Progress remains slow but steady, now a full 15 months since my Achilles tendon rupture and repair. The strength of my repaired right leg is pretty close to that of the left, even though the right calf remains slightly smaller. Range of motion has been quite good from early on. The calf cramps that were such a problem during the first months have resolved almost completely. Most importantly, I am back to the same level of physical activity as before the injury, including some light weight basketball. I get sore after a vigorous day of exercise, but a lot of that is in my old knees rather than in the ankle. I missed skiing completely last winter, and am looking forward to it. An early winter storm is already dumping snow in the Sierras as I write this.
To the recently-injured readers of Achillesblog, I encourage patience and a philosophical attitude. An Achilles tendon rupture is a rough, rough injury. But ultimately, time heals.
Progress continues, though more slowly than hoped for, now eight months post injury. On one leg, I can raise my heel off the ground about an inch at best. The injured calf is still smaller than the other. Running feels a bit awkward, though my general sense of balance is clearly improving. My calf swells slightly by the end of the day. The surgical repair site is mildly sore upon waking, or after sitting or standing for a prolonged period, but the soreness dissipates within a few minutes. I’ve been out shooting baskets a couple of times, but not willing to get into an actual game yet.
At my six month visit, my orthopedist was mildly concerned that the tendon might be healing long. My ankles have always been fairly flexible, and I can’t detect any obvious difference in the range of motion (dorsiflexion) one side to the other. In any event, I would do anything to avoid surgery again. For now, we are taking a wait-and-see attitude. I’ll see him again in another month.
My recent progress seems quite typical, judging by others’ reports on this site. Regular physical therapy visits have massaged, stretched and strengthened my ankle, slowly but surely. During the early stages post injury, improvements came pretty briskly, less so in the past couple months. Right now, about 21 weeks post injury, I still have some Achilles tendon pain, particularly on days following vigorous PT sessions. The leg is still edematous (swollen) at the end of the day. If I do not think about it, I limp slightly, though if I concentrate on my gait the limp is easily disguised. Flexibility is essentially back to normal, but muscle strength is slow to return. I am not yet close to being able to do a single leg toe raise. Balance remains poor on the weak leg, too. I have frequent night time cramps in the affected calf despite extra fluids, stretching and massage before bedtime. That narrow spot in the repaired tendon is still there, but is not particularly tender.
Both my therapist and my orthopedist think I am progressing as expected. I greatly appreciate the reports from the achillesblog community, particularly those who are a just a bit beyond my stage of recovery, returning to the football pitch, or the ski slopes, or the basketball court. Your stories stoke my optimism. In fact, I just learned about a interesting professional conference at Whistler in March. I might just sign up in hopes of doing some spring skiing.
My orthopedist looked at my repaired tendon and was generally pleased with my progress. That slight depression in the tendon was not concerning. He says that the Krackow type of tendon repair begins with several interlocking suture knots about each end of the ruptured tendon. The sutures are then pulled together with just the right amount of tension, pulling together the ruptured tendon ends. Over time, scar tissue sometimes forms most prominently in the parts of the tendon with the multiple interlocking knots, just above and below the ruptured tendon ends, resulting in a picture exactly like mine. The relatively thin section of my tendon corresponds to the point where the ruptured ends have been pulled together. There are relatively few knots there and so less scar tissue. Just above and below that point are parts of the tendon with more suture knots and more scar tissue. So that thin spot is not really thin, it is just less thick than nearby parts of the tendon. It is still healing as it should. No worries.
My orthopedist has emphasized at every turn the importance of not overstretching the surgically repaired AT during therapy, because of the risk of long term calf weakness. I have been (in my mind) fairly conservative with my exercises. Stretching has been gentle. Even so, my static range of motion is normal, i.e. plantar flexion and dorsiflexion just lying on the bed is pretty good. With more active movements, however, I clearly have decreased range, plus my right calf is still weak, so that I still limp when walking, and have great difficulty walking down stairs good foot first. I have not even thought about running yet. Then at the eleven week mark, my physical therapist turned up the intensity, with more vigorous stretching and strengthening drills. Even though the tendon is more tender as a consequence, I am hoping for more rapid progress. I must be moving beyond the (ill-defined) period where re-injury or overstretching is a significant risk.
One mild concern: when I palpate my repaired tendon, there is a point at the level of the medial malleolus where the tendon is thinner than above or below. That is, when I run my finger along the back of the tendon, I can feel a shallow depression about 2 centimeters long. Above and below that point, the tendon has some scar tissue and feels quite robust. When I stretch the tendon slightly by dorsiflexing the foot, the thin spot is less prominent but still there. In comparison, my older left repaired AT is fairly uniformly robust throughout its length. I’ll have to ask my orthopedist about it.
After I tore my left AT two years ago, as soon as I was able to hobble around in the walking boot with crutches, I was able to drive my car. Even though I was still uncomfortable, I had a sense of freedom and mobility. This year, after rupturing the right, I was forbidden to drive by my orthopedist for six to ten weeks post surgery. Of course, my doctor’s argument made sense. Even though that right leg recovered fair range of motion soon enough, and with the boot off I was able to gently push on the accelerator, in the early weeks post-op it was not strong enough to stop the car reliably and safely. I could learn to brake with the left foot, but he said that in an emergency people go back to their old habits and use that weak right foot again. My orthopedist added that if I were to get into an accident that somehow involved the legal system, if anyone noticed that orthopedic boot in the car, that I would absolutely, no questions asked, lose the case.
So I depended on my wife and limited public transportation to get around. Being unable to drive meant I could not work either, so I was cooped up at home. On the 42nd post-op day, i.e. exactly six weeks post surgery, without official approval from my orthopedist, I took the boot off and went for a cautious drive. What a joy. Two days afterward, I returned to work.
My first AT rupture happened when I was 54 years old, the second at 56, both while playing basketball. I have always been physically active, so I know those tendons have gone through some wear and tear over the years, but my Achilles tendons were never painful or tender before the acute episodes. The medical literature suggests that re-rupture of a surgically repaired tendon, or rupture of the opposite AT, are rare, with a risk of less than 5%, though those studies cannot control for changes in behavior after major injury.
I could say, then, that the second tear was “unpredictable,” but in fact I put myself in a position of risk by playing again. After the first rupture, I seriously considered quitting forever. Basketball is the most physically demanding thing I do and presents the greatest risk of further injury. But I went back. I talked about this decison with friends of my generation, and despite a host of different injuries, we love the games we play and return to them. Certainly, nothing gives me quite the visceral pleasure as a good pickup game. At the same time, the burden of a major injury is great, and falls not just on the individual, but on a lot of other people including family and friends, and even on fellow workers.
During my ongoing recovery, I watched Michael Jordan’s acceptance speech as he was inducted into the Basketball Hall of Fame. Unlike the standard player’s contract that prohibits playing basketball outside of official practices and games, Jordan’s contacts always included a “Love of the Game” clause permitting him to play anytime and anywhere he wanted, even given the risk of injury to an NBA superstar. I’m no superstar, but I understand that “Love of the Game.”
Will I play again? I have not yet decided. Logic tells me I should not. I certainly see few players my age out there on the basketball court, and lots on the golf course. We’ll see.
I have unfortunately had a few different orthopedic problems in recent years and have seen several different doctors in one of the large orthopedic groups locally. This group includes team physicians for a number of college and professional sports teams as well as the San Francisco Ballet, and the waiting room is full of autographed photos of famous athletes. The doctor who repaired my left achilles tendon two years ago was on vacation when my right was ruptured, so I was referred to the foot and ankle specialist in the group. I noted some small differences in the specifics of surgical technique between the two doctors, and I lack the expertise to say whether those differences are important or not.
However, I was struck by the difference in philosphy regarding rehabilitation, and that led me to read a little about it in the medical literature. My present doctor emphasizes early movement and early weight bearing, whereas my previous surgeon and one their partners who saw me for one of my follow-up visits, both preferred a significantly longer period of immobilization. So following my surgery I was into a walking boot and partial weight bearing two weeks post surgery. At that appointment, range of motion exercises were begun followed by gentle muscle strengthening. I can honestly say that I have retained more muscle strength and bulk, and am back walking again much sooner with this injury than with my previous left sided AT rupture. The concern, according the the two more conservative members of the group, is that an inadequate period of immobilization may threaten the ultimate strength of the tendon with risk of re-rupture. However, the medical studies I have looked at do not seem to demonstrate that increased risk. Time will tell.
I discovered this website a few weeks post injury and have found it enormously helpful. I thought I’d add some of my own thoughts and experiences.
For me, this is the second time around. I ruptured my left AT two years ago playing basketball, and survived the long process of surgery and rehab. My left leg never fully returned to equal its right partner, but I was able to ski, run and play basketball again. I had long ago stopped thinking about the injured leg when engaged in strenuous activities.
Then, now almost two months ago, playing in a lightweight pickup basketball game, I had that miserable deja vu experience, this time on the right. I should add at this point that I am a pediatrician in practice in the San Francisco Bay Area, and I recall from medical school the description of the typical achilles tendon rupture: engaged in vigorous physical activity, a sudden sharp pain in the heel accompanied by a distinct popping sound, a fall, and inability to bear weight. The patient often thinks someone kicked him in the ankle. That med school description matched my experience perfectly. I self-diagnosed in about one second. I almost cried, not from pain, but because in the next second the memories of that long recovery came racing back.
I made my way to the local ED for a splint. By the way, physicians who show up as patients in the ED get no special treatment, at least in my community. I still had to wait hours to be seen. Surgery followed two days later.
Having gone through this process before, I can be honestly optimistic.