6 wks, out of cast and into 2 shoes PWB, started PT!
Tuesday 14 April 2015 marked 6 weeks post-op and it was a great day. There wasn’t a cloud in the sky, it was warm, the humidity low, AND I CAME OUT OF MY CAST!
To recap, here is my timeline:
- Complete ATR on right leg on 1 Mar 2015
- Operation 3 Mar 2015 and into cast (foot angled about 50 deg away from neutral)
- 3 weeks post-op, changed to 2nd cast (foot about 35 deg from neutral)
The last 3 weeks
When I got into my 2nd cast at the 3-week mark, my leg started itching big time, making it tough to sleep. The new cast had less padding too so it was less comfortable. During the last 3 weeks, I’ve kept my leg elevated as much as I could as it would swell up inside my cast otherwise.
6 week mark - day of cast removal
After my cast came off it took most of the day for my foot to start waking up. ROM was very limited, and I didn’t know how to move around. Over the past 6 weeks on crutches, I managed to get around almost at normal walking pace by hopping. But trying to walk in 2 shoes (and 2 crutches) was very awkward as my tendon and ankle was really tight. I would go at a snail’s pace, and didn’t know whether to extend my right leg so that the foot was flat (this would result in knee hyperextension), or keep my knee bent and do a little hop over my right leg. When I put my foot down, my ankle joint and other parts of my foot would experience pain.
My protocol, which seems to be atypical, involved 6 weeks NWB in a cast then straight into 2 shoes. So the transition into 2 shoes is a big jump rather than a small step. I felt extremely fragile and vulnerable no longer having solid protection around my foot, and not having experienced any form of WB or foot movement since the ATR. I don’t have the option to put a boot or cast on as I navigate the crowded streets here in HK so I have to be extra cautious.
A great thing about taking the cast off was finally being able to clean my leg - what a great feeling! I noticed that my leg was also quite dark, this was partly due to my skin being irritated but also because of the build-up of blood and fluid. Surprising my right calf was not noticeably smaller than my left. I had measured my calves on the day of surgery as well as on the morning I had my cast removed; it turned out that I lost 3cm in girth on my right, but surprisingly I had also lost about 2cm on my left - I put this down to being very inactive period, so both legs wasted.
1st day post-cast – start of PT
I booked my1st PT session for the day after the cast came off. At first I was hesitant, thinking I should give it a couple of days – as recommended by my OS. But I was keen to get into rehab ASAP as I was due to travel by air about a week later so I wanted to be able to progress quickly. I also figured that the 1st session would mainly focus on ROM and waking up un-used muscles. After finishing the 1st session, I was glad I decided to start PT that soon.
My plantarflexion ROM was about 10 deg away from as far as my good foot would go, and could get my dorsiflexion position to about 20-21 degrees from neutral.
PT told me to do the following exercises as much as I can tolerate throughout the day:
- Dorsiflexion and plantarflexion
- Inversion and eversion
- Big circles and spelling alphabet with big toe
- Dorsiflexion stretch with weak elastic band (I said that I’ve been sitting on a chair with foot flat on floor and gradually pulling it back to give the tendon a stretch. She said this was fine too)
- Sit in chair with both feet on floor, lean forward and sway side to side transferring weight between feet
- Foot flat on floor, flex toes up, then push toes down to grip the floor
- Move a ball around using the sole of foot and press down on the ball as it feels comfortable
- Quad and ham-string: Leg raises, leg extensions, and exercise where leg is out straight on a bed or couch and you push down with your knee
PT said fluid/blood doesn’t circulate very well below the knee if your muscles, particular the calf, aren’t contracting, hence the reason for the swelling. So the exercises not only help ROM and strength, it helps move fluid. Massaging the foot in a movement up the leg can help also. Once the wound heals up, you can also start massaging across tendon gently to break up scar tissue.
Walking… after showing my PT my awkward walking, she said that if I can’t lead with the heel and rock over to the ball of my foot, it’s better to do toe-touches with a bent knee so as to not hyperextend the knee. It certainly was a toe TOUCH, as I was barely putting any weight on it. At this point, I think a lot of it is psychological, but I also don’t know how strong my Achilles really is.
2nd day post-cast
Better ROM. I tried to lead with my heel and follow through with a normal rock over to the ball of my foot, and I was able too. This felt like a huge milestone, and I was very happy about this. I started with barely any weight applied to the foot, but got to maybe 5-10% weight by the end of the day.
5th day post-cast
Over the past few days, I’ve had slightly more flexibility and greater ROM. Now maybe 10-15% weight whilst walking. I’ve noticed that with the added activity, my foot swells up like crazy now.
Questions:
- My PT said to do as much of the above prescribed exercises throughout the day as I can tolerate. What have your PTs told you - a couple times a day, multiple times a day with breaks in between, or as much as you can?
- When does the swelling go away? Does it continue for weeks/months, as the foot takes on more challenging activities?
- Roughly when can I drop down to 1 crutch, then no crutches? From some stories I’ve read, maybe I can drop down to 1 crutch after 1-1.5 weeks, then none after 2-2.5 weeks. What have you found?
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I did my early sitting ROM three times a day, I seemed to tolerate that fine.
Regarding swelling, copy from a recent response to brombones:
Swelling…ah the joys of swelling…NOT. For me personally I swelled pretty regularly from week 7/8 when I got into two shoes and was doing standing up PT…until about week 16, however it was never too severe and I RICE’d once a day and sometimes twice, always after the most active part of the day…at week 23 it’s very mild and irregular now, I haven’t iced for a week now. From reading the blogs I’d say, as with many things with this injury, the extent of anything is really individual, but most seem to report the end of swelling between 4 - 6 months or 16 - 24 weeks.
I went into two shoes between week 7 and 8 after being FWB in the boot for 4 weeks - so a very different protocol. Since you have been bearing no weight I’d advise dropping down to one or no crutch or FWB without assistance when you are ready. Trust me you’ll know because either you can do it without great discomfort or you can’t. When you can walk without aid you’ll be able to…I’d try a little at a time each day to see where I am.
Best of luck to you.
That didn’t seem very clear when I re-read it. What I am saying is that instead of having a time based plan of when to be FWB in two shoes, I’m suggesting you go to a readiness based plan without regard to time. How does that sound?
Hi, I am new to this forum but finding everyone’s blogs insightful and encouraging. I am at week 6 post injury (no surgery) and my protocol has been nwb the whole way so far in 4 different casts. I am excited to be in two shoes in two weeks time but apprehensive, so will be really interested in keeping up with your progress and compare the different pt routines.
Pearl
Donna, thanks as always for you comments. Yup, I understand you about the readiness-based plan, and I’ve just been listening to my body as I go. At this stage, I know I don’t feel ready to ween off 2 crutches yet. It’s just helpful to have a rough guide to where I should be at though.
Pearl, I know that excitement/apprehensive feeling you’re having. For now, try to find some enjoyment in the fact that there’s nothing you can do at this stage except wait for your cast to come off. Aside from you, the only person I’ve come across who has gone from NWB cast straight into 2 shoes is Nico76. He also had 8 weeks in a cast (3 casts), but had an op. So take a look at his story too.