ejbvmi’s non-op AchillesBlog

4 AUG 2015 - Rupture + 8 weeks

I had a nice surprise at PT yesterday. My therapist pointed at my cam walker boot and said “I think it is time to get rid of that.”

8 weeks post-injury, non-op, and very pleased to reach this milestone!

I will still use the boot if I need to get somewhere in a hurry, since I walk like a 110 year old man with a bum leg in two shoes… but it feels great to finally do it! (And drive my car again… so nice to be mobile again and I think the car missed me a bit.)

Even though I am thrilled to reach this transition, I am still very tentative with walking without the boot.  When I feel the tension in the AT as I walk, I waver between wondering if I am being a wuss for not allowing a bit more ‘pull’ on it and wondering if I am pulling on it too much.  I have not encountered any pain yet, and it seems to get easier to walk as the day goes on and it gets ‘warmed up’.  I’ll take it slow, and continue to revel in this new level of freedom.

For two weeks leading up to this milestone, I was on a vacation and walking 4-7 miles a day and removing a layer of my heel lift every 2 days or so.  While that was not always great for my heel, the AT was fine throughout and I had started to walk a little in our hotel rooms and stand in the shower.  The combination of lots of walking in the boot and a little indoor walking without it seems to have strengthened my injured leg a fair bit.  One might even accuse the calf of my injured leg of being somewhat “toned” (though it is still a chicken-leg compared to the opposite leg).

Probably worthy of mention: during week 8, I adjusted my boot so that it would allow up to 10 degrees of plantar flexion motion (range: up to 10 down, zero up).  After a couple days, I increased it to 20 degrees.  Has anyone else tried this technique?  I like the feeling of getting some motion in the ankle and calf instead of having it immobilized.  Clearly, I would not do this during the earlier weeks when the fixed angle facilitated healing the AT at the correct length.

Happy healing, everyone!

-Evan

21JUL15 - R+6 weeks, 3 days  (non-surgical, early WB protocol, FWB since the end of week 4)

1.  I hopped to the US and back to Germany this weekend.  I knew this would involve a lot of walking, but was surprised to see 6.5 miles on the watch at the end of one day.  While the AT was not bothered, I discovered that my boot is not really ideal for walking that far.  My heel was ready to call it a day by the time we finally boarded the return flight.

2.  At PT today, I stood bare and flat-footed for the first time since the injury.  It felt like a huge milestone… then we started working on putting tension on the AT and realized that there are many milestones still ahead.  Still, it was a satisfying step in the process.

3.  Also, we pulled out on of my 1cm heel lifts.  After that, it felt as though my heel had been plunged deeply into the depths of the boot.  Amazing what a difference 1 cm can make.  After walking a bit today, I am tempted to put 0.5 cm back in for a day or so.  Has anyone else run into a similar apprehension, or is 1 cm a ‘normal’ jump?

18JUL15 - R+6 weeks  (non-surgical, early WB protocol, FWB since the end of week 4)

I had my 6-week follow up with my OS this week, and he was very pleased with my progress.  The tendon is continuous, and everything looks like it is progressing well.  According to my watch I walked 5 miles that day, and though the foot was a bit swollen from being well below my heart all day and the tendon area was warm, I had no pain or discomfort.

The affected leg is getting much stronger, which is a welcome development considering that it was skin and bone only two weeks after the injury (atrophy happens FAST).  I’m not sure how much of this progress can be attributed to walking, the exercises or bike riding, but the combination seems to be working well.

My protocol calls for removing the heel lift in weeks 6-8.  My 2cm is comprised of two lifts of three layers each, so next week my PT will remove one of the layers, and we’ll see how that goes.  We are going on a vacation that will involve a fair amount of walking week after next, so I am in no rush to reduce the angle during a week when I will be walking a lot.

A friend asked about how to go about FWB, and posted a video of his PWB work with his boot set at 30 degrees plantar flexion.  For what it is worth, here are some initial thoughts that I shared with him, and I welcome any feedback from folks who have done WB in a boot set at an angle other than 0 degrees:

————-

“I watched your PWB video, and it was immediately obvious why you had the question of “how did you go about the transition to FWB?”  Key to the answer: Our boot setups are completely different.

My boot has been at a 90 degree angle (0 degrees on the setting… no plantar or dorsi) the entire time, and my plantar flexion is accomplished by means of 2 cm of heel lifts INSIDE the boot.  Therefore, the geometry of the boot (heel touches first, then rolls toward the toe) is “normal”.

Though my “Bledsoe EZ Set” boot can be set at any angle, the manual clearly says that weight bearing is not allowed at any fixed angle other than zero.  Your boot may not have this same prohibition, but at your current angle it seems like a real challenge to accomplish any WB that goes consistently into your heel where it belongs at this stage of the process.  You don’t want to be repeatedly stepping down on your toe, as that will place unwanted stress on your healing tendon.

I would recommend reading up on the manufacturer’s literature about your boot, to see what it says about weight bearing.  One thing to consider as an option is to set the boot to 0 degrees and accomplish the plantar flexion with heel lifts (not Dr. Scholls… the ones I have <“The Original ADJUSTaLIFT”> are much firmer and were installed by the OS office).  Walking with that setup has been relatively simple.  I walked 3-ish miles Monday and Tuesday, and 5 miles Thursday this week.  Though my pace is not all that fast, it was not uncomfortable and none of my other joints are bothered at all.”

Happy healing everyone!

-Evan

11JUN15 - R+35 days

I opted for to skip typing this time and go the video route.  I hope that this helps answer some of the questions people have had about exercises, etc..

https://youtu.be/pEJp0UoT7SE?list=PLu1nHtWBBf8YfYz6JCH4z_vrVBF592gHI

-Evan

9JUL15 - R+33 days

I am hoping to find out if something I have experienced is a common occurrence for folks who have been sitting and lying around too much.

For the past three days, when I woke each morning and sat up in bed, I experienced sudden dizziness to the point that I needed to plant both hands on the bed while I waited for the problem to pass.  It took a few minutes before I felt that my inner ear was happy again and I would be stable enough to walk.

After three mornings of this, I finally did some research and found "orthostatic hypotension" as the most likely culprit.  Essentially, this is a rapid drop in blood pressure due to blood rushing to lower extremities when rising from a lying or sitting position.  It can be linked to prolonged bed rest.  Though I am not on bed rest, I do spend a lot of time seated and reclined and I am not at a normal activity level.  I checked my blood pressure within minutes of leaving the bedroom this morning, and it was 117/72… completely normal at that point.

Has anyone else run into this?  I have had a "head rush"  while standing too fast a few times over the years, but the attention grabber here was that it happened three days in a row and took minutes to pass.  That was new.

Thanks in advance for any insight.

-Evan

UPDATE: Within less than two weeks, this problem went away entirely as I started to walk and exercise more.  Whether my "self diagnosis" was correct or not, my increase in activity level correlated with the problem going away… a very welcome development.

8JUL15 - R+ 32 days

Dirty Harry was right about that point.

I believe I may have bumped up against the limit of what my non-op AT was ready to handle again yesterday.  I started FWB in the boot late last week.  I “had to” go to a different city and take care of appointments in four different locations yesterday, and tried to mitigate the stress on my AT by taking my folding bike with me so that I cold scoot on it for all the outdoor short runs from car to front doors.

The folding bike was terrifically helpful, but I erred by not realizing that I was jamming too much movement into the day.  Even using the bike as much as I did, according to my tracker I walked over 3.5 miles yesterday… more than I anticipated, and probably too much, too soon.  Better to make gradual increases in activity as the body allows.

Things I have a greater appreciation for, and will make a more concerted effort to manage better in the future:

1.  The potential damage from an unexpected snag on the boot, loss of balance or failure to plan how to securely get into and out of a tight space like a car seat.  This happened to me yesterday while moving between a table and chair.   When I slipped and planted the foot to stop my fall, I put a lot more force into my injured foot than I would have done intentionally.  In a reflex situation like that, it is hard not to put that force into the ball of the foot and stress the AT.  While my AT is still connected, it was warmer than normal this morning… and I had a sharp pain (thankfully just once) at the rupture site for the first time since the injury while I was doing my exercises last night.  It is mid-day now, and after a little icing everything seems to be back to where it was before my excursion yesterday.

2.  Uneven terrain.  I have only been FWB for a few days, but have discovered that planting a rigid boot on uneven asphalt, concrete, etc can introduce torque into the foot and leg in interesting ways.  I am very aware of where my foot is going now, and step on flat patches whenever possible.

3.  Hurrying is the root of all evil.  I want to get where I am going, and I don’t want it to take five times as long as it normally would.  But it does.  Fighting that seems to incur risks that I don’t recognize until a slip happens.  Best to just get over the disappointment, accept that it is going to take a while to get where you are going, and plan for the extra time.

Positive developments:

1.  COMPRESSION SOCK.  I discovered first-hand that trans-oceanic flights with your foot well below your heart for over 12 hours are a recipe for spectacular swelling.  I have another flight across the Atlantic planned in a couple weeks, and picked up compression sock yesterday.  It was a bit of a challenge to put on, but should help keep the swelling from reaching such epic proportions.  The sock is useful on normal days outside the house as well, but especially so on long flights.

2.  My PT gave me a few new exercises:

The “Clamshell” (3 sets of 30, working up to 100 per set): https://www.youtube.com/watch?v=CiqvDV8pzRk

The “side plank”: https://www.youtube.com/watch?v=K2VljzCC16g

Foot inversion/eversion with bands (red and green).  She recommended using a table leg to anchor for the inversion: https://www.youtube.com/watch?v=16ZSqKbxPBY

Prone opposing arm & leg raise: https://www.youtube.com/watch?v=zjDRvW8WIVY

“Toe curls with a towel”.  While seated, put a towel on the floor under foot.  Using the toes of the injured foot, bunch up the towel by curling the toes.  Do this for 3-5 minutes, until the arch muscles fatigue.

———–

** UPDATEs:

1.  I posted all of the videos above and others to a playlist on Youtube:

https://www.youtube.com/playlist?list=PLu1nHtWBBf8YfYz6JCH4z_vrVBF592gHI

2.  Some great perspective from Shelly Prosko about the non-surgical path and the benefits of yoga and the right kinds of activity early during recovery:

http://physioyoga.ca/medical-therapeutic-yoga-for-achilles-tendon-rupture-the-missing-link-in-rehabilitation

and http://physioyoga.ca/media

———–

Happy healing, everyone.

4 July 2015 - R+28 days

With the exception of the foot extensions that I started doing this week (things are connected again… very exciting), my calf muscles have been completely unused for a month.  As a result, they are shadows of their former selves, and were more than a little resistant to waking up again.  The first time I tried to extend my foot downward in plantar flexion, the movement was minimal (despite the fact that I was sending “max effort” signals down there).  The movement seemed to be driven primarily from lower muscles (soleus, I presume), and the gastroc just sat there laughing at me.

What a difference a few days can make!  When I started doing my morning exercises today, I felt some contractions in the gastroc that caused me to do a double-take.  Did that really just happen?  Let’s do that again!  The gastroc is still essentially a bag of jello … but now I am able to generate contractions in it and dabble with some isometric contractions against the counterpart  tibialis anterior muscle.  Over the course of the past 20 minutes I have been able to generate significantly more contraction than those first tentative twitches.

Much like the evolution back to walking, this feels like a big deal because it is something my body has not been able to do for a month.

Another good day, and a significant milestone.

3 July 2015 - R+27 days (non-op path)

After dabbling on and off with PWB over the past week, I called my OS yesterday to ask for a clearer picture of what “weight bearing as tolerated” on weeks 4-6 of my protocol meant. I was just a few days short of my 4 week threshold, and while I certainly did not want to over-do it, the idea of putting crutches aside was enticing.

My OS told me that, so long as I was not experiencing pain and not over-doing it, I could put as much weight on the injured leg as I wanted.  Over the course of the day yesterday, I experimented and built-up in WB with one crutch and eventually found myself walking (more on my current definition of “walking” later) crutch-free.

I keep all weight on the right/injured foot directly on the heel.  I tried copying the Brady Browne “Zombie walk” (see Youtube if you have not already… I found his videos quite helpful) with my injured foot canted outboard to avoid rolling onto the toes… but my knee did not like the lateral pressure so I ceased using that technique.  The up-side of the cant was being able to let the injured foot pass behind me for a stride length that was approaching “normal-ish”… but since my knee didn’t like that on day one I was not going to keep doing it and risk causing other issues.

Instead, I have become a homo-sapien inch-worm.  My right/injured foot goes forward, and then my left comes up to join it.  Repeat as necessary until the destination is reached.  It is a slow way to get around, but within the apartment I have plenty of time.  The up-sides are huge: 1\ I can CARRY things.  2\ It feels like a huge milestone along the long road back to “normal”.

I had another PT session this morning, and took the crutches with me for two reasons: 1\ The hospital is on a hill, and I am only proficient and inch-worming on a level surface at this point in time.  I want to avoid risking any surprises or unnecessary pressure on the AT by negotiating a hill in the boot right now.  2\ I can move much faster with the crutches than I can using my inch worm walk.

My Physical Therapist was pleased with my progress.  She had me do a lot of active movements (full extension in plantar flexion “free” {amazing to again see evidence that the calf IS connected to the heel bone}; up to 0 degrees “free” and against resistance; inversion/eversion “free”, plus a number of upper leg and knee exercises to start building strength), and manipulated the foot a fair amount.  Generally, I the manipulations felt fine, but I’m still apprehensive about dorsiflexion movements that run into the “tension limit”.  She seems to be very understanding about the fact that I have difficulty relaxing for that movement… I suspect I am not the first to feel that way.

Overall, this week was HUGE for me.  First: Actively pointing my foot away from me was hugely gratifying after only a month ago “failing the Thompson Test” and having lost that ability.  Second: I can WALK now.  Sure, it’s a baby step, inch-worm movement, but I don’t care.  I am vertical without crutches, without any pain, and can roam around my apartment while carrying things.  Life just got a whole lot more livable.

I just ordered an “Evenup” shoe balancer to wear over the shoe on my “good” foot, and look forward to taking it for a test drive once it arrives in a couple weeks. (I learned about the “Evenup” from a thread on oscillot’s blog.)

http://www.amazon.com/gp/product/B006IUU2TK?psc=1&redirect=true&ref_=oh_aui_detailpage_o00_s00

When I was initially researching, I found myself reading medical studies for hours before I came across AchillesBlog and the wealth of information that is here.  Important decisions and actions are taken in those first few days.  So, in an effort to share with folks who are looking for answers soon after injury, I uploaded a video to YouTube today at: https://youtu.be/Bw6wktBPuPQ

Thanks to everyone in this community for your posts and feedback.  Your insights and simple sharing of your own experiences help me made informed decisions, and make me feel a lot less alone on this path.  My family is with me, but while they are doing an amazing job of supporting me, their burden is different than the one before those of us healing from this injury.  I am grateful for having you out there as my sounding board.

UPDATE: Case in point regarding this community: Many thanks to Donna for sharing the following instructional video on the proper way to walk in the cam walker boot.  https://youtu.be/4kGY4VBHqq8 I will start working up to rocking forward today!  Thanks also for the tips regarding the use of a compression sock during the walking phase and modern icing systems… I will look into both (since I still have plenty of time on my hands with my foot elevated most of the day… above my heart as often as I can).  Thanks again!!!

2 July 2015 - R+26 days

1.  Background:  a. I am on the non-op, early WB protocol path, and have been in a cam walker boot since day 2.  I was NWB for the first two weeks.  b.  My bias is toward taking it slow and steady, managing risk so that I only have to go through this recovery process once. c. My protocol calls for “Protected weight bearing with crutches” for weeks 2-4, and “Weight bearing as tolerated” in weeks 4-6.  I am on the threshold of the transition.

2.  With the caveat above, I wondering what others’ experiences have been with the weight bearing build-up.  I have been somewhat surprised that increasing weight on the foot (still in the boot) does not seem to cause any pain at all.  Over the past day, I have started using just one crutch, and feel as though I can probably walk around the house without using crutches at all.  My OS says that is OK so long as I still have no pain.

Are there pitfalls to “too much FWB walking” that I should be mindful of at this stage?  I still intend to use crutches on stairs and outside the house for awhile, since I feel more stable with them and can get around much faster than using my “zombie walk” (injured foot canted outboard for an easy lateral roll on the heel).

3.  Unrelated driving questions: a\ When did YOU start driving again?  b\ If different than the answer to a\, when did you reach a state where it was legal for you to drive again, according to the laws where you live?

I injured my right AT, which is not great if you need to drive to get to where you are going.  I have driven using my left foot only on a couple of “exceptional circumstances” occasions, but doubt the Polizei would be amused if they caught me doing so.

I will be in the boot for 1-2 more months, and am wondering when I am likely to be ready (and legal) to get behind the wheel again.  My assumption is that I will have to reach a state where I can safely drive without the boot and be confident about being able to execute a “panic break” level of force with the right foot without causing pain or AT damage.

Thanks in advance for advice & insight. -E

1JUL15, Sunday - R+25 days

Opening caveat: I’m an optimist.  Really I am.

However….

The various posts by folks who experienced re-ruptures are messing with my head.

I went into this process believing that, so long as I remained diligent with the PT and behaved myself, all would be well and I would probably only have to go through this timeline once.  While I still think that way, stories of Ortho Docs and PTs pushing someone beyond their healing AT ’s limits has affected my confidence in my team’s ability to truly know what my AT is ready to do.

As a result, I find myself inclined to slow down regarding increases in ROM or force placed on the AT.  On one hand, this seems like exercising prudent risk reduction, and on the other hand I can’t help but wonder if I am overreacting and perhaps limiting my potential progress.  I’m only 3 1/2 weeks post-injury (non-op) and just really starting my journey, so this is really a question of philosophical approach to the rehab.  I.e. trust the professionals (who won’t REALLY be affected if they get it wrong… I will), or throttle back a bit to mitigate the potential for re-rupture.  My PTs are not pushing, at least not yet.

Thanks in advance for any perspective from the veterans out there.  Come what may, it’ll all work out.  I am as left-brained as they come, and will be grateful for any data that can help me resolve this question and go forward with confidence in my approach.

I had PT again today, and it was the first time I was cleared to increase and decrease the plantar/dorsi angle of my foot “under my own power”.   Even though the angles were small, It felt great to see the toes move forward, since that seemed to indicate an actual connection between my heel bone and calf muscles.  Progress!

I’ve also been given the green light to do some stationary biking with the good leg and the injured leg in the boot.  Looking forward to getting in my first ride tonight!