dcoughlan’s AchillesBlog

Week 0 (Day 5)

May 3, 2014 · 12 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

Categories: Uncategorized

12 responses so far ↓

  • Stuart // May 3rd 2014 at 11:46 pm

    Hey Kellygirl - jump on this page and give this guy a hand. He is from you neck of the woods (concrete) and is going non op. I am sure Norm will lend a hand.

  • Stuart // May 3rd 2014 at 11:53 pm

    Just my personal view - you are already 5 days into healing non op and in a boot at 20 degrees. When you go for an MRI they are going to destroy any collagen bond that has started to form by getting you in position for the the test. That will put you back to day 1. The only real issue is if the gap in the tendon is quite large and the ends do not meet at the angle the foot has been set but even then non op will work. Isn’t the body amazing.

  • dcoughlan // May 4th 2014 at 12:25 am

    Thanks for the response Stuart! Never had an MRI before so this is new to me. I was expecting to just lay down with my foot pointed — is that not the case? Definitely don’t want to be forced into a position.

    I’ve definitely thought about canceling the MRI before. The only reason I haven’t is I’m concerned that (a): the approximation was never attempted by my doctor (although no one who was seen within 2 weeks ever failed so perhaps this is fine) and;

    (b) given my history of problems in the achilles / heel region, I’m wondering if there’s some additional type of calcification or problem with the bone attachment area that non-op won’t heal. I don’t understand the science on tear-from-bone vs rupture, though. If anyone does and can chime in, that’d be great.

    Thinking about canceling the MRI and sending over some of the articles instead to see what the OS thinks, though. Thanks again.

  • kellygirl // May 4th 2014 at 12:31 am

    Welcome and sorry to hear about your injury. Your early experience with the Dr. sounds like mine. I had to call around to doctors in my network to find one that would even treat me non-op. Almost all of them preferred surgery which I guess makes sense considering how much they can charge the insurance companies. Non-op is practically free in comparison–a few doctors visits and a boot! My PT experience was limited too. I wasn’t very impressed with my local facility and ended up only going a few times. I wasn’t doing anything there that I couldn’t do on my own.

    Your leg pains sound normal. I had them too very early on and I attributed them to immobilization. To me, they felt like cramps but went away pretty after the first week or two. Elevating is good and I’m sure the ice will help too. Great that you got in a boot so early. Hopefully you can avoid the cast and just get on a fast track protocol. I just read a post from Pete and he is FWB at two weeks! Best of luck. Feel free to PM me if you have any questions. I’m in the South Bay.

  • normofthenorth // May 4th 2014 at 1:34 am

    David, you seem unusually up to speed on the issues and the history of the evidence, etc. Not much for me to add here. Of course, now now that you’re going to become a flag-bearer for the non-op cure, you have to recover like Brady Browne! (And yes, Brady Browne’s YouTube videos are striking, from beginning to end.)

    If you want to read about an extreme case of a patient who had to fight for a good non-op treatment against massive opposition, check out achillesblog.com/johanna/ [aka "firstdayofsummer"]. In addition to FINALLY getting the treatment she wanted, she also seems to have changed the ATR practice of a pretty fancy hospital!

    Now that many of us have seen the Wallace study, we’re all going to be clamoring to find a health professional (could be an OS, but not necessarily) who will do what Wallace does for his patients: inspect and palpate the torn AT while the ankle is plantarflexed, to ensure that the ends are approximated. I assume that’s virtually hopeless anywhere except Ireland — unless you’re VERY pushy!

    I’ve never had an ATR MRI, so Stuart’s caution was new to me, too. But I HAVE read a study that suggested that the much-loved (and -performed) Thomson test might be harmful, by causing the already-contracted calf muscle to contract even more — possibly increasing the gap size and leaving the muscle in an even more awkward position until weeks later.

    The crass motives that both of you (DavidC and KG) attribute to private OSs who advocate ATR surgery may sometimes be correct, but (1) I think the vast majority of people involved are sincerely convinced that they’re doing what’s best for their patients (even when they invent 40% non-op rerupture rates — my WORD!?!?!). After all, if your only (or main) tool is a hammer, all your problems really DO look like nails! and (2) The difference between private-health USA and public-health countries can be seen in two diametrically opposite ways, depending on your initial bias: To advocates of ATR surgery and/or private medicine, the public systems are pushing their patients away from the best care because it costs too much. All in the eye of the beholder.

    As you may have seen from my early blog posts, the OS who talked me OUT of having surgery on my second ATR is the Chief Surgeon of Toronto’s pro football team, in the CFL. Maybe we should arrange a phone call between him and your sports-med guy. . .

    Finally, you say you’re in a “DJO MaxTrax Walker at 20º.” But the DJO MaxTrax Walker is a fixed boot, not a hinged one. (MaxTrax makes a bunch of hinged boots, but they all have “ROM” in their names.) So do you mean that you’re in a DJO MaxTrax Walker with a couple of heel wedges in it, to take your ankle to 20º? The evidence favoring hinged boots is pretty weak (Wallace and UWO both used fixed boots), but I still like them, though they do add some cost and some weight.

  • normofthenorth // May 4th 2014 at 1:47 am

    You also asked about “avulsions” (tears off the heel bone) vs. ATRs. I think those avulsions are the main (and only good) reason that most ATR patients are immediately sent for X-rays. Some ATs pull away from the bone, and some pull a piece of heel-bone away with them. I’m assuming that the latter (and maybe the former) would not heal properly non-op, but Wallace might give me an argument on that. (I used to say that “stale” ruptures would not heal properly non-op, but Wallace totally proved otherwise. Reruptures, too!) For sure, OSs use different surgical techniques to re-attach ATs to the bone when it’s separated, including drilled holes and sometimes screws.
    In addition to the X-Ray, simple observation and palpation should indicate if the rupture is extremely low, which makes an avulsion a possibility.
    I have heard of multiple-location AT ruptures — in fact, one of my three completely contradictory UltraSounds (at 1-week intervals!) indicated I had one myself — but my halfbaked-Physicist background suggests that they’re very rare. The high stress that causes an ATR might well stress or stretch other parts of the AT or calf muscle, but the chance of two “links” rupturing at exactly the same time seems vanishingly small. So I’d say if you can (or could) detect an ATR gap above the heel bone, you probably don’t have an avulsion.

  • dcoughlan // May 4th 2014 at 2:33 am

    Just had a scary but hopeful moment: was getting ready to stand after brushing my teeth and nearly hopped up onto the bad leg. Completely forgot about it!

    Kelly — I’m sorry you had similar frustrations! Ironic given how progressive the Bay is in so many other respects. If you need work done in the future I’ve had terrific PT experiences with Sports Medicine Institute in Palo Alto — they’re expensive and don’t take insurance up front as they’re a non-profit, but depending on your insurer you may be able to get visits partially or fully covered. Also had a great PT from Agile Physical Therapy who was in-house at one of the companies I worked for. Use of ultrasound and advanced massage techniques to reduce scar tissue are the big difference makers for me. I reached out to both about this and I’ll update if either pans out.

    Norm — Brady is quite incredible, isn’t he!

    I did have a palpable soft spot / dimple somewhere above the heel area, so I’m just going to go ahead and tell myself there’s no avulsion (thanks for the terminology!) and if it pops up in a few months I’ll address it then. Although I do have double injury history in my background: tore both calves simultaneously during the 2011 incident, and one wasn’t even bearing weight at the time. Therapist said she had never seen or heard of anything like it. Sympathy tear? Lightning striking twice? I’ll take my chances!

    You’re very right about the respective lenses for viewing public and private care too. I should not have painted with such a broad brush, and I will say that I do not believe my OS has sworn off his hippocratic oath in any way. The ambiguities surrounding the “best” option for treating ATR just expose the varying levels of inertia inherent in each system.

    Also you’re correct, that was not my boot. I’m in ROM walker http://www.djoglobal.com/products/procare/maxtrax-rom-walker — when it was being assembled the RA announced “I usually set these at 20″ so perhaps that means I’m at 22.5º (too afraid to remove the boot to check.)

    Finally if you’re serious about offering your doctor as a resource, I may very well take you up on that! My doctor has NFL experience in his background so perhaps he will be more inclined to listen to a peer than a young man with a pubmed subscription and way too much free time on his hands.

    Thanks again everyone!

  • Stuart // May 4th 2014 at 3:36 am

    Just to clarify, my father had an MRI for his and they put his foot at neutral. There may be some benefit in having one given what you have said but that is your call. Personally I did not have an MRI for mine.

  • normofthenorth // May 5th 2014 at 2:48 am

    I am serious, David, but I’m not sure how we’d make it work. I never exchanged emails with my OS, I just made appointments at the sports-med clinic he works at (when he’s not at Toronto General Hospital) and saw him there, maybe 3 or 4 times total.
    If you could get your OS to try to phone mine, I’m pretty sure he’d return the call, but that may be hard. I’m not sure mine would make a “cold call” to yours just because a patient of his from 3 years ago asked him to. Suggestions welcomed.
    I have mused about seeing my guy again — and also doing another test on the computerized dynamic-strength gizmo — but I’m already too busy with things that seem more important or more useful (like blogging and posting here!).

  • Roark // May 6th 2014 at 1:52 pm

    David,

    I had the same sensations in the first few weeks, especially that tightness in the gastroc part of my calf. Felt like it was cramping or pulling occasionally, but went away in a few weeks. I also had a lot of pain during the first few weeks every morning when i got out of bed. I could feel all the blood rush down to my Achilles and it felt like a migraine in my leg for about 15 minutes every morning that got better with movement.

    I’m also finding that I can follow the protocols found on this site pretty successfully at home on my own without needing to go to a physical therapist. I can also do a lot of yoga moves with modification, which I think helps get the blood flowing. If you have the discipline to do those exercises 3-4 times a day on your own, in my opinion, the only reason to go to a PT is to get an extra opinion and more objective baselines on progress.

    Oh yeah, my OS also assessed the gap closure by physically massaging/palpating the Achilles. He said he could feel where it was separated and he could feel that it was closed when I went back in about 3 weeks later. I couldn’t feel it when I tried, but that’s what you might be feeling. He said it will slowly fill in and knit back together as long as the torn ends are close enough together.

  • dcoughlan // May 6th 2014 at 2:24 pm

    Norm, thanks again for offering up your surgeon — fortunately got the all clear for PT without any additional intervention! Updated in a new post.

    Roark, thanks a lot for your descriptions. Sounds similar to mine and I’m very glad to hear your home therapy is going well. I also had the hope of doing some modified yoga myself so I’m very glad to hear it’s working for you!

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