bobfv’s AchillesBlog

Today marks 9 weeks to the day since my ATR surgery. In my last post I wrote about my outing to the ball game in shoes (boots) over the weekend. The following day I had a great PT session, working on standing calf raises and gait normalization, then yesterday my wife and I flew from Washington DC to LA. I wore my Aircast boot and had no problem at the airport, went right through “TSA Pre” without any extra scrutiny, and had no problem boarding. We sat in first class so I had enough leg room, and I took my Aircast off and replaced it with a comfortable street shoe with a heel lift as soon as I was seated. It worked out fine, I used two shoes to walk from my seat to the lavatory. A couple of hours in to the 5+ hour flight I put my vaso-pumps on my calves and let them run  for about 90 minutes, a hedge against blood clots. When we landed I put the Aircast back on.

At LAX we picked up our bags and took the shuttle to the car rental place. I am an LA native and learned to drive here, my wife is a little nervous about jumping on to the LA freeways, so I took off my Aircast, put on my tactical boots (see previous post) fired up the rental car and jumped on to the San Diego Freeway at rush hour. I had not driven in about 2.5 months, but I had absolutely no problem. No pain, no issues whatsoever. My heel just rests on the floor of the car and I plantarflex to operate the throttle and brake. Piece of cake! I am so happy to be driving again!

When we got to our destination in LA my ankle felt fine but it was swollen from the flying and driving, and I iced it down. I had not had any swelling in weeks but all those hours with the leg down on the ground took their toll. The swelling went away after icing and I didn’t even need to take a Motrin or Tylenol.

Today, celebrating my 9 week anniversary, I got up early and went to the gym. I went in two shoes - I picked up a pair of Hoka One trail running high-tops to give me support in the gym and they worked great. I rode the exercise bike for 45 minutes, then I did most of my PT exercises including one leg balancing, step ups, basic proprioception, and 2-legged calf raises. I recommend these great shoes for transition workout shoes. I put a 1cm heel lift in the heel of the right shoe.

That’s where I am at week 9. I feel like I am making great progress now and getting my old life back!

I had tickets to yesterday’s baseball game, Washington Nationals vs LA Dodgers, and I just had to go. The Washington Nationals are my adopted team, and the LA Dodgers are the team that I grew up with in Los Angeles so this was a must see. Since my injury I have attended two games, both when I was PWB in the boot with crutches, and I switched out my seats for ADA “handicapped” seats and everything worked out okay. Yesterday I decided to use my regular seats, which are all the way down right on the field in the 3B corner, meaning I have a loooong set of concrete stairs to go down and up to get to the seats. To top it off, yesterday was a heat warning day in Washington DC - high heat and extreme humidity with heat index values in the 100’s. If you have never been to the Washington DC area in the dog days of summer, the place is absolutely miserable. It is built in a swamp and it just swelters, and yesterday was predicted to be the hottest day of the year so far.

So with that background, I decided that it just was not practical to wear my walking boot - it would get uncomfortable, be difficult on the stairs, and also be difficult in terms of people stepping over me to get in and out of the row. I wanted to sit in my seats, not in the ADA section. Since I am at 8.5 weeks post-op and doing well in PT I decided to give it a go in two shoes.

I bought a special pair of shoes just for this purpose. My background is military and law enforcement and I am kind of a nut for tactical gear. A company out in California called 5.11 Tactical makes great equipment and gives me a veterans discount, so I chose them in selecting a protective boot to wean in to out of my Aircast boot. After looking through their selection I decided that I wanted the following qualities in my boot:

- 8 inch height for ankle protection
- lightweight and breathable
- stiff shank to prevent excessive dorsi-flexion
- ability to accommodate a 10mm heel wedge
- comfortable enough fit around my scar
- side zip for easy on and off

I selected the ATAC Sage 8 Inch CST Boot because it had all of those qualities in addition to a composite safety toe (CST) to protect my foot if someone stepped on me. The boots are very comfortable and I took them to my OS appointment and my surgeon really liked them and thought they would be a fine boot to transition into as I moved to two shoes, providing lots of ankle protection and support.

So I am still not driving, my friend picked me up and off we drove to Nationals Park in Washington DC, just south of the US Capitol. We had a parking space right next to the park and I had no problem whatsoever walking in my new boots! I walked a little bit slowly just out of caution, and I was very careful to avoid situations like curbs which would potentially put me into excessive dorsiflexion, but I did just fine. Once inside the concourse I walked all the way to the far side to get to my favorite sandwich stand, over to my seats, down the stairs - no problems at all. Sitting in the seats I was very glad I didn’t have the Aircast boot on as people stepped over me to get to their seats.

After the game I came home and iced my ankle but I really did not have any pain or swelling - I was very pleased as I had worried about both of those issues but neither materialized.

I consider the whole outing a great success, except for the fact that my adopted hometown team lost to my boyhood hometown team I hope this info is useful for anyone transitioning to two shoes. I am going to stay in the Aircast boot for most day to day activity for a couple of more weeks, as my OS had ordered, but it is nice to know I have this option and I am going to use the boots as I start driving again next week.

I had my 8 week post-op appointment with the surgeon today. The good news, everything looks fine. The bad news - OS wants me to continue conservatively over the next 3-4 weeks, wearing the boot most of the time, continuing with strengthening, and walking in two shoes with a heel lift at home. He also did not clear me to drive, which is a disappointment but one that I can work around (I have a very expensive, luxury paperweight form Germany in my garage!). He said that in a year I will not even remember if I was in the boot 2 months or 3 months, but just to be on the safe side to keep wearing the boot with one lift, and to wear my shoes with a lift when I do PT and around the house. It doesn’t really bother me - I have good ROM, I am getting my strength back, and I would rather not risk future problems, so I will stick with the status quo for now.

In physical therapy I am progressing to leg strengthening exercises now that I am healed and have a relatively normal range of motion, so I will continue to work hard to strengthen it up.

Here is a photo taken this morning - my 8 week post-op anniversary photo:

I am in the middle of my 7th week post-op and I have progressed in my PT protocol to a new set of exercises designed to get me back in two shoes and regaining my strength and balance. The protocol now includes:

• Normalize gait
• Progress calf strengthening
• Seated heel raise>>>standing heel raise>>>single leg heel raise
• NMES prn  (neuromuscular electrical stimulation as needed)
• Gradually progress dorsiflexion past neutral in stretching and strengthening
• Progress to equal ROM bilaterally
• Eccentric plantarflexion strengthening

I am enjoying these new exercises, for the most part, and continuing to do many of the exercises I learned in the past four weeks of PT.  I have stopped wearing the boot to bed at night and I take very short walks without the boot in the house, very carefully.  In PT I use my street shoes with a heel lift.  I am still doing seated heel raises and have not started the stimulation yet.  My range of motion is very good - I practically have the same ROM in both ankles, but I am not about to push it on dorsiflexion.  I am doing plantarflextion on the Total Gym in shoes which is kind of scary, because I have the balls of my feet on the machine and my heels off of it - the idea is to press down with my toes, but I am scared of slipping and going in to a big, unintended dorsiflexion.  I am also enjoying working on single leg balance - I alternate lifting one foot off the ground and standing on one leg for ten seconds at a time.

I have an appointment with the OS this coming Wednesday, and I am hoping to get his blessing to lose the boot and to start driving.  That will be exactly 8 weeks post-op.  Other than that I feel great, no pain whatsoever.  I bought a pair tactical boots which are lightweight and have a side-zipper entry and I plan to wear these in the first weeks out of my Aircast boot to provide extra support and protection. I have worn them around the house and they don’t seem to put any pressure on my scar, which has healed almost completely.

So I am at 6.5 weeks post-surgery on an aggressive protocol. I recently added new exercises at PT prefatory to getting back in to two shoes, which should be in about a week and a half. Since yesterday was a holiday Friday and my wife had yoga class at our gym, I hitched a ride with her and did a workout based on my PT, here is what I did (all with boot on):

Exercise bike: 40 minutes level 3 80 RPM
Leg lifts - 20 with each leg in all four planes of motion (boot on)
standing balance with 8# ball - 30 seconds on each leg
Leg presses - 2 sets of 10 with the bar and 2 10 pound weights
Squats “sit to stand” - 2 sets of 10
Step ups - 10 with each leg.

In the evening I took the Metro train into Washington DC for dinner with my boys so I walked about 4 blocks FWB with no crutch or cane.

Well, this morning I am sore, but “good sore” - both glutes and hips really feel the work I put in yesterday, which is great. I am looking forward to continuing with PT and with these workouts on my own! Can’t wait for the boot to come off so I can do even more. OS said strengthening with my legs and feet pushing away from my body is what I need to concentrate on.

Oh - also last week at PT, with the consent of my therapist, I had my wife come in while they were doing “scar tissue mobilization” massage and she learned how to do it, so now I am taking the boot off once a day for her to give me a massage and rub vitamin E on my scar. I also still take the boot off once or twice a day to use the vaso pumps (still a chance of blood clots until I am out of the boot) and I also take it off to shower, and to walk between the bathroom and my bedroom (very carefully!) after I shower and before I dress.

Today I visited the Orthopedic Surgeon 6 weeks to the day after my surgery.  I have been FWB in the boot for over a week and I am now walking without any crutches or cane.  The doc did the Thompson Test on both sides, noted proper function. He also noted atrophy in my right calf, fairly normal.  I have well-developed, muscular legs so the atrophy in the calf muscles is pretty apparent.

I told the doctor I have been showering out of the boot, standing on my bare feet in the shower and carefully walking from the shower to the bedroom to dress.  He looked a bit alarmed and told me to be careful. He also told me to continue physical therapy, and per protocol to begin to wean out of the boot.  He took one of the three lifts out of my boot which feels much better, and we set our next appointment for two weeks from today.  He still doesn’t want me driving for at least a couple of weeks.  He also warned me not to do any dorsiflexion past neutral in PT, and to continue strengthening through resisted plantarflexion, leg presses, and to start balance exercises.

I feel really good.  I have no pain at all.  My wound is healed and dry except for one little spot that continues to ooze just a little bit.  I have no problem putting more than my full body weight on my right leg wearing the boot - I stand up and put all my weight in that leg and it doesn’t hurt at all.

So, fingers crossed - I will wean out of the boot and continue physical therapy over the next two weeks.  I am extremely anxious to start driving again and hope to be cleared to drive in two weeks - I have a very expensive German paperweight sitting in my garage waiting for me to get behind the wheel!

That’s it for now - here are two pictures that my wife snapped during the exam - you can see the significant thickening in my right calf comparing it to my left one.