Week 11, plenty of updates
Sorry, it’s been a couple of weeks since my last update - been busy at work and been spending less time on my backside, which is a good sign of recovery. Much has happened of late…
Week 8 - Everyday I’m shuffling
At the 7 week and 5 days post-op point (1 week and 5 days out of cast and into 2 shoes), I started moving about indoors without crutches, a pretty big milestone! But I was far from having a normal walking gait. I was shuffling along, moving my injured (right) foot forward then bringing my good foot just slightly in front of my injured foot. But this has opened up a whole new world - I was able to make a hot drink and carry it over to the coffee table, and I was able to move items about in the apartment without carrying them in my satchel!
Week 9 - Monster week for change
Getting to neutral: A day or two into the 9th week I was able to get my foot to neutral, which was also another big milestone. It enabled me to stand with an even weight distribution over both feet and not have my right foot slightly in front. It is also another step towards a normal walking gait. By the end of the week, I was able to get about 8 deg beyond neutral.
Post-cast OS visit: Saw the doctor at the 8 week and 2 day mark and he thought I was progressing ok, but probably a bit behind average since I was barely at neutral, and still on 2 crutches. He encouraged me to be much more aggressive in my stretching, which is surprising since most protocols I’ve come across have said gentle stretching at this point. I asked if there was any risk of re-rupturing with this aggressive stretching and he said that it is minimum at this point. I told him I would feel a "tearing" sort of pain and he said that it’s normal - any stretching of the tendon actually results in slight tearing in order for it to lengthen. He said that he could prescribe painkillers if it’s the pain that’s holding me back from stretching more. The key point he gave about stretching was that it needs to be sustained for about 20 sec or so for it to be effective. I asked him about scarring and the size of the mass in my heel, and he said that it’ll take a couple of years for it to return back to normal.
Change of PT: I was happy with my previous PT but I would’ve only been able to go a max of 6 times due to an insurance benefit limit. I realised that my insurance would provide more PT sessions if I changed to another PT practice, so I made the change. I was very unimpressed with my new PT - not only was his personality obnoxious, he was quite hands off, with the session consisting of 5 min ultrasound, 20-30 min of TENS, and 15-20 min of waiting around for him. I’d say only a total of 5-10 min of time covering Q&A and hands on treatment (the previous PT involved a solid 45 min of hands-on 1-on-1 and no ultrasound nor TENS). The one positive from this first visit was that showed me how to get in behind the Achilles and massage away some of the swelling and scarring. I figured I would be patient and give him a chance.
Weaning off crutches: Did anyone else feel that this was an anticlimax? I mean, not only was there no fan fare and people high-fiving me with every step I make (jokes), it wasn’t exactly a clear transition point where you go BOOM, I’m now walking without crutches! It really is weaning. During week 9, at home I would be crutches-free other than when I would get up in the middle of the night, when I would use 2. In the office I would use 1, dropping down to none by the end of the week. Outdoors 2, dropping down to 1 by the end of the week.
Going solo on public transit: HK is quite a crowded city, there are lots of pedestrian obstacles to get to the train/tram/bus, and sudden stops wouldn’t be so great for the Achilles if I couldn’t access a seat. I’ve been riding public transport for a couple of weeks with my wife present, but mid-way through this week I finally built up the confidence to do it alone. Woohoo!
Week 10 - Look no hands!
At 9 weeks and 4 days post-op (3 weeks and 4 days out of cast), I finally felt comfortable enough to ditch the crutches outdoors - woohoo!
PT still disappointing: One of the sessions this week, I went for a whole hour without seeing the PT (other than him sticking his head in for 10 sec to see how I was). This hour was again filled with ultrasound and TENS (administered by an assistant who is more or less a receptionist!) and waiting for the PT to show up. The ultrasound head actually hurt my scar a bit, and it’s left a bit of a rash, which I’m not thrilled about either. The one thing I was happy about was that he got me on a stationary bike (medium resistance for 15 min and 40rpm) and got me doing leg extensions to work on my quads. I really had to push him to get advice on next steps and exercises I can work on between PT visits. He would let out a sigh and say, "Rome wasn’t built in a day", which I found super frustrating. I’m not looking to go do a marathon, but simply take the next step and work on rehab in between visits.
Back to the gym: Now that I’m more mobile without crutches and had some exercises could work on, I realised I could get back to the gym. I’d ride a stationary bike for 15 min and get a sweat on, do leg extensions, and work on areas other than my legs also.
Week 11 - Walking better, and walking away from my PT
My flexibility has been coming along - I can now bend my ankle so that the front of my knee is just in front of my toes. My walking has been coming along too, with the limp almost non-existent at times. I can now descend stairs with either foot without holding the hand rail. Although when stepping down with the good foot first, it’s not as slow and controlled and for larger stairs I end up landing the good foot out a bit to the side. I’m finding that my heel would be quite stiff at the start of the day, and both stiff and very sore by the end of the day.
Today I said bye bye to my 2nd PT clinic. Over the past few days, I put a lot of thought into whether this clinic is working for me. I felt that I’ve been wasting my time with this guy and couldn’t take it anymore. I consulted 5 PT friends who work across Australia, NZ, Canada, and the UK to get their perspectives about the treatment I was receiving, particularly around the reliance on Ultrasound and TENS. Here’s the low-down:
Ultrasound: 3 said that ultrasound can be helpful in healing and reducing swelling but only in the first couple of visits post-injury. 2 said that there is no evidence-based research that proves ultrasound is beneficial in rehabilitation, with one of these 2 saying you’ll be hard pressed to find an ultrasound machine these days in a reputable clinic in the country he works in.
TENS: All 5 believe that TENS is helpful for pain relief, with 1 emphasizing that it doesn’t always work well. However, I’m finding the pain manageable, and I don’t think this pain is completely avoidable anyway.
All 5 said that they would expect to see more hands-on rehabilitation, with a focus on strengthening and proprioception.
I will be going back to the previous clinic, but to a branch further away that happens to be covered by my insurance so I will be able to get more visits in too. I feel relieved to have parted ways with the useless PT and am looking forward to the next session.
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Hi. I’m glad you have changed physiotherapists. I am an experienced physio and own a few clinics. There is no evidence ultrasound would help at all other than the placebo effect. You would be as well served rubbing a raw carrot on your leg. The results would be very similar in my honest opinion. Ultrasound machines are very old fashioned and not used by most reputable physio’s these days.
TENS works for some. Most of the more recent research papers I have read has not found any significant benefit for its use. I can’t remember the last time I recommended it. You only really get any theoretical benefit when it is turned on and you get very little to no carry over. If you were in significant pain, the TENS machine was issued to you to use for prolonged periods outside Physio AND you felt it was reducing your pain and didn’t want other more obvious methods (analgesia) or they weren’t working for you, then and only then could I see why anyone could justify using TENS on you.
It sounds like a bit of a con where the Physio can be an unqualified and cheaper person to see you while they cram more people into there clinic. There is a Physio like that near here who always sees 2 people at once. One has a heat pack on while he gives ultrasound to the other. After 15 minutes he swaps the patients over. Terrible practice
Thanks for your comments Kristian, it’s reassuring that your thoughts are largely in line with my friends’. It’s unfortunate, but I actually think that a lot of “local” clinics here in HK work like the useless one I described. These clinics seem to make patients think that most of the rehab is done AT the PT visit, with electronic gizmos being a key part of the rehab, rather than BETWEEN visits - prolonging recovery would surely mean more visits to the PT and hence more $ for the clinic. There seems to be a noticeable gap between the local ones and the ones with lots of expat PTs. The first one I saw (the one I’m returning to) has a number of expats, or locals that have practiced abroad.
Thanks for the comprehensive update. Congrats on your independence on your commute and getting back to the gym. I have been on the stationary bike or seated elliptical since week 5 post op ( primarily in boot) though since week 10 without boot. I can go an hour, so my leg strength and cardio are pretty good, so assume you will progress pretty quickly there. So when your PT friends talk about next steps and focus on strengthening and proprioception- what type of exercises are they suggesting? I too feel like I am ready to move to next steps in my PT as well.
Linda, yes I think now that I’m back in a gym I would be able to make some progress. I’ve been avoiding the gym up until last week because I was still on crutches to move around. I think having a boot would’ve enabled me to get back into physical activity sooner, but my protocol is what it is. I spent 30 min on the bike today at a higher cadence but lower resistance with no problem, so I’ll build it up slowly.
Some exercises a PT friend suggested I could do are the following. But there is the caveat that she has not seen how I’m doing and individual cases vary. I will pay attention to what my body is telling me and won’t do all that she’s suggested until after I see my new PT next week and get his thoughts.
- Increase the cycling to 30 minutes - can do this daily should you wish but minimum 3x week.
- Double standing calf raises/heel raises holding onto wall/bench/back of chair for support - even weight through both feet - aim for 3 x 20 reps, 2-3 x day (let pain and fatigue guide you). 2/10 pain is probably ok but if it lasts more than 30 minutes post-exercise then you may have done too much.
- leg press going down as far as ankle range will allow- ie not placing excessive stretch on achilles
- hamstring curl
- single leg bridging
- core exercises
- swiss ball wall squats
- walking with theraband around ankles to activate gluteals
- balance work like on wobbleboards or cushions, single leg standing balance.
Hi HKexpat. That physio plan sounds much better than ultrasound and TENS. I’d personally be careful with the leg press and squats. Certainly don’t try this with any excessive weights. Not seen the walking with theraband around ankles but can appreciate the theory. I would suggest a better way would be to loop the theraband around your knees with enough tension so you have to gently push out against it to keep your legs in a good position whilst doing the Swiss ball squats. This is great at recruiting the glutes and avoids issues of tripping up with things tied around your ankles with walking.
Be careful if using wobble-boards. It is very easy to tilt back quickly into dorsiflexion. You need significant ROM and strength to safely do this. A better way in the early stages in my opinion would be a tilt board positioned to allow lateral movement to avoid the sudden dorsiflexion. Wobble boards usually have a circular dome underneath and allow movement in any direction. A tilt board has a rocker shape underneath allowing movement in one plane.
Arguably a more functional, practical and as good way is single leg standing. When this can be done easy and if safe to do so try closing your eyes. This takes the visual system out of helping you balance and challenges the proprioception more. Another good way is standing on one leg and catching a ball. You can bounce a tennis ball off a wall, challenging your balance and proprioception without the need for ’specialist’ equipment or anyone’s help.
Obviously this is general advice that cannot be applied to everyone. Check with your own PT before introducing any of this into your rehab.
Thanks for the advice Kristian. Good to see that you mentioned the 3 exercises I hadn’t planned to do prior to seeing my new PT - the leg presses, squats, and wobble board. I’m currently standing on one leg and will test closing my eyes in the next few days. One other way to simulate the walking with dynabands around ankles would be to lie down and do scissors with legs. While there, can lie on your sides and separate legs sideways to do outer part of thigh.
Yes the scissors one is good. I usually put the band around the patients knees when doing this. Also a clamshell motion with the theraband around the knees targets the glutes differently. Pop it in google images with clamshell flute exercises and you will see what I mean. Any questions feel free to pop them on my blog. Good luck
Joys of predictive text on phones. Glute, not flute