dcoughlan’s AchillesBlog

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!

Categories: Uncategorized

12 responses so far ↓

  • Stuart // Aug 2nd 2014 at 3:10 pm

    This is all good news. Wondered where you had gone. I did the same thing early on with this site. I was getting depressed trying to find some faster way to get back on my feet and reading so many different accounts was too confusing. Once I capitulated to my circumstance and go my head in order it was easier.

  • normofthenorth // Aug 2nd 2014 at 5:49 pm

    Nice wise words, DC!

    I think the mental part of the “plateau” is key for many of us. Finally being able to “walk” in 2 shoes (after everything that we’ve been through for the past ~8 weeks) is SO CLOSE to being 100%, that it seems like the rest of the recovery is just a stone’s throw, a couple more weeks away — but we all know it’s still a marathon.

    Look at it this way: The difference between day 1 — either moaning and groaning in bed post-op, feeling like our leg will explode if we lower it to the floor, or just holding that leg up in the air while we crutch-walk — and 4 weeks later (FWB walking in a boot for most of us) is SO HUGE, that it seems inconceivable that moving from FWB to walking perfectly in 2 shoes (or even returning to running and jumping, 100%!) will take much longer — but it does.

    Your delight with pool-walking as ATR therapy conforms with my own understanding — all based on what I’ve read here, since I never got into a pool after EITHER of my ATRs! But unlike your experience about compensating walking techniques holding back our progress, I think “just walking as normally as I could” — supplemented with some stretches and exercises, of course! — did a pretty good job of bringing my calf and AT back to full strength and full ROM.
    I HATED the idea of going back to crutches (1 or 2) or a cane after the boot, so I just refused. Instead, I just shortened “that” stride — initially always leading with my injured foot, then just stepping up to it, then stepping past it, then gradually farther and farther. My gait was otherwise perfectly normal (for me!), as I advise others to do. And I think that allowed my strength and ROM to progress steadily, until I finally had a full-length stride on both sides, with a full “push off” at the end. That final push-off took a week or two longer than I’d expected, but I think it arrived roughly “on time”.
    Of course, I threw in a bunch of seated and standing heel raises, 2-up-1-down, 1LHRs on the bathroom scale, etc., etc. And toe-walking and walking backwards, too. And bicycling (road) a lot, too, since it’s my main transport mode.
    But I think “just walking” — and progressively loading that leg at a more-and-more DF angle, as it recovered — was a key part of my recovery, both times. (Using a hinged boot, set to hinge from neutral to infinite PF, was also a helpful transition from boot to shoes.)
    I don’t think I ever actually encountered a physical “plateau”, though I was often disappointed (”mental plateau”) when I had set specific goals or made specific predictions of my progress.

  • dcoughlan // Aug 3rd 2014 at 9:38 pm

    @ Stuart — funny! I think I remember you mentioning you were also a big runner, so probably a similar mindset. I also wanted (and to a certain extent, needed) a fast recovery and any exposure to information that suggested the outcome would be otherwise was just too much.

    @Norm — I actually think it’s difficult to tell how much compensation is really happening without the opportunity to walk at reduced weight. I thought I was doing fantastically with my “walk” until I got into the pool for the first time and realized that I was basically just shifting weight between my feet using pretty much everything but my calf. After feeling things properly fire there was no way I could do anything but try to walk properly after that point! Everything else just felt like wasted movement.

    In fact I think pool training is so effective I’d wager that after 2-4 weeks of walking ~7x a week @ reduced bodyweight + a muscle gain diet, people can be doing 1LHRs on land. This is roughly the approach/ timeline of the successful athletes who have gone through the process in the past year. I think (hope) it’ll start to become a standard part of recovery protocols soon.

  • normofthenorth // Aug 4th 2014 at 1:52 am

    Interesting wager, and interesting experience. One of the few people here who had a chance to use the Alter-G reduced-weight treadmill seemed to be getting addicted to it, rather than progressing as quickly as you bet toward full-weight 1LHRs. I’m blanking out on her loginID now, but perhaps she or others will chime in. Either way, it’s a tiny sample, but a good study could settle the bet.
    Meanwhile, I agree that using either Alter-G or a pool (or the moon, or…) to accelerate a return to fully normal walking at partial body weight is a great idea — even if it does NOT eliminate “wasted movement” and “just shifting weight between feet”.
    First, there’s got to be a big mental boost from proving that everything already works normally again — just not at full strength yet.
    And secondly, many people do learn “funny walks” of various kind — including the extreme “pirate peg-leg” and the “duck walk” as well as many more subtle compensations — which can cause harm to other body parts and often have to be eliminated later with careful gait analysis and hard work.
    But stepping past your injured foot (on dry land) just as far as you can without scary discomfort or pain, and continuing to advance that point as your strength and ROM increase, seems to me like a very useful workout for a recovering AT and calf, far from wasted movement.

  • dcoughlan // Aug 4th 2014 at 3:44 pm

    I agree that walks serve as a good ROM / associated leg stabilizer workout, but I don’t think it’s actually physically possible to work the calf while walking @ full body-weight until you achieve a certain level of strength. Until you get in the ballpark of doing a 1LHR, it’s very very difficult to walk at a normal speed and get calf work in because of how our stepping biomechanics work. You could slow down to focus on taking enough weight onto the noninjured leg on each step to allow the calf freedom to fire, but that seems a little counterproductive. May as well just do modified heel raises at that point.

    But if you throw in the crutches and take off enough weight that your calf can get involved on every step, then you get all the ROM/stabilization benefits + you’re building the calf, all for the price of a crutch or two. To me that tradeoff was absolutely worth it.

    I would want to see the Alter-G protocol used (I searched the site but couldn’t find anyone who seemed to have consistent alter-G use starting shortly after getting out of the boot.) But if someone is doing daily walking (properly — this isn’t automatic — it took me until my 3rd session before I had the mental and physical control to get up onto my toes and fire the calf in chest deep water), + reduced weight single legged raises, then I’m hard pressed to see a reason why they won’t see linear progress until the land 1LHR.

    Another explanation for the alter-G addiction is that our biomechanics contribute a lot to how mystifying this injury is with its apparent plateau, e.g. I was capable of doing anything I wanted in the water before I could muster a full 100% bodyweight heel raise on land. So even when I *knew* I had >50% of my leg strength back, had bodyweight been my only reference point, I wouldn’t have known much.

  • normofthenorth // Aug 4th 2014 at 9:43 pm

    DC, when I hit 2 shoes, my initial bottleneck was DF ROM. For sure, I didn’t have any calf strength wither, but it was mostly DF ROM that limited how far I could step past my injured foot with my other one. I don’t think it took many days — maybe a week, tops? (my blog may remember!) — before I could take a pretty long stride. Then my walk was quite normal, except for the standard “dip-limp” at the end, when I was too weak to push off normally. But I kept trying — as I had done earlier in my hinged boot.

    I wasn’t pushing the calf muscle through a range of motion, the way I could at reduced weight (pool, Alter-G, crutches). It was more like an isometric contraction than a full-ROM exercise.

    But I think I still would have HATED going back to crutches, around 4 weeks after I’d put them away!!

  • normofthenorth // Aug 4th 2014 at 9:44 pm

    wither –> either! (Can you turn on AJAX Editing?)

  • dcoughlan // Aug 6th 2014 at 12:51 pm

    @norm — AJAX now on, sorry about that!

  • vegasjoey // Aug 8th 2014 at 11:55 pm

    Yeah. Once I went two shoes I haven’t gone back to the crutches. My gait isn’t perfect and I walk taking smaller steps but I can’t do it. I’m. At 13 weeks now and don’t want to see. Crutches again. I do. Have to consciously think about walking with proper form

  • dcoughlan // Aug 13th 2014 at 3:29 am

    I guess I’m a rare breed - really didn’t mind crutches at all once I was two shoed because I knew they were the only way I was going to walk properly and get better faster. (Was definitely not a fan of those first few weeks with them, though!)

  • BigE // Sep 30th 2014 at 12:16 pm

    DC,

    Sage counsel, much appreciated. I’m new to site, first post. I want to thank you and the many others who take the time to contribute your experiences, insight, and research. All have helped prepare me for what is next to come and set reasonable expectations and goals. I’m fortunate to have had great care, both at home-thanks honey…boys, and my OS (Emory Clinic) who has me on an ambitious rehab protocol. Thus far (6 wks post injury-full blowout, 4 wks post-op, FWB-day 24, no crutches-day 26, no pain, no set-backs, 2 rehab sessions) things seem to be on track, for that I’m grateful. Should things go sideways, I thank you all in advance for your advise and encouragement.

  • dcoughlan // Sep 30th 2014 at 2:29 pm

    Sounds like you’re on a good path, BigE! Keep it up.

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