Walking in my shoes within four weeks (updated)

I hope someone finds this useful.

I’ve been able to rehab my tendon and calf quite quickly since my surgery on 2/13/09.  My goal here is to share, in much detail (and length, I’m afraid), how I did it and what I’ve learned in the process.  This may, in particular, help others who are looking for a quicker rehab.  Parts of this note may also help those having a more standard rehab.  I’m certainly not claiming that this is the one and only “right way” to rehab.  It’s just what I did.  I’m sure others will have useful additions and changes.

Many people can’t imagine moving their rehab faster than their doctor recommends, feeling that their doctor knows their situation best.  There is, no doubt, some truth to that feeling, but there is also much variation in how different doctors will treat the same situation, so there is no clear “right way” to do this rehab.  It is natural to think that going slower and more carefully is safer, but a recent review of the medical studies that have compared different approaches suggested that a faster rehab is actually the safer way to go.  How much faster is best?  Maybe someday we’ll know for sure.

The big picture

I see four parts to the rehab, which overlap somewhat.  First, postoperative pain has to be controlled and the surgical wound has to heal well, without infection in particular.  Soon, the main goal is getting your flexibility reasonably close to normal, so you can walk fairly normally and get on with your life.  Most of the rehab includes regaining strength in your calf muscle, which will eventually make your walk truly normal.  Last, remember to care for the rest of your body.

I won’t say much here about that last issue, caring for the rest of your body.  We all have our favorite ways of exercising, and will find our own ways to keep up our general fitness.

I also don’t have anything to say about rehab after non-surgical treatment.  That may be the way of the future, at least for many of us, but I’ll stick with what I “know” from my own experience of having surgery.

This rehab worked well for me, but your mileage may vary. I’m 53 years old, in fair but not great shape.  For example, my idea of a great morning is a 50 mile bike ride, but I’m no racer, taking 3 1/2 to 4 hours to do it.  If I can do this rehab, I suspect many other younger or more fit people can do the same or better.  Here is how things progressed.

Surgery, pain, and skin healing

First, my completely torn Achilles tendon was surgically fixed five days after the injury. My ortho doctor described my tendon ends as very frayed, “like spaghetti,” and seemed concerned that the stitches might not hold well in that frayed tendon tissue. At the end of the surgery, a splint was put on the front of my shin and the top of my foot, keeping the foot plantar flexed (toes pointed down). The splint was held on my leg with an ace wrap. If you are stuck in a cast, your rehab options are more limited than mine were.  If you can talk your doctor out of putting you into a cast, and into something removable like a splint or a boot, you will have more rehab options.  This may require much assertiveness, perhaps even outright refusal of a cast.  I suspect the splint/wrap arrangement is better in the pain department, too, as the wrap just stretches when there is swelling, while a cast cannot change size to make room for the swelling.

That first night postop, pain relief was the big issue. I took my last narcotic pain pill 15 hours after the surgery. After that, I just used Aleve, which I take regularly for my arthritis, anyway.  Be aware that there is something called CYP2D6 deficiency, which 5-10% of people have, (myself included), and in such people codiene, oxycodone, and tramadol do nothing to relieve pain.  I was given hydromorphone, which does not need the CYP2D6 enzyme to work properly.

From one day to five days postop, I kept my splint on and kept my foot up as much as I could.  During those four days, I started the very beginning of my rehab, using the calf muscle just enough to make it twitch a little. This was about the lightest imaginable stress on the tendon, but I did a lot of it, (to music, most of the time).  This was the first of many types of exercise aimed at minimizing calf muscle atrophy.

Flexibility (and trying to minimize atrophy)

Five days postop, my doctor took a quick look at the surgical wound and redressed it.  The incision was healing well.  My doctor’s instructions at that visit were to remove the splint a few times a day and stretch the tendon, but only by using the tibialis anterior muscle. The tibialis anterior muscle is the one on the front of your shin that pulls your toes upward toward your knee.  He said that early stretching helps the tendon heal in a stronger fashion.  I did this stretch several times a day, and I did it as hard as I could. While the splint was off, I also started making circles (in both directions) with my toes, to work on my coordination, and also gain some confidence. A few days later, I began to work the calf against a tiny amount of extra resistance, by placing my index and middle fingers on the ball of my foot, pressing just a little as I pushed my foot downward. As time went by, I increased that finger resistance, (and increased the number of fingers I was pushing against). When doing this, I was careful not to put any more stress on the tendon than my doctor-approved stretches did.

I should point out that I never did anything that hurt during this entire rehab process. I was also quite careful about stairs until I started walking, going up and down stairs at home on my butt.  Even since I’ve been walking, I’ve kept my hand on the railing for safety.

I started another exercise after that five day visit, to keep my upper leg in some kind of shape. I would lay on my back, with my knee bent about 90 degrees, keep my “good” leg in the air (holding that knee with my hands), dig my “bad” heel into the bed, and lift my butt off the mattress. This works the muscles on the front and on the back of the thigh, and the butt muscles, too. I did this often, every day, until I was walking again. The weight is on the heel, so the toes bear no weight, and there is no stress on the tendon.  I went back to work ten days postop, the second Monday after my Friday surgery.

Twelve days after surgery, my stitches were removed. (My doctor told me to stay on the crutches, keep doing those same stretches, and he would see me in five more weeks. I wonder if he suspected, by my surprised look, that I wasn’t planning on waiting that long.) I continued the same exercises as before. Just a few days later, though, I could get my toes up to the point that allowed an odd form of walking. I could keep my bad foot out in front, bear weight on that heel (only) for a moment, while I moved by good foot forward a little. Then I would move the front foot forward a little, and repeat.  At first, (but not for long), I did this with plenty of hand support available to help with any balance problems. This shuffling walk reminded me (and many others) of the old Monty Python skit about the “Ministry of Silly Walks.”
http://www.youtube.com/watch?v=IqhlQfXUk7w
This was a slow and awkward way to get around, but it was an important beginning. Once I started walking, everything slowly but surely loosened up. I still used the crutches for covering longer distances, but most of my moving around my second week back at work was this “silly walk,” since most of my work is within a fairly small area.

Once the stitches were out, I often used two compression tubes, a little homemade pillow (placed around the back of the tendon, from the inside ankle bone to the outside ankle bone, to keep the swelling down in those little hollows between the tendon and the ankle bones), and an ace wrap over it all, to control swelling in the leg.  The swelling always makes me feel stiff and weak, so I’ve worn these things a lot.

Between roughly 2 1/2 and 3 1/2 weeks, that awkward walking gradually improved. I could bring the good foot forward more and more each day, until the good foot’s heel was just in front of the bad foot’s toes when the good foot stepped forward. During this important process, I continued to never stretch the tendon any harder than those doctor-approved stretches, (which I continued to do, along with the finger resistance calf exercises). During this time, I also made a point of planting the bad foot’s heel rather firmly and bending the knee a little while doing so, to work the bad leg’s upper leg muscles. At the end of this period, I was walking well enough to put away the crutches and the splint.

At that point, (3 1/2 weeks), I was pretty pleased with my progress, (being able to live pretty normally, in particular), so I “coasted” for awhile. I mostly just used walking for exercise, moved the good foot more forward, and began to, very gently, push off a little with my bad calf as I walked. I concentrated on walking as smoothly as I could. At about four weeks, many people didn’t notice the little bit of limp that remained in my walk, (that the bad heel stayed on the ground a little longer than normal, until the good heel took most of my weight out in front).  I also started pushing the ball of my foot into the top of the other foot, using my other foot’s tibialis anterior muscle for resistance, instead of my fingers.

Shifting the emphasis to strength

At five weeks, I finally started stressing that tendon a little harder than than the approved stretches, both in stretching and in calf strength exercises.  I started adding the other leg’s tibialis anterior muscle’s strength to the stretches, by putting the ball of my injured foot on top of my other foot, and pulling up with the tibialis anterior muscles of both legs.  At this point, I could sit down, and then push down on my toes to lift my heel off the ground. I did this a lot, often to music, no doubt making some people wonder if I had restless leg syndrome. By six weeks, I added the weight of my other leg by crossing my legs while doing this exercise.

At my 6 1/2 week postop visit, my ortho didn’t mind that I had been walking against his advice. He looked a little nervous when I told him that I had put my toes on a bathroom scale to test my strength and pushed down 140 pounds, but no harm, no foul. He said the tendon felt great. The physical therapist thanked me for making him look so good. They both said I didn’t need to come back to see them again, as I was pretty clearly well on my way to getting my strength back. (There are some health care dollars saved!)

Three exercises were added at that 6 1/2 week visit.  The first was two leg calf raises, putting as much weight as felt comfortable on my bad foot.  The second was to do a very slow jog, getting that feeling of rolling my weight over my bad foot as the other foot moved forward.  The third was to stand, lift my bad heel off the ground, and gradually lean more weight from my good foot to my bad foot until the calf gave out, then “fight” the heel’s fall to the ground.  At eight weeks, I was able to, barely and for just a couple of seconds, hold my entire body weight up on my toes.

Now, at ten weeks, I’m jogging half a mile (running bores me if it’s not on a basketball court) with an emphasis on that calf lift and push off, biking (which definitely doesn’t bore me) all I want, and working on single-leg calf raises.  I make a point of going up stairs on my toes, too.  I still do some stretching, but that’s not a priority for me now, as my range of motion, while not completely normal, doesn’t prevent me from doing anything.

While working on harder strength exercises the past few weeks, I’ve taken a page from the weightlifting book, alternating hard days with easy recovery days to get over the soreness brought on by the hard days.  Early on the “hard” days, but before I do the hard stuff, I can walk truly normally (see below).  After the hard stuff, though, it’s back to the weak-calf walk until the morning after the next day, and the cycle repeats.

The frustrating plateau: Will I ever walk truly normally?

In the first few weeks, when flexibility is increasing, and especially when the walk is going from “silly” to “almost normal,” your progress is very visible.  When the flexibility is good enough to take a reasonable step forward with your good foot, your walk is nearly normal, and the crutches and the splint/boot can be retired.  It feels great to reach this point.  Life is fairly normal again!  This walk isn’t truly normal, however, because that calf is weak, and your bad heel can’t come off the ground until the good foot’s heel strikes the ground in front and takes some of your body weight.

Getting to this nearly normal walk doesn’t take that long, so it is only natural to think that truly normal can’t be far behind.  It does take quite some time, though, because you can’t walk truly normally until your calf is much stronger.

During normal walking, while one foot steps forward, our weight rolls forward on the other foot.  For a moment, with every normal step, our entire body weight is held up by one leg’s calf muscle.  This is especially true with faster walking, and that’s why that subtle limp becomes more obvious when we try to walk fast.  So we can’t walk truly normally until that calf is strong enough to hold our body weight for step after step after step.

Gaining that much calf strength takes a long time, and progress seems to slow to a crawl.  Your calf is getting stronger, but it doesn’t show up in your walking until it can hold all of your weight.  I found that checking my calf’s strength on a bathroom scale was useful to check my progress at that stage.  I would put my bad foot’s toes on the scale, and then push down as hard as I felt comfortable doing.  My progress was more visible then, as I saw my calf could support more weight over time.

Last thoughts

I think the main thing that started me down this path was feeling that doing nothing but those stretches for several weeks was an invitation to severe muscle atrophy and a long rehab.  I soon knew I could do at least something to work that calf muscle, and very gradually build on that as my confidence grew and the tendon got stronger.  I also rejected the idea that the injured heel can’t bear any weight.  In my experience, the heel can take weight just fine, as long as the tendon is not stressed too much.  It is important to be careful, though!  Stairs, corners, doorways, slippery surfaces, and such can lead to surprise falls.  Mentally prepare yourself for a fall by imagining yourself going to your knees or your butt, and in particular *not* sticking out your injured foot to stop your fall.

I strongly suspect that most doctors are way too cautious, leaving many of us with withered calf muscles that take months to regain their strength. My atrophy was at its worst at about 4-6 weeks postop, when the maximum circumference of my good calf measured 17 inches, while the injured calf measured 16 inches (with the swelling squeezed out). You had to look closely to notice the difference.

This rehab didn’t require lots of time.  The commitment was not to hours a day of working out.  The commitment was more about consistency, akin to deciding to floss and brush your teeth after every meal for a few months.  It was not a huge effort, just one that required consistently working for gradual progress.

I never used any boots, wedges, or rehab gadgets. I really wonder if those boots, while they do protect us from accidental injury, actually hold us back in regaining flexibility. (And don’t get me started on those casts so many are stuck in for weeks.) I did this rehab with crutches (a necessary evil, and check out those forearm crutches, as some people like them more the standard armpit style), my splint, an ace wrap, two compression tubes, and my little homemade tendon pillow. I started riding my bike at nearly four weeks postop, so maybe that counts as rehab equipment, too. Mostly, though, it has been just walking and some simple no-equipment exercises.  This means that this rehab is inexpensive and potentially available to most people having this surgery.

I’m left wondering how this rehab plan would work for others. Was I foolish but lucky, or is this a basic plan lots of people could safely use?  I’m hoping some folks who want a faster rehab will give this a try, likely with some of their own ideas thrown in, and let us know how it goes.  Improvements in how doctors handle problems sometimes come from us patients.  Maybe this could be one of those times.

It may not make any difference after a year or more if one’s rehab is slow or aggressive, but I think the first months after my injury have been and will be a lot more pleasant, (and less expensive, with less work time lost, and less hassle for family and friends), than the experience of most people who go through this nasty little detour in life.

14 Responses to “Walking in my shoes within four weeks (updated)”

  1. Wow, I’m amazed at how fast you progressed. You weren’t worried about re-rupture at all? How did you rupture your AT in the first place? I am 7 weeks post-op and still in the boot using one crutch, putting about 75% of my weight in my bad leg. I am working out every day (rowing machine, weights, interval work), but I’d love to start cycling soon. When you cycle, do you clip into the pedals?

  2. Hi sehrlich,

    Sure, there is always a risk of rerupture, but I’m not convinced that delaying flexibility and strength work is any safer than what I did. There is a situation I’m much more familiar with that may offer an excellent analogy.

    Extremely premature babies are at risk for a disease called necrotizing enterocolitis (NEC) that makes rerupture look lame in comparison (poor joke intended). About one out of four babies who get NEC are dead within 24 hours! One of the risk factors for NEC is simply being fed milk (as opposed to intravenous nutrition). Due to fear of this terrible disease, many years ago very premature babies were not fed milk at all for weeks after their birth. Over the years, though, it was figured out that this “careful approach” caused atrophy of the intestines, and the risk of NEC was not reduced by this practice at all, the disease was just delayed until the baby was older. I suspect being so “careful” after Achilles surgery is a very similar situation, the risk not being reduced, only delayed. Having said that, of course there are limits to how hard one can push.

    Reading about my rehab in the space of a few minutes probably makes it seem more aggressive than it really was. The changes were very gradual, and I never felt like I was pushing my luck.

    I popped my tendon playing basketball, suddenly changing direction from moving back to moving forward.

    When I first started biking four weeks postop, I had the arch of my foot on a flat pedal, and wore my splint in case I had an awkward stop. It was eight weeks out when I started clipping into my pedals, without the splint, and riding normally, except I didn’t try getting out of the saddle until last week.

    I think it was Dave Barry who wrote that snowboarding is for people who don’t think regular skiing is lethal enough. Does that sound about right?

    Best wishes,

    Doug

  3. Well, I’ve been snowboarding for 10 years and this is my first injury! And this was a fluke anyway - I just went to turn and it popped. I am now 8 weeks out and plan to start biking tomorrow. I taught a yoga class in my boot on Tuesday and was able to do most of the class, which was exciting. I think I’ll get my strength back pretty quickly - the ROM is the hard part.

  4. Hi sehrlich,

    Isn’t that the freaky thing about these injuries, that they so often happen with an unremarkable movement? It’s easy to understand how an ankle gets sprained when you land on someone’s foot, or a knee ligament gets injured during an ugly twist of the leg. But these ATRs so often seem to happen when we’re doing something very ordinary, something we’ve done thousands of times without problems.

    From the point of view of how I did things, getting nearly all of the ROM back was pretty easy, because I didn’t have a boot holding me back. I hope you’re right about strength recovery being easier for you, but most people who have been through this found regaining calf strength to be the longer process.

    Have fun on your bike! I know how terrific it felt for me to get back on the road again.

    Best wishes,

    Doug

  5. Hi Doug,

    I get my sutures out on Monday, which will be 10 days post-surgery. I’m currently in a cast, but I want to get out of it ASAP. I have almost no pain as long as my leg is elevated and it’s easy for me to flex my toes and calf muscles. What should I push for on Monday and how can I convince my doctor to get rid of the cast?

  6. The main thing, in my view, is to get something removable, either a splint or a boot. If you can take it off, then you can do stretching and strength work on your own terms.

    How to get doctors to change from their usual way of doing things is a delicate matter. Some are flexible and willing, others won’t bend at all. I think all you can do is make it abundantly clear that this is what you want to do, that you’re willing to accept any risks that entails, and see what happens.

    You can, if you are willing to push this hard, simply refuse to have a cast put on. They can’t force it on you. You may have to “fire” your doctor and find a new one who can accept your plans.

    I don’ t know if this would work, but perhaps your care could be taken over by a physical medicine doctor, especially one who specializes in sports medicine. It’s all about rehab now, so you don’t really need a surgeon anymore.

    Good luck,

    Doug

  7. Doug,

    I had my 2nd post-op on Monday and am now 11 days post surgery. They took my staples out and the area around the incision looked really good. There was no redness or discoloration whatsoever…all flesh colored. My only concern was the incision itself. Most of the pictures I’ve seen on the blogs have an incision going no lower that an inch above the top of the heel. My incision went almost all the way down my heel and my doctor didn’t really give me a clear answer as to why…guess that was just the nature of my injury. They only took a “window” out of the cast and then put the window back in and secured with an ACE bandage.

    I took your advice and pushed very hard for the boot. The doctor (ortho-specialist) was noticeably annoyed and kept trying to avoid the conversation. Well, I was pretty determined thanks to this blog site and he eventually agreed to a compromise, which I wasn’t happy about but he is the doctor after all. He agreed to move up my boot date by a week and a half, so I now get it on May 21st. However, I’m not allowed to bear any weight on the boot until June 8th as my foot will still remain completely plantar flexed. He said he wants to very gradually bring my foot back to 90 degrees, which annoyed me but I chose to save that battle for another day. As soon as I get the boot, I’m going to consult a second specialist so they can see the whole leg.

    Another weird thing was he didn’t want to give me the operative report…and still hasn’t. I’m sure he’s probably legally obligated to give me a copy, but it’s not like I’m going to take the trouble to subpoena the thing. Perhaps my second opinion doc can request it for me much easier.

    I thought maybe I was being overly critical and I should just let the doctor do his job, it’s just hard for me because there is overwhelming evidence indicating that I should be able to do partial weight bearing before the 6 week mark. My main concerns now are severe muscle atrophy and complete lack of flexibility.

  8. Hi again,

    What can you say? Doctors have a comfort zone, and going outside that zone is scary for them. It’s frustrating, though, how some doctors are convinced that early mobilization is too dangerous, when many other doctors do exactly that and have better results. In the long run, it probably doesn’t make much difference how aggressive one’s rehab is, but we would all prefer to recover more quickly in the short run, wouldn’t we?

    As long as it has healed well, I wouldn’t worry too much about the length of the scar, unless you think a shoe rubbing on an area of thin skin could be a problem.

    If you really want to see the operative report, you should be able to get it through the medical records department at the hospital. They will probably charge a fee for the copy, though.

    Best wishes,

    Doug

  9. Hi Doug, thank you for posting on your experience. I am now 10 days post - op on a cast. Surgeon proposed 4 weeks but is willing to cut it open or switch to a hinged cam walker earlier. I think I will go for having it open to allow some passive therapy and then going for the booth. For now I was looking at your ‘butt-lift’ exercise but even that you suggest it’s just pressure on the heel, it didn’t feel right to me at this point. Perhaps since this was some time ago you have some new insight and perhaps others could comment as well on early exercises and choices. Thanks again,

  10. Gabe-
    Here’s a post I wrote up on early exercises:

    AchillesBlog.com/ryanb/2011/09/27/73/

  11. Thank you Ryan. These start at 4 weeks or so if I understood correctly. I guess not much before then.

  12. YMMV of course… The first 2 weeks I was limited to upper body weightlifting. As soon as I got to PWB (19 days post surgery) I added walking, up to 2 miles. Kayak, and spin bike were added after 3 weeks. Swimming after 4 weeks. I’ve kept a daily blow-by-blow record of my rehab schedule here.

  13. Hi Gabe,

    I’m glad to hear my old blog is actually being read by someone! If an exercise doesn’t feel right, it’s probably right to not press your luck.

    Regarding working your hip extensor muscles, perhaps the same exercise could be done with something (firm but not too hard) under the knee, so you are pushing on the back of your knee, and not on your heel. Of course, if you could find a fancy weight machine that does the same thing, that would be great.

    There is another way to work the knee extensor muscles (quadriceps), which I wrote about a couple of years ago. Go to this site, and scroll down to near the bottom:

    achillesblog.com/doug53/2009/08/08/six-months-on-calf-at-full-strength

    I hope this helps,

    Doug

  14. Ryan you betcha YMMV… Congrats on your fast recovery! I’ll be very happy going at half your pace…and back to jogging eventually. Soccer, we’ll see…
    I’m looking at early options other than traditional casting to minimize atrophy and return to basic functioning early but safely. Best,

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