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

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.