DavidUK’s AchillesBlog

Met with my surgeon today - yes, the man himself! I was attending his clinic, six weeks post op and in a NWB cast. I attended anticipating that I would have my cast removed, and replaced by another NWB cast for 2 weeks, with my foot coming up towards neutral, with a view to a third NWB cast for a further 2 weeks after that. Then into a boot. At least, that’s what I expected based on my initial post-surgery meeting with the surgeon’s team - as before (see previous posts), however, with multiple medics in the clinic the protocol changes according to who you meet. This time, I was lucky enough to get the top dog - with the following conversations taking place…

My surgeon reviewed the notes - “ah, yes, we’ll replace your cast with another. If we can get to neutral we will see you in four weeks, otherwise we will see you in two weeks for a further cast in neutral”. Ok, thinks I, this is what I expected. So, in all innocence, I ask “And then into a boot?” And that’s where it gets interesting…

“A boot?” Say’s the surgeon “Hmm, you could have a boot today, in fact you could have had a boot 2 weeks ago [4 weeks post-op]. We will put you in a boot today instead of the cast - if we can get you to neutral, we will see you in 4 weeks, if not, we’ll see you in two weeks to get you to neutral”

“That’s great” I say, wondering why he would have suggested NWB casting for another 4 weeks. “PWB?” I ask?

“FWB as and when we get you to neutral” and off I go to have my cast removed and boot fitted!

In the event I ended up with 10 degrees of plantar flexion (I think thats the right term, toes slightly down still) in a ROM boot, with instructions to continue to be NWB until I return in two weeks to be set to neutral.

So, in a sense, I am happy - better a boot than a cast, and I feel confident to add a little PWB into the mix over the next couple of weeks. I am, of course, once again struck by the differences in protocol between medics within a team, and also the somewhat ‘on the fly’ nature of the decision making. Also struck that, once again, the medic did not examine my achilles - he reviewed with me when the cast was on, and despatched me to the plaster room to have the cast removed and the boot fitted. This means that my wound / AT region have not been reviewed by the surgeon or any of his team since the day of the operation. I wonder if this is common practice.

So, I am scheduled to meet with my surgeon (or someone from his team!) on Monday 24th May. I am currently in a NWB cast, with my foot at something like 50 degrees down from the neutral position. Based on my discussion with the medics when i got this first cast (replacing the back slab two weeks post surgery, c. 3.5 weeks ago) my expectation is I will get another cast for 2 weeks, taking my foot further up towards neutral, and then a third cast for a further 2 weeks with my foot at or near neutral. Following that third cast (all three casts are NWB), it’s back into a ROM boot and back to physio. That’s my expectation, although as per comments on one of my earlier posts, if i meet with a different member of my surgeon’s team, who follows a different protocol, then things may change. Watch this space!

On one of my earlier posts (The First Time) i mentioned that when i was in a cast following my initial rupture, i had some real psychological issues which i have seen referred to elsewhere as ‘cast-rophobia’. Two or three times i had real panic attacks, a deep sense of confinement and a need to rip the cast off. Each time these feelings were acute for a couple of hours, but the sense of despair lasted for a day or two each time. This time round (post surgery for re-rupture), however, no such problems. I have wondered whether this was anything to do with the fact that first time round i had a heavy plaster of paris cast, whereas this time i have the much lighter fibreglass. One could hardly describe the fibreglass cast as ‘comfortable’, but certainly it’s less uncomfortable than the plaster of paris cast. I think, however, that, given that the issues occurred fairly soon after casting, the problems were more to do with delayed shock and a realisation that, actually, this was a major injury which would take a good long time to recover from.

So, let’s see what Monday brings - at least i get to see my leg again, if only briefly!

daviduk

So, things were going well. Out of plaster and into the boot, weekly physio and starting to walk without the boot in my house. Then one Sunday evening in mid-April, walking in my house without the boot, I stood on one of our dog’s toys and ‘bang’. Not sure whether I went over on my ankle or whether it was the action of putting all my weight down through it, but the ‘bang’ seemed as loud as the first time and the pain and swelling were much worse. It was pretty clear to me that my left Achilles had re-ruptured, and the thought of going through the weeks in plaster all over again left me close to tears.

A trip to the ER followed. In truth there was little they could do - a ’squeeze test’ gave some hope, with some movement of my foot, and I was booked in for a meeting with the consultant the next day. Unfortunately, that consultant examination confirmed a full re-rupture. Apparently the squeeze test may indicate some Achilles function when in reality this is caused by skin / muscles contraction - the consultant was easily able to feel a gap (I hadn’t felt for this myself as, in truth, I was in denial!)

First time round I had the conservative treatment (plaster only) This time round there was no choice and i was booked in for surgery two days later.

Just before the operation, the surgeon explained the possible outcomes. One potential issue was that the tendon may have shortened over the previous months, and there might be a need to cut higher and loosen it at the top so it could be pulled down. I was warned not to be surprised if the wound was much bigger than the anticipated 5″ or so. In the event, no such complication arose. The surgery seemed to go well and i woke up in a half cast, with ballerina toes again!

Two weeks later, off with the half cast and on with a full fibreglass cast. The consultant advises this first cast will be on until 6 weeks post-op, then another cast for 2 weeks and another for a fruther 2 weeks, then into the boot again.

So, since mid-January I have either been in a non-weight bearing cast or, for a short time, a boot. I have lot’s of thoughts about treatment options, and am struck by the differing protocols followed by different (all clearly experienced / capable) medical practitioners. I’m also struck by the differences between the UK and US approaches, in areas such as propensity to recommend surgery, views on early weight bearing and so on.

I look forward to sharing / discussing these views - I still have plenty of time on my hands!

This is a piece I wrote when I was recovering from my initial rupture - full of depression and hope! Little was I to know what was to come…

People will tell you that when you rupture an achilles tendon you may feel (and even hear) a ‘pop’ in the back of your leg. Let me tell you, when mine went it felt like I was kicked in the back of the leg by a carthorse. As I fell to the floor of the squash court I looked round to see what had hit me. It was certainly not my opponent who was at the back of the court wondering who had just banged on the door. As reality set in, so did the pain. Imagine the worst cramp you have ever had in your calf – and double it. I was rolling around in an undignified heap on the floor of the court, an ignominious end to squash playing days.

I was what some websites describe as the ‘typical’ candidate for an achilles rupture. Over forty, male, and playing one of the high risk sports - I even came across the term ‘weekend warrior’ on some websites, how offensive is that? However, having read more widely in my spare hours sitting with my leg up, I now know how ridiculous such ‘typical’ profile is. I was pretty fit having played competitive sport since early teens. Keeping fit involves 4 – 5 visits to the gym each week, running 5k – 10k on the treadmill, using the exercise bike for an hour or so, and regular weights sessions. I had noticed an increase in niggling injuries, the odd thigh strain and calf strain, and eight weeks before I ruptured the achilles in my left leg I had ‘tweaked’ the tendon in my right leg. That had just felt like a clip in the back of the ankle from my opponent’s racquet, and I was in recovery mode, missing a couple of matches and making sure I warmed up properly as I got back into it. That’s what made the rupture all the more galling, having warmed up more conscientiously than ever before the fateful match (and leading 2-1 and 6-5 when it went!).

Whenever you have an injury, it’s amazing how everybody around you knows what to do because ‘it happened to a mate’. I was helped off court and sat down with an ice pack. The pain eased fairly quickly, leaving just a dull ache. At first I assumed I had pulled my Achilles. Unable to put any weight on my left leg, I hobbled through the shower, got myself dressed, and settled in at the club bar! Somehow things didn’t feel too bad after a couple of pints of beer. I was midway through my third pint when I made what turned out to be the fateful discovery. Running my hand down the back of my ankle, I felt to see how swollen it was – and had a sudden, sobering realisation that, for a two centimeter length, where there should have been achilles tendon there was nothing. I could push my fingers into the gap. This was not good.

By this time it was late, and having scrounged a lift home (and lied to my wife about how bad it was!) I headed for bed. The next morning, in the cold light of day, the seriousness of the situation could not be ignored. The gap hadn’t gone away, and I couldn’t move my foot up or down nor put any weight on it. This was one for the ER.

The triage nurse took 30 seconds to give me his view – a full rupture of the achilles tendon in my left leg. This was confirmed by the doctor, who gave me the treatment alternatives. Either surgery followed by a plaster cast, or just a plaster cast for six to eight weeks. Whichever choice I made, I was in for a substantial period of incapacity, followed by physiotherapy. The doctor tactfully suggested that, whilst surgery may be the best alternative for a young, active, athlete, it may not be the right option for ‘older patients’ (I’m 48). he explained that the surgery involved a c.5” cut in the back of the ankle, some fairly heavyweight stitches to pull the tendon together, and the possibility of infection in such a big wound where the skin is drawn so tight. The ‘conservative’ option of putting the leg in a plaster, with toes pointing down to push the two ends of the tendon together so that they join up again, has less risk of infection (although a higher risk of re-rupture). On balance, and accepting I would never be squash world champion, I opted for the conservative approach. Toes pointing down, I was plastered from just below my knee to my toes and sent home.

My experience in ER was excellent, with great people and excellent care. The only hiccup was the doctor insisting I would have to be plastered with my toes pushed up as far as possible. A little scary as this is exactly the opposite of the correct treatment. Fortunately, when I insisted he checked with the nurse she set him straight. She also told me about the night when they had two squash players into the ER at the same time, in adjacent cubicles, one with a ruptured achilles and one with a racquet injury across his face. It turned out that that guy with the ruptured tendon had thought his opponent had hit him in the back of the leg, so he turned round and clobbered him with his racquet. One very sheepish squash player with his leg in plaster and one very angry one with a cut face!

This was the first time I had ever been in plaster, and it was a staggeringly miserable experience. The general unpleasantness is the inconvenience and discomfort of being immobilized in such an uncomfortable position, not able to put any weight on my left leg. More unexpectedly, I found myself suffering from anxiety attacks – and discovered that there is such a thing as ‘cast claustrophobia’. Three nights in (the day I was told by my consultant I would have the first cast for 6 weeks, then another for 4 weeks, and a final one for 2 weeks) I woke up in the middle of the night in a state of panic – no way could I tolerate being ‘confined’ in the plaster for another minute, let alone 10 or 11 weeks. I wanted to soak the plaster off, or cut it off, anything to free myself. The realization that there was simply nothing I could do was terrifying. The feeling lasted 24 hours that time, and returned three more times over the first few weeks of immobilization.

Over time, the psychological issues reduced, and I was left with the physical discomfort. One day, getting cocky on my sticks ‘walking’ around town, I slipped and landed with my full weight on my left leg. For a few horrible minutes I thought I had re-ruptured my tendon. Fortunately, the pain eventually subsided and, chastened, I took to my reclining chair for a day or two.

I met with my consultant (or, rather, his registrar) seven weeks after being put in plaster. I went into the consultation with a mix of eagerness (I was getting to see my leg again) and trepidation (I was going to be put into another cast – would the anxiety return?) I was absolutely delighted when he suggested that there was an option of having a ‘Range of Motion’ (ROM) boot rather than a cast. Having been immobilized in the cast whilst the two ends of the tendon glue together again, the next challenge is to stretch the tendon back to a sufficient length, regaining strength and mobility. The ROM boot allows adjustment of the foot position and the angle of the ankle, gradually allowing for more weight to be put on the recovering limb, and coaxing the foot back to a natural position by altering the angle of the ankle and removing, over a period of time, wedges under the heel.

Seven weeks in plaster had left my calf and thigh muscles pretty skinny, and I was surprised how swollen and bruised my ankle still was. I could feel my tendon, no gap but a little lumpy and definitely needing care to stretch out. Getting in to the boot was a challenge given the lack of movement and the pain associated with bringing my foot up or putting any weight at all on it. The boot is a big, heavy contraption, but after a day or two it was getting easier, and I was actually putting some weight on my left leg, albeit still using two sticks.

Weekly visits to hospital for physiotherapy and to have the ROM boot adjusted. Thanks to advice from a fellow sufferer (the value of blogs!) I am getting some physiotherapy privately as well as using the NHS service. This is going to be a slow process, and there is always the danger of pushing too hard and having a relapse.

I am fifty in 2011, and some months ago I tentatively set myself a goal of doing a triathlon before the end of 2011. Now that my squash (/ football / tennis / badminton / cricket) days are behind me, this seems like a more valuable target to set myself. Running, cycling and swimming form a good part of my rehabilitation program – I like the idea of making that a competitive goal.

And that may have been the end of it…

This could be a very long or very short post!

In the short version, I would tell you how in January 2010 I ruptured my left achilles playing squash, and then re-ruptured it in mid-April when i tripped at home.

I get the feeling, however, that the long version is something I need to get off my chest! I have found this site to be a fantastic resource over the past few months, and wanted to set down my experiences in the hope that they may be useful to fellow sufferers, and also to welcome any thoughts / comments people may have on my situation.

So, introductions. My name is David, I am 48 years old and live in the north of the UK, near Manchester. I have been into sport all my life, playing some sports to a decent standard and all sports enthusiastically! Over the last few years squash has been my main competitive sport, with a great deal of running / static cycling / weights to keep in a reasonable shape to play squash. In more recent times, my squash playing was interrupted while i spent 3 years working in the states - i kept up the fitness regime but let the squash slide. It was as I got back into the sport on my return to the UK that i injured myself.

And now the long version!