February 15, 2016 - 9 Month Progress

February 15, 2016

So it is mid-February and I ruptured on May 10, had surgery on May 20, 2015, that puts me 40 weeks and one day post injury, and 38 weeks and 5 days post surgery. I just round it off to 9 months.

My last update was around Thanksgiving, when I did a turkey trot at a fast walking pace. I have made very steady progress since then. I work out on a treadmill 5-7 days a week. My main focus has been on progressing from a “walk” (one foot down at all times) to a jog (periods with both feet off the ground). During December we were out in California for a couple of weeks and I took advantage of the nice weather to take daily 4 mile walks in my Skecher’s Shape-up Comfort Walker shoes. Back here in Northern Virginia, I have been hitting the gym daily. My basic workout has been 40 minutes on the treadmill - the first 10 at a fast walk - 3.5 mph - then the second ten minutes also at 3.5 but increasing to a 10 percent grade by adding one percent per minute - the third ten minutes lowering from 10 percent to zero grade, then the last ten minutes at my fast walk 3.5 mph. In mid-January I had to go for a treadmill stress test ordered by my cardiologist and I did fine, all the way through the fourth stage, which is 4.2 mph at a 17 percent grade!

In the past week I have incorporated jogging into my workouts. My jogging speed is 4.2 mph, a very light jog, but a jog. Today I did 10 minutes fast walk (3.5) then 15 minutes jog (4.2) and the last 5 minutes at 3.5. I hope to get up to 20-30 minutes of jogging within the next week or two, and to then get out on the road and properly jog a 5K in the early spring. My jogging is sure to help my Achilles heal (hey - double entendre!) as the jogging action adds a plyometric push-off aspect to the motion.

In addition to the walking and jogging, I have continued with the strength and balance exercises I learned in physical therapy. About 3-4 times a week I do 100 heel raises of different types. I can just barely do a one legged heel raise on the healing leg - I am a little disappointed because it is so easy to do on my good leg, but I am trying to remain patient. I also do toe presses on a leg press machine, and I walk on my toes using a Theraband for resistance. I also use an “Indo-Board” for eccentric strength and balance training, and do one legged floor toe touches.

My walking is absolutely fine - I am a little sore sometimes but I have completely lost any trace of a limp. I force myself to use a full range of motion when I go up and down stairs, and I work through morning stiffness when I wake up.

I am not taking any type of medicine since I don’t have any pain. I am very careful about my footwear now. I wear Skechers Shape-ups as much as I can. For gym shoes I am wearing Asics Gel-Kayano 22’s with the insole removed and replaced with blue ‘Superfeet” orthotics. I have a pair of low Gore-tex Under Armour boots for bad weather and I have a gray merino wool Superfeet orthotic in them. I am also back in my favorite daily shoes, a pair of low cut Vibram-soled Timberland shoes, and I got low profile carbon fiber Superfeet liners for them. My dress shoes are Allen Edmonds Park Avenue shoes - I don’t have to wear them every day, and I can’t get even the lowest profile black Superfeet into them, but I do okay when wearing them.

My scar has healed very well - I continue to use Bio-Oil once or twice a day, and a couple of days a week I use a silicon sheet over the scar.

So I am hoping that the last three months of my healing - taking me up to my one year anniversary on May 10 - will continue to go smoothly and I will continue to progress. My goals in the next three months are to be able to run a 5K in 45 minutes or less, and to be able to do one legged calf raises evenly on both legs.

Best of luck to everyone in your healing.

Post-Op Week 2-4, Physical Therapy and PWB

June 19, 2015

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).

May 20, 2015 Surgery - Achilles Tendon Repair

June 15, 2015

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.

Tendinitis and the road to rupture - the pitfalls of cortisone

June 15, 2015

I started having Achilles tendon pain and inflammation around the time I ran the Marine Corps Marathon in 2007.  I was able to manage the intermittent pain and swelling with NSAIDS, especially Motrin. The tendinitis came and went over the next few years, increasing with my level of activity.  I stopped doing several longer runs in favor of 5K’s and 5 milers and I noticed as my training miles increased, so did the frequency and intensity of my Achilles pain.  In addition to NSAIDS I used compression socks, but nothing really gave me very good relief.

In Fall of 2011 I was training for a marathon and the right tendon really flared up, to the point that it was impeding my workouts and I could feel nodules.  I went to my primary medicine physician and he referred me to a physiatrist at a local orthopedic medicine group.  The physiatrist (an MD specializing in rehabilitation and pain management) said that I was stuck in a cycle of inflammation, and I needed to get that inflammation under control to get my pain under control.  She prescribed 800mg Motrin 3 times per day (the max dosage) and the use of Voltaren Gel, a prescription anti-inflammatory.

I continued to train and to use the anti-inflammatories, but my right Achilles tendon in particular presented severe tendinitis.  After a few months of anti-inflammatories, my physiatrist suggested a cortisone injection to get the swelling under control.  She warned me that these injections were associated with Achilles Tendon Rupture (ATR) and told me that I would have to lay off any exercise for a few weeks after the injection.  She also told me that she could not inject directly into the tendon, just around it.  We went ahead with the injection and within a few days my inflammation was gone and I felt fine.  I laid off of running, but I was feeling completely normal post-injection for the fist time in years.

About a month after my first injection, I was out in the yard splitting wood and I tripped over a vine and fell, hyper-extending my right Achilles tendon.  Immediately I felt the swelling and inflammation flare up again, and about a week later I went back to the physiatrist and I asked her for another cortisone injection, which she gave me.  Following the second injection I took a nice layoff over the holidays, and in early 2012 when I resumed running workouts I was doing fine.

Throughout 2012 and 2013 I picked up my mileage, sometimes with sore Achilles tendons and sometimes not.  My right was always more sore than my left, and had the nodules that I could feel about mid-length.  In 2013 I ran the Army Ten Miler here in Washington DC and felt great, then in Spring of 2014 I ran the Rock and Roll DC Half-Marathon and felt very good doing it.  I continued training in 2014, with intermittent Achilles tendinitis plaguing me, and treating it with lots of anti-inflammatories.

In October 2014 I ran the Army Ten Miler in Washington DC.  I had been busy and had not done as much distance work as I should have, but I gutted it out and ran the race with a great time, close to my personal record.  After the race, my Achilles tendonitis returned with a vengeance, particularly in my right Achilles tendon.  In retrospect, running a ten mile race without the proper training base was a good recipe for injury.  I went back to the physiatrist and I explained what I was experiencing and I told her that I wanted another cortisone shot since they had worked for me before.  She again warned me of the association between cortisone shots and ATR rupture, but said that this would only be about my third shot in three years, and she shot me up again in mid-November, 2014.

After my cortisone injection in November 2014 I felt great - the swelling went down and I went back to daily 3 mile training runs.  I was fine for about six weeks, and then in early January, 2015, I had a twinge in my right Achilles after a run.  It got worse, and developed into a serious case of tendinitis.  I went back to the physiatrist and she told me to rest, ice, and use anti-inflammatories.  I stopped running and instead switched to using and exercise bike and and elliptical trainer, which didn’t put as much strain on my Achilles.  Since the last cortisone shot only gave me about 6 weeks of relief she ruled that out as an option for additional treatment.

On Valentine’s Day 2015 I went to the gym at lunch time and did a vigorous workout on the elliptical trainer.  Afterwards, my right Achilles flared up and for the first time seriously impaired my walking - I had suddenly developed a limp due to a sharp pain in my right Achilles.  I continued to limp around, as I had some international travel to do, and my limp and the pain grew worse.  Around the beginning of March 2015 I awoke one morning to find a hematoma under my skin around my right heel.  This, coupled with increasing pain, lead me to go to the ER.  The ER doc examined me and told me that my Thompson test was good - no rupture, but he was concerned about the pain, the nodules, and the bleeding.  He splinted me and sent me to an orthopedic surgeon in the same practice as my physiatrist.  The OS ordered an MRI and it came back, in mid-March 2015, as a small but moderate partial-thickness tear in my right Achilles a couple centimeters above my right heel.

Now that I had my diagnosis, physical therapy and a walking boot were prescribed for me, which I began immediately.

A footnote - in retrospect, I would never have taken the cortisone injections.  All the literature I can now find, plus my doctor’s own warnings to me, list cortisone injections as a leading contributor to rupture, and I had multiple injections in the area of the Achilles which tore and eventually ruptured.  I think part of the problem is that I went to a pain doctor to manage my tendinitis. In retrospect, I should have consulted an orthopedist. The very first thing my orthopedist told me when he examined me post-tear was "NO MORE CORTISONE!"  I think that someone who sews these things together for a living would have advised me against the injections, although in defense of the physiatrist, she did warn me.  Right before she shot me up.

I was on the road from a tear to a complete rupture - which came not long afterwards.

First Post!

June 15, 2015

Hello everyone. I had trouble getting the blog set up but I am here now and anxious to share all the details of my Achilles story. I am a 57 year old white male and I have been athletic my entire life. I live in Northern Virginia, just outside of Washington, DC, and I am a partner in a small consulting firm. I played Football in high school, Rugby in college, and have been doing recreational distance running since college, mostly 10-mile and half-marathon distances with a couple of marathons thrown in. I am 5′10" tall and I have a heavy frame and while active and athletic I have struggled with my weight my whole life, from the high end of normal to the low end of overweight, but I have never stopped being very active both outdoors and in the gym, averaging 15-20 miles of running per week over the last 35 years or so. While I am progressing well now almost 4 weeks post-ATR surgery on my right Achilles tendon, I want to go back in time and give you the whole history of my tendinitis, treatments, Achilles tear and eventually my rupture and repair.