bobfv’s AchillesBlog

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.

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.

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.