Nine months…should I try surgery?

Hi folks,

I would appreciate input/advise…(thanks to Norm and Stuart for their kinds words at the ~7-month mark).

Full rupture of my left achilles Dec 1, 2014, nearly nine months ago. Treatment was non-op as is common here in Canada, 12 days in plaster splint, followed by Breg (make) boot with wedges.  I believe I have healed long and am looking for options to get closer to 100% recovery.  Rehab protocol was UWO, but that was during winter and I slipped on ice more than once and was using crutches during the first two weeks.

I met with a foot-ankle OS today and discussed options (1) shortening surgery or (2) more time to allow for healing.  The foot-ankle OS believes I healed long as there is less dorsiflexion resistance when she pushes up on my injured left foot compared to my uninjured right.  The treating General OS had similar thoughts during an appmt four weeks ago.  Range of motion is very high and similar in both feet.

I have read through TomTom’s blog and other veterans’ blogs on the healing long issue.

I am now 50 years old, 5-10, 180 lbs, and fairly active - walking, group road biking, exercising at gym, downhill skiing are main activities.  I visit with a PT 2-4 time per month who works on the scar tissue, dry needles (electronic pulsing) the calf, gives me exercises, etc.

Here is what I am experiencing:

(1) left calf atrophy: 2 to 2.5 cm smaller than right

(2) wimpy 1 to 2 cm heel raise and sometimes brings pain to left achilles

(3) 30 minutes of elliptical or running results in sore/tight soleus-achilles and some ankle stiffness, all in the next 2 day; similar result with 1+ hr of road biking or 3 x 15 sets of 2 up 1 down bent/straight knee heel raises on flat surface; there has not been any swelling for months.  Slight limp is present after a 30-min run.  OS recommends no running or elliptical for the next four weeks and wearing a ~1 cm or more heel wedge in an attempt to tighten the achilles (I have been trying with little if any success it seems).

(4) unable to hop up and down on injured foot (heel strikes floor)

Although I do not like the prospect of surgery and rehab, I also do not like the prospect of having a weak calf/long achilles for the rest of my days.  Perhaps I am being impatient as it has been only 9 months.  I have not had any significant surgery and so am also concerned about complications from surgery.  If I was not active, the choice would be easier - continue with the non-op recovery.

Thanks in advance.

16 Responses to “Nine months…should I try surgery?”

  1. Hi Stuart,
    Thanks for the feedback.
    The repeated reply has been deleted…maybe one too many times!
    I have read where others (Savvy 525) experience calf soreness for 3-4 days after a 5k run even after 13 months post ATR. Like me, he struggles with1 leg heel lift but able to do other activities.
    Is the calf soreness reasonable at this stage? My guess is yes due to atrophy.

  2. Brad - I am not sure about the pain and it is diffiucult to summise without seeing you. That is probably why I suggested in the deleted post to start at the basics and work up with a strengthening program. I am trying to work out in my brain how a tendon which has healed long will cause pain once it is healed. Maybe someone else has an idea. If the pain is in the muscle and it is of the lactic acid type after exercise then your muscle is getting used to the work and it should go away as it strengthens. If you have healed long then it will never be equal to the other leg in strength so it may be a little more painful if you are pushing hard. I hope you remember most of what I said in the deleted post but for the benefit of others later, I feel you should see how it goes in another 3 months before contemplating surgery and then get a second opinion. You could always send a message to the others you have mentioned and see if they are still having the problem or how it was resolved.

  3. Hi Stuart,

    Thanks…I plan to take your advise and try more basics like walking.

    I will try to explain more about the soreness…
    After 30 min of exercise, I have soreness/tightness in my achilles and calf, which remains for a few days. e.g. I ran 5k on treadmill 3 days ago and there is still some tightness from ankle to gastroc. This tightness is most noticable when I plantar flex with straight knee while standing. This is when I also notice that I have little push off strength at end range of plantarflexion, compared to uninjured right. When seated, I can flex the injured calf and feel the tightness. This calf is 2 to 2.5 cm smaller than uninjured calf.

    I have seen little if any progress with the calf raise in the last two months or more and that is the frustrating part as I sometimes have a slight limp after 30 min of exercise (fatigued calf /achilles).

    You are a kind soul to help us steer through rehab!

  4. Brad - I really can’t explain the pain. Perhaps you need some deep tissue massage of the tendon but you say you are being treated for scar tissue. There are indicators this is a strength issue but I am not really certain. PT’s usually have a pretty good idea about these things but if you are not getting much out of the current one then perhaps a change. I am not saying the current one is bad but sometimes a fresh look can help. You mention dry needling with electronic pulses. If you mean they are using a TENS machine for the pain then you are wasting your money and that alone would push me to another PT. The relief is only temporary and it is not treating the cause. Keep us posted. You have me curious.

  5. Stuart

    Thanks again for the feedback.

    Dry needling is new to me…it is a form of acupuncture where needles are inserted into the muscle (gastroc and soleus in my case) and then pulsed electronically for 10-15 minutes for muscle contraction. The calf feels like it was worked/fatigued after treatment.

    The decision to have / not have surgery in a few months weighs on my mind. On one hand, I would like to return to being closer to 100% but am concerned that at age 50 there could be complications from surgery that could set me back even further (1st treatment was non-op). Also, I would not enjoy the rehab/lack of mobility, but during a second rehab, I would be much more cautious about elevation, weight bearing, etc.

    Both Norm and yourself are cautioning me to only consider surgery after 12 mos earliest. I have it stuck in my mind (partly from reading other posts) that the only way I can increase the push off strength (for running, jumping, hiking, etc) is surgery and rehab. But could this result in further muscle loss (injured calf is 3/4″ smaller) or other complications?

    If I could just get some more push off strength, then I would not consider surgery as an option.

    My foot-ankle OS prefers non-evasive treatment over surgery but has not ruled out the latter. She was planning on doing some research/consultation on how to treat an AT that has healed long (will meet with her next week). I have seen 2 OSs in past month and both think healed long due to less passive resistance to DF on injured left (DF ROM is plentiful and similar on both).

    Appreciate any further comments you may have!

  6. Brad - it seems you have most things covered and now it is really a matter of waiting. I am not sure about the electric dry needling. I know acupuncture works but putting electrodes on them to make the muscle pulse. It reminds me of one of those machines they sell on a shopping network with electrodes you put on you stomach and claim it will give you rock hard abs. They are TENS machines and research has shown they do nothing for muscle development and only temporary pain relief. The main complications from surgery would be infection and wound healing. Also there is a small chance they could shorten you too much. I would expect your strength to be less on the injured leg at the moment but they are similar in flexion. What does that say? If you were long on the injured side you would dorsi-flex further. In the end it will be your decision and the anguish it takes to make that decision is yours as well. Happy to help if you need to bounce things off someone. Be patient though and maybe seek a second opinion regarding your PT.

  7. Stuart - Although dorsi flexion ROM is high and similar with both feet, my foot ankle OS (1st appmt with her was last week) and treating OS both believe I healed long since there is less resistance (spring) to plantar flexion in my injured left compared to my right. WIth my legs horizontal and relaxed, they push up on my feet and the injured left has less resistance. Also, the foot ankle OS observed my injured left to be resting several degrees higher in DF than the injured left.

    Do you believethese are indications that I have healed long?

    When I attempt a 1LHR (1-2 cm height), the momentary pain in my Achilles is a 2 or 3. The heel raise seems to have plateaued from mo 7 to 9, despite doing 2 downs, 1 ups, cycling, elliptical, walking, physio, etc.

    Must admit that when I was in a plaster splint (not a full cast around my calf) for the first 12 days, I returned to my desk job immediately after injury and did pwb for short walks to adjacent offices, etc. and suspect that this did not help with the healing.

    Thanks again for being a sounding board!

  8. Brad - I do agree there is a chance you have healed long but still feel it is too early to call and way too early to determine how much it is going to affect the rest of your life. Certainly too early to make any big decisions about surgery. Many people have been weight bearing from day one and this has not caused any problems with healing as long as the tendon was protected. I keep going back in my mind to the pain you are having and cannot see how that would be any indication of you healing long and I feel it could be more to do with conditioning and strength. These are only my thoughts so I suggest you speak to the experts about it. From what I have read, those who have healed slightly long adjust quite well and I am sure if you asked them after 2 years if they would have surgery to fix it and the long recovery most would say NO.

  9. Stuart - Any thoughts or experiences of being fitted with orthotics at 9+ months to increase push off strength? To date, I have not used orthotics.
    Is it common for patients (I am age 50) to continue healing into the second year? I recall seeing a post by Norm about this.

  10. Brad - healing a tendon has been shown to NOT be age affected and yes it is not only common but normal for everyone to continue to improve up to 2 years. The gains will be slower after a year but all good studies do followup after 2 years. I have orthotics and use them for exercise but I really should wear them in every shoe. I am not sure if they will increase your strength but they will help with your biomechanics. If your arch collapses or rolls in when you walk extra pressue is put on your Plantar fascia tendon (from your heel to big toe) and this puts more pressure on your achilles and from there it travels up your leg and to your back. I would recommend orthotics to anyone who has had this injury.

  11. Stuart - I am curious what time zone / city is home to you? I am in eastern Canada, 1 hr from the Atlantic. :)

    You advocate waiting at least 12 mos before considering surgery to shorten the achilles. Is this because of the long recovery, potential for further calf atrophy, potential for other complications, and or tendon is still healing?

    From your readings and research does push off strength improve in the second year?
    My gastroc and soleus on injured side are often tight after repetiitive exercises like cycling, walking, heal raises, etc. The injured calf is about 2 cm smaller. Maybe that is why? I can usuallyp feel the tightness and strength deficit with each push off while walking. Massage therapy provides temporary release.

    I meet with the foot ankle OS on Thurs. She was taking 2-3 weeks to research / consult on non-surgical treatment for achilles that have healed a bit long and increase push off strength. I prefer to avoid surgery, but wish to increase push off.
    Thanks again for the feedback.

  12. Brad - firstly I am on Australia Eastern time. Regarding your questions. As I have mentioned before, there is a chance you have healed long. There is also a chance other factors are at play. These may be in conjunction or separate. Your tendon is healed to an extent but it is still remodelling. I have noticed how much thinner my tendon is now compared to 12 months. It will always be thicker because the new tissue will never fully resemble the uninjured tissue. There is still a great deal NOT understood about tendons and how they heal but there is a consensus that the remodelling stage takes up to 2 years. In that time more collagen type (I) will form, replacing the weak and disorganised type (III). Type (I) is aligned with the forces, strong and organised. They are also understanding more about the funtion of this tendon and it appears it is a bit different to most tendons in the way it absorbs and transfers energy. Apart from the studies I have read, I have noticed a great range of outcomes from reading accounts on this site. Some people struggle with strength and yet after a year or two they are doing fine. Some notice a strength deficit and others say they have returned to normal. I believe your strength will increase over the next year with proper management and after that you will be in a better position to decide if it is affecting your life enough to undergo surgery. I really cannot judge if you have been managed well to date and if you have not then it would contribute to your lack of strength now. As I said earlier, start from stratch and increase incrementally. I would also suggest you do not run for the moment. Work more with eccentric loading which is the going down slow. I will be interested in hearing what your doctor says. My injured calf is still a bit smaller than the other but my push off strength is fine. I have noticed the injured side is still prone to atrophy if I take a break from exercise and specifically eccentric loading exercise.

  13. Brad, I’m sorry I missed or ignored this thread, despite your note on my own page inviting me to comment. Fortunately, you’ve hadnStuart here, doing an great job. I’ll comment on your newer page, though Stuart did say one thing here that I’d like to respond to (if I can find it again!). Yes, here it is:
    “If you were long on the injured side you would dorsi-flex further.” I’ve repeated this logical truism here a bunch of times myself, but I now doubt that it’s reliably true. At both election extremes, there are several “stops” limiting the ankle from flexing further, and muscle-tendon length is only one of them. The kind of approach your OSs are taking - with multiple data inputs leading to a complex and semi-subjective - is probably the best anybody can do.

    Other than that niggle (which changes ~0), I second all of Stuart’s comments. Many ATR patients improve in the second year. And many (most?) have asymmetrical calves, somewhat smaller and sometimes a bit changed in shape - either post-op or non-op, and regardless of whether or not they have any functional deficits.
    In your case, or any case that involves pain, or even discomfort that isn’t of the normal post exercise variety, I’d recommend backing WAY the $%&⅝ off, and staying there until all hints of that pain/discomfort are gone. Like Stuart, I’m not sure you’ve healed long, though it is very possible and probably even likely. But I also think you’ve been too good a patient, pressing your rehab exercises too hard in a well-meaning and understandably frustrated drive to get to 100%. But if you press to pain, that pain can easily become chronic, and it may hold you back forever.
    Normal stiffness resolves in a couple of days, but pain from abusing a healing body part can take much longer. My blog tells a personal story from my ATR #1, when about 3 minutes of stupid overexertion led to A MONTH of taking it way easy, back in my boot AFTER I could walk PERFECTLY (and did) in bare feet! Staying in that boot for a full month was a total PITA, but that’s how long it took for all hints of that pain to vanish, and I don’t regret a day of it. Nor have I ever experienced a hint of that pain since, in the ensuing ~14 years.
    I don’t know HOW easy you’ll have to take it, but I bet your leg knows. I’d say do whatever you have to do, to avoid that pain completely, and don’t return to more strenuous activities until it’s gone for sure.
    Like you and Stuart, I’ll be pleasantly surprised if you get all the way to 100% this way, but I think it’s worth a try for several reasons. Mostly, I’ve been shocked that I am functionally 100% despite a quite substantial strength deficit on my left (ATR #2) side. I only had it measured way early in my rehab (and it was ~65-70% of the other one then - my blog “And the results are IN” remembers), but I’d be shocked if I ever got past ~85%. Yet I have NEVER noticed a difference walking, running, cycling, or even playing both kinds of volleyball at a fairly high level! Other than in a clinic strength test, I only notice it while doing straight-leg heel raises! If your results are similar (after you ditch the pain), you’ll probably decide that 90% - or even 85%! - is an A+. But not with pain lurking around the corner, so see if you can “lose” that first.
    Of course, as always, this is just advice from “a guy on the Internet”, though one who’s been there twice, read a lot of studies, and read/heard a lot of ATR patients’ stories…

  14. Lots of typos from my phone, sorry! Brad, if you can enable “AJAX Editing” in your settings/options, we posters will be able to clean up our own messes.
    One doozy:”At both election extremes” should read “At both flexion extremes”!

  15. Thanks Norm for adding your comments as I hoped you would since you have clearly a deficit in one leg and Brad needs to hear you can live well with it. I can’t give him that experience. We have had some private chats which echo much of what you have said.

  16. I suffered from complete ATR on Dec. 19th, 2014. I underwent surgery on Dec. 20th, 2014 and followed the full (and very conservative) rehabilitation protocol. I never really experienced pain.
    6 months after surgery, I still couldn’t walk without limping and heel rise on the injured foot was impossible.
    My surgeon refuses to admit that I healed long and pretends I have not enough strength. For the past 4 months, I have been doing a lot of sport and exercise to recover muscle. But I still can not do heel rises.
    So I have been to other foot surgeons who confirmed that my increased range of motion on the injured side was a sign that I healed long. As for the way out, it is left to me. Either I learn to live with my disability or I go for surgery. It’s a really personal choice…

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