CardioJunkie’s AchillesBlog

It’s been a year since my accident and and in seven days it will be one year since surgery.  I’ve been reading posts from folks a few months ahead of me and from those who were posting 1-2 years post-ATR.  This site has been fantastic for learning from others.

I’ve had other sports injuries in the past, but Achilles Tendon Rupture has been the toughest recovery.  The Achilles repair from ankle to calf has been mostly quiet since Month 6.  The Achilles insertion to calcaneus repair has taken longer.  Looking from the back of my right foot, the reattachment to the heel is on the left inner side, the ankle to calf repair at the center, and since I was going to have surgery, I decided to have my Haglunds Deformity removed which was on the outer right side of my Achilles.

At 5 months, I still had heel pain and my doctor said the repairs can take a year to heal.  If unresolved after a year, he can evaluate if a second surgery is required. The injuries slowly improved and every few weeks, there was less stiffness and aches from activity.

This is a catch-up post since my last one at Month 5.

6 Months – More Challenges, Lessons Learned

At 6 months, I sprained my ATR ankle while pushing a door open at work. This was a 1.5 month setback.  I had to revert to modified versions in my activities and avoid running or jumping.

In hindsight, I should have continued with the heel raises and Theraband as my physical therapist had told me.  In the return back to my favorite fitness activities, I performed less of the rehab exercises.

Since my ankle was not full strength, I was unbalanced and had pain in my right IT-band and knee.  My left ankle, knee, and leg were also sore because they were taking on most of the load.  I think I was subconsciously favoring my non-injured leg during activities.  Even both shoulders started to hurt from weight training because of uneven use of my legs.  After researching, I found exercises to target the ankle, feet, and knee muscles during my activities.  I had to look beyond the squats, lunges, and gym machines I was already used to doing.

Once my ankle was restored, I continued with strengthening the leg muscles.  One activity for my quads, knees, and legs was regular biking on the hills around my neighborhood.  This helped strengthen all of my leg muscles.

I used to assume my body can keep up with whatever I do.  If there is anything I learned from this experience is a better understanding that the muscles are part of a body system that work together.  If there is a deficiency or imbalance, they will let you know.

9 Months – Finally (and an Extra Benefit from Rehab)

Things steadily improved by 9 months, took off, and I have not looked back since June.  My right calf was getting stronger every few weeks.  By focusing on jump squats, lateral jumps, broad jumps, etc. I was able to add strength to my calf to finally do box jumps.

I still had to remind myself not to put most of the load on my non-injured leg and work on use of my right leg.  There is not a lot of think time during fast-paced sessions while I do various activities like sprawls and then transition to tire jumps.

In the past, my right ankle, unlike my left, did not have good balance ability.  In Yoga, my right leg can wobble a bit.  I could not get the muscles on my right leg to work as well as my left.  With all the extra attention during recovery, I’ve developed better balance on my right leg.  I think Physical Therapy, incorporating leg balancing activities, and having better coordination of the foot and ankle muscles helped.

1 Year – Looking Forward

I’ve been going full out on my activities for the past month.  I still experience periodic tightness around the surgery sites and some twinges at the surgical wound and heel.  Every few weeks these are becoming fewer and shorter in duration.  I’m optimistic that everything will resolve themselves in the next few months.

At the end of August, I will be hiking and kayaking the Na Pali Coast in Kauai.  I am signed on for the next 50 mile charity fund-raiser bikeathon (I had to miss this year’s).  I am looking forward to the 2015-16 ski season.  I really enjoy my outdoor hill biking, so I am checking into the Spin class schedules.  In September, I am trying out classes in Tabata and ViPR, so no more holding back from new activities.

It is a great feeling to be back.  Life is moving on past ATR.  For everyone out there who are at the beginning of their journey or hit bumps along the way, it does really get better with time.

Be patient with yourself, understand that everyone has their own timeline to recovery, and take things at a slower pace.  It’s okay to take a break from activity when you need it and one day soon you will be back to where you want to be.

I feel like life as I knew it is within reach.  Overall, I am progressing each week because I have been moving forward with fitness.  After my ski trip at Week 18, I was ready to return to my classes (Thanks to the encouragement along the way by HereWeGoAgain and Norm).  I have been back for five weeks at my regular weekly classes in Kickboxing, Step/HIIT, and Boot Camp.  I’m not running hard or jumping onto high platforms yet.  In the short-term, I switched some plyometrics with alternatives. I am working on incremental build-up in my classes.

I was concerned that the Achilles repair at the heel meant I could not do exercises that involved planking. But over the last few weeks, I worked my way to burpees, mountain climbers, push-ups, and single/double/side leg planks.  I am currently refocusing energy back on ankle/calf strengthening because running faster and getting more power in jumps can only come from getting that last bit of strength back into my injured leg.  Some examples of what I am working on in my classes:

- Doing Now at Shorter Duration and Range — Running, jump rope, jump squats, jumping jacks, broad jump, jump onto low platform

- Modify for Now — Alternating lunges instead of dynamic jump switch leg lunges, jogging instead of high knees

- What’s Next — Building strength in injured leg for more power, running at faster pace, endurance

My Achilles/heel injury discomfort is gone on some days and returns on others.  My therapist thinks that the heel reattachment is tight after surgery.  When I feel the heel discomfort, a few minutes of walking with long strides, Pro-Stretch, or squatted heel raises loosens it.  It took some trial and error to find something that worked.  For some reason the squatted heel raises work the quickest for relieving the tightness and I came across it on Tom’s Blog.  (It’s in the “tomtom” exercise sheet and I’ve adapted his excel sheet to track my PT exercises and workouts.)  I asked my therapist and she said it stretches the soleus. Stretching takes time and on the days when I am racing to the gym after work, trying to get stretching done can be rushed.  But investing time for stretching beforehand pays off before I engage in an activity.  Prior to this set of injuries, I only stretched after a workout, never before.

My calf is still thinner and not 100%.  I have tightness at the ankle late at night or in the morning when I get up. The thickness in my Achilles is slimming down and I am starting to see a return to what my therapist calls the “hourglass” shape.  The surgical site is becoming less sensitive.  I don’t have incidences of swelling. Things have calmed down at the injury areas.

For a summary of my ATR post-op recovery timeline, check out my first blog post for Weeks 1 to 12.

My Physical Therapy:

I wanted to capture my thoughts about my Physical Therapy experience.  My PT started at Week 12 at the end of my two-shoes period and is wrapping up in the next few weeks.  Because of the Achilles tear at the heel requiring titanium reattachment, the doctor kept me at NWB for a longer time (5 weeks).  I accumulated a lot of PT visits (at three times/week) because I had to address my troublesome injury #1 AT/calcaneus issues. Injury #1 gave me a very tough time.  I call this injury #1 because my accident sequence was partial AT tear at insertion to the heel first, followed by injury #2 which was the Achilles tear to the calf muscle.  The MRI noted that I had a third injury, a sprain to one of the ankle ligaments.

My doctor has told me that my ATR injuries are “unusual” because I had two Achilles injuries in the accident.  During two-shoes, the two injury sites were behaving independently, with swelling alternating between the ankle or heel (sometimes on both) depending upon the activity.  Of the two, #1 gave me the most issues.  Walking or biking for very short durations at 12+ weeks caused hot swelling and stiffness.  The injury #2 repair, where the Achilles severed from calf, resolved itself fairly quickly within three weeks of PT while the heel injury took longer.

I have to give a lot of credit on my recovery progress to my therapist and to the modalities which helped move me further along in recovery.  The treatments helped accelerate pain reduction and swelling.  Without them, I would have struggled for months with pain and swelling.  When I look back over the weeks of PT, I see fast progress.  The treatments helped speed the healing process, especially for injury #1 at the heel.

At 5 weeks post-op, I realized that other than routine follow-ups, my doctor’s job is pretty much done and I will be in the hands of a physical therapist.  My doctor will write the PT scripts when I request them and receive progress reports from the therapist.

This is not my first trip through Physical Therapy (e.g., broken tibia from skiing, torn calf muscle, sports-related injuries, but never for surgery).  I started by checking local therapists.  Questions that come to mind are:  Do I go with a large medical-affiliated institution or do I go with a small independently owned one?  I’ve had good experiences with hospital-based ones where you are assigned to a dedicated physical therapist.  With some of the smaller offices, the PT decides treatment and then leave you with a PT Aide or PT Assistant. I decided to go with a small practice after interviewing therapists and office staff.  Another consideration was whether I should get a therapist who is into sports.  In the end, I decided that if I needed to, I can look for a sport medicine professional or a personal trainer with rehabilitative experience.

At each visit, I asked questions.  I wanted to understand the muscular-skeletal mechanics of movements as related to my injury. I want to know whether my shrunken foot will go back to normal, why we need inversion/eversion, why does eversion get restored quickly, where does the AT start and end, etc.  With some terminology and knowledge, I can research, learn, and be self-aware of the muscles, tendons, and ligaments in the foot, ankle, and calf.

In addition to the therabands, foot drills, heel raises, and progression exercises which you can do on your own, my PT treatments included modalities which took about 30 minutes at each visit.  (Caveat:  My terminology may not be 100% accurate, but you can look them up on the Internet).

For Both Injury #1 and Injury #2

(1) Joint Mobilization – My therapist flexed and held my ankle/foot in several directions to increase ROM.  She flexed my foot DF by applying a lot of pressure.  I was nervous about the DF mobilization at the beginning because my therapist pulls on my ankle to increase the joint gap, and then flexes the entire foot upwards by applying a lot of pressure to the foot and ankle.  I worried about whether it can cause damage. However, because of flexing, I was able to get my DF restored almost 100% within 2 weeks (measurements and comparison with my uninjured ankle).  With my DF restored, I could focus on walking with better gait.

(2) Massage Therapy – Vigorous massage of the Achilles from foot, heel, ankle, Achilles, and up through the calf.  Besides restoring blood circulation, this also helped with dispersing the dark discoloration around my ankle.  I had no feeling in my calf when I stretched it in the early weeks, but with the circulation and nerves back, I feel the calf muscle during a stretch.

(3) Biodex – Because of Achilles/heel pain, I could not do double heel raises in the early weeks.  I used a Biodex that was set up for eccentric calf exercises.  The machine applies torque and I have to push with my foot which then targets the calf muscle.  A Biodex machine assists in a lot of other PT isokinetic/eccentric functions, but my sole use was for the injured calf.  A picture of a Biodex was posted by someone in an earlier AT Blog.

For Injury #1/Achilles Insertion to Heel

(1)  Neuro-Electric Stimulation with Cold Wrap  (switchover to hot wrap as treatment progressed) – The therapist attached four electrodes for two channels (Red/Black) with cross-over, 1 pair R/B to outer ankle/heel and 1 pair to inner ankle/heel.  The electricity level is adjusted to your tolerance. The purpose is to stimulate the nerves and blood flow circulation in the injured area and help reduce swelling.  Another reason is to address the pain and discomfort with my Achilles insertion at the heel.  I had dark discolorations on both sides of my foot from the heel up the ankle to the base of my calf.  This is blood that pooled there from the day of the accident. The discoloration started to disperse after a few weeks.  The skin tone on my ankle is almost back to normal.  This treatment also helped reduce the occurrences of swelling and stiffness.  After 3 weeks, I had no more swelling and most of the stiffness was gone by 5 weeks.

(2) Cold Laser – My therapist used a hand-held flashlight-like device on my heel and calcaneus bone.  Cold laser was used instead of ultrasound because of the titanium metal at my heel bone.  This addressed my heel pain.  After 3 weeks, my heel pain was much improved and gone on most days.

My Physical Therapist

My therapist is a bright, quick-thinking, and creative 78 year old woman (not a typo and she looks younger) and she is the owner.  I was not sure about her when I met her (e.g., “I need someone who is into sports. How is she going to help me with my recovery?”).  I have since learned that she has a lot of experience and in treatment of ATR.  She takes the time to massage the small muscles in the foot, Achilles, and calf.  Because of work schedules, I did switch appointments and see a couple of other therapists on my visits, but none of them can do DF mobilization with as much strength (Lesson: Never underestimate an individual’s strength and technique).  Or provide a similar massage (it seemed the younger therapists were tentative about applying too much pressure).  My therapist likes applying some older techniques which rely on massage and joint mobilization.  She mentioned that in the “old days” there were no therabands, balls, or equipment that are available in PT nowadays.  I was a little amazed at this.

My therapist was an ATR patient when she was younger.  She was crossing a ditch being dug up for a water pipe and her foot did not make it fully across.  Her foot slipped into the ditch and ended up at an extreme angle and she ended up with an ATR.

She probably doesn’t have a lot of patients like me who ask a lot of questions about the tendons, muscles, alternative exercises, and return to daily living.  After a few visits, I learned to trust my therapist and her judgment.  She had a lot of information to share and I was not shy about asking for help with my heel problems, exercises at the gym, future things to look out for, and post-PT self-maintenance.  She made adjustments to my treatment when I told her about issues or pain.  She also offered alternatives when I could not effectively perform an exercise.  When I had swelling from an exercise in the early weeks, she helped me see that I am not ready for that activity yet and to try it again in another week.  Because of my therapist, I am well along the way towards recovery.

This past Christmas week was the ski trip I originally thought I would be leaving my skis at home. I envisioned spending days in front of the fireplace with a mug of hot cocoa, hanging out at the spa, or waiting at Miguel’s Cantina for everyone to return from skiing. Over the past month, I’ve done a ton of squats, lunges, weights, and conditioning so that I can ski by Christmas. I was glad to get in the gondola, head to the top of the mountain, and hit the slopes with everyone.

At Week 15, I felt the beginnings of a turnaround in my recovery.  There are days when I don’t pay a lot of attention to injury #1 and #2 because the swelling and pain have decreased.  I’ve been able to build strength in my foot, ankle, and calf and this has allowed me to focus other activities.  There are days in which I overdo things, so I pull back, reassess, and move on.

Overall strength increases are at a faster pace because I am able to do more.  I’ve been developing my workouts based on what I learned at PT, knowing what works for my muscles, and customizing depending on how my injury is feeling.  I am building towards a return to Kickboxing and Step classes in some form without plyometrics in the coming weeks.

Walking and Stairs – A few weeks ago, I was trying too hard to walk with proper gait and go down the stairs.  The strength in my foot and ankle was just not there.  My therapist had me walking on the balls of my feet and maintaining single leg balance on a Bosu.  I added other activities to increase strength.  I am walking heel to toe with push-off and walking down stairs more normally.  My right leg is not 100%, but I don’t worry about it because advancing fitness and activities should help that along.

Physical Therapy – I do double heel raises and single ones down on most days.  My heel AT sometimes gets aggravated, but has steadily improved.  My therapist understands that I want to progress to running, so one new exercise is hopping with both feet or hop in and out on a springboard.  Eventually, I will alternate to single leg as a progression towards jogging.  In another exercise, I stand balanced on dino disks and catch a ball being thrown from different directions and heights.  My therapist encourages me to try activities at the gym for a short time and see if my AT can tolerate it.  If I am not able to do an activity now, I try again in another week.

Workouts – I center my workouts around single leg activities.  When things start getting easy, I transition them to a faster pace or add more dynamic movements:

- Weights/Conditioning:  P90X DVD workouts, single leg body hinges with weight or barbell, squats and lunges of all angles and types on glides, etc.

- Kickboxing:  I work single leg balance by doing kickboxing drills.  This involves repeated sets of front kicks, roundhouse kicks, sidekicks, and back kicks.  I do footwork with uppercuts, jab-cross, or hooks in standing, lunged, or varying foot positions.

- High Step Platform:  I do fast sequences of knee strikes, side leg out with a short hop, and back leg raise on a step platform.  Eventually, I will advance these to beginner Plyometrics workouts (YouTube link is in Ron’s Achilles blog).

What’s Next – I just finished a couple of Kickboxing classes which combine Karate, Muay Thai, and Boxing.  Even though I have to wait on fast footwork, high knee running, jump lunges, or jump kicks, I can complete everything else.  I was extremely (and happily) sore after the first class.  In the coming weeks, I will work on increasing pace and endurance.  In my mind, the way to build strength is by doing fitness activities you are familiar with, at a controlled pace, and listening to your injury.  There is still a lot of work to get back to Boot Camp, HITT, or Tabata style workouts, but I am making progress.

WEEK 12 – Physical therapy continued at three times a week and my PT used neurostimulation, hand massage, and joint mobilization. At the same time, the AT at the heel got a little worse due to the PT and exercises. But over the course of one week, I saw improvements in flexibility and progress.

Walking – I was not able to walk correctly during two-shoes because of the swelling, so my walking gait is off.

Workouts – Returned back to the gym to incorporate heavier weights and other ways to get strength in my right quad/upper right leg.  I resumed Pilates and Yoga classes three times a week (no planks, no military push-ups).  I did a lot of variations of lunges, some with glides, squats (double, single assisted), sometimes sets with barbells.  For hamstring, I did deadlifts or stand with a ankle weight on my right leg to work the hamstrings.  Several times a week, I used the hip abductor/adductor and leg press (both legs, single right).  I continued upper body and core work.

Weeks 13-15 – PT has really helped my ankle/foot ROM and strength.  Incidences of swelling at the ankle (injury #1) are reducing.  Now the swelling seems to be mostly at the AT insertion to heel (injury #2).  My quad and leg strength are increasing.  For now, I will work on getting the rest me stronger.  The foot, ankle, and calf strength recovery may take longer, but I am seeing incremental improvements with each passing week.

Walking and Stairs – This has been a real battle.  I need to consciously correct my walking gait.

Physical Therapy - I am hampered by pain with the achilles at the heel, so my PT has started me on the Biodex machine (applies torque to strengthen the ankle and gastrocnemius muscle).  PT has incorporated the aerobic step for step-ups and Bosu with knee/leg lift to work the foot, ankle, and calf with some instability.  I am also trying to do sustained single-leg balance on the Bosu (this is PT’s idea and are hard to do even on my good leg).  I can do standing calf raises, but they require stretching of the achilles/calf beforehand (Pro-Stretch, dino disks).  At home, I found that I can stand on my mini-trampoline to do calf raises and “walking” on on my toes without pain.

Workouts – I have a workout log to track my progress.  I am thinking of variations to engage multiple muscle groups and will adapt some from my Bootcamp classes.  In my Pilates and Yoga classes, there are a lot of standing leg balances and I focus on pointing my foot and flexing ankle DF.  The classes use slow movements to engage muscles from different angles.  I cannot use a stepper or elliptical trainer because the movements cause pain in my AT, but I will try again in the coming weeks.

Exercise - I started incorporating a lot of squats, squats with barbells and more advanced movements.  I worked the right quad/leg more intensely to start restoring strength and muscle.

Caution on Exercise and Movement – I talk a lot about doing exercises because being fit has been a key part of my life.  Doing exercises while you have an injury can be a safety issue or put you at risk of injury.  I weighed my options and decided that I was able to maintain some exercises.  I think you should only do what you are capable of and use good judgement.  I am not advocating that everyone should exercise during their ATR recovery.  How many times did I have “near misses” on crutches, go across a wet floor, or took a turn on the rollabout too fast?  You don’t want to increase your risk of injury or delay your healing.