My ATR Story…and Subsequent Re-Rupture

On the evening of June 26th I fell down a 4 foot high set of steps I had just constructed in our back yard. Extreme pain but no “pop” that I recall. Just the sound of me hitting the deck below. No blood (except my forearm and a cut in my mouth from hitting a large retaining wall boulder). No bone sticking out anywhere. Do to the pain, I was certain it was broken. But after about 15 minutes the pain subsided somewhat and I was able to stand on it without any increase in pain, although I couldn’t walk normally. Hmmm, no blood or bones protruding and I can walk on it (sort of). Must have sprained my ankle or strained my calf muscle I thought. After a couple of days I decided it must not be that serious since I was still able to get around so I thought I’d give it some more time to heal on it’s own and continued to finish building the deck and going to work every day during the next three weeks. (First mistake!) After three weeks it wasn’t getting any better so I visited my Dr. and her diagnosis was achilles tendonitis. She prescribed a walking boot and some topical ibuprofen drops to apply to the achilles area. She offered to have me see a specialist if I wanted but I declined. If my Dr. thinks it’s tendonitis and doesn’t think it’s serious enough to even have it X-Rayed then that’s great news, right? (Second mistake!) After all, it’s not broken and apparently there’s no torn calf muscle like I suspected. A ruptured achilles never crossed my mind since I’d always heard that you couldn’t walk if you ruptured it. And it wasn’t broken since I could walk on it (somewhat) without much pain. I thought I’d be good as new in a couple of weeks. Two weeks later - still not getting any better. Still can’t walk normally. Leg is still swollen. Back to the Dr. and requested to see a specialist. Hobbled into the specialists office a week later and a quick glance and ultrasound showed a complete achilles tendon rupture with about an inch of space between the ends of the tendon. (Finally figured out why it wasn’t healing!) The surgeon’s schedule was booked and it was two more weeks before I had the ATR surgery on Sep 7th, 10 weeks and 2 days after the injury. (Time is not your friend when it comes to ATR surgery I was told). The surgery went well. Stitches came out at 2 weeks. Went into a walking boot after 5 weeks and then 2 shoes at 7 weeks. There was light at the end of the tunnel, finally! The PT referral got screwed up somewhere between the surgeons office and my insurance so my first PT appointment wasn’t scheduled until Nov 20th so for three weeks in two shoes I resumed my normal daily activities without any PT. On Nov 17th, a week before Thanksgiving and ten weeks post surgery, I was delivering a letter to the mailbox in front of my business and slipped on a railroad tie that I stepped up onto (Third mistake!). I knew instantly that it wasn’t good. The pain was exactly the same as my first rupture. I raced to the surgeons office and waited for an hour for him to show up at his office. He saw me without an appointment and confirmed my worst fear. Totally ruptured again! Devastated! I DO NOT WANT TO DO THIS AGAIN!!!! My second surgery is this Wednesday, Dec 14th. The tear is in a completely different spot just below my calf muscle. The surgeon will be taking the tendon from my foot and a cadaver tendon to repair it. The prognosis is that once I’m 100% recovered in 6 months to a year, I’ll only have about 30% of the strength of my other foot. Not even sure if it’s worth going through another surgery and lengthy recovery (and being away from my business) for only 30% usage but I’m hoping the surgeon is wrong and that I can have greater strength with a lot of hard work. The thought of wearing knee high logging boots for the rest of my life in order to protect the tendon is not very appealing! So, that’s my ATR surgery story - so far. I’m writing this blog in the hope that anyone reading it will learn from my mistakes (and to get some frustration off my chest). First Mistake, not seeing a doctor right away! Thinking back on it now, my Dr. probably didn’t take the injury seriously because I didn’t. I believe that the 10 weeks from injury to surgery is the main reason I re-ruptured and believe me, you don’t want to go there. Second Mistake, if your Dr. offers a second opinion take that as a hint that he or she may not know what they’re talking about! Third Mistake, do not take unecessary risks during recovery. The simplest things will trip you up if you’re not extremely careful. If I had just stayed on the flat sidewalk going to the mailbox instead of taking a shortcut across a flower bed I probably would not be staring a second surgery in the face right now. Wishing everyone a speedy recovery wherever you find yourself in this marathon.

14 Responses to “My ATR Story…and Subsequent Re-Rupture”

  1. Holy cow Jerry- that is quite the saga.

    > The tear is in a completely different spot just below my calf muscle.

    So when you landed on your leg, the previous injury survived the load, but your Achilles ruptured in a new spot?? That’s just nuts! Is the doc telling you this is a “new” injury (if it’s in a new spot, I think it has to be), unrelated to the old one?? Any reason to believe that the entire tendon was weak (ongoing tendonitis or something)?

    > I’ll only have about 30% of the strength of my other foot

    We’ve talked about this before here… you can think of the calf and Achilles as two parts of the same system. The calf muscle is the actuator, the Achilles should just work like a cable. When your doctor says you’ll only get to 30%, is he talking about the calf? Or the tendon? When you reach the strength limit of your calf- you just cant push any harder. When you reach the strength limit of your Achilles (as you now know), it breaks. Is he saying you’ll always be weak? (weak muscle)? Or, is he saying you’ll always be at much higher risk for re-rupture (weak tendon)? I think that’s a very important distinction to make/understand.

    > If I had just stayed on the flat sidewalk going to the mailbox instead of taking a shortcut across a flower bed I probably would not be staring a second surgery in the face right now.

    Going back to your earlier point… if your Achilles tore in a totally new place, then I have to think this new tear could have happened at any time. If anything, your weakened calf (atrophy from the 1st rupture recovery) should have made this second tear less likely…

    I sure hope things take a turn for the better for you. I understand your frustration; but I don’t see any viable option to your current plan. Best of luck, and please keep us posted-

  2. Ryan, The Dr. said the repair held and I re-ruptured in a new spot above the repair but I didn’t see the MRI myself to confirm it. He didn’t really have one solid reason why it tore somewhere else other than “sometimes it happens”. After reading a lot of the blogs on this site, I get the sense that for every Dr. performing these surgeries, there’s a different protocol/procedure/answer and I don’t know if I have a competent Dr. or not since there seems to be no consensus regarding the “right way” to do it to compare him to. I have to say I’m not 100% convinced that the original repair held and that I re-ruptured in a completely new spot, but I don’t have any proof otherwise and I don’t know why the Dr. would lie about it either (other than pride). Doesn’t make any sense to me at all why my tendon would tear somewhere else from a simple slip other than my theory that the tendon is in a weakened state due to the long timeframe between the initial injury and the new one. Regarding the 30% strength after recovery - it has to do with the foot tendon (can’t think of the name of it) that’s being used as my new achilles tendon and it’s 30% the size/strength of my original tendon. So basically I’ll always be at a high risk of re-rupture due to a smaller/weaker tendon. That’s why I questioned myself about going through all of it again. When I asked the Dr. what would happen if I ruptured a third time he said there would be no options left to repair it and that I would be in the condition I am right now - shuffling along without an achilles. Don’t know if that’s a scare tactic to force me to be more careful next time or the truth! I’m an outdoors type guy and am having a hard time wrapping my mind around doing the things I like to do with an achilles tendon 1/3 the size of my original. All I can do at this point is have the surgery and recover my foot to 30% and start figuring out how to bowhunt elk in a walking boot! Appreciate the well wishes……….and I’ll keep everyone posted on my progress. Jerry

  3. Hi Jerry. Sorry to read about your re-rupture. I know what you’re going through…I tore and re-tore my Achilles three years ago. I think the one thing I learned was that you can’t beat yourself up with what-ifs.

    If it makes you feel any better, I re-tore my Achilles while wearing the boot about six weeks after the first surgery. Yep. Hard to believe but I mis-stepped and felt a faint pop. And, similarly, it tore above the original injury. My surgeon had a cadaver tendon at the standby during the second surgery but did not use it. Instead, he cut a rectangle from the fascia of the calf (as explained to me, the membrane-like film on a chicken breast) and folded it over the second repair. The surgeon claimed, to check on the strength of the repair, he pulled on the tendon like a water skier behind a boat.

    After this second surgery, I developed a wound that wouldn’t heal. This prevented any real rehab for over two months. I finally healed and got better. Unfortunately, because of this prolonged recovery, my calf seems to be permanently 30% or so smaller.

    Okay…now the good news. Since my full recovery, I have had no issues with my tendon aside from it being a little stiff at times and not being able to bend my leg as far as my good one. I have no problem going barefoot and if I wear shoes, mostly sneakers, I don’t even notice it at all. I had to retire from my weekly basketball game but I took up cycling. In the last year, I’ve put on over 5000 miles on my bike!

    My surgeon, who went on to head a medical school ortho program, had never had a re-rupture and he was in uncharted territory with me. After he left, I was handed off to another doctor in the clinic but didn’t like his handling and I switched doctors. If you can, don’t be afraid to switch doctors to someone you are more comfortable with.

    The other thing my surgeon said, when I asked him if I could tear it a third time, was that it was probably more likely that I would tear my good one than the now-thick and rebuilt bad one.

    In any case, I wish you the best of luck in a speedy recovery. The road may look look long and dark but, trust me, there is a light at the end of it. After all, every journey starts with one step…even if it is on one leg.

  4. > Regarding the 30% strength after recovery - it has to do with the foot tendon (can’t think of the name of it) that’s being used as my new achilles tendon and it’s 30% the size/strength of my original tendon.

    Is the plan to replace a segment of your Achilles with the “foot” tendon? Or to re-enforce/augment your existing tendon? If the answer is “replace”, then it might be worth asking about a cadaver (full strength, preferably one from a 400lb rugby player) tendon, as Dave’s doctor was considering. . That might be an option, which could yield a better than 30% result.

    Again, best of luck-

  5. dave, Thanks for the encouragement. As you know, the tunnel seems darker and longer if you have to do it all over again! In my case, it’s already been 5-1/2 months since the original injury and I will be back at square one beginning tomorrow morning. For me, this injury has been more mental than physical since it disrupts so much of my daily life and for such an extended period of time. I know I’ll eventually get through it but it makes me feel better to gripe about it in the meantime - especially to people that have already been through it. Thanks for listening!

    ryan, My surgeon plans to use the tendon from my foot along with a cadaver tendon. He explained that my foot tendon is to provide live tissue/blood supply to the repair so my guess is that the existing tendon is being replaced. What has me stumped though is that as Dave said, his surgeon expected the repaired tendon to be stronger than his good one even after the re-rupture (which was my prognosis after the first surgery). My surgeon said to only expect 30% strength of my other foot after full recovery with this new surgery due to the reduced size/strength of the foot tendon which indicates to me that my tendon is being completely replaced. Perhaps because the injury is now so old and the tendon has atrophied so much? I don’t know that answer. I plan on asking this afternoon when I go pick up my RX’s. Thanks again for the well wishes. I may not be able to blog for a day or two but I’ll keep you posted.

  6. Again, the very best of luck with your surgery Jerry. One thing I did was give my surgeon a digital camera, and have him take some pictures during surgery. It really helped me to see and understand just what was going on in there. Given your situation/history - and if you don’t mind some gruesome pictures - I’d sure be inclined to ask your surgeon to do the same. It would be interesting to see the current tear, and it’s relationship to the old injury. Also, I’d want to know how the current tissue, cadaver, and foot tendon were all used together.

  7. Much success with your surgery.

  8. Good luck, Jerry, and keep us posted. Lots of folks here who were told that they had very high ATRs, just below the calf muscle, were streamed into a non-op protocol, because many surgeons are reluctant to operate up near the muscle. Maybe the multiple grafts is a response to that challenge, though I’m puzzled (like others) by the 30% prognosis. Hope it works out well.

  9. This makes me cringe. I’m sorry but hope that your surgery goes well today and that you are back on the road to recovery. Keep us posted.

  10. Jerry sounds like a nightmare. The foot tendon they are proposing I suspect is the Flexor hallucis longus tendon.

    This is the tendon that you use to pull your big toe down.

    Its a well known procedure for chronic ATR.

    I had it offered for an elongated tendon after a rupture in April 2010.

    Never went ahead with it as intensive physio has got me to a stage that I am happy with.

    I think the 30% reduction in strength is an exaggeration
    so your surgeon covers his backside.

    My surgeon said that I would never have athletic performance in the tendon but 30% was never mentioned.

    I think also what your surgeon is talking about is a reduction in performance of the calf muscle, not the strength of the transfered tendon.

    If the tendon was 30% weaker than a conventional achilles then I am not sure that the procedure would ever be carried out.

    My surgeon said that the Flexor hallucis longus tendon would be weaker than the achilles but with physio it would strengthen.

    If you think about it a repaired achilles is obviously weaker than a healthy achilles, but with physio more collagen is produced to repair and strengthen the damage.

    The same should happen to the transfered tendon.

    Sorry I came to your post a little late, as you are probably recovering from the surgery as I type. Hope it all went well, and I hope you have a good recovery and final outcome.

  11. So sorry to hear about your double rupture. I almost made the same mistake about not seeing a Dr. right away and I also had a Dr. who didn’t take the injury seriously, but my gut told me otherwise and I ended up having surgery sooner rather than later. Good luck with your second round!

  12. Surgery went well. Much more painful this time though. Good news! Surgeon said there was a little bit of tendon running laterally that was still intact from the initial repair and that he was able to use it in addition to the cadaver and flexor tendons. Apparently, the pre-surgery MRI indicated more damage than was actually found once he opened it up. I’ll know more about the surgery details and new prognosis at the one week follow up next week. Thanks to all for the well wishes.

  13. Great to hear that you got some good news for a change Jerry. Hopefully you’ve turned the corner, and this is the start of a full recovery for you-

  14. I’m sorry about your re-rupture and good to hear good news from the surgery. Best wishes for your recovery,

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