brad’s AchillesBlog

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?

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?

Kevin

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 biol

Hi Brad,

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

Kevin

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!

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….

Kevin

Brad - good to hear things are progressing well.

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.

Hi Brad,

Just checking in. How is the recovery going?

Kevin

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.

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.

Kevin

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?

Thanks,
Ken

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.

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.

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.

Kevin

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.

Kevin

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.

Thanks,
Ken

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 surge

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.

Kevin

Thanks for the post - definitely keep us informed of what you find and choose to do, as achilles lengthening seems to be one of those topics that is not fully understood, so any additional data points will be helpful for those recovering.

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…

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.

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”!

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 discom

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 noti

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.

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.

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.
Thanks!

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.

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!

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.

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 streng

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.

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!

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.

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.
Brad

Hi, this is a comment.
To delete a comment, just log in, and view the posts’ comments, there you will have the option to edit or delete them.