3 weeks post-op… time to change the cast
Two days ago marked 3 weeks post-op for me so I thought I’d post an update.
Dealing with a cast and crutches
As all of you can probably relate to, immobility is quite a pain in the butt. Hong Kong is especially tricky I think - fast moving escalators, pedestrian footbridges, and it’s a busy city with lots of people and traffic. I’ve had to rely on my other half a fair bit (I definitely haven’t held up my portion of the household chores!). It’s the simple things that I miss - like being able to make a cup of tea and carry it over to the coffee table. I spent the first week off work, then headed back to the office - partly just for some company and to get out of the apartment.
A big disappoint has been cancelling our trip to Sri Lanka over Easter. We were due to fly out tomorrow, but after the first night showering in the comfort of my own apartment, I knew it would be a challenge in a cast and crutches somewhere more intrepid. Probably could’ve managed it, but don’t think I would’ve enjoyed it as much.
How my leg has felt
At the time of the rupture, I had a bit of pain but it wasn’t too bad unless someone actually touched the rupture zone. As long as it was still, it wasn’t enough to warrant painkillers. The emotional pain definitely hurt more, knowing that there’s a long journey ahead and that I may not return to as good a form again.
The past 3 weeks haven’t been too painful either, but it does tend to vary with how swollen my foot is. The swelling isn’t to do with the operation, but more so with it being in a cast and whether there’s a lot of blood flowing down there. I’ve been surprised that I’ve had to keep it elevated most of the time - it doesn’t take too long for it to swell up if I’m sitting with my foot down, or standing.
First post-op visit to the OS
The night before my doctor’s visit, I figured I would do some exercise - I did some sit ups and push ups (on knees). I had been doing nothing since the operation, partly because of laziness (just feel so zapped of energy when you sit on you butt all day), but also because I didn’t want to sweat up inside my cast.
Off to see my surgeon. I’ve spent 3 weeks post-op in a cast now so according to the protocol he follows it’s time to adjust my foot angle and put a new cast on for 3 more weeks. It was a fairly nervous time - I was curious to see how my tendon and wound are healing, but the act of sawing off the cast was also a cause for nervousness (they used an oscillating saw that supposedly doesn’t cut skin easily).
The doctor cleaned the wound, which looked quite good, and then proceeded to push against the base of my foot to stretch the tendon. I could feel that the tendon was really tight, which was such a foreign sensation. I had mixed feelings too. I could feel that the tendon was well connected, which I was quite happy about. But as he pushed, I was super worried that it hadn’t healed enough to take that level of pressure he was exerting. I don’t think he applied a brutal amount of force, but it felt slightly beyond gentle. He applied another cast with my foot in a new angle. Initially my foot was at about 50 deg away from neutral (foot flat on floor while standing), and now 35 deg from neutral. It seems like a long way to go to get to neutral in one go!
I asked him about the next steps and he clarified that I will be in 2 shoes in 3 weeks’ time with the aid of crutches for about a week thereafter. For the past 2 days, my leg has felt slightly more achy than before, but not too bad. This cast has less padding though, so it’s quite a bit more uncomfortable.
Questions for you veterans:
- Has anyone else had their foot stretched like how I described, either at the few-weeks mark, or in PT sessions later on? I assume it’s normal for angle changes from cast to cast, but wouldn’t imagine that it would be done before removing each wedge for the moon boot protocol.
- Is a jump from 35 deg to neutral quite big? It’s 35 deg! Given that I only stretched it 15 deg in the first transition.
- 6-weeks out of a cast and straight into 2-shoes, what level of dependence on 1 or 2 crutches can I expect? Will I be able to walk fairly normal soon after?
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The first few weeks are by far the hardest and at 3 weeks it does feel like you are facing a mountain in terms of recovery. Hang in there it gets so much easier and in a few months you will be in a much different place.
I am a bit confused about the degrees you are describing for your foot angles. Starting with a foot pointed at 30 and moving up to 0 is a typical way of describing it. The actual numbers (0 or 90) are not important but the range of movement is, and that is only 30 degrees. I don’t think it is possible if you have already had the angle of your foot adjusted to still have 35 degrees available. Would the angle changes be more like 15 degrees each?
I’d like to preface this by saying we are all under diff. protocols and it is never my intention to imply mine is better than yours or yours is bad. My intention is always to state what my experience was and the reasons my medical team give me for it or why I chose it myself. I like to focus on the fact that in a year we will all pretty much be in the same place regardless of the way we had our repair or rehab…I YAY for that! Here is to happy healing for everyone. With that said hongkongexpat your protocol is very different than mine and I think that is A OK! Big smile. I think Nico had a similar protocol and he’s done great. So maybe he’ll pop in and help us out here.
Que 1 Has anyone had their foot stretched?: No one ever pushed on my foot until after 6 weeks. OS said not to because of the way tendons heal. My experience was the following; Initial positioning of the ankle in equinus (sit on a table and hang your foot down, this is equinus the natural relaxed position the foot will fall into) cast for 1 week, stitches out, cast in equinus again for two weeks = tot. 3 weeks. After 3 weeks into Boot at 30 degrees plantaflexion, all weight on heel with the help of 3 heel wedges which were removed during weeks 4 - 6 bringing foot from 30 degrees to neutral over those 3 weeks as I bore weight, I was FWB weeks 3 - 6 (neutral is standing on your two feet, sometimes mistaken called 90 degrees because there is a 90 degree angle between the leg and foot) OS reasoning was that the tendon is best stretched slowly between weeks 3 - 6 even better if you are bearing weight at week 3 as research suggests that early weight bearing is helpful to healthy tendon repair.
Que 2 Is my change in degrees of plantarflexion big?: I’m not sure. I can only share what my doc did and why he did it. If you read the AAOS Evidence-Based Clinical Practice Guidelines you will see there are a lot of gray areas, non consensus, therefor Docs have to use their own experience and give weight to the research they believe in giving us protocols. I always ask my OS why he wants things the way he does. Your doc has a reason for his protocols too, just different than mine.
Que 3 part 1 At 6 weeks out of cast into 2 shoes, what level of dependence on crutches can I expect?: I don’t know, those who skipped the boot may be more helpful to you in answering this. I do know that walking is the best rehab there is! My protocol called for weaning off the boot between weeks 6 - 12, that means using two shoes some of the time and the boot some of the time. I was ready for 2 shoes between week 7 and 8. OS instructions were to use two shoes when safe outdoors and when indoors at home or PT. Use boot when not safe in or out of doors, when tendon needs rest, when you will be on your feet for long periods to avoid unnecessary fatigue/stress on tendon, foot in general. OS reason…the rate of rerupture is high and drops off significantly between weeks 12 - 16 due to tendon healing phases.
Que 3 part 2 Will I be able to walk normal soon after?: It is my personal experience and my observation from the many blogs I’ve read as well as my OS and PT’s knowledge that it takes time to walk the same as we did before the injury. So what is different? First of all the calf is atrophied…no one escapes this though the degree of it does vary. Without calf strength the other muscles, tendons in the foot, ankle, leg will compensate and don’t work quite the way the calf would if you had it at full strength…you may limp…limps seem to vary from mild to severe as does the length of time before the limp diminishes. You may fatigue and tire easily as those smaller tendons tend to fatigue easily, you may have swelling, you’re gait may be off due to the inequity of long period of NWB. You may have incision insensitivity due to the surgical repair and incision, wearing certain shoes may or may not be an issue. The degree of stretch in your tendon may be off - for example you won’t have the stretch needed to go down stairs properly at first. There is a wide variety of things that will restrict walking normally right off…but I can assure you from my exprience and that of bloggers that it improves day by day…so focus on one day at a time and marvel at the improvement over say only a week at a time…it will be quite a bit if you see it from that point of view. My walk is almost normal now at 20 weeks, not normal but almost. I still fatigue when walking too long but each week I am able to walk longer and I swell but not much at all and not as often, I have no limp, I can’t walk as fast as I used to but I am certain that I will, my stretch is great and if my knees weren’t so bad walking downstairs would be no problem…and that’s me. Hopefully others will share their experience. From my observations of the reports of others and the professionals it seems that “forgetting about the injury and walking as we did pre injury or normal occurs between 6 - 12 months. Maybe a little earlier for some and a little later for others. I don’t know if anyone never walks normally again…I can’t imagine that unless there was some extreme complication. I could be wrong and as always welcome being corrected if I’m mistaken on anything.
Hope that helps…as always take what is helpful and leave the rest! Best wishes to you!
Thanks for the replies. Any replies from others would be appreciated!
Sorry, I think I confused everyone with the angles. I initially wrote the post with “90 deg” being foot flat while standing but then relabeled it to be “neutral” after reading some more blogs. However, I forgot to change all of my text so it became inconsistent and confusing. I’ve amended it so hope it makes sense now.
Donna, if I read your comment correctly, you moved from 30 deg to 0 deg in the space of 3 weeks. I think this gradual change makes complete sense. But I’m stuck in a cast for 3 weeks at 35 deg, and will make a sudden transition to 0 deg, which seems more agressive. In saying that, I’ll be on crutches so might be able to stretch is now and then rather than forcing it to 0 deg full time.
Yes, you understood me correctly. I don’t think of what you are doing as sudden transition from 35 to flat footed because once out of the cast at 6 weeks you don’t have to just start walking…you can spend time on ROM and partial weight bearing and ease into it…I’ve noted that others in your situation are ready to just go to neutral, put shoes on and start early walking…I think you’ll just have to wait and see where your body is at that point…but really I think it’s going to be fine. Will you be doing PT and if so will when will you start? ROM asap as you are out of the cast is going to feel great…you have so much to look forward to, really. Big smile.
Donna, I will do PT sessions but at this stage I’m not sure if it would be straight out of the cast, or days/weeks after. I will start looking for a good nearby PT soon.
You may want to plan ahead as far as shoes goes. Your foot may be swollen or end up swollen during the day and shoes that have fitted you before your ATR may not work for the first month. If you can find trainers with a lift at the heel it would be great, that way you are not totally at neutral. You may need to check and see if they have minimal structure around the top of the heel. Soft heel cups are another option that many find comfortable, sometimes the heel itself can be tender.
At 6 weeks you need to be very careful. Once you are out of a cast or boot the protection for your tendon is lost and the risk of re-rupturing needs to be taken seriously. Not trying to scare you, but you are in a busy environment. Where you are walking outside also plays a big part in how easy it will be for you to manage. Flat well paved ground is at the easy end of the scale, steeps hill or soft uneven ground are very tough.
Stretching? I think a good PT will know how much and when. Donna has recently posted some great advice on how to choose a PT.
All the best
Thanks Herewegoagain.
Donna, what’s the link to your blog? Maybe I’m doing this wrong but I can’t seem to find it by entering “/donna”.