5-wk post-op from shortening surgery; 19-month update

Hi All,

It has been months since my last post, but thought I would add this for the benefit of all.

To recap, full ATR was Dec 2014 followed by non-op protocol.  In Nov 2015, a surgeon with much ATR experience confirmed via visual exam that I healed long.  I suspect long heal caused by loose plaster splint and too much early dorsiflexion past neutral.  Symptoms of my long heal:

- 1-2 cm heal lift max

- cramping, fatigue, twitching in calf muscles, especially after exercise; I could run 6k on treadmill, but fatigue and slight limp after this

- calf muscle atrophy (~3 cm smaller in girth)

Seven month wait from exam to shortening surgery on 9 June 2016; ~1.5 cm of tendon removed.  No pain and very little swelling to date.  Tendon is definitely tighter now. Here is a summary of protocol (surgeon’s ATR protocol)

- wks 0 to 4: NWB in casts with foot at ~30 degrees (surgeon increased this from 2 to 4 for me)

- wks 4 to 8: PWB in VacoCast at 30 degrees increasing to FWB; NWB exercises, pool exercises

- wks 8 to 9: FWB decreasing angle 5 degrees each day as tolerated (physiotherapist not familiar with VacoCast but after demonstrating, agreed to substituting an airboot and wedges with the Vaco); transition to 2 shoes at end of week

- wks 9 to 13: wear AchilloTrain Pro (soft compression ankle brace by Bauerfeind); range of motion, strength proprioception exercises; do not allow ankle to go past neutral during this and previous stages; no lunges, squats as these place excessive stretch on tendon)

- wks 18 plus: increase dynamic weight bearing exercises (jogging, weight training, etc)

- at 6-9 mos, if patient has regained 80% strength, return to non-contact, non-sprinting sports

- at 12 mos, if patient has regained 100%, return to running, jumping sports

Comments on protocol welcomed.  Thanks to Stuart for earlier feedback.  Really looking forward to getting this behind me and trying to be patient. Happy healing to all!

19 Responses to “5-wk post-op from shortening surgery; 19-month update”

  1. Hi Brad,

    The timing of your post is perfect. I am currently 7 months post op and I just found out this morning that I healed long and am going in for shortening surgery….hopefully not a 7 month wait! I am aiming for surgery at the end of August. My symptoms are:

    - no lift at all on the bad leg - just cannot get enough strength.

    - 3 cm difference in calf circumferance

    - I am still limping

    - inflammation of other tendons in the ankle from compensating for lack of achilles function

    -severe pain about 5 cm above where tendon inserts into the heel.

    -oddly enough my dorsiflexion is not that much more than my good leg. In fact I feel it feels like the front of my ankle is the constraint…but he says that can be the case sometimes.

    In my discussion this morning the ankle ortho he iterated exactly what you you mention above for weeks 0 - 9. I didn’t get past that.

    I wish you well in your 2nd recovery and keep posting as I am interested to hear how it goes.


  2. Hi Kevin,

    Thanks for the comment and I read your latest posting.

    If your surgeon does regular shortenings (every 2 wks), then he must be a good surgeon. I am in Canada (public health care) which explains the 7-month wait for surgery.

    Our symptoms are similar. I had similar DF on both sides after healing, but less DF resistance on injured left. I recall my peronneal tendon being inflamed, likely due to compensating for long Achilles.

    For surgery, I consented to an FHL transfer, but tendon was in good shape so surgeon elected for shortening only. From my readings, this is consistent with what others have had done.

    Did you have an MRI to confirm elongation? My MRI showed my tendon to be 4 cm longer on injured side than non-injured, but only 1.5 cm removed for proper tension setting and end-to-end suture repair. I suspect the extra 4 cm was partly due to the calf muscles having contracted.

    Do you know what technique your surgeon will be using? Some are trained in V-Y, Z-plasty, and/or end-to-end. My MRI was ordered by another doc, not my surgeon who focused more on ensuring the tendon was tightened during surgery.

    I hope you find this helpful…this journey certainly teaches patience and not to take health for granted.


  3. Hi Brad, Kevin,

    I’m sorry to hear that both of you healed long.

    I ruptured my achilles tendon in mid Apr, and decided to pursue non-op recovery using the early weight bearing protocol and am now about 3 months into the recovery. I’m able to stand and walk around with my injured leg. However, one day in the second month I feel I may have overstrained my injured achilles and “stretched” it. I’m curious, were there any tell tale signs early on to indicate that you may have healed long? Could you feel a large lump on the back of your heel? Did it hurt to plantar flex? How does one know if they’ve healed long?

    Appreciate your advice and feedback. Hope you both heal well.


  4. Hi Ken,

    I didn’t have an MRI but the surgeon was very confident it is long based on visual tests. I am scheduled for shortening surgery on April 30. I don’t know the name of the procedure that you mentioned before but he explained it and basically involves making a Z like pattern in the tendon (so maybe its the Z-Plasty you mention).

    My frustration lies with the instability of the peroneal tendon…the surgeon seems to discount the issue because I cannot routinely replicate the subluxation. Since the usual fix for a subluxating tendon is surgery my fear is to go through achilles shortening surgery and then realize I have to go for another round of surgery for the pereoneal after. I want a “2 in 1″ if I need surgery to shorten my recovery cycle time to normalacy. The problem is we don’t know if the peroneal issue will get better once the achilles is shortened so that it is not inflamed from having to over compensate anymore. Frustrating set of circumstances.


  5. Hi Ken(Last post was for Brad sorry),

    Other than the incident I had the day after surgery (see my post) there were no telltale signs for me until the later rehab process began at around 5 months. I obviously had weak plantar flexion at months 3-4 but due to limited DS ROM from the surgery there were no signs. After plateauing in recovery I began to suspect something else was wrong….unfortunately not until about 41/2-5months.

    The challenge is that during the early rehab phases it is difficult to ascertain how much is normal recovery and how much of it is due to something else. I suspect the only thing that could definitively answer the question of healing long at month 3 would be a MRI. My sports med doc told me an Ultra Sound is even inconclusive at month 3 because the normal mass of scar tissue can make it difficult to determine if the tendon has healed long.

    Sorry ….not much help but this is from my experience.

    Good luck.


  6. Brad - Good to hear from you again and sorry for the delay in welcoming you back. I have been up in the backcountry snow since last week. I am pleased to read you did not need the FHL transfer. Your protocol is on the conservative side of the curve but it is a workable one. I would stick to the plan but even with the docs these plans are guides so if you do better than expected you may progress a little quicker through each stage.

  7. Kevin - Sorry to hear about your peroneal. Maybe this will help. Several months ago I was doing many eccentric heel raises in a futile attempt to strengthen my Achilles. The peroneal became inflamed likely due to compensating for the long Achilles. I stopped the eccentrics and a few weeks later, the peroneal went back to normal. I read a similar post by normofthenorth. (too many eccentrics on a long Achilles inflamed other tendons). Yes, one rehab cycle is preferred.

  8. Hi Kevin,

    Thanks for the response. In your initial post, you mentioned the doctor was very confident that the tendon had had healed long based on visual tests. Do you know what specific visual tests/cues he performed/saw to deem your achilles healed long, instead of lack of calf muscle strength?


  9. Hi Brad,

    1) According to him the medial side of the calf was severely wasted relative to the lateral side.

    2) When lying on my stomach with my legs bent 90 degrees (soles of feet facing ceiling) he said my injured foot drooped lower to the ground…he called it “resting tension”.

    3)Grastrocnemius/Soleus muscle was significantly “higher” up than the normal leg. He said this is normal with this injury but at 71/2 months in an active adult this should be closer to the other one.

    4)End of range planter flexion - when resisting against his hands the end of range plantar strength was almost non-existent. According to him at almost 8 months even a weakened calf should have more strength at this range of motion.

    He went on to say that each of these are not indicative by themselves but grouped together at this point he said they are “classic” symptoms of healing long. I did ask about a MRI and he said it was unnecessary because as you point out he will create the correct tension during surgery.

    Sorry for the brevity…..on my phone so hard to type.


  10. Despite me asking the question, on behalf of Brad, thanks for the feedback Kevin. Jk, but seriously, thanks for your clear descriptions. They are helpful as there really isn’t much information on what visual symptoms on determining whether one has healed long or not.

    Wishing you a safe, speedy, and full recovery.

  11. Hi Brad,

    Just checking in. How is the recovery going?


  12. Kevin - Recovery is going well. 8.5 wks post-op and one more week in the boot, but who’s counting! At 7 wk post-op visit with surgeon, he was pleased to see tendon was tight and could flex ankle only to neutral. The slack that was in the tendon pre-surgery and which limited my heel raise to 1-2 cm seems to be gone. I can walk a few steps on the balls of my feet. Pre shortening surgery, when I tried doing this, the slack in my AT would cause my heel to drop.

    For me, the toughest part of all this was losing my mobility again. But I can now see the light at the end of the tunnel. Long story short, glad I had the surgery. Having a scheduled surgery does allow one to prep for being immobile. Did your peroneal settle down?

    Your surgeon was very thorough with the visual exams. Did your peroneal settle down any??

    Hope you find this helpful.

  13. Brad - good to hear things are progressing well.

  14. Excellent news Brad…..you are past the hard part. It must feel fantastic to have strength in your calf again! I go for shortening surgery on Aug 30….so preparing the house for things I learned the first go around.

    My pereneal tendon has calmed down a bit….it has not popped in a bit but it is still swollen from over compensating. Hopefully no long term issues there.

    Keep in touch….


  15. Stuart - As I’m sure all do, I appreciate your feedback and advise throughout this journey.

    Kevin - Knee scooter / walker was a big help during the NWB weeks. I also used the iWalk 2.0 but found the scooter better on flat indoor surfaces. And of course a re-usable shower bag (I used Curad) and a shower stool. All the best!

  16. Hi Brad,

    2 day count down until shortening surgery for me. How’s things going for you? Still on target?


  17. Kevin - Long story short, I am continuing to make progress and I am glad I went ahead with the procedure. To date, 11.5 wks post-op and I have been walking without the boot (slowly) since 9.5 wks. The transition to 2-shoes was not easy. For the first week, I used a cain and limited myself to walking over even ground (indoors, sidewalks, asphalt, etc) without the boot. I must be blessed with good circulation though as post-surgery swelling has been minor (localized in tendon area). There is tightness/discomfort in the tendon when I walk causing me to limp or feel like I am limping. I started trail biking but am no where near ready to start jogging.

    You are relatively young, healthy, and active and so are a very good candidate for recovery. I have had no complications to speak of. But the journey is long (or feels long) and requires patience. Per my protocol, until week ~16, I am suppose to avoid lunges, squats, and other activities that place excessive stretch on Achilles so as to avoid healing long.
    I will leave you with a quote from my surgeon…”this recovery is not a no pain no gain activity, but you need to let biology do its thing.” In other words, let the healing take place and don’t be aggressive with the exercises (follow protocol).
    From your past notes, it sounds like you are in good hands with your surgeon. Keep in touch! Brad.

  18. Hi Brad,

    I am now 6 weeks post shortening surgery. My surgeon had me doing active plantar flexion at 2 weeks with a focus on tightening my calf at the end of the range. I can say that I have less swelling this go around….which I guess is good. I took out a wedge this week and am supposed to take one out every week. I will be neutral at 8 weeks.

    Thinking back to your recovery…when do you think you first noticed that this surgery was a success? I am am not doing any heel lifts yet….only active planter flexion off the end of my bed (no weight). I don’t really notice any difference in calf activation from before. There is still a stronger contraction on the outside of the calf which is what I had before when my peroneal tendon was overcompensating. Trying not to over think this….but given this is my second time through my mind can over think this at times.

    I see in a post you said you could walk on your toes at 7 weeks. My surgeon does not want me doing this…but I am quite certain I will not be able to do this by then.

    How is the recovery on your side?


  19. So, my Achilles, too has healed long. Now that you are further out from your shortening surgery, my question for you is whether you’d say the second surgery was worth it?
    I know not to expect that my “flat tire” (as I like to call it) will never have the same pounds per square inch that my good leg has, but were the gains of strength and function from the second surgery to shorten the tendon worth the pain, hassle, recover time of starting over?

    I feel like I work around my strength deficit fairly well. Most people don’t notice any limp, I run (though not as fast or far as I used to). I have a 4cm difference in calf circumference, most of the atrophy is on that medial side. The plantar surface of my foot has a subtle ache 100% of the time. I can only lift my heel about half was up when doing a single leg toe raise. The deficit in that leg is a disappointment for me, but I also seem to work around it for my regular daily stuff fairly well.

    Are you glad you had your tendon shortened now that you’re fully recovered again?

Leave a Reply

To prove you're a person (not a spam script), type the security word shown in the picture.
Anti-Spam Image

Powered by WP Hashcash