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For informational purposes only.  Here is my MRI report on my ATR.

HISTORY: Evaluate for Achilles Injury

TECHNICAL FACTORS: Sagittal, coronal and axial imaging was performed using T1-weighted, T2 weighted, and fat-suppressed imaging techniques.

FINDINGS: A high grade tear of the Achilles tendon is identified approximately 8 cm proximal to the calcaneal insertion.  Only a markedly attenuated remnant of the Achilles tendon appears to remain in continuity.  Retraction of the proximal mytendinous fragment is identified and the proximal and distal fragments are separated by a fluid-filled gap measuring approximately 3 cm in length.  Marked thickening and abnormal signal intensity involve the distal tendon fragment consistent with intratendinous edema and hemorrhage.  Marked adjacent soft tissue edema is observed.

The tibialis posterior and flexor tendons appear intact but mild increased fluid surrounding the tibialis posterior tendon is observed.  No tarsal tunnel mass is identified.  The tibialis anterior and extensor tendons appear normal.  The peroneus longus and brevis tendons appear intact.

No acute osseous injury is identified.  Edema involving the distal soleus muscle is observed compatible with strain.

The anterior and posterior inferior tibiofibular ligaments appear intact.  The anterior and posterior talofibular ligaments appear intact.  the calcaneofibular ligament and deltoid ligament appear normal.  There is no evidence of transchondral injury involving the dome of the talus.  The ligaments of the sinus tarsi appear normal.

CONCLUSION: left ankle
High grade tear of the Achilles tendon approximately 8 cm proximal to the calcaneal insertion.  The retracted proximal tendon fragment and the thickened distal tendon fragment are separated by a fluid-filled gap measuring approximately 3 cm in length.  Only a markedly attenuated remnant of the medial aspect of the Achilles tendon appears to remain in continuity.

END REPORT

Pics of MRI - sorry I am unable to rotate the pictures so they are upright.

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If anyone was curious as to what exactly is done during an ATR repair I’ve transcribed the procedure notes for anyone to take a look at.  It is not to be implied that if you decide to have operative ATR repair that this will be exactly what happens but it’s just a general overview of what to expect.

PROCEDURE DATE: 06/06/2016

SURGEON: XXXXXXXXX

ASSISTANT: XXXXXXXXX

PREPROCEDURAL DIAGNOSIS: Achilles tendon rupture, Left

POSTPROCEDURE DIAGNOSIS: Achilles tendon rupture, Left

PROCEDURE PERFORMED: Achilles tendon repair, Left

ANESTHESIA: General

ESTIMATED BLOOD LOSS: Less than 25 ml

TOURNIQUET TIME: 40 minutes

BRIEF CLINICAL HISTORY:
Patient suffering a Left Achilles tendon rupture.  Patient was seen and noted to have a gap and the tendon edges were not able to be approximated.  We had discussed nonoperative functional bracing versus operative management and given the risks and benefits of both, patient wished to proceed with operative management.

DESCRIPTION OF PROCEDURE:
Patient was seen in preop holding area.   Proper site of surgery was marked.  Patient was taken to the operating room, positioned supine.  General anesthesia was administered.  A nonsterile carefully padded tourniquet was placed onto the Left upper thigh and the patient was then placed in the Left lateral decubitus position with all pressure points padded including an axillary roll.  The leg was prepped and draped in usual sterile fashion.  Leg was exsanguinated and the tourniquet inflated to 290 mmHg.  A medial approach to the Achilles tendon was performed.  Paratenon was opened.  The tendon was completely ruptured.  Both edges were cleaned up so the frayed edges were minimized and number 2 Tycron was used in a modified Krackow stitch.  A 4 core suture repair was performed.  The same procedure was done on the distal segment.  Once the 2 segments were prepared, the foot was plantar flexed to a neutral position, and the sutures were tied completely.  A running 3-0 Monocryl was used for an epitendinous stitch.  The paratenon was then repaired using a 3-0 Monocryl, the skin with an interrupted 3-0 nylon.  20 cc of 0.25 percent plain Marcaine were infiltrated in wound edges.  Sterile dressings were applied.  A splint in equinus was applied and the patient was brought to the PACU in stable condition.  I was present for all portions.

XXXXXXXX, CNP was utilized given the complexity of the case, need for skilled mobilization and retraction.

End report.

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Pre-Op

My Pre-Op was scheduled for 2 days after I found out my results.  It was pretty uneventful and mostly just the surgeon explaining the procedure and what to expect afterwards.  I came loaded with questions since it’s been 2 full weeks since my injury and all I’ve done is read about ATR everything!  The doc was very patient with me and my list…literally a list that I wrote and brought with me.  It was nice to have all my questions answered and I was able to leave with a good feeling about the upcoming procedure.  In fact, I was very excited that my recovery now had a direction and I was on my road to getting back to life as I once knew it.  One thing of note that my surgeon told me before I left.  She said that I would be asked on the day of my surgery if I wanted a nerve block.  She told me to tell them no.  She said it is one of the least painful procedures they do and it’s not necessary.  She stated that it was a short procedure, that I’d be intubated with an LMA and, to my pleasure, would not be needing a urinary catheter.  My surgery was scheduled for the following Monday (pre-op was Fri).

Surgery Day

This day could not have come soon enough!  I was almost giddy to have this surgery done and couldn’t sleep the night before because I was excited.   That morning, I helped my wife and kids get ready for work and daycare and waited for my mom to come and get me.  My surgery was scheduled for 12 noon and was instructed to arrive at 1030.  My mom gave me a ride to the hospital and waited with me until it was time to start the operation.  I had a knee walker delivered to the hospital for me to use once I was done.  The surgeon came in again and marked the correct leg that was to be operated on and the anesthetist came an let me know what to expect.  A nurse started an IV and after a little waiting it was time to go.  I walked into the OR under my own power and jumped up onto the bed.  The room was very cold.  There were people milling about and I wasn’t worried or concerned.  The CNA placed an O2 mask on my face and was talking to me until…I….uhh…..

Ok, time to wake up….wait..what…done?  Huh…that seemed quick.  Yep, done.  Upon waking up, I felt groggy but not bad.  It took me awhile to become fully coherent.  My wife had arrived to take me home and she told me that the Dr had called her and said everything went well.  She said that she stitched my AT little tight so that I had the best chance for regaining as much strength as possible and to lessen the chance of healing long once things got stretched out.  I hung out for a little while and then they said I was good to go.  I didn’t feel any pain but that was normal due to the anesthetic and I no longer had a lower leg.  It had been replaced with a big splint (no cast) that I was told couldn’t get wet and that I had to keep on until my first post op.  Boo…  Oh well, time to go home.
My splint

Discharged

Discharge was easy and I was able to use my knee walker immediately.  My wife drove me to the pharmacy and we picked up my meds.  I was given Norco.  Prior to my surgery, I picked up some potassium to combat cramping, vitamins because I’d probably not be eating much and stool softener because opioid induced constipation is a very real thing! haha.

The rest of the day wasn’t bad.  I laid on the couch with my foot elevated and relaxed as best I could.  My mom brought my son over to say hey but took him to her house for the night.  I needed some piece and quiet and my boy has more energy than 10 puppies.  haha.  Everything was simple and up to this point I’ve had no pain. I really wish that I had more to report after the procedure but it really was uneventful.  We’ll see how tomorrow goes….

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So it took about a week but I finally got the official MRI report back from the radiologist. He states I have a high grade tear approx 8 cm proximal to the insertion of the calcaneus and approx 3 cm gap in AT. He also stated that all other tendons, bones and muscles are unaffected.

So, that’s it. It’s broke and it’s broke good! It’s decision time. Well, in the last week, I’ve had a lot of time to think about how I want to proceed pending the results of the MRI. I originally was leaning towards the Non-Op route but have since fully, 100% changed my mind! A few factors were present in my decision making process and since I’m a very logical thinker by nature I spent a long time rationalizing it.

This is my take (although I’m a paramedic I am no doctor and nothing I say should be used as anyone else’s decision making process, this is just for your information on how I came to my decision):

1. I know the AT is a tendon and not a bone and any healing done is inherently not as strong as the original and therefore will be weaker than it’s counterpart after healing.

2. The injury was described as two mop heads needing to be mended together as my tendon frayed instead of snapped. That said, I didn’t like the thought of trying to get the ends of the tendon close and just hoping that it would heal properly.

3. I fully believe that a repair that is secured with sutures is far superior than simple scar tissueholding the tendon together. To me, it was like having concrete with rebar vs concrete without rebar. The concrete with rebar will hold up much better than without. Also, add in the fact that the surgeon will visualize the tendon, debrade the tendon and then affix each side together securely. There’s no doubt that the tendon is put back together and not just left to chance.

4. And finally, the biggest factor is my profession. As a firefighter and paramedic I rely on the strength of my whole body, especially my legs, in order to fulfill my duties and provide the best service I can for the citizens that I serve. That said, it would not be fair of me to not seek the best treatment for myself and then place someone else’s well being in my hands. To me, a repair that is as strong and as sound as possible was the only direction that I could go and feel good about it.

So that was it, the decision was made and after thinking it through, it was a very easy one.  FOR ME.  This decision may not be for everyone but that’s your own decision to make.  The only thing I’d stress to anyone facing ANY medical treatments….don’t let people tell you what to do.  Find out as much as you can about your condition and available treatments.  Listen to wise people and hear them out and consider all options.  If you ever don’t feel right about something, seek out a second opinion or even a third if need be.  It’s your body and you have the responsibility to be your own advocate for your care.  Once it’s done, you can’t complain about your treatment if you just sat idly by and did nothing or said nothing.

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So my appointment day finally arrives and I meet with the PA of the Orthopedist.  He does the run of the mill tests for ATR and concludes what I already mostly knew.  I have an ATR.  No shocker there. He was pretty great though, he took as much time as I needed to explain the injury, the surgery, the kind of recovery time and answered all my extensive questioning.   After he evaluated me he went and got the Orthopedist who is a good friend of my wife’s family.  We made small talk and he checked me out again.  He said it’s an ATR also but is unsure of the extent of the injury. We agreed that I should get an MRI even though I knew they tend to be quite extensive.  As far as I was concerned, I wanted to know the FULL EXTENT of my injury, not just someones best guess.

As far as the treatment was concerned, he told me that I had 2 options.  I could try to go non-op or I could have surgery.  If I got surgery then he said he’d be referring me to their foot and ankle specialist, which I was fine with and grateful to him for knowing his own limitations and wanting to get me to the best person possible for treatment.  At this point, I was leaning toward non-op.  I did not want the financial burden of having to pay my insurance deductible etc etc.  I was totally thinking with my wallet at the time.  At the end of the evaluation, he told me there’s nothing more we can do until we see the results of the MRI and make the decision on which treatment I would choose.  The Dr put me in a boot with about a 2 inch heel lift to wear for the time being and to protect my AT until we know more.  From there I went to the scheduling person to schedule an MRI.

I had to wait until the next day to get in to the MRI.  I’d have to say that I wasn’t quite prepared for the MRI as I believed I’d be.  They ask if you’re claustrophobic and if loud noises scare you, to which I replied no.  As a firefighter being in tight spaces and around loud noises are a common occurrence.  Not that I”m saying that I enjoy those things, but I can handle them decently enough.  Anyway, the MRI wasn’t what I’d expect.  First of it was freezing cold!  Which I understand but didn’t expect.  They gave me a gown to wear and headphones tuned to the music station of my choice.  I laid on the table and the tech arranged my feet in the configuration that he needed me to be in for the imaging.  He lashed my feet together to make them stand upright which I think was the worst part.  It was very uncomfortable to have my feet like that for so long.  The tech asked if I was okay and then told me that it’d be about a half hour.  I don’t know if I wasn’t paying attention or thought he was kidding but I didn’t think that it’d really be 30 mins!  He left the room and the machine clunked and bonked it’s way to life.  Um….I’m sure that MRI machines are very expensive and I know they’re technologically super advanced but this thing sounded like a large commercial dryer with cinder blocks inside.  It was loud!  So I settled in and just waited.  I tried to sleep but I was uncomfortable so I couldn’t.  I made the mistake of opening my eyes and catching a glimpse of the timer so then I stared at the timer count down to zero…then reset to another time…then countdown to zero…then reset again to a longer time….then countdown to zero…over and over for about 30-35 mins.  Let me tell you….counting down every second for 30 mins is agonizing….especially since I was very uncomfortable.  I was very happy when it was over.   The tech let me out and let me change back into my clothes and helped me out.  The images were available right away but I had to wait at least 24-48 hrs for them to be read by a radiologist.  At least that’s what he told me.  As it turns out, I got to wait a full week for mine to be read.

In the mean time, I had access to the images and got to see my injury for the first time.  I could see the abnormality and pooled blood.  I could see that it was ruptured but I couldn’t tell if it was fully ruptured.  It kind of looked like there was a teeny tiny bit of tendon still trying to hang on.

Here’s a few pics from my MRI…this is my actual injury, not just one off the interwebs…

ATR

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So Saturday morning came and I felt zero pain in my AT.  As I lay in bed, I think that maybe I’m okay and that I got excited about nothing.  I step out of bed and attempt to take a step and NOPE….nothing.  No movement, no strength, no ability to do a toe raise…nothing.  Okay, the previous night I did not sleep well.  I tossed and turned and thought of being hurt and out of work, possible surgery, long recovery time etc etc.  Along with that was the scouring of the internet to find all things ATR, which brought me to this site.   In my research I found something called “tennis leg”,  the injury that involves snapping your plantaris tendon which usually has a quick recovery.  I hoped beyond all hope that I’d be fine in a few days to a week and this scare would be nothing more than that….a scare!  I texted my brother in law about the tennis leg possibility which he didn’t agree with based upon where my initial pain was.  So I made and “appt” with him for anytime this morning.  His words were, “just park by the black car and meet me out back.”  Um…okay.

So I did as I was told, parked by the black car next to the back door and told him I was there.  A few minutes later he emerged from the clinic and performed the exam…in the back lot.  He said, this way you won’t get a bill.  Works for me…

He felt around and poked and prodded and squeezed and all the while, I still had very little pain.  Yes when you push on it it hurts but nothing just standing there.  He determined that he THOUGHT it was a partial tear but that he could not totally be sure.  He said he had a buddy who is an Orthopedic surgeon here in town who would be able to better evaluate me.  He did some magic and got him to see me quickly.  It was quickly but quick as in a few days…not hours.  So I got an appt for Wed, 5 days post injury.

I was supposed to work the next day but was fully incapable of performing my duties.  I am a career firefighter/paramedic, being on my feet is my livelihood.  I had to call in sick.  I HATE CALLING IN SICK!  I’ve only done it a couple times in 5 yrs.  But it wasn’t all that bad, took that shift off….then had 3 vacation shifts ahead of me which would buy me another 11 days.  Not terrible…i guess my timing was perfect.  So much for getting my boat out over the Memorial Day weekend.

The next few days were okay, all things considered.  I could walk by putting my foot out to the side and basically using my leg as a peg leg…like a pirate, no wood, hook or parrot.  My ankle swelled a bit but not terrible.  Nothing really out of the ordinary aside from not being able to walk normally.  Still I had no pain.  I guess, it could be worse.

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So apparently I won the lottery!  Just not the lottery I’ve ever dreamed of winning.  On May 20, 2016 I joined achilles tendon rupture club!  Oh lucky me!  Quick aside, I have had issues with my right achilles in the past.  I injured it doing our bi-annual obstacle course for the SWAT team that I am a part of and it’s been sore off and on ever since.  It never really did anything other than be very sore which I attributed to being a strain.  I never took any time off or even said anything about getting hurt running the course, I just figured that it would eventually get better.  It took a LONG time to finally get to the point where I could run without pain and I’ve had aches and pains ever since.

That brings me back to May 20.  I was participating in a softball game and I was bound and determined NOT to get hurt.  I haven’t played softball regularly in a number of years, and it was a pick-up tournament which I had no intention of taking seriously.  Prior to the game, I made it a point to run and stretch and stretch and run and adequately warm up as to not get hurt.  The game started and went normally for about 45 mins.  I played the outfield and ran here and there and felt pretty good.  I had an at bat and got a hit, next batter up got me to second and the following batter batted me home.  Sounds fantastic!  Therein lies the issue…I wish I would have struck out, or gotten thrown out at first, or second, or third…  I started my run from second base and rounded third mindful that I was not going to be “going all out” because this game means absolutely nothing.  When I was about 10 feet from home I felt myself get hit with the thrown ball which didn’t hurt but since it was the ball I slowed down because there’d be no play at home.  I crossed home plate and then heard it…THE BALL HIT THE CATCHER’S GLOVE!  Um…what?  Didn’t the ball hit me?  How did it already get to the catcher?  Why does my foot feel funny?

**dang, i think i pulled a muscle**

I made my way towards home and came to the realization that something was terribly wrong.  Something that I’d never experienced before and something that felt really strange.  I had some soreness, not pain, in my lower calf and the arch of my foot felt numb.  Every step I took felt as if i was stepping on the edge of a hole with the ball of my foot falling in the hole with my heel landing on the edge of said hole.  A very strange feeling indeed.  My teammates asked me if I was okay because they could see I was walking very weird.  I instantly told them no and that something is very very wrong.  At this point I still didn’t have any pain just soreness.  I sat in the dugout and could feel that my achilles was very soft, almost non existent.  I compared it to the other side and it felt very different.  I immediately sent a text to my wife and let her know that I think that I’d hurt my achilles and possibly ruptured it.   The rest of that game and the next game I sat in the dugout having no clue as to the journey that I’d just set myself upon.  No clue whatsoever.  I could stand, I could walk…sort of, maybe its just a partial tear.  I got myself a bag of ice and watched the remainder of both games alone in the dugout.  I went through almost every phase of grief at that time. Now the worst part…my injury was to my LEFT achilles!  I’d spent all my time focusing on warming up my RIGHT achilles and only passively warming up my left.  *sigh*   The games ended and I went home.

In the meantime, while I was still at the game, my wife began the first part of my treatment…contacting a medical professional.  My brother in law is a PA and told me that he would be at the clinic in the morning and that I should come by and be evaluated.

By the end of the night, I made it home and climbed into bed.  I truly thought that maybe…JUST MAYBE that i’d wake up in the morning and all would be well.  Or that I’d be sore but able to walk with things moving towards normal.  Up to this point, I’d just had soreness…still no real pain.  My brain wanted to minimize the problem with the lack of pain equaling lack of true injury.

Come Saturday morning, I come to realize that I’m wrong…

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