darren99’s AchillesBlog

April 2017

Thankfully the MRI results proved my left achilles that ruptured 5 baseball seasons ago healed poorly.  My orthopaedic surgeon (OS) described it to me as the tendon healing in a very disorganized manner and agreed with me that it healed long. The MRI report stated prominent fusiform enlargement and intrasubstance mucoid degeneration.  Surgery to fix the tendon was the best solution.

Yes, I meant to say thankfully.  I’m not crazy and there is renewed hope.

A Medical Mulligan

So after 4 and a half years of pain, doctors, MRI’s, steroid injections, and physiotherapy I have decided to tell my achilles rupture story.  I hope to provide a unique perspective on the surgery vs. conservative treatment debate and then give updates on my status once I restart the entire process.

Unfortunately after 4.5 years I have been told I need to start over.  If I want to have a better quality of life, attain more functionality, and live with less pain and swelling, I must give the medical community a mulligan and try again.  In 2012 I was advised that a non-surgical approach for an ATR was the new standard in treatment. In 2017 I am now told I need to have surgery to fix what did not heal properly after conservative treatment. To some extent I want to tell my story on here because 4 and a half years ago I came to this website looking for answers and advice and maybe if I had read a story like mine I would have chosen a different path.

Before I have the anti-surgery crowd criticize me for potentially impacting the decision of a new ATR victim, I say up front that my particular experience is likely not the norm.  There has to be others like me out there, however and people should be aware of the possible negative outcomes of the conservative approach.  Much of what one reads online seems to say that conservative and surgical treatments have similar results.  Well, that has not been my experience.

I apologize in advance for the length of this first post, but 54 months is a long time to catch up on.  Hopefully those of you who read it find it informative.

Rounding 3rd Base

September 6th, 2012.  Was it really that long ago?  I was playing baseball during the lunch hour in Montreal.  I live in the Vancouver, BC area, but worked in Montreal often.  Being I travelled so much I did not get to play sports like I once did and had been looking forward to getting on the field.  My first at bat and I hit a long ball to right centre field.  My 42 year old body darted out of the batters box and ran hard around the bases albeit not near as swiftly or as athletically as I once did.  As I was rounding 3rd base I noticed the ball was coming back in from the outfield so I instinctively put it in a higher gear to make it home safely…when it happened.

I heard and felt the snap in my head before I tumbled in full flight to the ground.  I turned my head around and accusingly asked the 3rd basemen if he hit me.  Of course he hadn’t, but it’s the classic instinctive reaction you hear about.  I actually knew my achilles was gone.  I’ve watched and played enough sports to know and I’ve heard stories from friends and teammates who ruptured theirs or who had seen one happen.  I started feeling pain, but it was from my shin and knee where the ground had torn up my skin when my left leg gave out and drove itself into the ground.  I was helped back to the bench disappointed that I never did make it to home plate!

Montreal - Worst Hospital Care in Canada?

I was hauled off to the ER of a local hospital by my work colleagues.  They were debating the whole way which hospital to take me to since the wait times in Montreal are notorious for being incredibly long and as an anglophone they didn’t want to take me to a French hospital.  Surely something like this though wouldn’t take too long to get looked at I remember thinking.  It was around 1:30 pm when I got to the ER that Thursday.  I sat in the waiting room bleeding all over the place and writhing in pain from the spasms in the back of my leg until 9:45 pm.  Once I was finally seen by a doctor I told him about hearing and feeling the snap.  He told me he believed I just tore a calf muscle since that’s the area where most of the pain was and that I should go home and give it a few days of rest.  He would get an orthopaedic surgeon to contact me and see me in a few days just to make sure.  I’m still waiting for that call, by the way.   He asked a nurse to clean and bandage my knee and shin.  I asked if I could get some crutches and was scoffed at for such a request.  He didn’t think I needed them.  I insisted and once the nurse "cleaned" my wounds I was sold a pair of crutches.

Back home in White Rock

After a painful night full of leg spasms I booked the first flight available back home.  I knew something was wrong with my leg and wanted to get back to ‘civilization’ (with all respect to my Montreal friends}.  I went to the Peace Arch hospital in White Rock shortly after getting home and was seen by a doctor in the ER within 20 minutes.  After less than 1 minute of examination, he told me my achilles was completely gone and that he would get me in to see an orthopaedic surgeon early the next week.  He also asked the nurse to clean up my leg as there was still gravel and dirt in the wounds!  They had to topically freeze my leg in order to scrub everything out and then bandaged it up.  Nice job Montreal nurse!  I was told the wounds were fairly severe and that I would need to keep fresh dressings on for a couple weeks.  To be honest the pain from the superficial wounds on the front of my leg was more severe than the actual achilles rupture.  The wounds took about 2 weeks before some form of skin/scab formed and before the pain subsided.  I was sent home in a standard aircast in a neutral position until I could see the OS.

The Orthopaedic Surgeon…How Ironical

It was a few days before I got into the OS office.  I met the young OS and nearly laughed out loud at the irony…he was a new doctor that was getting some experience in BC until he returned back home to…..Montreal!

He told me he was pretty sure the achilles was fully ruptured and that I had a decision to make: either to have surgery or to treat the rupture conservatively.  The catch was that the OS practice I was sent to no longer treated any achilles rupture surgically.  If I wanted that option I would have to be referred to a different office.  To the young doctor’s credit, he said he was not in agreement with this policy and said that if he were back home they would likely do surgery.  I was sold a pin cam walking boot and was told that regardless of my decision that I would eventually need this boot as part of the recovery process .  I was sent to get an ultrasound done and was to return back the OS office in about a week to inform them of my decision.

Surgery vs. Conservative Approach

If you are reading this and have to choose between having surgery or not to repair your rupture I honestly pity you.  It is an extremely difficult decision to make, especially if you have no life-threatening reason to avoid surgery. While no longer any sort of athlete and definitely not in the best shape of my life, I had no medical reason to sway myself away from surgery.  I worked in an office environment, which I partially think the medical community views as being disadvantaged from a health perspective and certainly not urgently requiring surgery in order to return to work.  I never heard once from anyone that a 42 year old recreational athlete and coach should have surgery…but maybe they should?

I must have spent 3 straight days reading everything I could find online about ATR’s, especially about the conservative method and early weight-bearing.  To this day I still hold an unwarranted grudge against the medical community for not having a more definitive treatment protocol.  Why should it be left to the patient to decide, isn’t that what doctors are for?  I ended up getting 3 opinions from doctors on what they would do:  the official opinion from my assigned OS and 2 informal opinions from other doctors .  It was 2-1 in favour of the conservative approach and I ultimately chose that path.

Dr. X’s Protocol

I won’t mention the doctors name here, but after 4+ years of lost time I would not recommend him.  The young OS from Montreal followed this mentor’s protocol for conservative treatment as follows:

• Pin Cam Boot for 12 weeks+
• Starting at maximum plantar flexion for 6 weeks and then every week increased dorsiflexion until neutral
• Partial and full weight bearing once the boot was neutral enough to put weight on it.
• Physiotherapy started at 12 weeks

I’m sure this seemingly late weight-bearing protocol played some part in my poor healing process. Who knows how much though.

On the Mend

After about 4-5 months post-ATR I did see improvement and was able to walk adequately.  Another work colleague (around the same age) ruptured his achilles about 3 weeks after I did and had surgery.  I recall his recovery time was much faster than mine as he was walking and skating well before I was.  Still, I was not too concerned about my progress at this point.  I did notice that I started getting pain in my right hip, but the doctor and I attributed this to the opposite side hip compensating for the weak ATR leg and the slight limp that remained. This should dissipate in short order I believed.  Physiotherapy was stopped when I was told there wasn’t much more to be done from her point of view. More on this later.

After about 6 months the pain in my right hip intensified to the point of being a nuisance.  The OS eventually suggested a steroid injection in the hip, which did help for a few months.  The achilles was still weak but it seemed to slowly improve and harden as time went by.  It was also noticeably thicker than the other tendon, but this was also expected.

1-2 Years Post-ATR

After about a year I still couldn’t do a one-leg heel raise and couldn’t run.  I just couldn’t push off well enough.  When I walked any more than a few blocks or had to walk across an airport terminal I would be in pain later that evening and more so the next day both in my achilles and my hip.  My achilles was harder but still didn’t feel healed yet. I was given another cortisone injection in my hip AND one in my achilles for the pain. Like before, the injections seemed to help with the pain for a few months, but eventually wore off.

I believe my achilles had reached it’s maximum recovery stage at about 24 months.  It was around this time that I didn’t notice any further improvement in strength or hardness.  I still couldn’t achieve a full heel raise and couldn’t run any great distance.  I tried playing sports a few times but it was never near the same as prior to the injury.  I kind of resolved myself to the fact that this was as good as it was going to get.

3-4 Years Post-Injury

The hip pain intensified month after month.  Even after further injections the pain would come back quicker and with more intensity.  If I happened to roll on my side when I slept I would be awakened to the feeling like my hip was on fire.  My achilles would also ache and become swollen whenever I got some sort of exercise using my legs. The only time my hip or achilles didn’t actually hurt was when I just didn’t move. I was sent for an MRI on my hip and the results came back as a degenerative tendon.  Another tendon issue?!  Surely this had to be somehow related to my achilles considering I never had any hip issue until the rupture.

My OS told me that based on the hip MRI results that I just couldn’t be active anymore.  I was told there are developing techniques where blood is injected into the tendon to try to regenerate it, but the effectiveness is really not proven yet. My best bet to avoid pain in my hip and achilles was to be sedentary.  When I suggested the hip pain is a result of the achilles not being right he just said there is nothing that can be done about either. I was 46 years old when I was told this.  46!  I decided I needed to get another opinion. I am fortunate to have an aunt who is an MRI radiologist.  She asked a doctor where to go for help and he said the "FAST Clinic" in Vancouver that specializes in foot and ankle issues.

The Foot and Ankle Specialist

Seven months after getting a referral I finally got into the FAST clinic…more irony.  The OS was quite surprised at several things:  the weakness of my left leg (calf and achilles), the size of the tendon, the size of the large bump where the rupture presumably occurred, and the swelling of the area.  He ordered an MRI and asked me to go for physiotherapy to try and work on the strength of the calf then come back in 6 to 8 weeks.

An Excellent Physiotherapist

Thanks to Google, I found a local physiotherapy clinic that had several very good reviews.  I wanted to try someone different than last time and I really lucked out with this decision.  The gentleman that worked with me is excellent and proved to me how mediocre the physiotherapy I had following the ATR was.  My left calf was 1 inch diameter smaller than its counterpart and my right hip was extremely weak as well.  I’m not trying to blame the previous therapist, the reality is that everything is weak from 4 years of achilles problems.  My physiotherapist proved to me in short order that the achilles healed long.  When doing dual heel drops on a declining leg press machine, my right calf felt like it was going to burst, yet my left calf was under no strain at all.  He told me that he can really help me with the hip and calf strength, but only up to a certain point since he just couldn’t help with achilles.

Now that I have experienced some excellent physiotherapy, I cannot stress enough how important it is to find someone that really knows what they are doing and to work hard at this stage of recovery.  My guy charges a flat fee per session no matter how long you are there for.  I would spend 2 hours at the clinic on the exercises with him working directly with me on and off for about 40 minutes. I find this method so productive.

The MRI Results

I went back to the foot and ankle clinic 2 months later with a stronger leg and hip, but the pain and swelling was even more prevalent, especially in my achilles.  The MRI results showed the achilles did not heal properly.  Disorganized, degenerative tissue and a 1 inch x 1 inch bump at the rupture site.  I had 3 options:  continue living with what I have now, an annoying brace that I would likely need indefinitely, or surgery, with the latter being his recommendation.  It was a surprisingly emotional response that overcame me when I heard this.  For one, I was expecting the OS to say there was nothing they could do and secondly, there was a moment of redemption in that I knew something was wrong and just needed to find the right person to confirm it and do something about it.  I didn’t hesitate in accepting the surgical option despite it meaning my loved ones and I would have to go through the entire healing process all over again.

Hope

I think this is what I want people to understand and hopefully appreciate.  That the poor result I received from the conservative treatment was so inadequate that I am willing to subject myself to starting this journey all over again in hopes of a more functional limb and a better quality of life.  Again, I’m not saying the conservative approach is bad for all, nor do I claim that my results are typical.  I do claim, however to be a proponent of being informed and aware of all the possibilities when having to choose between having ATR repair surgery or not.  Poor results like mine are a possibility and I really didn’t consider this when I had to make the decision the first time.

If you read this far, thank you!  It is therapeutic to the mind to regurgitate the journey so far.  I don’t have a surgery date yet…a few months I am expecting.  I look forward to any comments and to hear others’ experiences as well and hope to continue posting occasionally as this process continues.

** UPDATE **  I just learned today that surgery wait time is 9 to 12 months.  For as grateful as I am for all we have in Canada, waiting another year to have this correctly is ridiculous and embarrassing.  It is so deflating when I found out how long it would be, especially considering the renewed hope I had that there was hope of it being fixed soon.

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