my rupture.  The Reston Surgery Center is a large outpatient facility in the same building as my orthopedic surgeon’s medical group, on the campus of a medical complex which includes Reston Hospital Center, our community hospital. During my second opinion, I had asked the doctor about the safety of having the procedure done in an outpatient facility vs a hospital and he explained that statistically there is no greater risk, and that for an Achilles Tendon Repair (ATR) there is no requirement for any specialized equipment that would require that the surgery be conducted in a hospital.  I was comfortable with the Reston Surgery Center, I had a couple of procedures unrelated to my ATR done there over the years.

Prep was pretty simple, no food after midnight the night before the surgery, no aspirin for a week.  I was scheduled for surgery after lunch.

My wife and I went to the center at lunch time and waited for our 1310 showtime.  At 1415 they told us that the surgeon was running late, and shortly thereafter I went in.  The nurse apologized and said they were late because Dr. Kartelian was working on an unexpectedly complex case, setting an arm, but he would be done soon.

The nurse explained that I would get a nerve block which would numb my leg from the knee down for about 24 hours, and then I would be sedated during the procedure.  They gave me oral Celebrex, an anti-inflammatory, and IV Tylenol prior to surgery, and an IV anti-anxiety drug.  No narcotics.

I should interject here that I hate narcotics and they nauseate me.  The pain had been so bad since the Rupture that I started taking Vicodin several times a day along with Promethazine to prevent nausea.  Now with the nerve block and Tylenol they told me I would not need or get narcotics for the surgery.

An anesthesiologist came in to my bay and stuck a needle behind my right knee and in a few minutes I was completely numb from the knee down.  It was a strange and uncomfortable experience.  My toes tingled, but I could not feel anything from my knee to my toes and I could not move my foot.  I looked at it and “ordered” it to turn left or right and it just did not do anything.  It was like being paralyzed.  Before this had a chance to sink in, they took me in to the operating room, put me on my belly, and knocked me out.

An hour later I came to in the PACU, feeling a little woozy.  There was no pain, I still could not feel my lower leg.  I looked down and there was a big ball where my right foot should be - it was a dressing consisting of a spilnt and plaster with elastic bandages all around and my foot pointed down at a pretty sharp angle. This is referred to as a “plantarflexion splint” and I believe it is the typical post surgery dressing for ATR repair. I was instructed not to bear weight and I was given two pumps for my legs to prevent blood clots (more on those later).  I was wheeled out to my car and hopped in and my wife drive me home.

I was amazingly lucid that evening.  Because our bedroom is up a long staircase we set up a bed on the main floor of my house in a room we use as a small library. I relaxed, kept the leg elevated, and I applied ice frequently to the area right above my dressing.  I was not too uncomfortable and not in pain, but still freaked out about the numbness in my leg as the nerve block was still on.  I had purchased a knee scooter and I used it to scoot to the bathroom and to the bed.  It was a Godsend, I strongly recommend a knee scooter to help you during your non-weight bearing post-op period.

I did not take any narcotics that evening and at bedtime I took a Xanax to relax and fell asleep.

That wasn’t so bad.  My nerve block hadn’t worn off yet.

The rupture occurred on Sunday May 10, 2015. On May 12 I got in to see my surgeon, Dr. Kartelian.  He described surgical and non-surgical options.  I thanked him and told him that I was going to get a second opinion at George Washington University Hospital, a world-class teaching hospital here in Washington DC.

The following day I got in to see a Professor of orthopedic surgery at the University.  He told me the exact same thing about surgical and non-surgical options that  my "home" orthopedic surgeon, Dr. Kartelian, had told me.  Basically there is a non-surgical option which is not recommended because of the incidence of rerupture, the failure to return me to pre-rupture strength and activity, and the length of recovery.  Surgery had risks from infection and anesthesia but the incidence of each was low and the repair from surgery resulted in very good outcomes and very low chance of rerupture.

After these two consultations I decided to go with the doctor close to my house, Dr. Kartelian.  My surgery was scheduled for the following week, May 2o, 2015.

I am glad I got the second opinion.  While the two opinions were almost exactly the same, the post-op protocols that I discussed with each doctor were polar opposites.  Dr. Kartelian, who ended up performing the surgery, had a very aggressive post-op protocol, moving in to the boot, starting physical therapy, and bearing weight as soon as possible after the surgery.  The Professor at the university was an older man, and he was also a foreign educated physician although he had lived in the US for dozens of years and had fellowships and awards and an excellent reputation.  He told me that his protocol was eight weeks in a long leg cast before I could start therapy - a very conservative approach.  While not the deciding factor, I really liked the idea of an aggressive rehab protocol, and from my reading, this type of therapy was on the cutting edge and patients were having excellent success with it.

I am really glad that I picked the surgeon with the aggressive protocol.  I had some nominal atrophy of my right calf in just the few weeks I was down, I can’t imagine how the leg would look after 8 weeks in a full cast!  Getting in to physical therapy has motivated me to work hard and to get better sooner.  Being able to take the boot off and apply vaso pumps and ice has been a Godsend, although I realize how careful I have to be and how vulnerable I am in those brief intervals out of the boot.

I suggest to anyone who has the opportunity to get a second opinion that you just go ahead and do it.  Ask about the surgery, the anesthesia, pain relief, edema control, clot control, and post-op rehab protocols, as well as anything I forgot to mention.

In the previous post I recounted how an innocent stumble resulted in the full-thickness rupture of my already torn right Achilles’ tendon.  It was a beautiful Springtime Sunday at about noon, just outside the ball park (Nationals Park in DC - to see the nationals play the Braves).  I immediately tried to get up but my right leg just didn’t work, I knew immediately that I had ruptured the tendon.  I did not hear a pop or snap, but then again, with a moderate tear already diagnosed, my tendon was probably just hanging on by a thread.  I rolled around, my sons were concerned, and I looked up to see a Good Samaritan, and older lady in a Washington Nationals jersey, hand me a paper wipe to clean my bleeding right knee.  Out of nowhere a lady in scrubs was next to me, telling me she was a nurse and I appeared to be seriously injured.  I told her I had an injured Achilles and I was sure I had ruptured it and she told me to remain still while she called EMS and got me an ambulance.  At the same time, uniformed Nationals Park workers showed up and told me to stay still while they called medical.

My leg hurt bad, and I could not move my right foot up or down. A large hematoma was forming under the skin, and my leg felt as if it was full of fluid.  I thought about my predicament - Washington DC’s Fire and EMS is notoriously incompetent, and hospitals in DC are full of people with gunshot and stab wounds.  There are actual recent cases in the press about DC Fire not responding and leaving people to die. I was not going to risk my care to these clowns.  My two sons, both over 6 feet tall, picked me up and we got over to my car parked just outside the park.  I told the boys to enjoy the game, and I got in my car to head to my neighborhood hospital in Reston, VA, about 2o miles away.  I promised my sons that I would pull over and call 911 if I couldn’t drive.

My advice is that if you rupture your right Achilles, do NOT try to drive.  Post-rupture, your right foot is just a big block at the end of your leg that you cannot flex up or down.  My foot was getting numb and my calf was swollen and filled with fluid.  It was stupid, but I managed to slowly drive out to the Virginia suburbs, about 20 miles.  It hurt like  hell, I called my wife at home and asked her to meet me at the ER with my Vicodin prescription.  I parked outside the ER and drug my bad leg in and stumbled into a wheelchair.  My wife arrived and I chomped down two Vicodin while the intake nurse put a cold pack on my leg.  After a short wait I went in to treatment, the ER doc gave me the Thompson Test and diagnosed the complete rupture.  He started an IV and gave me 1mg of Dilaudid IV and sent me to X-ray.  No bone issues on the X-ray, so I got another mg of Dilaudid (that stuff is fantastic - 8 times stronger than morphine) and he put me in the boot and sent me home.

When I entered the treatment room at the ER the baseball game that I had just left was playing on the TV and it was just starting.  I was in the ER for about 3 hours, so I watched the entire game - our hometown Nationals beat the Braves 5-4!

So, diagnosed with a moderate tear following the MRI in mid-March, 2015, my Physiatrist told me she was no longer my doctor.  She told me to wear the boot for a month and then go and see a surgeon in her practice.  She told me that I was beyond pain management and needed to consider rehab and repair options, including surgery.  She also sent me to physical therapy (PT) during this month.

So from mid-March to mid-April I spent two days a week in PT strengthening the damaged (partial-thickness tear) right Achilles’ tendon (AT)  and wearing the boot most of the time.  I had a pretty pronounced limp from the injury, but still I only wore the boot about half the time.

In mid-April 2015 I had my initial meeting with the orthopedic surgeon, (OS), Dr. Kartelian.  The OS asked how I was, I said about the same, my leg hurt.  He took one look at the MRI and told me that I needed surgery, the question was just when.  I told him that I had a business and pleasure trip to Europe planned from mid-May to  June 2 and we agreed that I would continue PT until the trip, take the trip, and then see him to schedule surgery when I returned on June 2.

So I continued according to plan.  I was set to leave on May 15 to fly to Geneva.  On Sunday, May 10, I arranged to meet my two adult sons at Nationals Park in Washington DC to take in an MLB game.  The Nationals were playing the Atlanta braves for the third game of a three game series that Sunday and the Nats had won the first two games, so we were looking for a sweep.

On Saturday May 9 I went to the gym, rode the exercise bike for 40 minutes and then did all my balance and strengthening exercises on my torn right Achilles’ tendon.  I got up on May 10 and drove in to DC and parked my car at Nationals Park, the Major League Baseball stadium.  I linked up with my two sons who live in DC and we decided to go inside the park and grab a bite of lunch before the game.

It was a beautiful day and I walked with my two sons towards the Center Field gates along Half Street, just a few blocks South of the U.S. Capitol.  Physically I felt good, but I had a slight limp due to my Achilles tear.  It was a lovely warm, clear day without the stifling humidity that comes to DC later in the season.  Walking along, I stumbled just a bit on my left foot - unusual for me because I am usually very sure-footed, but I had on some new shoes and I just stumbled a bit.  I immediately put my right foot down to catch my weight and avoid falling down, and I caught my toe on the top of the curb.  With my right toe on top of the curb, all my body weight came down on my right heel, which did not have the ground to stop it and hyperextended my torn Achilles’ tendon, instantly rupturing it.  I fell straight to the ground, lacerating my right knee.  I was not able to get up, and the pain was intense.  I knew immediately that I had "graduated" from the tear to the rupture club.