dcoughlan’s AchillesBlog

Week 24 - Watch Your Back?

October 18, 2014 · 15 Comments

Hope everyone is doing well! Writing to share some of my rehab experience and get a little feedback from the crowds here.

Like many of you I’ve spent a decent amount of time trying to figure out “why” this happened and what, if anything, I can do to keep it from happening again. One hypothesis I have is that the root trigger for my rupture did not so much start with the achilles/leg but actually in my lower back. This hypothesis was primarily inspired by my experience of pre-rupture achilles pain that was temporarily alleviated after back-focused weight lifting.

While I’m not convinced that there is a “one size fits all” explanation for ruptures (so many things are involved from the back all the way down to the achilles that it’s very difficult to isolate just one cause out of the back -> glutes -> hamstrings -> calves -> achilles chain),  for a number of reasons I think that starting at the relative “top” is a good place to look, which is why I’m initially focusing on the back.

After some research I narrowed down the potential “back” triggers to two primary contenders: the sciatic nerve and Psoas muscle. It turns out there’s already been a study that demonstrates a possible correlation between achilles rupture and sciatica: http://www.ncbi.nlm.nih.gov/pubmed/9631229 While this certainly won’t be scientific, I would love to poll the crowds here and see if folks can confirm the study results to any degree / have any family/personal history of sciatica / scoliosis / low back pain /if you were spending an abnormally high amount of time sitting in the days/weeks leading up to your ruptures / anything back + achilles rupture connections you would like to share.

Additionally, while probing the sciatic/achilles relationship I came across a few references to the Psoas muscle and decided to try a “Psoas release” technique I found online, which is where things got really interesting. After performing the stretch I immediately took a few steps and, to my extreme surprise, for the first time since the injury, my leg felt entirely “normal.” It’s difficult to describe, but prior to those steps I felt that there was a certain level of explosive push off power or “spring” missing from my injured leg. It wasn’t enough to notice in day to day life or to hold me back functionally– everything was progressing on schedule, normal ROM/able to walk/run/jump/do full height single legged heel raises/etc. But if I tried to do an activity that truly exposed the leg (namely running at full gallop) I could tell that there was a little something missing and a definite asymmetry between my injured and uninjured legs and the way my feet struck the ground.

I had chalked this up to power deficit/weakness, so I was completely stunned when I took a step and all of a sudden it felt like my leg was finally 100% engaged when it hadn’t been just seconds earlier. My first impulse was to cry tears of joy, and my second was to take off running down the hall in celebration. In my defense, this feeling was 6 months in the making! Fortunately I was alone so I didn’t look like a total lunatic.

Then, after a few blissful steps, almost as if a switch was flicked, the feeling of “something missing” returned. I stopped running and tried the release stretch again, and then took a few steps. No improvement. Tried the release again, nothing. Waited 10 minutes. Tried it again. Nothing. I searched for a different Psoas release technique online (there are many) and I tried that. Success! I walked around for a bit, and then sat down. When I stood up a few minutes later, the “missing” feeling was back.

This on/off between releasing the Psoas, feeling the “good feeling” and then a quick return to the “something missing” feeling continued for the rest of the day. Interestingly, after some experimenting I realized that if I walked around with my knees bent (like a t-rex — again, good thing I was alone), I could consistently produce the power feeling, but somewhere in the action of straightening the leg, the “missing feeling” would return, and it wouldn’t come back unless I performed the release, and sometimes not even then.

The next day I found the achilles significantly less stiff when I woke up in the morning (I had been experiencing tightness that required massaging/light stretching/warming up in the morning before I felt comfortable walking quickly, now it just took a few steps). I did the Psoas release and found the “good feeling” returned, and was beginning to stick for longer durations, including some seated periods and some t-rex leg to straight leg extensions.

By the third day I woke up with almost no stiffness, and after a few steps the “good feeling” engaged without me even doing any release, and then it remained for the rest of the day. Which brings me to here. I’m going to continue to experiment with this and check in with my own PT about it, but I wanted to see if anyone else has experience with the Psoas that they can share, or if their PTs can provide feedback on it. Caution: I definitely would not try any of these releases or stretches without talking to a PT first, especially if you’re in the earlier (pre week 12-16) phases of rehab. From what I can gather the muscle is fairly potent, and working on it appears to have both physical and neurological implications, so it should be manipulated carefully. Its location also makes it physically difficult to release (I’m guessing some of my “failures” may be attributed to me failing to perform the proper release technique more than anything else), so a PT will be best positioned to help in that regard as well.

Caveat that there are some other variables that I’ve been throwing into the mix, including a new (significantly firmer) mattress and lower profile shoes. I think that those may actually be contributing to the reduced morning stiffness (not the Psoas release), but jury is out on that one.

That’s all for now, but to everyone out there in rehab land, just continue to hang in there — things can truly change in a matter of days with this injury, so stay positive, keep up with the PT, and you’ll be back before you know it.

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Week 13 (Day 96)

August 2, 2014 · 12 Comments

Hi Fellow Healers,

Hope everyone’s recoveries are going well! Had to take a break from here because I realized checking the site was starting to bring me down a bit —which is not the point of AchillesBlog!! I just wasn’t able to read about setbacks or references to the “frustrating plateau” without feeling bad for the person experiencing the setback and then starting to wonder “is that going to happen to me?” Not productive thoughts for healing, so I decided to go cold turkey for a while.

Fortunately I’m at the point where I’m walking around at full speed/stride, expect to be cleared to run in about two weeks, and generally feel like things are under control, so I wanted to share two things I learned in case others find them helpful. Usual caveat applies — I am not a doctor or medical professional of any kind, and you should always run things by your Doctor/PT before trying them.

I mentioned that the “frustrating plateau” troubled me when I was reading about it. People were clearly impacted, but I didn’t see a scientific explanation for it— nothing to suggest that progression shouldn’t be continuous until you reach full strength. My theory now is that the frustrating plateau people reference is the result of two factors:

(1) Mental: I think it’s partially the result of setting unrealistic expectations: If you think you’re going to be walking perfectly in a week, it’s probably not going to happen and you’ll find yourself frustrated and disappointed. But if you expect it to take a few weeks, and you focus on the progress you’re seeing instead of thinking about how far you’ve got to go, you’ll probably find the experience a lot easier.

(2) Physical: I think some people try to race out of two shoes and lose their crutches with the expectation that they’re building strength. The truth is that while that works to improve ROM and stabilizing muscles, it’s physically impossible to truly “walk” in the early post-boot stages because the calf isn’t yet strong enough. Instead the injured leg compensates, and it generally does so in a way that deprives the calf from getting almost any kind of load at all, which keeps muscle development on the slower side.

The way to avoid compensating and actually engage the muscle is by reducing your bodyweight to a level the calf can actually support, thereby allowing you to take real steps. Getting into a pool or on an alter-g treadmill, doing seated / double legged heel raises, and continuing to use crutches while walking around all work to take off enough weight that you can target the calf. I didn’t get rid of my second crutch for 3 weeks after moving into two shoes, and would have held onto it even longer if I didn’t have a work commitment, because I realized I just wasn’t achieving much of anything whenever I walked without it. It’s obnoxious, but I think it pays to be patient on this one.

I started 2-3 pool sessions a week starting a week after I went into two shoes, but I would have gone 7x a week immediately after I got out of the boot if work didn’t get in the way.  Legs always felt better when I came out than they did when I got in (but the calf should feel a bit torn up the next day — that means you’re doing it right!) and my gait improved dramatically even after the first session. The bulk of my time (sessions increased from 35-55 mins) was just spent walking up and down the length of the pool and doing single legged heel raises.

That’s all for now, but if anyone has any specific questions about pool training or other things, feel free to ask!

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Achilles Science

June 2, 2014 · 33 Comments

A break from my updates to talk about what I’ve learned about effectively treating this injury through my research.

IMPORTANT: THIS IS ALL CONJECTURE. I do not have an MD, nor am I in any way certified to be dispensing medical advice or interpreting medical literature. These are all conclusions that I drew after reading through a number of papers/studies. I thought it might be interesting to others as I found myself quite curious after this injury. If you find any of this interesting, you should go perform your own research and report back! And always, always listen to your doctor. At the end of the day I am just another guy with a ruptured achilles on the internet, trying to give a little something back to Achilles Blog because it’s been so helpful to me.

Okay, I ruptured my achilles. What’s happening down there? [I recommend reading citations 1/3 in full if you're interested in the hard science, but I've summarized them and others according to my own understanding below]

Your achilles tendon is made up of a lot of things, but most importantly, it’s made up of collagen. Post-rupture tendon regeneration involves rebuilding the tendon’s collagen structure across 3 separate phases,: (I) Inflammatory; (II) Repairing; (III) Remodeling. The length of these stages varies from individual to individual (and from paper to paper!)

I: Inflammation is just what it sounds like — your body does its best to reduce the inflammation and swelling associated with the rupture. Lasts roughly one week.

II: Repairing: During the scaffolding phase, the body begins to put together a rough guide of what the achilles is going to look like, and recruits available collagen and whatever else (debris, tissue, etc.) it can find to fill it in. Occurs through weeks ~2-4ish.

III: Remodeling: The real structuring begins. The “filler” is gradually replaced with locally produced collagen, and crucially, that collagen begins to order itself in the direction of applied force. This final step in the repair process continues for quite a while, two months (or longer!)

The direction of applied force part ordering is the key to strengthening the newly formed tendon — achilles collagen relies on being physically “loaded” to direct it as to how to order itself. Without these directions, the collagen will not align properly, rendering the newly formed tendon quite weak. This explains why 6 weeks in a cast might not be the right way to treat this thing, and the impetus for developing the more ‘aggressive’ (what a relative term) protocols that we’re now familiar with.

Why does this process take so long?

While many parts of our bodies are constantly rebuilding themselves over time to stay at optimum strength, the achilles does not. In effect, the achilles is built to last a lifetime — studies have shown that many of the building blocks present in someone’s achilles in their teen years are still there in their 50s! [2] This slow turnover means a slow (and somewhat ineffective) healing process.

My doctor/friend/the guy on TV said my achilles will never be the same. Is he right?

Technically, yes — your new tendon, even after it successfully generates, is fundamentally different from your pre-ruptured one  [3] But that’s not a reason for despair because it doesn’t mean the function of your new tendon is automatically compromised. A number of people, from professional athletes to many folks on this board, have managed to resume their previousactivities in full. It might not be a carbon copy of the original, but that’s just fine!

The differences basically boil down to varying levels and behaviors of two principle types of collagen that we’re concerned about when it comes to achilles makeup: Type 1 (strong!) and Type 3 (not as strong!) A high ratio of Type 1 to Type 3 is desirable. Unfortunately, ruptured and post-rupture tendons seem to be a little heavier on the T3, and therefore, biomechanically different. [3][4] Addressing this disparity is part of a good recovery, and I’ll discuss that a little later.

What does this mean in the case of surgical vs. non surgical?

On the question of surgical vs. non surgical, one theoretical advantage I see to surgical treatment is that it could allow for faster / increased levels of loading, which could theoretically increase the Type 1 collagen levels/ordering quality of the new tendon. Enhanced surgical techniques, e.g.using a collagen ribbon during the surgery, appear to have potential on this front.[5]

I can’t find anything that suggests that surgical treatment in isolation improves Collagen T1 production or ordering, which is what we care about long term, so for the most part this potential appears untapped. To me, this explains the parity between surgical / non-surgical outcomes after identical protocols — the primary theoretical advantage to surgery (if there was one) was effectively neutralized when they adopted the same timeline!

One secondary advantage to surgery is that the strength of the tendon is stronger in the earlier stages after a surgical attachment vs. a non-non surgical one — e.g. if you started pulling on a surgical tendon vs. non surgical at week 2 the surgical would be stronger. But that doesn’t appear to have any long-term bearing.

So my personal call is that non-surgical is the way to go (for now — I do think an ideal surgical treatment could be developed that uses techniques like the collagen ribbon and other collagen-boosting / instant loading methodologies). I’m not sure that the short term benefit (e.g. potentially preventing a rerupture from a fall at week 4 that would have taken down a non-op) is worth potential surgical complications, and I don’t see clear long-term benefit.

Also, given Wallace’s track record it doesn’t appear that there are some tendons which require surgical treatment to repair — and once you’re at the remodeling stage, the way it repaired doesn’t appear to be important (it’s all about the collagen levels and ordering), so I’d go non-surgical every time. (Minus avulsion — still unclear about that one.)

But why do all the pros get surgery?

I don’t think we’re going to see a major athlete go non-surgical for quite a while, if ever. There’s too much risk for the doctor (something goes wrong and they’ll lose their entire pro athlete practice and get sued for malpractice — everyone else went surgical, what were they thinking?) and no science yet pointing in the non-surgical direction to suggest a superior outcome. Shame because it would be great to see what all these T1 collagen producing machines would do non-op.

Okay, I got my surgery/no surgery, now what can I do to improve the recovery process?

Here’s where things start to get farther away from science and more into the land of conjecture as the various approaches arepretty difficult to test on humans (although a number of brave rabbits, rats, horses and cadavers have been sacrificed to aid our understanding).

In its simplest form the goal is to give the tendon its best shot at producing large quantities of well-ordered Type 1 collagen. As far as approaches go, we have two avenues: physical, and biological/other.

Physical:

On the physical side of things the question is: how much activity is enough to provide the fibers with as much stimulation and direction as possible without overdoing it and over-stretching or re-rupturing a very malleable tendon. We’ve seen different approaches across the PWB/FWB spectrum, but this is the hardest thing to figure out because it’s so individualized.

Based on reading as much as I could about successful athlete protocols (Kobe, Crabtree, Beckham, Dominique Wilkins), I’ve noticed a common thread of fairly aggressive activity levels using reduced-weight-bearing sources (e.g. alter-g treadmill and/or hydrotherapy). This makes sense — an early-stage-remodeling achilles can’t take a full load, but it can take a lighter one, and the exercise will be beneficial both from a loading/ordering perspective and any potential increases in T1 collagen production which appear to correlate with strenuous exercise [6]

So my goal has been to exercise as much as I can NWB and PWB while incrementally increasing FWB levels. I’m less concerned with ROM, except to the extent that I need to mobilize my ankle in order to walk properly — for me the holy grail of loading appears to be in the form of real steps that communicate to the achilles exactly what length and where it needs to be to walk, so my focus is on incrementally building to those.

But again, this is all conjecture — it’s entirely possible that the quicker you can get to simulated ROM by extending an NWB foot, the better (planting an early seed of ordering?) Without testing it’s hard to say.

Again, it’s all a balancing act and without a lot more studying it’s hard to say what the right amounts of load are, but it becomes a personal question of listening to your body and trying not to over-do it in a way that will compromise healing.

Biological/other:

Ironically this is where I think we have the greatest potential to increase beneficial outcomes, and yet it seems to get the least amount of attention (at least my OS never mentioned these things to me.)

Given the fact that tendon regeneration is fundamentally a process of cellular reconstruction, I started looking into collagen production. Factors include diet (I’ve switched to a high-protein diet), rest, exercise (see above), and then I found some studies showing that the following may be helpful with aiding Type 1 Collagen formation:

  • Low Level Laser Therapy [7]
  • Ortho Silicic Acid [8] - note, animal test only

I’m also taking a general collagen supplement: (Great Lakes Gelatin, Collagen Hydrolysate, soluble powder, available on Amazon) — hasn’t been shown to specifically aid T1 production, but it appears to have generally positive effects for athletic injuries [9] and no obvious side effects so I figured why not?

So that’s my summary (and again I’d like to re-emphasize how unqualified I am to give it). I hope some people found it interesting and/or helpful and would love to hear any comments/questions/insights/corrections/etc.

Happy healing!

[1] http://www.oliverfinlay.com/assets/pdf/wang%20(2006)%20mechanobiology%20of%20tendon.pdf

[2] http://www.news-medical.net/news/20130218/Research-reveals-how-quickly-the-Achilles-tendon-can-regenerate.aspx

[3] http://bjsm.bmj.com/content/36/5/315.full

[4] http://www.ncbi.nlm.nih.gov/pubmed/12472252

[5] http://www.ncbi.nlm.nih.gov/pubmed/24666979

[6] http://www.ncbi.nlm.nih.gov/pubmed/10908411

[7] http://www.ncbi.nlm.nih.gov/pubmed/20662033

[8] http://www.ncbi.nlm.nih.gov/pubmed/12633784

[9] http://www.ncbi.nlm.nih.gov/pubmed/18416885

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Week 4 (Day 32)

May 30, 2014 · 2 Comments

Wanted to wait for my second PT session before posting. Good news is that things appear to be on the right track, despite a little bit of a scare yesterday.

My progression to this point (non-op)

Days 0-13, NWB @ 20º Vacocast

Days 13-26, NWB -> PWB — slow and cautious transition.

Days 26-31 PWB-> FWB.  I was careful to slowly build the amount of time I spent FWB — couple steps the first day, 15 minutes the second, hour the third, etc. No significant pain at any stage. Maybe a tinge here and there but those don’t really register anymore.

Day 30: introduced stationary bike with boot (5 mins first day, 10 the second). No resistance on bike, and no pain.

Day 30 (night, before bed): Set Vacocast to 20-15º hinged. Felt a stretch in the achilles, but would describe it as pleasant more than anything. Went to sleep and felt no stretching sensation in the morning when I woke up.

No real ROM exercises to this point (I had started some feeble ones around week 2, but then decided that I didn’t feel ready for it and wanted to wait for PT instruction.) Started daily hip/glute/upper body/core work.

Day 31: Big scare. Was seated at a table and adjusting my leg in the process of either standing up or sitting down (the fear instantly wiped that detail from my brain) when I felt a very soft click/snap in my heel, below the rupture site (and below the achilles insertion point.) I was moving carefully and the force was about 1/50th compared to the impact that caused the injury, but I suddenly found myself with several new degrees of ROM in my heel that hadn’t been there seconds ago. In a way the leg felt great, as if something I didn’t realize had been holding it back suddenly unlocked, but at the same time my brain began screaming “RE-RUPTURE” and I began to feel blood rushing into the heel and I experienced a terrible pit in my stomach. I felt no pain in the actual achilles but my brain didn’t care and I was convinced that the leg was developing the disconnected feeling that accompanied the original rupture.

Took FWB steps to grab my crutches from across the room and felt no pain, but a little “loose” in the boot. Made it to my bed and felt the achilles - it seemed intact but there was no convincing my brain. I propped the leg up, reset the Vacocast up to 30º and mentally prepared to start the first 4 weeks over again while I browsed achillesblog for rerupture information. Fortunately I came across two users (eva and ryanb) who had experienced a similar sensation to mine and it was just scar tissue. I remembered that I had felt tingling in the same region (bottom/outside of heel) during the recovery phase, and also during ultrasound treatment for tendonitis years ago. Finally started to relax a bit but still had some rushing blood / pain sensations and every new feeling made my stomach turn. Managed to calm down and went to bed cautiously optimistic.

Day 32: Went in for my second PT appointment, told her what happened and she said it sounded like some scar tissue detaching to her too. No swelling, no pain anywhere when squeezing, and signs of life after a Thompson test was performed. Phew. Achilles looks and feels noticeably stronger than it did at Day 16. Some defect is still visible but it’s filling in. Note: I think most of this progress has happened in the last week because I remember being massively discouraged when I looked around Day 25 — the achilles had little body or shape to it at that point and I started to wonder if I was properly attaching.

We started to talk about the protocol going forward and my PT was under the impression I had NWB instructions from the OS. He actually hadn’t really said anything except “go forth” when I said I’d like to try a functional rehab, and mentioned that I’d be transitioning to shoes around week 8. I revealed that I had been walking around for about a week in accordance with the UWO / Exeter hybrid protocol I’ve been following. She was a little hesitant but then had me walk around the facility for a bit so she could watch. I didn’t have my evenup (arrives tomorrow, been using a hiking boot in the interim but there’s still 1/2″ inch difference) and at 30º my gait was pretty awkward. She gave me some pointers and then I have another appointment Monday where  I’ll bring the evenup/protocols/I’m in the process of incrementally taking the boot back to my pre-panic 20º and we’ll figure it out from there. In the interim added one small resistance exercise to my daily PT (only in one direction as the other one produced a little bit of pain).

Will spend this weekend transitioning back from 30-20 (set it to 25 when I got home, will go to 20 tomorrow night provided no complications) and PWB -> FWB. Annoyed at myself for cranking back to 30º for effectively nothing and hoping the angle yo-yoing doesn’t have any negative impact, but what can you do!

Hope everyone else is doing well,

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Week 2 (Day 16)

May 14, 2014 · 4 Comments

First PT appointment in the books and I’m quite pleased. Really like my therapist — unlike the OS she has full confidence in non-op results and referenced research through JBJS / Wallace (which either came up in conversation with the OS or have become a part of my patient file).

Gave me a set of daily hip and quadricep stretches / exercises to do in advance of my next visit (~4 week mark), and said she would introduce motion and weight related therapy in weeks 4-6.

Today’s session was a lot of feeling and massaging, generally working liquid up from the ankle area toward the knee. I was initially quite hesitant to move the leg around as much as she wanted me to, and it quivered quite violently for the first 15 minutes or so, but then things calmed down and it actually started feeling quite normal.  Pretty much zero pain in the entire region when she pushed and prodded around. At one point I could feel her trying a Thompson test that didn’t produce much of a result (she said “Yeah, nothing really there” casually) but I’m not terribly surprised as there’s almost no muscle in the calf to activate! She told me I should try some light massage when I have the boot off for showering, too.

We didn’t really discuss a PWB to FWB progression, so I think I’ll continue my approach of “PWB as needed” when I’m walking around and hold it there. I actually feel like I could go to FWB right now but will wait until I’m past the 4 week mark because there’s no sense in pushing things.

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Week 2 (Day 15)

May 13, 2014 · 2 Comments

The healing continues. Recovery has been pretty much the same, spending most of my time reclined with my leg at various stages of elevation. I try to get a little physical activity in each day in the form of 10 to 15 minutes of upper body work with a resistance band and some light core on a balance ball.

A few small updates: ice/contrast baths, Vacocast, PWB/Rom, physiotherapy, tendon regeneration research, and general feelings and sensations.

Ice/Contrast Baths: Started doing these a few days ago and I’ve found my leg never feels better  than it does for a few minutes after I take it out of the bath, which is a great mental boost if nothing else, so I’ve kept it up. What I’m doing: filling a large bucket with water (tall paint /5 gallon buckets tend to work well for this) and a substantial amount of ice, so that the water line is roughly around the mid calf. I then sit on a stool with both hands locked under the hamstring on the injured leg for support/to make sure the leg stays suspended, and I submerge the leg, careful not to touch the bottom or sides of the bucket. Then I count to around 500. When finished, I lift the leg out and run shower-hot water up and down the leg for about 1 minute, just to get general sensation back. Then it’s off to elevate and enjoy the feeling of “wholeness” my leg seems to get after these baths.

Warning: some people find their first few ice baths quite painful for the first 2 minutes or so before their body numbs, so don’t be worried if you try it and it hurts at first.

Vacocast: My Vacocast arrived last week and I delayed putting it on until yesterday as I was adhering to a solid “2 weeks in the same position” (in my case, 22.5º fixed on my clinic-issued ROM walker) as seems to be the trend for most of the modern protocols. Initially I felt all sorts of weird bulges / pressure points with the Vacocast liner, so I took the boot off and put the Vacocast on my good leg to work out the lumps. Left it on the good leg for a few hours in an effort to break it in, and then put it on the injured leg again. Found the liner much more comfortable.

Overall: Would absolutely purchase again as the pros significantly outweigh the cons.

Pros: Enhanced rigidity and security brings me a lot of mental comfort as I feel more comfortable moving the leg around. The Achilles Rocker wedge feels much more natural / conducive to walking than the one in my old boot (and it’s removable!). Washable liner.

Cons: Heavier (not by much, but enough to notice.) Hotter (I had exposed toes in my last boot, which probably dropped the temp a fair bit). Slightly more pressure in the toe box, but still enough where I can wriggle my toes, which I do fairly often. Takes more time to get in and out of the boot (and some initial instruction manual reading or online tutorial watching if you don’t have a doctor to fit you.) Higher profile means you’re really going to want to take some kind of measures to approximate heel heights on your good/bad legs.

PWB/ROM: Tried taking a few PWB steps last night but my calf was not really having it (pain in the upper-middle region), so I settled for a few seconds of balancing it on the floor, heel down, and putting some slight weight into it. Felt my calf shake a little bit under the strain (2 weeks and all the muscle is truly gone!) Figured that was enough for day 1 and headed back to elevate. Made another attempt this morning and was able to approximate a walk up and down the hall with very little pain, and some tightness in the calf that I generally associate with healing, so I was okay with it. Tough to say how much weight I was really putting on the leg but it wasn’t much. Most of all, felt great to be doing something with the leg. Going to continue to take it real slow for now.

On the ROM front, I actually have more than I expected. I’ve been doing some reallllly light exercises before my ice baths. I’m pleasantly surprised with how much mobility I already feel, and am contenting myself with that, not pushing it, and waiting to see what the PT recommends on that front.

Physical Therapy: Shopped around for PTs last week and decided to go with my local clinic. My first PT appointment is Wednesday (tomorrow) and we’ll see what I’m in for. I know the clinic uses an aggressive/functional rehab protocol on their surgical repair patients, so my hope is to go in there and convince them to treat me identically to a surgical patient. I think they’ll go along with it — getting the okay from my OS, who is quite respected, should help. (I won’t mention the part about his extreme skepticism.) If they somehow refuse, I spoke to a second PT last week who was more than willing to entertain the idea of trying something new (despite being totally floored when she heard I was going non-op.) Don’t want to publicly share names until all is said and done, but for any Bay Area / Peninsula folks reading this a few months from now who want information, feel free to get in touch and I’m happy to talk about my experiences in detail.

Tendon Regeneration: I’ve been looking into the actual science behind tendon research in an effort to better understand the various approaches of the different therapies. e.g. why some start the weight bearing (or “loading”) process earlier than others. From my research I think the general scientific understanding is (and this has mostly been achieved through experimenting on animals, less on humans) that loading the tendon does something to enhance the ordering/alignment of reconnecting fibers in a way that is superior to what happens if they’re simply left alone, without loading (e.g. immobilization.)

When and why this happens is still an open question. Some science points to the fiber-ordering starting around week 4 post injury/op (weeks 0-4 being generally spent with initial healing and collagen generation), which may explain why Wallace’s patients had success with the NWB -> FWB transition after 4 weeks (the loading started at roughly the time of ordering). At the same time, there is no evidence suggesting that weight bearing before the fiber ordering commences is unsafe in any way. I found one recent Scandinavian study where they tried immediate weight bearing on non-surgical patients, with no negative effects. For those interested, this article provides a great, balanced overview of op vs. non-op thinking and protocols: http://www.danmedj.dk/portal/pls/portal/!PORTAL.wwpob_page.show?_docname=10547073.PDF

With the above in mind, I would love to see a combination of of Wallace’s technique of physically manipulating the ends combined with immediate weight bearing in an attempt to get a “best of both worlds” protocol. (Assuming neither has a negative influence on the other, which hasn’t been studied.)  Also, to whatever extent homeopathic / Eastern medicine treatments can influence initial collagen formation and subsequent ordering, those would be beneficial to implement as well.

General sensations: I get the odd pain and tingle every now and then. Some of this is to be expected as I had achilles problems prior / a bump (which is now reducing, similar to what Roark mentioned in his comments, which is interesting). They don’t last for more than a few seconds at a time, but still makes me a bit nervous when they happen. Looking forward to getting an image at 6 weeks to confirm that things are healing as they should be so I can really put my mind to rest about pre-injury implications.

Happy Healing!

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Week 1 (Day 8)

May 6, 2014 · 4 Comments

Pleased to announce I am now the proud owner of a prescription for physical therapy for an Achilles Tendon Rupture. (No surgeon conference necessary, Norm, but thank you so much for the offer!) I will say, for anyone who finds themselves in the unfortunate position of needing to advocate for a non-op, that doing the research is imperative. After some light back and forth the final outcome was the prescription, but my OS made it clear that he doesn’t see any way that the tendon will heal properly. I now have my sights set on unleashing a Brady Browne-esque performance inside his office in 9 months.

The search for a physio begins, although it appears that the one attached to my clinic actually does practice non-conservative treatment (but they restrict it post-op patients!) so I’m hoping to talk them into adapting their aggressive protocol over to me and my boot. I’m mostly looking for ultrasound and massage to break up attendant scar tissue, and access to a leg press for more controlled weight application.

The Leg: General soreness is starting to creep in, but swelling is also reducing. Sunday night I developed a new and persistent tightness in the calf. Iced and heated and it went away, but then returned again the next morning when I got out of bed. This is one example of how reading too much can hurt you — it was the type of cramp that I never would have thought twice about before but I wanted to be on the safe side after reading clot reports here, so I moseyed over to urgent care. Doctor did some light touching of the calf and concluded it was fine but ordered a blood test just to make sure. All well! (Minus a little bit of a hard stretch I was forced into when the PA elevated the table with my booted leg on it without warning. Felt a decent stretch pain on the lower right side of the calf but it dissipated quickly.)

I’ve almost accidentally popped up onto the leg a few times in the past few days now. I find it feels particularly good after I finish showering — I’ve been washing by sitting on a stool in the center of my bathtub and extending my leg out of the tub area (I use a washcloth for my leg later to keep the achilles restricted as long as possible). Something about either the angle or the heat feels great (glute/achilles relationship, maybe?) so I’m going to try to replicate it in other settings and see if it does anything.

Going to start some light upper body and core exercises this week as I’m finally comfortable lifting my leg into different positions (still NWB.)

All in all, things are looking up! Hope everyone else’s recoveries are progressing well.

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Week 0 (Day 5)

May 3, 2014 · 11 Comments

Hi Achilles Blog Friends,

Starting up a blog of my own to track my progress and experiences through what I hope will be a successful non-op recovery. Have already found this blog to be an incredibly positive influence both in terms of information and general morale, so I’m hoping to contribute in whatever way I can!

The Injury: Just finished a day of studying for my last grad school exam and jumped onto a high school track to get a quick workout in. The workout was quicker than I expected: 150m into my first repeat I felt a snapping sensation on the back of my right leg and had to pull up.

I’m no stranger to lower leg injuries (struggled with them for years as an avid runner in high school and college). Previous injuries (the ones I can remember, anyway) include: ITBS, sprained ankle, achilles tendonitis, heel spur, torn calves (both at once, yikes). Never had surgery for any. Ran through them with varying degrees of pain until I was paired with a great physio for my calves and managed to heal things up quite well. That was in 2011, and I’m now a month shy of my 27th birthday. Unfortunately the healing was so complete I forgot I was injury prone and attempted this track workout without having run at all for almost 2 weeks, and without having done any kind of speed work for at least a month if not longer. Ironically my last thought to myself coming around the curve was “I’m surprised at how good this legs feel right now.”

The Aftermath: Came to an abrupt halt, flexed my foot around a bit trying to determine what was going on (wish I hadn’t done this!) waddled roughly a mile to my parents’ home where I had been staying, grabbed some ice packs, elevated my leg, and started googling. Didn’t take much time before I was pretty sure it was a ruptured achilles. Father got me to Urgent Care a few hours later and the doctor confirmed. I was placed in a splint and sent on my way with a referral to call the OS in the morning to set up a pre-surgical appointment. “They LOVE doing this surgery,” the doctor said.

That phrase set some alarm bells off in my head. Why would surgeons be known for loving a particular type of surgery? Because it’s helpful, or because it’s profitable? I went back to searching when I got back home. Came across all the non-op studies that are cited here and after skimming them I felt quite positive about exploring the non-op route, and quite negative about the implications of privatized healthcare. I don’t think it’s any coincidence that the US is generally lagging behind national health countries when it comes to non-op advocacy — just look at where the economic incentives are pointing.

Went to sleep and headed in to see the OS the next morning. Mentioned to the nurse I was thinking non-surgical and she was a little dismissive. Then the surgeon came in and performed a Thompson test, told me it was ruptured, and said I should get surgery. I said I was interested in going the non-surgical route, and he came back at me with a host of what I now call “2007 era” statistics — even quoted a re-rupture rate as high as 40% for non-ops! I hadn’t done enough reading to be fully confident in my responses, so I shook my head in agreement but said I wasn’t sold and I would need more time to decide. He proposed an MRI (I’ll have one on Monday) and a followup discussion (Tuesday morning.) Before the surgeon left I asked to be placed in a walking boot (the nurse mentioned they had them earlier) and a PA fitted me into a DJO MaxTrax ROM Walker at somewhere around 20º http://www.djoglobal.com/products/procare/maxtrax-rom-walker

I came back home and went right back to the internet (fortunately my university pubmed subscription is good through the end of this month!) Read quite a bit and began to see the evolution from 2007 era to modern thinking on non-op rehabilitation protocols. Realized that my clinic’s physiotherapists may be a little behind the times on those as well — the surgeon quoted a lengthy 8-week cast time as part of the reasons to avoid non-op.

Fired off two emails to local PTs I worked with in the past to see if they either had or were willing to develop aggressive protocols. Still awaiting responses from them. If I can’t persuade the clinic to try something new, I’m afraid I’m going to have to go this alone by cobbling together routines for the therapy bits and then using PTs to supplement with ART and ultrasound as necessary. Would much rather have my hand held through the process because I imagine it’ll be trickier in the later stages, but I feel so strongly about going non op that I’ll do it alone if I have to. If anyone reading this has experience with treating this non-surgically in the CA Bay Area, please comment or let me know how to get in touch with you privately as I’d love to chat.

How My Leg Feels: (Warning, this is excessively nuanced, but I figured it may be of use to someone who is worried about experiencing similar sensations down the line, so I’m listing in detail): Things actually feel quite good, considering. Certain regions of the achilles were sore to the touch when I was examined by the doctor, but only about 5-6 on a 10 pain scale. Over the past few days I’ve been feeling the occasional aches and pains in my forefoot at but I think those are more related to the positioning/tightening of the straps on the boot than anything else. Had a day where I felt some sharp pointed pains in the bottom outside of my heel (below the ankle) that I thought may have been a sore peroneal tendon but that appears to have gone away now. Occasionally if I reach for some things across my body it produces a sore sensation in some back-of-calf muscle (I can’t really tell which) but that dissipates quite quickly once I adjust the leg. Occasionally I’ll get a feeling of liquid or bubbling in the lower heel as well. Still noticeable swelling across the entire leg region. Hasn’t changed much since the first injury.

Therapy: Not much to do now as I’m NWB regardless of what happens. I’m fortunate enough to have a caretaker around from afternoon through evening most days so I’ve been able to spend most of my time laying down with the leg either resting flat or elevated. Every now and then I’ll loosen the straps on the boot, open up the shell, and run my fingers up and down the exposed parts of the leg, lightly, just to remind the nerves that they exist. I also wiggle the leg very softly from the upper quadricep. It doesn’t move much inside the calf area, but I can hear things stirring a bit. I also spend some time focusing my breathing “into” the calf. This is a yoga technique to relax and open an area and I’ve found it produces some pleasant rumbling sensations in my calf so I’ve kept it up. Finally I’ve found that light upper body cardio (just punching my hands in the air) while reclined also seems to wake things up a bit.

I also started icing last night by very carefully inserting a flat ace bandage like this one http://www.amazon.com/gp/product/B00717YEO8 in between the back of the calf and the boot. Don’t know if it does anything but I figure getting more blood into the area won’t hurt either.

Diet: I’m eating as much “tendon food” as I can. Lentils, beef stews, dark green vegetables, fruits with antioxidants, walnuts, sardines, etc. Supplementing with daily protein shakes http://www.amazon.com/Optimum-Nutrition-Standard-Chocolate-Packaging/dp/B000GIQT2O/ and Emergen-C Joint Health http://www.amazon.com/Emergen-C-Joint-Health-Tangerine-30-count/dp/B0079V687C  Drinking as much water as I can, too.

Up Next: Taking my final exam Monday afternoon, MRI Monday evening, and meeting the OS Tues morning. I could already tell I was not my OS’ favorite patient when I left the office last week. Not sure how things will go at the followup. I have no doubt that he is an excellent surgeon (he works for a major professional sports team, as do all the surgeons in the clinic’s office), and the office walls are littered with signed jerseys and photographs praising repairs well done, but I feel like I’m going to have to put my foot down on this one (get it?)

I have one final reason for really wanting to avoid surgery: a good friend passed away 72 hours before I stepped on the track. He also happens to be an alum of the school I’ll be graduating from, and I was already planning on dedicating my walk at commencement to his memory. Of course it will now be more of a PWB shuffle, but I don’t think I’ll even be able to go to graduation if I have surgery due to the risk of clotting during a cross-country flight while in a cast. Whatever happens will happen, but it’s given me some strength and another reason to fight for the non-op route. And things like this video of a 9 month non-op give me a tremendous amount of hope: http://www.youtube.com/watch?v=6LobdP5LPXI

So that’s all for now. I’ll end with a big thanks to all the regulars who have made this place as great as it is, particularly Norm for making me feel sane in questioning surgery, Cecilia for her protocol aggregation, and the rest of you for all your support. Looking forward to getting through this one together.

David

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