jdrg’s AchillesBlog

Always wanted to know what it’s like to stomp around in sexy stillettos…  Ok, so this may not have quite the same sex appeal but it’s still pretty fun to tower around in this get-up.  I’m almost 5′10″ so this puts me at around 6′.  Back in my high jumping days, I desperately wanted to be this tall. I was the short one on the team

My husband made this AWESOME shoe for me so I can walk more normally with my boot on.  Brady Browne is inspiring but I really don’t want to do the zombie-walk thing if I can avoid it.  My physio literally squealed in delight when she saw it too.

Here’s the recipe if you’re ‘handy-like-that’:

• an old runner (You’ll be trashing it afterward.)
• 3 giant foam puzzle pieces (dollar store variety) or equivalent substitute
• polyurethane glue
• jigsaw
• belt sander
• clamps

(Tip: He stuffed the shoe so it didn’t get too destroyed when clamped & glue was drying.)

I’m mostly walking around with this indoors right now (short walks outside) but there are plans to tack on a bit of rubber tread (might try bits of an old bike tire or climbing shoe rubber) so that it has a bit more grip and won’t wear out too quickly when I start putting on more miles. Can’t wait!

I’ve finally entered a new chapter in the ATR recovery process.  Last week, I received ‘official consent’ from the OS to go ahead and weight-bear until I can loose the crutches.  Yes to getting on the bike at the gym, in the pool, etc. too. I’ve actually been PWB for awhile already (and have been in the pool too shhh!) trying to follow some of the recommended faster protocols cited in this blog community, but it is nice psychologically to have someone ‘in the know’ say, “Yep the thing has grown back, it’s attached, and you can start stressing it and your legs can get some exercise.” Yay!  I know there’s still a ton of work ahead and I’ll probably still hit some frustrating obstacles, but I am so glad to be at a more active recovery stage.

Interesting sidenote: Was also told not to bother with physio for another couple weeks since “I’ll only be doing a few ankle circles and minor stretches back and forth, up and down for now.”  I could not disagree more!!! (already been doing the ROM exercises for weeks) and I’ll use this little post to encourage anyone out there with decent medical coverage (or the extra cash) to go find a great physio and get at it.  For me, this has made a huge difference in increasing my ROM and decreasing the inflammation and stiffness in my foot and ankle.  Except for the thickened tendon area, whenever I massage the foot and ankle and do my exercises, my foot goes back to looking normal again and feels so much less stiff and awkward.  The lump of scar tissue where the tendon has healed is also slowly going down with each and every ultrasound/massage treatment.  For me, the physio has been a huge support physically and mentally.  (Below: My ankle workout spot. A bit shadowy but my ankles are pretty much the same now and you can just see the theraband and wiggleboard my husband made- plywood with an old squash-sized ball screwed on underneath - bottom left of pic).

Even more interesting sidenote: One of the practitioners I saw was so enthusiastic about the new research I showed her, she got together with some other physios in the area and they signed up for some webinar sessions together to learn about new protocols (in general, not just ATRs) and exchange info/experiences.  She said it was easy to get bogged down with life and continue practicing the way she always had without looking at some of the new information out there.  Our conversations were just the motivation she needed to check out something new.  I wanted to share this with you all to offer kudos for the rigour and dedication many (Norm especially!) have shown in examining the literature and regularly sharing it with us all here.  You likely make more of a difference than you might realize.  Thank you!!

What a difference a week can make.  After my last frustrating visit to the doctor, I really appreciated the reassuring comments from folks on this site (thanks all!).  These, and a check-in with the physio - who is a keeper! - made me feel loads better about things.  While away for the family ski vacation, I also sought a ’second opinion’ from a cousin of ours who is a physician.  He reassured me that the very basic ROM physio I had been doing was definitely fine and that my doc was likely just ultra-cautious.  These exercises (toe scrunches/back and forth, ankle circles and alphabets but not past neutral) still feel so great every time I do them and immediately help reduce the stiffness and swelling in my ankle.  I also find that I can put an increasing amount of weight on my foot without discomfort now.  I’m still using the crutches at all times, just shifting a little more onto the foot occasionally when standing/chopping/at the sink, etc.

On another note, I have developed a small bulge at the location of the injury.  I’m hoping this is just scar tissue.  It seems to be worst immediately after the boot is off and goes down with some light massage so maybe it’s just where the compression area in the boot ends/starts.  Not sure.  I’m pretty sure it’s not the tendon unattached and bagging down, since I can now flex my calf a little by pointing my toes or just by squeezing gently.  That would indicate there’s some attachment happening wouldn’t it?

Arrrgh! Had been feeling pretty good this last week or two.  I’ve been kayaking for some cardio and was growing tired of waiting to see someone for follow-up (OS said I could come back in 5-6 weeks and to take one heel wedge out of my boot per week but offered no other info).  I’d been reviewing the literature on this site and other sources and decided to take some initiative so I booked an appt. with a physio.  Their centre’s site impressed me because it included posts summarizing relatively recent studies about ATR:

• New-Study-Challenges-Surgery-for-Achilles-Tendon-Ruptures
• Recovery-from-Achilles-Rupture-without-Surgery
• Early-Ankle-Motion-after-Achilles-Tendon-Tear
• Cast-and-Walking-Boot-Used-to-Treat-Achilles-Tendon-Tear

The physio agreed that early motion was important to keep the rest of the foot/ankle joint healthy but was leery of early weight-bearing (b/c I’m non-op) without an ok from the OS or seeing an ultrasound.  She did at least say she would look into recent research I’d mentioned and ask some of the specialists about it at her next shifts at the hospital.  (She works part-time at the sports centre and part-time at the hospital).  First person I’ve met who’s actually said, "I’ll look into what’s been published lately!!!"

She started me on some very light, basic ROM ankle exercises seated with the boot off (eg. gentle massage of ankle, heel, arch, toes, some toe scrunches, small ankle circles/alphabet but NO dorsi-flex past neutral).  I immediately felt less stiff in the ankle/foot and my swelling went right down (i.e. My foot/ankle almost looks normal with a tiny bit of swelling below inner ankle).  I was feeling very pleased with the "feel" of it all (never mind the mental state of finally being able to DO something).

Today, I needed some more paperwork signed for work/insurance so I went to see my GP (she’d been away and her locum was the one that had done all my previous paperwork/decision-making, etc. when the ATR took place).  She is not pleased that the boot has come off at all and doesn’t think I should be doing any physio yet.  She wants me to see the specialist and get the green light from him on these physio exercises and to get another ultrasound again before proceeding.  Tried calling the specialist’s office and got an answering machine of course.  Who knows when I’ll get an appt. for an ultrasound or a green light for physio?!?  Not excited about more waiting and wondering for ?!? weeks without any answers, especially if the ortho ends up saying, "Oh no problem, some light ROM physio, seated and out of the boot is just fine at this stage (4 weeks)."  Meanwhile, I’m sitting on my duff waiting for another 2-4 weeks just to get an appt. to find this all out!  At this point I really feel like ignoring today’s appointment and continuing on the schedule I’ve started (and that others on this site have successfully followed).  I don’t want to risk not healing properly/re-rupture and be labeled a "non-compliant patient", but I also don’t want a slow, crummy recovery if I’m stuck on a path that’s too conservative.  Any other non-op experiences out there (besides Norm of course ) to back me up on this?  I really can’t stand these head games…

This is more than likely all placebo-effect stuff and I run the risk of trying to pass myself off as a DIY homeopath here, but when my husband was recovering from ACL reconstruction I remember looking into foods and supplements that are supposedly ‘ligament-friendly’, or at least helpful for someone recovering from injury/surgery.  His injury was not the same as an ATR (and this is not the advice of a qualified doctor or nutritionist!!) so you can take it or leave it, but here’s my list for those who are interested.

Cautionary note: Any supplements can interact with other medications so if you are taking pain killers, antibiotics, heart meds, etc. make sure to consult a physician before adding to your regimen.  Also, many are not FDA regulated so I personally stick to real food as much as possible, and only use reputable supplement brands.

• Bromelain - taken on an empty stomach acts as a proteolytic enzyme/anti-inflammatory (or just eat a ton of pineapple)
• Tumeric - anti-inflammatory, promotes soft tissue repair (and my friend Rashmi’s curries are awesome!)
• Vitamin C - helpful for producing collagen among many other benefits (pick your food)
• Berries - for the vitamins and anti-oxidants and b/c they’re yummy (we make lots of homemade smoothies or treat ourselves to Happy Planet/Bolthouse, $$$ but worth it)
• Soup Broth - the real kind, where you boil the bones for hours - (possibly one of the few natural sources for chondroitin and glucosamine?)
• Red wine - thins the blood to help avoid clotting. (I’ll take a glass of red over aspirin/ibuprofen any day!)

We’ve also both avoided pain meds as much as possible, and as soon as possible after surgery/injury, since these can cause indigestion, constipation, react with other supplements and interfere with the body’s ability to make most efficient use of nutrients.  Also, mixing alcohol and acetaminophen is a definite NO so again, I’d personally opt for that occasional glass of vino with dinner, a balanced diet including some of the great foods above, rest, ice and elevation.

I have a serious weakness for a decent Americano in the morning, but coffee (and other types of caffeine) can interfere with vitamin absorption so I’m trying to be more careful about the timing of these (i.e. no point in washing down that multivitamin with coffee.  Just makes for some very expensive pee!).  I’m also trying to drink more water to make up for my little addiction.  Not a chance I’m giving coffee up for good though

There’s likely tons of others out there that I’ve yet to come across, but after reading some other Achillesbloggers’ posts about similar topics, I may even start eating jello!! Eeew. (check out Ryan’s post).

• Dennis on eating right and losing weight
• Ryan on tendon nutrition
• Hung on change of diet to boost healing
• Obsessive C on nutrition
• Jacksprat’s diet

Btw, if my husband had to choose one sport of choice it would be skiing, and he was prepared to forego all other ‘knee-taxing’ sports (i.e. the beer league men’s soccer team he was part of when he tore the ACL!) to once again ski as hard and fast as he wanted without ‘mentally’ holding back.  His ACL recovered beautifully.  In fact, his surgeon called him a phenomenon!  (Something he annoyingly likes to remind me of whenever the opportunity arises :)  He was very diligent about rehab and physio, and definitely followed his own version of an early movement/weight-bearing protocol, but we also tried to focus on some of these things nutritionally because it seemed like it just couldn’t hurt.  My two cents…

Just wanted to share a few happy milestones and a healthy dose of perspective.  Yes the adage is true that when faced with challenges, one is lovingly reminded of life’s many blessings.

Yesterday marked the end of Week 2 post-ATR and:

• 1st (of 5) felt heel wedges taken out of the ‘moonboot’ (my pet name for the Ossur Rebound Air Walker boot I’m currently in)
• 1st time shaving my injured limb
• 1st time driving the car on my own
• 1st girls’ nite gathering with friends
• 1st time back in a pair of jeans (I managed to stretch a pair of bootcut Mavi’s over the moonboot. Yay!)

Small victories, I know, but they still felt great!

Also, I have been completely overwhelmed by the generosity and love that’s been pouring in from family, friends and colleagues.  We have been treated to so many gifts of baking, meals, flowers, offers to drive our kids to/from practices, etc., bookstore gift certificates!  I am incredibly grateful to have such kind and thoughtful people in my life.

My partner has been unbelievably patient and supportive.  He rigged up the bike cart system (in header photo) to get me outside and down to the beach for a glass of wine within days of getting the cast on.  My kids have stepped up beyond my expectations too.  They even made up a weekday chart for who will be on dinner prep, dinner clean-up or "errand kid" (which basically just means who will let Mom boss them around and have them do chores that can’t be accomplished on crutches).  I know everyone will get tired and all this will likely wear thin after a few weeks, but I am still so blown away by their maturity and cheerful, helpful support.

As I spend a little more time sitting around than my usual life affords, some more ’silver linings’ that come to mind include…

• I’m not pregnant and my kids aren’t babies/toddlers anymore.  Hats off to all of you out there who are doing it.  You are AMAZING!
• I didn’t have my gigantic (to the top of my thigh) cast on in the middle of August.
• The main living space in our house (including master bedroom and bath) is all on one floor. Yay!
• I have great medical coverage and can take the needed time off work to heal. (I have been self-employed in the past so I am incredibly thankful that there isn’t added financial stress for our family right now).
• My left Achilles is injured so I can now drive an automatic (with my thigh propped up on a pillow to avoid too much weight on the boot rested on the ground).
• I’m still reasonably flexible so I can/could still get dressed and bathe on my own with the giant cast and now, with the boot system.

Cheesy, I know. Couldn’t help it…

It probably sounds odd but I was initially upset when I heard that the orthopedic surgeon said I wouldn’t be having surgery.  At that point, every study I’d come across said that those who’d had surgery after an ATR recovered more quickly and that there’s a smaller % chance of re-rupture than a conservative, non-operative approach.  Provided the patient was young, healthy, athletic and wanted to return to sport, surgery sounded like the way to go.  I felt cheated.  Wasn’t I young/healthy/athletic enough?

Thanks to this site (Yay Dennis!), and ‘normofthenorth’ in particular (thanks Norm!) and some perusing of the grey lit., I’m beginning to feel more optimistic. Norm will quickly point out that recent (2010) research out of the University of Western Ontario (UWO) found that "accelerated functional rehabilitation and nonoperative treatment for acute Achilles tendon ruptures" indicates that, "all measured outcomes of nonoperative treatment were acceptable and were clinically similar to those for operative treatment. In addition, this study suggests that the application of an accelerated-rehabilitation nonoperative protocol avoids serious complications related to surgical management" (Willits et al, 2010, conclusion).

• Willits, K. et al., Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures: A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation . The Journal of Bone & Joint Surgery . 2010 Dec;92(17):2767-2775.

The following more recent 2012 study affirms these findings…

• Alexandra Soroceanu, MD, CM, MPH, et al. Surgical Versus Nonsurgical Treatment of Acute Achilles Tendon Rupture: A Meta-Analysis of Randomized Trials. The Journal of Bone & Joint Surgery . 2012 Dec;94(23):2136-2143.

Experts in the field are definitely still debating this topic (Battles of Achilles: The operative vs. nonoperative treatment debate ) but for my situation, rupture above/upper area of the musculotendinous junction, most surgeons will elect not to operate.  This is because sutures at or above this musculotendinous zone will not hold.

• The Achilles Musculotendinous Junction: A Survey of Orthopaedic Surgeons. Retrieved March 2, 2013, from http://faoj.org/2009/12/01/the-achilles-musculotendinous-junction-a-survey-of-orthopaedic-surgeons/

Short story - I am officially on the non-operative path and will now need to make sure my OS and PT are onboard with a more aggressive functional treatment protocol like UWO’s.  For more great discussion on surgery vs. no surgery for ATR you can also check out Norm’s site and the comments on Ryan’s blog here , and the main Achilles blog page on ATR rehab protocols, publications and studies .

Btw, if you’re interested in more famous folk who’ve been on this ATR recovery marathon, here’s a couple great lists by Brendan and Adam .  Thank guys!

I spent the first week in a massive cast (up to the top of my thigh) with my leg elevated above the level of my heart as per the ER admitting physician’s instructions.  Within the first 24hrs I had discovered this site and already learned a great deal about ATR (Thank you Dennis!).  As a result, I entered the ER with many questions and concerns.  Unfortunately, these weren’t very well received. I was advised that I was in good hands and to just trust whatever doctors told me to do.  A little ironic given that the following week, when I finally saw the orthopedic surgeon, his assistant did a double take when she saw the cast I’d been in for over a week and said, (I quote), “This is totally unacceptable!”  Also worth noting, I had been told that this specialist had originally refused my GP’s referral the Friday my cast was put on and only agreed to see me because “my GP wouldn’t stop harrassing them” (this time quoting the specialists’ receptionist).  If we hadn’t been so persistent, I could have been in that “unacceptable” cast for quite some time…

Lesson learned - It’s no joke that sometimes you need an advocate (or to be your own) just to get a specialist’s ear and to ensure that you’re getting the necessary care toward an optimal recovery.

I ruptured my left Achilles tendon on Feb.13, 2013.  I am a reasonably fit 36yr old librarian and mom of three.  I love to run, do yoga, pilates, swim in the ocean, play volleyball, etc…. Before the injury I had slowly been getting back into shape after ‘putting on a few’ while completing my Masters degree.  For 8 months, I had been running regularly and slowly getting back into shape (or so I thought), so all the references in the literature to thirty-something "weekend warriors" being most susceptible to this injury hits close to home.

The injury took place at a fitness class doing resistance wind sprints (i.e. the runner and a partner have a large elastic around their hips with the partner resisting while the runner tries to sprint and pull them along).  I had been doing yoga, skiing and trail-running that week as well.  Maybe a little too much at once?!?

Like many others, I initially thought I had been booted hard in the calf/Achilles region from behind.  Apparently this is a common assumption based on how the rupture feels.  I immediately raised the leg on a large exercise ball thinking that this was just a bad kick and would result in nothing more than a bruised, swollen ankle.  Once the intense heat and pressure subsided, I tried to stand up to stretch it out but it felt like someone else’s foot attached to my leg.  My calf muscle immediately cramped and I was back on the ground.

That night, I kept the leg elevated and iced it until (after calling the nurse hotline) we decided to go to the ER to check it out. The doctor ordered an ultrasound for the next morning, which confirmed a complete rupture at the musculotendinous junction (where the tendon inserts into the calf muscles) with a 1.3cm distance between the tendon and muscle.  My GP sent the ultrasound to the orthopedic surgeon on call at Lions Gate Hospital in North Vancouver, Dr. Alan Baggoo, and told me that he had confirmed the radiologists’ diagnosis, but that I was not a candidate for surgery due to the location of the rupture. He said that I should be sent back to the ER to have the leg casted in an equinus (pointed toe) position.  The day after the injury, Valentine’s Day, I was back in the ER getting a massive cast on (up to the top of my thigh)!! Not the most romantic Valentine’s Day evening, but definitely memorable!