It’s Always Darkest Before the Dawn…Or Whatever Cliche Suits You

Within this post I’m going to be blunt and get extremely real. The first 4 weeks were the hardest weeks of my life. In a sense I should count my blessings…it wasn’t cancer, no death in the family, no addiction, etc. I would eventually get healthy and be just fine…but god damn! Going from being in complete control of my life, running around, playing basketball, running from one lecture to another to being couch bound, no driving, crutching everywhere was a punch in the gut. The things you need hands to do quickly become evident. Making coffee was a pain, cooking, taking the trash out, doing laundry…all nearly impossible on crutches. While my injury was relatively painless unless I touched or put weight on it, my swelling was horrendous. I truthfully spent 20 hours or so on my back for the first 2-3 weeks. Unfortunately that means I don’t have much to write about for that time period. Nevertheless, here are some tips to help you cope:

  1. Accept help from others! This was a bit tough for me, but I have a good friend at school that drove me to the classes I had to go to, bought me groceries, checked up on me etc. My neighbor took my trash cans to the curb every week for 2 months. My Girlfriend (a no nonsense nurse that lives by the code “no blood, no foul”) even softened up. My Mom came to stay with me for two separate weeks (more on that later because that woman is a saint and deserves her own post)
  2. Notify work, school, whatever your responsibilities are, that you’re checking out for a week or longer. If you have EMB, excellent, use it all. If not, do what you have to do to get the necessary time off. I was lucky that my school was accommodating. Most of my lectures are recorded and available online so I didn’t have to go to campus on a daily basis. Activities that I had to be present for, including some exams, were postponed by a few weeks. Take the time you need. I had two colleagues go through this in my past career. Both took a solid 3 months off. I didn’t start attending class regularly until I hit about the 2 month mark. You can’t rush it and you aren’t going to feel normal for a while.
  3. Stay MENTALLY busy, it is good for your soul and will stave off depression. At the time of my injury I was still consulting for my old workplace so along with school, I ramped that up a bit, albeit from the couch.
  4. Ice and elevate often. Your leg is going to feel like shit as it swells in the boot/cast. It will feel a thousand times better if you keep it elevated and ice every few hours. I made a habit to always ice right before bed. Helped me to get comfortable while trying to fall asleep
  5. Get a shower chair. I read a lot of info on things that will help during the recovery, some I purchased, some I didn’t. The one thing that I would recommend is the shower chair. If you stand on your leg you will eventually slip and your reflex will be to plant your bad foot…not good. I purchased a scooter that I never used (felt more stable on the crutches), a fancy boot that I used once or twice (wasn’t as comfortable as the free boot from the ER) and held off on the i-crutch (didn’t seem safe). The one purchase I couldn’t live without is the shower chair. I can fully stand in the shower now, but I may keep it. Call me soft but my shower chair has become a luxury item.
  6. I did start taking a multivitamin. I can’t really say if this helps or not, but vitamin C is important for collagen formation which should in theory should help the tendon heal and reorganize.

That should do it for now. In my next post I’ll concentrate on what I may have gotten wrong and would change if this happened again, and of course my Mom’s visit :)

Going Non-Op

So on 09/17/18 I got my MRI, as I noted in my previous post. To sum things up, it was a full rupture and atypically high from the insertion point on the heel. These findings, along with my wishes, led my physician to believe I would be a successful candidate for conservative treatment. I’m not sure if I mentioned it already, but one day after my initial appointment (8 days since rupture) I had roughly 1.6 inches of heel lifts inserted into my boot. For those of you that haven’t had the pleasure, the lifts keep your toes pointed down to allow the ends of the ruptured achilles’ to approximate. At this point, my treatment plan was as follows:

  1. Two weeks non-weight bearing, boot, crutches, etc
  2. Weeks 3-6 begin partial-weight bearing as pain tolerates. Ideally 25% weight week 3, 50% weight week 4, 75% weight week 5, and 100% weight week 6
  3. Begin PT at week 6
  4. Transition out of boot around week 12

I can’t stress enough the importance of getting your treatment plan in writing from your physician. While it may not always be possible to follow it step by step (I was much slower during the first 6 weeks and sped up during the last 6), it is a huge mental boost to have goals and a solid plan. As we all learn, the mental toll over the first few weeks is likely the hardest part of the journey.

So with wedges in my boot, plan in hand, and crutches always within reach, I began the healing process.

Thompson Test…Always

So exactly 1 week post rupture, one week of limping around campus in a boot set to neutral flexion, I went to my appointment with the orthopedic surgeon. Within 1 minute he diagnosed an Achilles’ rupture. It’s literally that easy. Had me kneel on a chair, squeezed my good calf then my bad. I distinctly remember dropping a four letter word after he squeezed the right calf and pointed out the deficit to his resident.

Knowing that surgery would mean 2-3 weeks on my back and likely dropping out of school for the semester I explained to the doc that I was resigned to treating the rupture conservatively. He told me to make an appointment for an MRI then we could discuss treatment. By virtue of having a professor that owns and operates an outpatient MRI I was able to schedule an MRI within a few days. As an aside, an MRI is truly not required or necessary to diagnose a ruptured Achilles’. As I’ve stressed, Thompson, Thompson, Thompson. If you are interested in conservative (non-surgical) treatment, an MRI will help your physician determine if this is a suitable route. I’m only a first year med student, so I won’t pretend to know the ins and outs of the Achilles’ protocol, but from my research and common sense I would imagine that there is a point at which the tendon may be separated far enough from the other end that conservative treatment is not advised. When your insurance inevitably tries to foot you with the MRI bill, kindly remind them that if you choose the conservative route you will be saving them a considerable sum.

So…I got the MRI. It took about 45 minutes and I got to listen to The Beatles through the whole thing. My professor, hell of a guy and hell of a doctor, brought me into his office to review the images. He showed me where the rupture was (a few inches below my calf muscle) and explained that while there may be a few threads hanging on, for all intents and purposes it was a full rupture. He performed another ultrasound so he could show me exactly how shredded my garbage tendon was. Long story short, full rupture, a ton of shadowing on the ultrasound (shadowing = bad), and a bit of a chuckle when I asked if I would be laid up for “about six weeks”. He assured me the road would be a bit longer.

The Emergency Room and the Ultrasound

Having recently sat through numerous “lower extremity” lectures, it didn’t take long for me to suspect that my injury was more than a simple strain. I couldn’t forcefully point my toes or flex my calf. At roughly 11pm, 4 hours post injury, I decided it was worth a trip to the ER. If nothing else I would get piece of mind, a walking boot, and a reason to postpone a quiz that I wasn’t quite prepared for. I hobbled my way to the car and drove the half mile, knee locked, to the hospital. My school is in a small town and the hospital is tiny, so there was no wait. After filling out some forms it wasn’t more than 15 minutes before I saw a nurse and physician. The physician was quick, poked around the tendon near the insertion on my heal, and told me he thinks it was a “bad strain”. It’s hard to blame him as my rupture was high up so through the swelling you could still feel an in tact tendon near the heal. I had recently learned about the Thompson Test, but was too excited that it wasn’t ruptured to press him for more information. I did ask for a walking boot so I could attend anatomy lab in the morning. He obliged, gave me a boot, some crutches, and a note to see an orthopedist if it was still bothering me in seven days. As I’m writing a post on “Achilles Blog”, you can pretty well guess that it didn’t improve over the next seven days.

My injury and ER visit was on a Thursday. That weekend, with the boot strapped on, I limped around, cooked, studied, enjoyed a glass or six of wine, and waited for the swelling to subside. It was Tuesday, while participating in an ultrasound lab, that I realized the physician in the ER was dead wrong. We were learning to perform ultrasounds on the upper extremities, shoulder, rotator cuff, etc, and I decided to have a teaching fellow help me ultrasound my Achilles’. I’ll spare you the medical jargon and leave it at this: It was clear something wasn’t right. I scheduled an appointment with an orthopedist for the following day.

In retrospect I should’ve known something wasn’t right in the ER but as I wrote earlier, I was damn excited that it “wasn’t ruptured”. Your best intentions, hopes, and excitement can often get in the way of the truth. Trust your intuition and always push your doc to dig deeper and explore further. This injury isn’t a strain and it’s not a sprain. Some people are in excruciating pain, others, like me, little to no pain. The bottom line however, is that if you can’t forcefully flex your calf and point your toes, something is wrong. Give it the old trash can test: Find a trash can with a foot pedal that opens the lid. If you can’t operate it easily and without pain, schedule an appointment with a physician and ask for the Thompson Test. Better yet, watch a 3 minute youtube video and have a friend or family member perform the Thompson Test on you. As far as diagnostic tests for Achilles’ dysfunction, it’s as definitive as they come.


Not quite like Kobe Bryant, but essentially Kobe Bryant

While my original injury was on 09/06/18, I haven’t quite had the time (or stomach) to document my experience until recently. As I try to put this “journey” into words, my hope and expectation is that my blog can serve as a guide and a light to a recent rupture. Be sure that the first month is dark, but as the swelling goes away and the time passes, the wins come quickly…so stiffen that upper lip and hold on.

Prior to my rupture I had seen my fair share of life changes. In July of ‘18, at 33 years old, I quit my job in health care administration and started medical school. It was definitely the right decision for me, but with the avalanche of school work I went from running 20-25 miles a week to studying non stop, eating like a college student, and cranking out 5-10 miles on a treadmill if I was lucky. I also had the brilliant idea to join an intramural basketball league after not playing competitive ball for roughly ten years. As my doctor put it, I was a textbook Achilles’ case.

Three games into the season I got a rebound, threw an outlet pass, planted my foot to sprint up court, and bam…welcome to Crutchville. My rupture was atypical in that there was no audible “pop”, and I didn’t feel a pop. It felt like I was kicked, but there was little pain, just the “pins and needles” sensation up my calf muscle. I did immediately hit the floor, but was able to limp off the court under my own power. A teammate got me some ice and I sat out the rest of the game truly not thinking the worst.

Although it was my right leg that was injured I was able to limp up the stairs and drive myself home with a straight leg and locked knee. I even stopped for dinner at Taco Bell. I remember texting with a teammate and my girlfriend that night, telling them both that I had strained my calf and would be back on the court in about a week. Little did I know…